Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Springbrook during CMS and state inspections, most recent first.
The facility failed to transmit MDS assessments within the required timeframe for 5 of 7 residents reviewed. During survey review of MDS records and staff interview, CMS information showed that several assessments were transmitted late, including assessments for multiple residents with ARDs that were not sent on time.
Inaccurate MDS Coding for Colostomy, Fall With Fracture, Surgery, and Nephrostomy Tube: The facility inaccurately coded MDS assessments for two residents. One resident with a colostomy was coded as always incontinent instead of not rated, and another resident’s MDS failed to code a fall with major injury after a femur fracture, the related surgical repair, and later incorrectly coded an indwelling catheter/nephrostomy tube that had already been removed.
Environmental Maintenance and Room Condition Deficiencies: Surveyors observed multiple damaged or incomplete environmental features throughout the facility, including holes in walls, exposed drywall, broken blinds, missing outlet covers, damaged HVAC components, cracked or marked room plaques, torn wheelchair upholstery, damaged bed footboards, and worn furniture and bathroom fixtures. The Maintenance Director stated maintenance concerns were entered through TELS, that some rooms were checked by section rather than routine room checks, and that older beds and equipment were being reviewed.
Facility staff failed to complete quarterly MDS assessments within the required timeframe for 6 of 7 residents reviewed during the annual survey. Medical record review and staff interview showed that several residents had late MDS completion dates, indicating the assessments were not finished within 14 days after the ARD.
Meals Served Did Not Match Meal Tickets: During lunch tray line observation, staff served a resident turkey instead of the garlic egg noodles listed on the meal ticket and substituted broccoli for squash medley after the kitchen ran out of the menu item. The issue affected 11 of 83 trays, including residents in the dining room whose meal tickets still listed squash medley.
Failure to develop a comprehensive care plan for a resident included missing care plan documentation for a left femur fracture after a fall, hospital transfer, and surgical repair with intramedullary nail fixation, as well as missing care plan documentation for a nephrostomy tube and its care while it was present. Record review showed the resident returned from the hospital after surgery, but the care plan did not reflect these conditions or interventions, and staff acknowledged the omissions.
Inaccurate documentation of advance directives and medication-related care plans was identified. Two residents’ social services assessments stated that no advance directive was present and that no discussion, opportunity, or educational materials were provided, while the DSS said residents were asked and materials would be offered but the template was confusing. In addition, a resident had an active order and care plan for anticoagulant/antiplatelet monitoring even though there was no current order for either medication, and the DON was notified of the discrepancy.
Staff failed to protect resident dignity by entering rooms without knocking first. During survey observations, multiple GNAs opened doors and walked into resident rooms before knocking, and one resident stated that some staff do not knock before entering.
Double diapering of dependent residents. Two residents reported that a GNA was placing two diapers on them, including using cut-up pull-ups as pads, despite one resident being dependent on staff for personal hygiene and transfers and another having an ADL deficit with incontinence-related skin concerns. The GNA said residents were changed every 2 hours and as needed, and the DON stated double diapering was not allowed.
A resident’s MRR lacked documentation of review, and a consulting pharmacist’s recommendation to separate levothyroxine and a multivitamin by at least 4 hours was not addressed. The MAR still showed levothyroxine at 6 AM and the multivitamin at 9 AM, and an RN later verified the pharmacy recommendation had not been followed. Pharmacy reviews are generally completed monthly.
A resident’s medication orders were found to be incomplete because several drugs, including Eliquis, Diltiazem, Ezetimibe, Hydralazine, Losartan, and Tamsulosin, did not include an indication for use. The record also showed Lasix ordered for pleural effusions without a physician order for monitoring and documenting side effects. An RN UM stated that medication orders should include the medication, dosage, route, frequency, and indication.
Unlabeled and undated food items were found throughout the kitchen and dry storage areas, including opened frozen foods, dry goods, salad dressing contents, and produce. Staff stated opened items should be labeled with the item name and date opened, but multiple items were not. Surveyors also observed refrigerated and frozen delivery items stacked on the floor in the dry storage room, and the FSD was unable to identify a process for putting away items when deliveries arrived early.
The facility failed to report a serious injury of unknown source to the state oversight agency as required. A resident experienced an unwitnessed event, was later found by a spouse with legs hanging off the bed, and subsequently complained of left leg pain, leading to hospital evaluation. Imaging identified an acute left hip periprosthetic fracture of the proximal femur. Facility documentation stated there was no fall and the cause of the injury was unclear, yet the Administrator did not report the incident, believing the injury occurred when the spouse repositioned the resident's legs and that it was therefore not reportable.
A resident experienced an unwitnessed event reported by the spouse, who found the resident’s legs hanging off the bed and repositioned them. The resident later complained of left leg pain and was sent to the ED, where an acute left hip periprosthetic fracture was diagnosed. The facility subsequently discussed the case in a risk meeting and documented that no fall occurred, but did not conduct a timely or thorough investigation at the time of the event to determine how the injury of unknown source occurred, relying instead on an assumption about the spouse’s actions.
A resident was transferred to an acute care facility, but staff did not complete the required MDS discharge assessment. During a complaint survey, review of the resident’s medical record showed no discharge MDS, and the MDS Coordinator confirmed in interview that the assessment had not been done and could not explain how it was missed, resulting in a failure to ensure an accurate assessment process.
A resident with altered mental status, neurological conditions, muscle weakness, and a history of multiple unwitnessed falls was repeatedly assessed as high risk for falls and had a care plan intervention for a fall mat. Despite this, observations on two separate days found the resident in bed without a fall mat in place. The resident had previously sustained hip fractures following unwitnessed falls and an episode where the resident’s legs were found dangling off the side of the bed. The UM and ADON acknowledged that the fall mat should have been in place per the care plan, and record review showed there was no corresponding physician order for the fall mat until the day of the survey.
Multiple residents did not receive medications as ordered due to improper administration techniques, lack of medication availability, and inaccurate documentation. Staff were observed extracting insulin from pens using syringes instead of pen needles, using unlabeled medication containers, and failing to notify physicians when medications were unavailable. The DON was unaware of these practices, and the pharmacist confirmed that the methods used were not appropriate.
Several residents who required assistance with ADLs and had limited mobility were found without access to a working call light system in their rooms and bathrooms. Despite facility policy requiring accessible call lights and prompt reporting of malfunctions, multiple work orders for broken call lights were left unresolved, and no manual call bells were provided. Staff and maintenance were aware of the ongoing issues, but residents remained unable to reliably summon help when needed.
Three residents experienced unsanitary and uncomfortable living conditions due to the facility's failure to replace a damaged, leaking commode toilet and to maintain cleanliness in resident rooms and bathrooms. Persistent odors, visible contamination, and delayed maintenance were observed, with staff and administration aware of the ongoing issues.
Three residents did not receive their prescribed medications as ordered, including a topical analgesic, a pain-relieving patch, an iron supplement, and an oral diabetes medication. In some cases, the correct medication was not available or was substituted with a different product, and in others, the nurse failed to administer the medication as ordered.
Surveyors identified an 11% medication error rate after observing multiple failures, including missed doses, incorrect medication administration, and improper handling of medications by nursing staff. Errors included not administering prescribed pain relief, antihypertensive, iron supplement, and diabetes medications, as well as substituting the wrong topical medication. Staff interviews confirmed these actions did not follow physician orders.
An opened Humalog insulin pen was found on a medication cart with only a handwritten room number and lacking required labeling such as patient name, physician name, and date opened. An LPN confirmed using the unlabeled pen for insulin administration, contrary to facility policy and pharmacy standards that require full labeling of all insulin pens.
Surveyors found that medications were not administered as ordered for several residents, with some doses given late and others not available at the time of administration. In multiple cases, nurses administered medications more than an hour after the scheduled time, and some medications had to be reordered or were missing entirely. There were also instances where medication administration techniques did not follow physician orders, and documentation showed incomplete dosing for prescribed treatments.
A resident with documented hearing and vision difficulties did not have a care plan or interventions developed to address these needs, despite assessments and therapy notes indicating sensory deficits and an order for cerumen impaction treatment. The DON confirmed the absence of a care plan for these issues.
A resident was served a lunch tray containing rice, despite rice not being listed on the resident's meal ticket and the resident's stated dislike for rice. The kitchen manager and administrator both acknowledged this as a staff error.
The facility failed to report abuse allegations within the required timeframe for three residents. A resident with severe cognitive impairment was allegedly slapped by nursing assistants, another with moderate impairment alleged mishandling by a nursing assistant, and a third resident reported verbal abuse by a night supervisor. In each case, the facility did not notify the state survey agency within the mandated two-hour window.
A facility failed to thoroughly investigate an allegation of neglect involving a resident with paraplegia and end-stage renal disease. The investigation lacked interviews with staff assigned to the resident, and the facility could not verify the neglect claim due to insufficient evidence.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in missed treatments and lack of timely assessments. One resident's pressure ulcer deteriorated without prompt consultation with a physician or wound NP, while another resident did not receive prescribed wound treatments consistently. Interviews revealed a lack of awareness and documentation regarding these deficiencies.
A resident with a history of stroke and moderate cognitive impairment did not consistently have physician-ordered bed rails installed, despite a care plan indicating their necessity for safe bed mobility. The facility's failure to ensure the presence of bed rails, due to multiple bed replacements and inaccurate documentation by staff, resulted in a deficiency in accident prevention measures.
The facility failed to maintain complete medical records for at least five years post-discharge for two residents. One resident, with complex medical conditions, had no MARs or TARs available, while another resident's records were incomplete due to management changes. The facility's system limitations and transition issues led to this deficiency, as confirmed by the Administrator and DON.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to transmit MDS assessments within 14 days of completion for 5 of 7 residents reviewed during the annual survey. During review of MDS assessment material and an interview with facility staff on 4/28/2026 at 12:05 PM, surveyors found that CMS information showed the MDS assessments were not transmitted timely. The late transmissions involved Resident #22 with an ARD of 4/13/26, Resident #41 with an ARD of 3/20/26, Resident #80 with an ARD of 4/13/26, Resident #47, and Resident #58.
Inaccurate MDS Coding for Colostomy, Fall With Fracture, Surgery, and Nephrostomy Tube
Penalty
Summary
The facility failed to code MDS assessments accurately for two residents reviewed for falls and continence. For one resident, the admission Medicare 5-Day MDS coded bowel continence as always incontinent even though the resident had a colostomy and the assessment also coded the colostomy. The resident was observed in bed, alert and oriented to person, and stated the colostomy bag was not leaking. The record also showed a physician order for colostomy care and a comprehensive care plan addressing colostomy care. For another resident, the record showed a fall on 2/19/2026 with left thigh pain and a fracture of the left femur, followed by surgical repair with intramedullary nailing and fixation on 2/20/2026. The discharge MDS was coded as 2 or more falls without injury instead of a fall with major injury, and the quarterly MDS did not code the orthopedic surgery that occurred within 30 days. The resident’s hospital discharge summary documented the fracture and surgical repair. The quarterly MDS for the same resident also coded an indwelling catheter/nephrostomy tube even though the nephrostomy tube had been removed on 2/4/2026, as documented in a nurse’s progress note. A unit manager confirmed the tube had been removed. The surveyor identified these coding discrepancies during record review and interviews with the RN MDS Coordinator and other facility staff.
Environmental Maintenance and Room Condition Deficiencies
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment as multiple areas throughout the building were observed with damage or missing components during the annual survey. Surveyors observed a hole in the dining room wall near the basement stairs, damaged drywall and a detached footboard outside one room, a large horizontal hole in a hallway wall, an indented and exposed wall area outside another room, broken window blinds, a television wall mount that exposed multiple holes in the wall with a wire visible, an HVAC unit with a missing cover exposing internal parts, room number plaques that were cracked or written on with Sharpie, a nightstand missing a drawer, and a call bell wall outlet without an electrical outlet cover. The Maintenance Director stated he was informed of maintenance concerns through an online system and that the facility was in the process of fixing many maintenance concerns since he started in March 2026. Additional observations found a punched-in hole behind a resident room entrance door, a bathroom toilet seat with scraped-off areas exposing brown wood, a nightstand missing a front wood piece, broken baseboard, chipped paint exposing wood near a window ceiling, a wheelchair with a torn seat and damaged arm and back rests, a resident report that a phone could not receive calls, and a bed footboard ripped off exposing sharp edges. During interview, the Maintenance Director said staff used TELS to place work orders, that he rounded daily with weekly and monthly checks, and that the facility did not do regular room checks but used a section-by-section plan. He also stated some beds were old and mechanical and that he was checking and removing old equipment, repainting rooms, and touching up the building. The surveyor and facility leadership later walked the areas and acknowledged the concerns.
Late Quarterly MDS Assessments
Penalty
Summary
Facility staff failed to complete quarterly MDS assessments within 14 days after the assessment reference date for 6 of 7 residents reviewed during the annual survey. The deficiency was identified through medical record review and staff interview on 4/28/2026 at 9:35 AM. The report states that the MDS is a standardized assessment process used to identify each resident's individual needs, plan care based on those needs, and ensure care is provided as planned, and that it is to be completed 14 days after the ARD. Medical record review showed that Resident #22, Resident #41, and Resident #80 each had an MDS completion date of 4/13/2026 that was late.
Meals Served Did Not Match Meal Tickets
Penalty
Summary
The facility failed to ensure residents were served meals according to their meal tickets during the lunch tray line. During observation, staff began plating the lunch meal and later identified that Resident #19’s meal ticket called for garlic egg noodles as the main item, but the kitchen did not have garlic egg noodles available. Staff served the resident the regular menu main item of turkey instead. The observation also showed that the kitchen ran out of squash medley, which was listed on the menu and meal tickets, and staff substituted broccoli. The deficiency affected 11 of 83 trays observed during the lunch meal tray line, including Resident #14, #19, #30, #39, #41, #51, #58, #66, #70, #87, and #92. Staff #15 stated that 10 residents eating in the dining room would receive broccoli even though their meal tickets indicated squash medley. The Food Services Director stated that he or the assigned cook reviewed meal tickets before each meal to ensure special food requests could be prepared and that enough food on the menu was available for each resident.
Failure to Develop Comprehensive Care Plans for Fracture and Nephrostomy Tube Care
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #13 after the resident sustained a fall with left thigh pain on 2/19/2026, was transferred to the hospital the same day, and was diagnosed by x-ray with a left intertrochanteric femur fracture. The resident underwent surgical intervention on 2/20/2026 for intramedullary nail and fixation of the left intertrochanteric femur fracture and returned to the facility on 2/23/2026. Review of the medical record on 4/30/2026 showed there was no comprehensive care plan addressing the left femur fracture or the operative procedure for the intramedullary nail and fixation. Further record review on 5/1/2026 showed the resident had a nephrostomy tube when readmitted to the facility on 12/4/2025, and the tube was surgically removed on 2/4/2026. The comprehensive care plan with revisions did not show a care plan for the nephrostomy tube or for care of the nephrostomy tube during the time it was present. In interviews, the employee responsible for the care plan process acknowledged the missing care plan information, and the DON was informed that the care plan did not reflect the femur fracture, surgical repair, nephrostomy tube, or nephrostomy tube care.
Inaccurate Documentation of Advance Directives and Medication-Related Care Plans
Penalty
Summary
The facility failed to ensure resident medical records were accurately documented and maintained according to professional standards for advance directives and medication-related care planning. For two residents, the social services assessment documentation indicated they did not have an advance directive, that additional conversation about advanced care planning was not provided, that the opportunity to complete an advance directive was not provided, and that advance directive educational materials were not provided. The Director of Social Services stated that residents were asked about advance directives and that materials would be offered if they did not have one, but also stated the template was confusing and could be interpreted several different ways when documenting. For another resident, the medical record contained an active physician order for monitoring related to anticoagulant/antiplatelet medication use, including observation for bleeding and other adverse signs, even though the resident did not have an active physician order for an anticoagulant or antiplatelet medication. The record also showed a care plan goal stating the resident would remain free of complications related to anticoagulant therapy, with interventions to give medications as ordered and monitor for side effects and signs of abnormal bleeding, bruising, and petechiae related to anticoagulant use. During interview, staff identified the interdisciplinary clinical team as responsible for the care plan process. The DON was informed that the resident was not currently receiving an anticoagulant or antiplatelet medication, yet the active physician orders and care plan still reflected monitoring for complications related to those medications. The DON acknowledged the concern and stated she would review and follow up, and no additional information was provided at survey exit.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
The facility failed to maintain residents’ dignity by not having staff knock before entering resident rooms. During the survey, a GNA entered a room with the door closed without knocking and only said “knock knock knock” after opening the door and walking in. In another observation, a GNA opened and entered a resident’s room without knocking and then knocked on the side of the door after already entering. In a third observation, a GNA opened and entered a room without knocking, and the staff member stated she thought both residents were out of the room. A resident interviewed during the survey stated that some staff do not knock before walking into the room.
Double diapering of dependent residents
Penalty
Summary
The facility failed to provide residents who were unable to perform activities of daily living with the necessary assistance to maintain personal hygiene. During the annual survey, Resident #54 stated that a GNA put double diapers on them at night and had done so again the prior night, and the resident reported developing redness on the peri area and bottom because of the double diapering. The resident’s care plan documented an ADL self-care performance deficit related to impaired balance and a potential for impaired skin integrity related to incontinence, fall risk, and decreased mobility, with interventions including keeping the skin clean and dry. Resident #109 also reported that staff had been putting two diapers on them because they were on Lasix, and the admission MDS documented dependence on staff for personal hygiene and transfers. The physician’s order showed Lasix 40 mg daily. In interview, the GNA stated she changed residents every 2 hours and as needed, said she would check cognitively impaired residents, and acknowledged that if residents were not changed frequently they could develop redness and/or a UTI. She stated she used one diaper, but when asked about the allegations, she explained that she cut out pull-ups and used them like a pad on residents. The DON stated staff should not be double diapering and said it was not allowed.
Failure to Address Pharmacy MRR Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to a consulting pharmacist’s recommendation for Resident #88, whose medication regimen review for December 3, 2025, lacked documentation that a review had been conducted. The pharmacist had recommended that the resident’s multivitamin be administered at least 4 hours after levothyroxine, but review of the April 2026 MAR showed levothyroxine continued to be given at 6 AM and the multivitamin at 9 AM, only 3 hours apart. During interview, the Regional Clinical Nurse stated they would check whether the December 3, 2025 MRR had been addressed, then later verified that the pharmacy recommendation had not been addressed and that the MAR still reflected the same administration times. The staff member also stated that pharmacy reviews are generally completed monthly.
Medication Orders Lacked Indications and Monitoring Documentation
Penalty
Summary
The facility failed to ensure that physician medication orders for Resident #111 included appropriate indications for use and appropriate monitoring/documentation for side effects. During medication administration observation, the surveyor later reviewed the resident’s record and found orders for Apixaban (Eliquis) 2.5 mg twice daily and Furosemide (Lasix) 40 mg daily for pleural effusions. The Eliquis order did not include an indication for use, and there was no physician order for monitoring and documenting side effects related to Lasix. Further review of the resident’s medication orders showed additional medications without an indication documented in the physician orders, including Diltiazem 360 mg nightly, Ezetimibe 10 mg daily, Hydralazine 50 mg every 8 hours, Losartan 25 mg daily, and Tamsulosin 0.4 mg at bedtime. The RN Unit Manager stated that medication orders should include the medication, dosage, route, frequency, and indication. The DON was informed that several of the resident’s medication orders lacked indications for use, and no additional information was provided at survey exit.
Unlabeled Food Items and Improper Storage in Kitchen and Dry Storage
Penalty
Summary
Food was not stored in accordance with professional standards, as multiple opened items in the kitchen and storage areas were found unlabeled and undated during survey observation. On 04/27/2026 at 7:34 AM, the freezer contained opened, unlabeled french toast sticks, green beans, and chicken patties, and the refrigerator next to the freezer contained opened, unlabeled turkey bacon. At 7:46 AM, additional kitchen observations found opened, unlabeled quick creamy wheat, plastic containers with what appeared to be oatmeal and creamy wheat, opened and unlabeled all purpose flour, and a large jug of salsa picante that was opened and unlabeled with the date it was opened. The refrigerator with salad dressings also contained a plastic container of an orange substance with no label or preparation date, and a bag containing a head of iceberg lettuce that had previously held approximately 6-8 heads of lettuce was opened and unlabeled. Staff #15 stated that when anything is opened for the first time, it is expected to be labeled with the item name and date opened, whether kept in the same container or transferred to another container. Further observation at 7:53 AM in the downstairs dry storage room found an opened box lined with a blue bag containing raisins exposed to the air and unlabeled with the date, as well as an opened loaf of rye bread marked best by March 27th. Later, at 7:50 AM, approximately 15 boxes of various refrigerated and frozen items were observed stacked on the floor in the downstairs dry storage room. Staff #15 stated the truck had dropped off the items not long ago and that the Food Services Director would arrive shortly to put them away. At 8:18 AM, the freezer and refrigerator items were still stacked in the room while the Food Services Director was beginning to label the items while they remained stacked. The Food Services Director later stated the truck had arrived earlier than normal and was unable to identify a process for putting the items away if delivered early.
Failure to Report Serious Injury of Unknown Source to State Agency
Penalty
Summary
The facility failed to report to the Office of Health Care Quality (OHCQ) an incident involving a resident who sustained a serious injury of unknown source where abuse or neglect had not been ruled out. Record review showed that the resident experienced an unwitnessed event in the facility, during which the resident's spouse found the resident with legs hanging off the side of the bed and repositioned them. Staff did not witness the event, and the resident was unable to explain what had occurred. The resident subsequently complained of left leg pain and was sent to the hospital for further evaluation. Emergency Department provider notes documented diagnostic imaging that revealed an acute left hip periprosthetic fracture, described as a new fracture of the left proximal femur. The resident later returned to the facility. Facility documentation indicated that staff concluded the resident did not have a fall in the facility, and the cause of the injury remained unclear. During an interview, the Administrator confirmed that the incident was not reported to OHCQ, explaining that the facility believed the injury occurred when the spouse moved the resident's legs and therefore did not consider the event reportable, despite the serious injury of unknown source.
Failure to Investigate Serious Injury of Unknown Source
Penalty
Summary
Surveyors found that the facility failed to complete a thorough and timely investigation of an incident involving a resident who sustained a serious injury of unknown source. Record review showed that the resident experienced an unwitnessed event in the facility, during which the resident’s spouse reported finding the resident’s legs hanging off the side of the bed and then repositioned them. Staff did not witness the event, and the resident was unable to explain what had occurred. The resident complained of left leg pain and was sent to the hospital, where Emergency Department records documented an acute left hip periprosthetic fracture. Interview and document review revealed that the incident was later discussed in a facility risk meeting, and the facility documented that the resident did not have a fall in the facility. The risk meeting discussion occurred several days after the event, and there was no evidence that a timely or thorough investigation was conducted at the time of the incident to determine how the injury occurred. The Administrator stated that the facility believed the injury happened when the spouse moved the resident’s legs and confirmed that no additional investigation was conducted to determine the cause of the injury.
Failure to Complete Required MDS Discharge Assessment
Penalty
Summary
Facility staff failed to complete a required Minimum Data Set (MDS) discharge assessment for a resident who was transferred to an acute care facility. During a complaint survey, medical record review for Resident #2 showed that the resident was transferred on 2/3/26, but the resident’s MDS record did not contain a corresponding discharge assessment. In an interview, the MDS Coordinator acknowledged that a discharge assessment had not been completed and stated, "I did not do one. I have no clue how this fell off the radar." The Nursing Home Administrator was later informed of this concern by surveyors. This deficiency reflects the facility’s failure to ensure that an accurate and complete MDS discharge assessment was performed as part of the federally mandated Resident Assessment Instrument process, which is intended to identify each resident’s individual needs and support appropriate care planning.
Failure to Implement Care-Planned Fall Mat for High-Risk Resident
Penalty
Summary
The facility failed to implement care-planned fall prevention interventions for a resident identified as high risk for falls. The resident was admitted with diagnoses including altered mental status, hydrocephalus, seizures, intracranial injury, and muscle weakness, and had a documented history of multiple unwitnessed falls on 01/09/2026, 01/15/2026, 02/12/2026, and 02/19/2026. A fall care plan initiated on 02/19/2026 included the use of a fall mat as an intervention. The resident had been transferred to the hospital following an unwitnessed fall that resulted in a confirmed hip fracture and later returned to the facility. Fall risk evaluations completed on multiple dates consistently identified the resident as high risk for falls. On 03/23/2026, the resident’s spouse reported that the resident’s legs were dangling off the side of the bed, after which the resident complained of leg pain and was transferred to the hospital, where a new left hip fracture was confirmed. Subsequent observations on 04/01/2026 and 04/02/2026 showed the resident in bed without a fall mat in place on the right side of the bed, despite the care plan calling for this intervention. During interviews, the Unit Manager and the ADON confirmed that the resident was a high fall risk and should have had a fall mat in place per the care plan, and the ADON stated that there should have been a corresponding physician order for the fall mat. Review of physician orders on 04/02/2026 revealed no active or prior order for a fall mat, and the ADON confirmed that an order for the fall mat was only written that same day.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to provide medication administration that meets professional standards for five of eight sampled residents. For one resident with diabetes, staff were observed extracting insulin from an insulin lispro kwikpen using an insulin syringe, rather than the manufacturer-recommended pen needles. Multiple nursing staff confirmed this practice, citing a lack of compatible safety needles in the facility. The insulin pens used were also not properly labeled with the resident's name, dose, or route, only displaying handwritten dates and room numbers. Staff interviews revealed that this practice had been ongoing for several months, and the central supply manager had instructed staff to use insulin syringes due to supply shortages. The facility pharmacist confirmed that extracting insulin from pens with syringes is not appropriate and can damage the pen, potentially leading to dosing errors. Another resident with a prescription for a topical analgesic did not receive the medication as ordered, despite documentation indicating it had been administered. The nurse responsible stated she thought she had given the medication but had not. For a resident prescribed amlodipine for hypertension, the nurse withheld the medication due to low blood pressure, placed the tablet in an unlabelled medicine cup, and stored it in the medication cart with only a room number written on it. The nurse later administered the medication without a new physician order and could not recall if the resident's blood pressure had increased. The medication administration record did not reflect that the medication was given as ordered. Two additional residents did not receive their prescribed medications (vitron-C and Jardiance) because the medications were not available in the facility. The nurse did not notify the physician about the missed doses. The Director of Nursing confirmed that the affected residents should have received their medications as ordered and that documentation should be accurate. The DON was not aware that staff were using insulin syringes to extract insulin from pens.
Failure to Maintain Functional Call Light System in Resident Rooms
Penalty
Summary
The facility failed to provide a functioning call light system in resident bathrooms and bathing areas, as required by policy, for three residents. The policy mandates that each resident must have access to a call light at the bedside, toilet, and bathing area, with calls relayed directly to staff or a centralized location to ensure timely response. Staff are instructed to report any call light issues immediately and provide alternative solutions until repairs are made. However, multiple work orders for broken call lights remained unaddressed, and no manual call bells were provided in affected rooms. One resident, admitted with diagnoses including infectious gastroenteritis, congestive heart failure, and diarrhea, required assistance with activities of daily living (ADLs) due to limited mobility. This resident's call light was found detached from the wall, with no manual call bell available, making it difficult to summon staff when help was needed. Another resident, who was cognitively intact and dependent on staff for ADLs, reported that the call light in their shared room had not worked for four months, and no manual call bell was present. This resident also expressed concerns about staff responsiveness due to the ongoing issue. A third resident, also dependent on staff for ADLs and identified as a fall risk, was found in a room where both call lights were nonfunctional. Staff were unaware of the broken call lights until the time of observation and interview. The maintenance director acknowledged awareness of the issue and difficulties in obtaining replacement parts, while the administrator and DON were informed of the ongoing problems. Despite the facility's policy and the residents' needs, the lack of a working call system persisted, leaving residents without a reliable means to request assistance.
Failure to Maintain Sanitary and Functional Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for three residents. One resident, who was dependent on staff for all activities of daily living and had diagnoses including spastic quadriplegic cerebral palsy and spinal stenosis, was observed in a room with several dark spots, dried food droppings, and black and brown substances on the walls. The resident reported that the facility did not adequately clean the room or walls. Two other residents, one with unspecified dementia and chronic kidney disease requiring substantial to maximum assistance with personal hygiene, and another with end stage renal disease and a history of falls who was independent with ADLs, experienced ongoing issues with a damaged and leaking commode toilet in their shared bathroom. Both residents reported strong, persistent odors and visible contamination in the bathroom, including black and brown substances on the stool area, stained and discolored floor tiles, and a pervasive smell of urine and human waste. One resident stated the issue had persisted for over two months, leading them to use staff bathrooms instead. Interviews with the Housekeeping Director and Maintenance Director confirmed that the bathroom required significant repairs, including floor and toilet replacement, and that the odor could not be eliminated despite repeated cleaning. Both directors indicated that the administrator was aware of the ongoing plumbing and maintenance issues, which had been present for several months. A private plumber's work order documented repairs to the toilet bowl and recommended further replacement of toilet bolts and pipes.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to administer medications as ordered by physicians for three residents. One resident with a history of seizures, hypertension, diabetes, and dysarthria did not receive a prescribed topical analgesic (Biofreeze) to the right shoulder as ordered. During observation, the assigned nurse did not administer the medication and later stated she thought she had done so. Another resident with polyneuropathy, diabetes, osteoarthritis, knee pain, vitamin D deficiency, and anemia did not receive a prescribed Salonpas pain relieving patch (lidocaine) to the knees or a Vitron-C tablet for anemia. The nurse on duty administered a different medication (lidocaine and prilocaine cream) instead of the prescribed patch and did not administer the Vitron-C tablet, citing unavailability of the medication. A third resident with diabetes, osteomyelitis, and peripheral vascular disease did not receive a prescribed Jardiance oral tablet for diabetes, as the medication was not available at the time of administration. Both the pharmacist and the Director of Nursing confirmed that these residents should have received their medications as ordered. The deficiencies were identified through record review, medication administration observations, and staff interviews.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11% with 5 errors out of 43 opportunities. Specific incidents included a nurse failing to administer a prescribed topical analgesic to a resident as ordered, and another nurse not administering an antihypertensive medication due to low blood pressure, subsequently storing the medication in an unlabelled cup in the medication cart and later administering it without confirming the resident's blood pressure status. Additionally, a nurse administered the wrong topical medication to a resident, substituting a lidocaine and prilocaine cream for a prescribed lidocaine patch. Two further errors involved the non-administration of prescribed medications (an iron supplement and a diabetes medication) due to unavailability, with staff confirming that the residents did not receive these medications as ordered. Interviews with staff and the pharmacist confirmed that all residents should receive medications as per physician orders, and the Director of Nursing also acknowledged this expectation. The observed failures included both omissions and incorrect administration of medications, as well as improper medication handling and storage practices, directly contributing to the elevated medication error rate identified during the survey.
Unlabeled Insulin Pen Found on Medication Cart
Penalty
Summary
Surveyors observed that an opened and used Humalog (insulin lispro) pen was stored on the West Wing Medication Cart without a label indicating the patient name, physician name, or date used. The only identifying mark on the insulin pen was a room number handwritten with a black marker. Staff Nurse #6 confirmed that he administered insulin using this unlabeled pen and believed that the room number was sufficient for identification. The facility's policy, as provided by the Director of Nursing, requires that insulin pens be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. Further interviews with the Director of Nursing and the pharmacy consultant confirmed that all insulin pens must be labeled with the patient's name, physician name, and date opened. The pharmacy consultant also stated that any opened, unlabeled insulin pens should not be used and that the facility should notify the pharmacy to order a new, properly labeled pen. The failure to label the insulin pen as required by both facility policy and professional standards led to the identified deficiency.
Failure to Administer Medications as Ordered and Ensure Medication Availability
Penalty
Summary
Surveyors identified that the facility failed to ensure medications were administered as ordered for multiple residents. In several observed instances, medications scheduled for administration at specific times were given more than an hour late, and some medications were not available at the time of administration. For example, one resident did not receive lactulose as it was unavailable, and other medications were administered over an hour past the scheduled time. Another resident was missing multiple medications, including an inhaler and furosemide, which had to be reordered, and received the remaining medications late. Additional review of medication administration records revealed that some medications, such as Flonase nasal suspension, were also not available as ordered. The acting DON confirmed that the facility had some ability to pull missing medications from emergency supply but acknowledged the issue of unavailability. Further deficiencies were observed in medication administration technique and documentation. One resident with a gastric tube did not have the tube flushed with water after medication administration as ordered, which was confirmed by the nurse involved. Another resident did not receive all prescribed doses of a medication for cerumen impaction, as the medication was only administered for three days instead of the four days ordered. These findings were corroborated by interviews with nursing staff and review of medication administration records, which showed missed or incomplete doses and deviations from the facility's medication administration policy.
Failure to Develop Care Plan for Sensory Deficits
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing the hearing and vision deficits of a resident. Physical Therapy notes indicated that the resident was educated and engaged in a home exercise program to improve lower extremity strength, and the therapist communicated with the unit manager about the resident's inability to see and hear. The Minimum Data Set (MDS) assessments showed changes in the resident's hearing ability, and the Medication Administration Record (MAR) documented an order for Debrox otic solution for cerumen impaction in the left ear. Despite these documented needs and changes, a review of the resident's care plan revealed that no interventions or care plans were developed for the identified hearing or vision difficulties. The acting Director of Nursing confirmed during an interview that no care plan or interventions were in place for these needs.
Failure to Honor Resident Food Preferences
Penalty
Summary
Facility staff failed to honor a resident's food preferences during meal service. During lunch observation, a resident refused his lunch tray because it contained rice, which he dislikes. Review of the resident's meal ticket confirmed that rice was not listed as part of his meal preferences. The kitchen manager acknowledged that this was an error, and the administrator agreed that the kitchen staff made a mistake in this instance.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse within the required timeframe for three residents. Resident #27, who had severe cognitive impairment, was allegedly slapped by two nursing assistants. The facility was informed of this incident on the morning of December 22, 2022, but did not notify the state survey agency until later that afternoon, missing the required two-hour reporting window. The Administrator was unaware of the late reporting and could not determine why it occurred. Resident #32, with moderate cognitive impairment, alleged that a nursing assistant dropped their legs while providing care. The facility was informed of this allegation on March 24, 2022, but did not report it to the state survey agency until later that evening, again missing the two-hour reporting requirement. The Director of Nursing, who was not employed at the time of the incident, confirmed the reporting delay, and the Administrator was unsure why the report was late. Resident #13, who had no cognitive impairment, alleged verbal abuse by a night supervisor and reported the incident to a corporate representative. The facility was informed of the allegation on December 4, 2023, but did not notify the state survey agency until later that day, outside the required timeframe. The Director of Nursing and the Administrator confirmed the late reporting, acknowledging that the incident should have been reported within two hours of awareness.
Failure to Conduct Thorough Investigation into Alleged Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect involving a resident with a medical history of paraplegia, end-stage renal disease, pressure ulcer, and dependence on renal dialysis. The resident, who had intact cognition, was transferred to the hospital and subsequently passed away. A family member alleged neglect through a certified letter, claiming the facility did not provide safe and proper medical services to the resident over a specified period. The facility's investigation documents lacked interviews with staff who were directly assigned to care for the resident during the alleged period of neglect. The facility's policy required a comprehensive investigation into allegations of abuse or neglect, including interviews with relevant staff. However, the investigation only included witness statements from staff who were not assigned to the resident during the critical period. The Administrator acknowledged the absence of interviews with the appropriate staff and admitted to losing the certified letter that initiated the investigation. Consequently, the facility was unable to verify the neglect allegation due to insufficient evidence from the investigation.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing of pressure ulcers for two residents. For one resident, the facility did not consistently complete and document weekly wound assessments as per the care plan. Additionally, there was a failure to promptly consult with the attending physician or wound nurse practitioner (NP) regarding the deterioration of a pressure ulcer. The resident had a medical history including type 2 diabetes mellitus and peripheral vascular disease, and was admitted with two Stage III pressure ulcers. Despite initial improvements, a new Stage II pressure injury developed and later deteriorated to an unstageable condition without timely intervention or documentation of assessments. For the second resident, the facility did not provide wound treatments as ordered. The resident had a medical history of multiple sclerosis, type 2 diabetes mellitus, and a Stage IV pressure ulcer of the sacral region. The facility's records indicated that the resident's sacral wound treatments were not administered as prescribed, with several treatments missed over a period of time. This resident's wound was debrided weekly by a wound physician, but the facility failed to consistently follow the prescribed treatment regimen, leading to missed treatments and delayed initiation of new treatment orders. Interviews with facility staff revealed a lack of awareness and documentation regarding the missed treatments and changes in wound conditions. The Director of Nursing (DON) and other staff members confirmed that there was no documentation of the wound nurse practitioner being notified of changes in the wound conditions, and there was a lack of consistent wound assessments and timely implementation of treatment recommendations. The facility's policies on pressure injury prevention and management, as well as notification of changes, were not adhered to, contributing to the deficiencies observed.
Failure to Implement Physician-Ordered Bed Rails
Penalty
Summary
The facility failed to consistently implement a physician-ordered intervention for bed rails for a resident, which was intended to assist with safe bed mobility and minimize the risk of falls. The resident, who had a history of cerebral infarction, end-stage renal disease, and moderate cognitive impairment, was admitted to the facility with a care plan that included the use of 1/4 side rails for turning and repositioning. Despite the physician's order and consent from the resident's responsible party, the bed rails were not consistently installed on the resident's bed. Observations and interviews revealed that the resident's bed was replaced multiple times due to mechanical issues, and the new beds did not always come with the required side rails. Nursing staff documented that the side rails were in place, even when they were not, indicating a lack of verification and adherence to the physician's order. The resident reported that the facility was supposed to install bed rails but had not done so, and staff interviews confirmed that the bed rails were not present at times due to bed replacements. The facility's policies on fall prevention and bed rail use were not followed, as evidenced by the lack of consistent implementation of the bed rail intervention. The nursing staff and maintenance personnel failed to ensure that the bed rails were installed on the resident's bed, despite the documented need and physician's order. This oversight led to a deficiency in providing adequate supervision and accident prevention measures for the resident.
Failure to Maintain Complete Medical Records
Penalty
Summary
The facility failed to maintain complete medical records for a minimum of five years from the date of discharge for two residents, as required by their policy. Resident #33, who was admitted with complex medical conditions including acute hematogenous osteomyelitis and end-stage renal disease, had no Medication Administration Records (MARs) or Treatment Administration Records (TARs) available for review. The facility's Administrator acknowledged the inability to retrieve these records from the electronic medical record system for records older than three years, which was contrary to the facility's policy. Similarly, Resident #34, who had a medical history of chronic obstructive pulmonary disease, dementia, and other conditions, was discharged from the facility without complete MARs and TARs for several months prior to discharge. The facility was unable to provide these records, and the Administrator indicated that the records might have been lost during a management transition. Additionally, therapy notes for Resident #34 were not available due to a change in the therapy service provider. Interviews with the facility's Administrator and Director of Nursing confirmed that the expectation was to maintain complete medical records for at least five years post-discharge. However, due to system limitations and management changes, the facility failed to comply with this requirement, resulting in incomplete medical records for the residents in question.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,726 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Silver Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Suites Rehabilitation And Wellness Center | 1.7 mi | ★★★★★ | 28 | 1 |
| Fairland Center | 2.1 mi | ★★★★★ | 5 | 0 |
| Autumn Lake Healthcare At Silver Spring | 2.2 mi | ★★★★★ | 15 | 0 |
| Autumn Lake Healthcare At Arcola | 2.2 mi | ★★★★★ | 23 | 0 |
| Riderwood Village | 2.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.