Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Creekside Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Kitchen staff failed to follow food safety practices when a cook was observed preparing breakfast trays without a hair net. In addition, the Dietary Mgr could not produce current cooling log documentation for potentially hazardous foods, and multiple cooked items were found in the walk-in refrigerator with dates spanning several days.
Failure to Provide Advance Directive Information: Multiple residents who were documented as capable of making their own medical decisions had no evidence in the chart that advance directive information was offered or discussed. Record reviews found missing AD, HCP, or related documentation, and the SW Director stated that residents should be offered this information at admission and care plan meetings, but there was no evidence it occurred for the affected residents.
A resident experienced a change in condition that led to EMS being called and the resident being pronounced deceased, but the facility failed to notify the physician and document the change in condition and transfer decision. Record review showed a change in code status from full code to DNR and EMS involvement, yet there was no change in condition note, no documentation of who called EMS, and no physician order to send the resident to the hospital. The DON reported that nurses are expected to assess the resident, immediately notify the physician, obtain and document transfer orders, and record all actions taken, but confirmed that these steps and related documentation were missing in this case.
Surveyors found that the facility failed to report allegations of neglect and staff mistreatment to state authorities. A resident’s family had repeatedly found the resident in a very wet or soiled brief, with documentation showing delayed care due to the resident’s agitation, and another grievance described a GNA raising a fist toward a resident and making a hostile remark. Although these concerns were documented internally and one was referred for psychiatric services, there was no evidence that either allegation was reported as a Facility Reported Incident to OHCQ, and the NHA could not explain the failure to report.
A dependent resident with muscle weakness, morbid obesity, chronic pain, and mobility abnormalities required substantial/maximal assistance for showering but did not receive showers as scheduled. A prior shower order was discontinued, and although the DON stated that all residents are routinely scheduled for showers twice weekly based on room and bed assignment, documentation for one month showed only one scheduled and one unscheduled shower provided. There was no additional documentation of showers or refusals in the medical record, shower/skin sheets, or aide task records, despite the resident’s dependence on staff for this ADL.
Staff failed to treat residents with dignity by entering rooms without knocking or asking permission and by not protecting privacy during care. A cognitively intact resident reported that an RN entered to perform a fingerstick without consent and that personal care was provided with the door open and the privacy curtain not pulled, leaving the resident exposed and embarrassed. Surveyors also observed a GNA and an LPN enter 8 resident rooms during breakfast tray pass without knocking, announcing themselves, or requesting permission, despite facility policy requiring staff to knock and announce before entering resident rooms.
Late Admission MDS Completion: A resident admitted after a respiratory infection had an Admission/Medicare 5-day MDS left in progress with multiple sections incomplete. The MDS nurse confirmed the assessment was completed, signed, and accepted after the required timeframe and acknowledged it was late; the NHA also acknowledged the late MDS.
Incomplete MDS Cognitive Assessment: A resident with Parkinson's disease and unspecified dementia had quarterly MDS assessments with Section C left not assessed, and the last BIMS had been completed months earlier. The MDS nurse confirmed a cognitive assessment was required for the quarterly MDS but was not done, and the NHA acknowledged the incomplete MDS sections.
Missed Care Plan Meetings After Required Assessments: The facility failed to document required care plan meetings for multiple residents after MDS assessments. One resident with stroke and dementia had a scheduled meeting that was not shown to have occurred, another resident with Parkinson’s disease and dementia had no documented meetings after the last one in May, and a third resident stated they did not participate in a care plan meeting and the record lacked evidence of resident or RP participation or notification.
Failure to obtain an order for increased O2 and to complete follow-up assessment after a resident with COPD and continuous O2 needs developed SOB. Staff gave an inhaler, elevated the HOB, and increased O2 from 2 to 3 L/min without a physician order, and there was no documented response to treatment before the resident was later found without pulse or respirations. The DON confirmed there was no order to titrate O2 and no evidence of staff follow-up.
A resident at very high risk for pressure injuries had a low air loss mattress set to the maximum firmness/weight level even though the resident weighed 160.2 lbs, and the wound nurse confirmed the setting was incorrect. The resident also had ordered weekly skin checks, but nurses signed the eTAR showing the checks were done while only two skin assessments were actually documented, leaving three scheduled assessments without supporting documentation.
Failure to Monitor Wanderguard Device: A resident with Alzheimer's disease, severe cognitive impairment, and a documented high elopement risk had a wanderguard placed for safety, but the record contained no evidence that staff regularly monitored the device for placement or function. An agency nurse said she checked the device and that documentation should be on the TAR, while the DON confirmed there was no documentation that the wanderguard had been monitored as required by facility policy.
Failure to document pain assessment and non-pharmacological interventions before PRN pain medication administration. Two residents had PRN pain meds given without evidence that pain location, intensity, or NPI were assessed or documented first. One resident reported that pain meds did not always help and that NPI were not being provided, while another resident with chronic respiratory failure and stroke-related weakness had repeated PRN oxycodone doses documented with pain score listed as NA. The DON confirmed the missing assessment and documentation.
A facility failed to keep documented provider responses and rationale for pharmacist MRR findings in residents’ permanent records. One resident with complex medical issues, including DM and HF, had a pharmacist recommendation to assess insulin and glucose orders and consider an endocrine consult, but the chart only contained an unsigned, undated note stating no response was required. Another resident’s chart showed only partial MRR documentation for the year, and a report with a provider signature lacked a date and did not clearly show when or whether the recommendation was addressed in the medical record.
A resident with DM, HF, and malignant neuroendocrine tumors required multiple meds, including insulin before meals and at bedtime. The resident stated morning meds and insulin were given together late, after the time they were supposed to be administered before breakfast. The eMAR showed the meds were signed as given, and the DON confirmed that meds scheduled for early morning were actually given at 11:37 AM, which was outside the facility’s timely administration window.
Failure to perform hand hygiene and maintain sanitary medication storage. Staff did not clean their hands during meal tray delivery to multiple resident rooms and during medication administration to two residents. In addition, a medication storage area behind the nursing station was visibly soiled, with debris on the floor and a sink basin blocked with packaging, and the IP could not provide documentation of hand hygiene audits or related staff education.
Failure to Educate and Offer COVID-19 Vaccination: The facility did not document education or offer of the COVID-19 vaccine for multiple staff and residents. An RN infection preventionist stated that residents received vaccine education in the admission packet and that vaccines were ordered for consenting residents, but she had no evidence that staff were educated or offered the COVID-19 vaccine, and the NHA acknowledged there was no evidence the vaccine was offered to staff or residents.
Call Bell Not Accessible and Delayed Staff Response A resident was observed near the edge of the bed with the call bell cord partially disconnected from the wall outlet and out of reach while asking for assistance. The resident reported that delayed staff response to call light activation was not unusual and said staff had taken up to an hour to respond. After the surveyor reconnected the call bell and activated the pendant call button, no staff responded for about 8 minutes.
The facility failed to ensure required training for two agency GNAs. The NHA and staffing scheduler reported that about 80% of GNA staffing was agency-based, while the HR Director said she did not provide training for agency staff, including monthly training. When surveyors requested training records, one GNA’s packet lacked key details such as the instructor, training length, and proof of testing or grading, and no training evidence was provided for the other GNA.
A resident with severe cognitive impairment and high elopement risk was able to access an unsecured mechanical/boiler room after staff failed to ensure laundry and mechanical room doors were locked when unattended. The resident was found on the floor with minor injuries, and staff and maintenance interviews indicated the doors were likely propped open, allowing unauthorized access.
Two residents with bariatric needs suffered serious injuries after falls from beds that were not equipped with appropriate bariatric mattresses and frames. In both cases, staff failed to follow safety procedures and did not provide the required level of assistance or ensure the correct equipment was in place, resulting in fractures and hospitalizations.
The facility did not ensure timely reporting of alleged abuse incidents, as required by policy and regulations. In several cases, residents with significant medical and cognitive conditions experienced or were alleged to have experienced abuse or mistreatment, but staff failed to notify the administrator and state agencies within the mandated timeframes. Delays in reporting were confirmed through staff interviews and record reviews, with some incidents not reported for several days.
A facility failed to maintain complete documentation for an abuse allegation investigation involving a resident with dementia and other conditions. Required written and signed statements from all staff involved, including the reporter and other staff present during the incident, were missing from the investigation file. The Assistant Director of Nursing and Administrator confirmed that the investigation documentation was incomplete and that no additional information was available.
The facility failed to notify the local health department and post signage about a gastrointestinal outbreak affecting approximately 24 residents. The ADON, also the Infection Preventionist, did not inform the health department despite recognizing the outbreak, and there was no signage at the entrance to alert staff and visitors.
Facility staff failed to create a comprehensive care plan for a resident with a prosthetic eye, who also had Alzheimer's and Lewy Body Dementia. The care plan did not address the specific needs for cleaning the prosthetic eye or managing related behaviors, despite the resident's admission several months prior. The deficiency was confirmed by the DON.
A facility failed to renew a cleaning order for a resident's prosthetic eye after multiple hospitalizations. The resident, with Alzheimer's and other neurocognitive disorders, initially had their spouse manage the eye care. As the resident's condition worsened, staff took over, but the order was not reinstated post-hospitalization. The ADON discovered the omission during a chart audit and reinstated the order without notifying the physician or documenting communication with the spouse.
A resident with hypertension was administered Clonidine despite physician orders to hold the medication if systolic blood pressure exceeded 150. The facility also failed to notify the physician when the resident's systolic blood pressure was above 160, as required. These oversights were confirmed by the DON during a review.
A resident with cognitive impairments was inappropriately restrained by staff in a wheelchair against a wall, preventing movement. Despite the incident being reported, the staff member involved continued to work in the facility without proper documentation or disciplinary action. The facility's failure to address the incident led to a determination of immediate jeopardy, highlighting concerns for resident safety.
The facility failed to recognize and address changes in resident conditions, leading to immediate jeopardy. A resident received morphine routinely instead of as needed due to a physician's error, which was not communicated or corrected by staff. Another resident experienced ongoing abdominal issues and significant weight loss without timely medical consultation, resulting in their death from sepsis and shock. These failures highlight the facility's inability to promptly assess and address resident conditions and ensure proper medication administration.
A facility failed to prevent injuries to residents due to inadequate supervision and unsafe equipment. One resident sustained a severe leg laceration during a transfer, while another fell out of bed during ADL care, resulting in a hematoma. The facility's reliance on agency staff without proper orientation and missing information in the Kardex contributed to these incidents.
A resident requested a transfer to another facility shortly after admission, but the LTC facility failed to document or act on this request. Despite the resident's capability to make informed decisions and clear communication with the Social Worker, no evidence of discharge planning or actions taken was found. Interviews with the DON and Social Worker confirmed the oversight, leading to a deficiency noted by surveyors.
The DON was not working full-time in her designated role due to being assigned additional duties as the IP nurse after the previous IP nurse resigned unexpectedly. The facility, licensed for 80 beds, requires the IP responsibilities to occupy 40% of a full-time equivalent. The NHA acknowledged the issue and stated that another staff member is in training to take over the IP role.
The facility did not conduct annual performance reviews for GNAs, affecting five staff members who had been employed for over 12 months. The DON confirmed that performance reviews and competency evaluations were not completed since she took on her role.
The facility failed to implement proper transfer/discharge procedures, lacking essential information in notices and effective discharge planning. Residents were not informed of bed-hold policies, and some did not receive timely physician visits. Additionally, the facility did not provide required communication and behavioral health training to all staff, including new hires.
The facility's quality assessment and assurance program failed to prevent repeat deficiencies related to reasonable accommodation of needs, pharmacy services, unnecessary drug regimens, and medication error rates. Despite previous corrective actions, these issues persisted, as identified in recent and past surveys. The NHA acknowledged the recurrence of these deficiencies.
The facility failed to implement proper infection prevention and control measures, including inadequate use of PPE during resident care, improper handling of exposed needles during medication administration, and insufficient laundry and water management practices. Staff did not wear gowns when required, and the laundry room lacked separation between clean and soiled areas. Additionally, the facility's infection control policies were outdated and not reviewed annually.
The facility failed to provide mandatory effective communication training for direct care staff, as revealed by a review of employee files for five staff members. Interviews with HR and the DON indicated uncertainty about past training tracking methods, and despite recent efforts to provide training materials, no documentation of effective communication training was found.
The facility failed to ensure required training on abuse, neglect, exploitation, and dementia management was completed for several staff members. Documentation was missing or incomplete for multiple employees, including some who had no record of receiving necessary training. The DON and HR were unable to confirm past training, and recent efforts to provide training lacked proper documentation.
The facility failed to provide mandatory infection prevention and control training for its staff, as revealed by a review of employee files. Four GNAs had no documentation of receiving the required training, and interviews with HR and the DON indicated that training had not been consistently tracked or conducted. Despite some training materials being available, comprehensive documentation was lacking.
The facility failed to document that GNAs received the required in-service training, including abuse prevention and dementia management, and did not conduct annual performance reviews. A review of employee files showed a lack of training records, and the DON confirmed that training had not been occurring until recently. Limited evidence of training was found in the Annual Education Fair binder, with some staff lacking documentation of completed training.
The facility failed to provide mandatory effective communication training for its direct care staff, as required by the facility assessment. A review of employee files revealed no documentation of such training for GNAs hired between 2010 and 2022. Interviews with HR and the DON confirmed the absence of training records, and a review of corporate training materials and an Annual Education Fair binder did not show evidence of effective communication training.
The facility failed to conduct a comprehensive facility-wide assessment, omitting critical information such as the average number of residents and necessary staff competencies. The assessment did not evaluate the training program for staff, contractual individuals, and volunteers, resulting in several GNA staff members lacking essential training. Additionally, the facility did not include a risk assessment using an all-hazards approach, as identified during a staffing review.
The facility failed to conduct thorough investigations for injuries of unknown origin and allegations of abuse and neglect for several residents. One resident had unexplained bruises, but the facility did not complete the final report or interview other residents. Another resident's fall with injury lacked investigation documentation. A resident was restrained without proper investigation or documentation, and another's elopement was not properly investigated. Lastly, a resident's injury was not investigated or documented, despite a complaint of being bumped during a transfer and a subsequent tibial fracture diagnosis.
The facility failed to ensure timely and accurate physician documentation and medication review for several residents, leading to discrepancies in medication orders and delayed medical interventions. Issues included incorrect medication dosages, outdated medication lists, and delayed uploading of physician and NP notes to the facility's EMR, affecting the quality of care provided.
The facility failed to uphold residents' dignity during meal assistance, as staff were observed standing over residents while feeding them, contrary to the facility's policy. Interviews revealed staff were unaware of the policy, although they recognized the importance of eye contact. The DON confirmed the expectation for staff to be seated during meal assistance.
The facility failed to provide written notification to residents and their representatives when residents were transferred to the hospital. Three residents were transferred without receiving written notice, as required by regulations. Interviews with nursing staff revealed a lack of awareness about the need for written notification, and the facility's policy did not include this requirement.
A facility failed to maintain a medication error rate below 5%, with errors observed in the administration of medications to four residents. Errors included incorrect timing, undocumented administration, incorrect dosages, and administering medications not ordered. These issues involved multiple staff members and were confirmed by the DON.
The facility failed to notify resident representatives and physicians of changes in condition and falls in a timely manner. One resident was found on the floor, but their representative was informed 24 hours later. Another resident with knee pain was not promptly communicated to the family or physician, despite visible distress. A third resident with multiple sclerosis and dementia experienced several falls without timely notification. Staffing levels were cited as a reason for these lapses.
A resident was transferred to the hospital without the required minimal information being provided to the receiving facility. The facility's policy did not specify the necessary documentation to be sent during a transfer, and the absence of a Hospital Transfer form was confirmed by the DON and Administrator.
A facility failed to create a care plan for a resident with a high elopement risk, as indicated by an assessment score. Despite the risk, the resident eloped, and no care plan was developed during their stay. The DON confirmed that a care plan should have been established.
Kitchen Food Safety and Cooling Documentation Deficiencies
Penalty
Summary
The facility failed to ensure kitchen staff used hair nets during food preparation and failed to ensure potentially hazardous food items were cooled according to acceptable standards. During an initial kitchen tour, three kitchen staff were observed preparing breakfast trays, and one cook was seen behind the counter placing cooked food items on plates while the other two staff called out meal ticket items. That cook was not wearing a hair net and confirmed she was not wearing one when asked. Later, the walk-in refrigerator was inspected with the Dietary Manager, and multiple cooked food items were observed with dates ranging from 1/20/26 through 1/31/26, including mechanical beef, bacon, beans, turkey, roast beef, pureed beef, pureed chicken, mechanical chicken, sausage patties, and beef mac. When asked about the cooling process for potentially hazardous foods, the Dietary Manager stated the facility kept documentation in a binder, but the latest cooling log entries were from September 2025. She then stated that it looked like the facility did not have one and indicated it was the cook's responsibility to document the cool down process.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide residents with information to formulate an advance directive for 4 of 4 residents reviewed for advance directives. Record reviews and staff interviews showed that residents who were documented as capable of making their own medical decisions did not have evidence in the record that advance directives were discussed or offered, and in several cases there was no advance directive, health care power of attorney, or related documentation in either the paper chart or electronic record. One resident was admitted in late 2025 and was certified by the facility medical provider as capable of understanding and making medical decisions, but there was no documentation that an advance directive was discussed or offered. The Social Services Director stated she discusses advance directives with newly admitted residents and documents those activities in progress notes, but the resident’s progress notes contained no social services documentation. In a later interview, she confirmed the resident was capable and did not have an advance directive, but she had not been able to offer or discuss advance directives during a meeting about possible discharge. For another resident admitted in mid-2025, the medical record showed the resident was capable of making medical decisions and had no advance directive in place, but the social services assessment section for advance care planning was left unanswered. The Social Services Director reported that her audit found the resident capable and without an advance directive, but she had not yet provided the necessary information to formulate one. For two additional residents, chart reviews showed a MOLST form but no advance directive or power of attorney documentation, and the Social Services Director stated that residents should be offered advance directive information at admission and care plan meetings, yet there was no evidence this occurred for those residents. She also stated she had not received clear training on how to complete or screen for advance directives.
Failure to Notify Physician and Document Change in Condition and Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of a significant change in condition and of the decision to transfer the resident from the facility. Record review for one resident who later died showed progress notes documenting a change in code status from full code to Do Not Resuscitate (DNR) and a subsequent note that EMS arrived to pronounce the resident deceased. However, there was no documentation of a change in condition assessment, no progress note describing the events leading up to EMS involvement, and no medical order indicating that the physician had ordered the resident to be sent to the hospital. During an interview, the DON stated that nursing staff are expected to immediately notify the physician after assessing a resident with a change or decline in health status, and that if the physician decides to send the resident to the hospital, an order should be entered and all actions documented in the medical record. When reviewing the resident’s record, the DON confirmed EMS had been called but could not identify who called and noted that the nurse should have documented this. The DON also confirmed there was no medical order to send the resident out and no change in condition documentation, and stated that the nurse should have completed a late entry if the situation had been chaotic. The DON acknowledged the concern that there was no documentation indicating that nursing staff notified the physician of the resident’s change in condition or the decision to transfer.
Failure to Report Alleged Abuse and Neglect to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report alleged abuse and neglect to the proper authorities as required. A complaint intake from Adult Protective Services, filed on behalf of a resident’s family, indicated that the family often found the resident in a saturated, wet brief or soiled while at the facility. Review of the facility’s grievance logs showed that on 12/08/2025, staff documented that the resident’s family reported the resident had been left sitting in a very wet brief, and that staff had delayed care due to the resident’s agitation. The documentation reflected an internal review and referral to psychiatric services, but there was no evidence that this allegation of neglect was reported to the Office of Health Care Quality (OHCQ). Further review of the grievance documentation revealed another grievance dated 09/31/2025 in which a Geriatric Nursing Assistant (GNA) was reported to have raised a fist toward a resident and stated, “Don’t tell me what to do. I know how to do my job.” There was no evidence that this allegation of staff mistreatment was reported to OHCQ. During interview, the Nursing Home Administrator acknowledged that allegations of abuse and neglect are reportable and could not provide a rationale for why these grievances were not reported as Facility Reported Incidents. The administrator also confirmed that the facility was using a templated, non–facility-specific policy. No additional evidence was provided to the surveyor before the conclusion of the survey.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received scheduled showers as required. The resident, admitted in mid-2025 with muscle weakness, morbid obesity, chronic pain, and gait and mobility abnormalities, had a prior medical order for showers on the day shift every Monday and Thursday, which was discontinued on 9/2/25. A quarterly assessment dated 9/18/25 documented in section GG that the resident required substantial/maximal assistance to safely complete shower activities, indicating dependence on staff for this ADL. A complainant reported that the resident would go 11 days without staff providing showers. Record reviews conducted in early February 2026 showed no active shower order and no documentation in the medication administration record that showers were being provided. Facility staff reported that shower/skin sheets are completed whenever a shower is given, and that all residents are scheduled for showers twice weekly based on room and bed number, which would have placed this resident’s showers on day shift every Wednesday and Saturday. Review of September 2025 shower/skin sheets showed only one documented shower on an evening shift, and review of nursing aide task documentation showed one additional shower on a day shift. No other documentation was found to show that showers were provided or refused on the other scheduled days. In an interview, the DON confirmed that in that month the resident received only one scheduled and one unscheduled shower and acknowledged the concern.
Failure to Knock Before Entering Resident Rooms and Protect Resident Dignity
Penalty
Summary
The facility failed to treat residents with dignity when staff entered resident rooms without knocking or obtaining permission and when personal care was provided without protecting privacy. Resident #48 was admitted for rehabilitation after an acute hospitalization for sepsis and had a BIMS score of 15, indicating intact cognition. During an interview, a RN knocked on the resident’s door, stated he had to check the resident’s blood sugar, and entered without asking permission. The RN then put on gloves, picked up the resident’s hand, and performed a fingerstick blood test without first obtaining the resident’s consent. The resident also reported that during another episode of personal care, the door was open and the privacy curtain was not pulled around the bed while the resident’s body was exposed, which the resident said was embarrassing. The resident further described a care plan meeting involving the ADON and social worker that became a shouting match, and stated staff would not listen to the resident or family member when care concerns were discussed. The surveyor also observed staff entering multiple resident rooms without knocking during breakfast tray distribution on the 400 hall. A GNA and an LPN entered rooms 406, 409, 410, 411, 412, 414, 415, and 416 without knocking, pausing, announcing themselves, or requesting permission before entry. This occurred in 8 of 8 resident rooms observed during the meal tray pass. Facility policy titled Resident Rights and Dignity, revised 2025, stated staff are expected to knock and announce themselves prior to entering resident rooms. During interview, the GNA stated staff usually just go in during meal pass because they are trying to get trays out quickly, and the DON confirmed that staff are expected to knock prior to entering resident rooms.
Late Admission MDS Completion
Penalty
Summary
The facility failed to ensure that an admission MDS assessment was completed timely for Resident #32, who was admitted after a hospitalization for a respiratory infection. The RAI process and MDS requirements were reviewed, and the resident’s record showed an entry date of 1/20/26 with an Admission/Medicare 5-day MDS and ARD of 1/24/26 listed as in progress. At the time of record review, only Section F and Section K had been completed, and multiple other sections of the MDS remained incomplete. During interview, the MDS nurse stated she received notice of new admissions from the admissions office and had access to hospital records before admission. She reviewed Resident #32’s admission MDS documentation and confirmed the resident was admitted on [DATE], the MDS set date was 1/24/26, and the MDS was completed, signed, and accepted on 2/03/26. After calculating the timeline, she acknowledged the admission MDS was not completed timely and stated it should have been completed on 2/02/26. The Nursing Home Administrator later acknowledged the late admission MDS, and no further evidence was provided by the end of the survey.
Incomplete MDS Cognitive Assessment
Penalty
Summary
Ensure each resident receives an accurate assessment. The facility failed to perform required resident assessments for 1 of 6 residents reviewed for unnecessary medications. Resident #2 was admitted in February 2024 and had diagnoses including Parkinson's disease and unspecified dementia. A quarterly MDS assessment completed on 12/11/25 showed Section C with a dash and the questions marked as not assessed, meaning no cognitive assessment was done for that section. The RAI process and MDS assessments are used to screen residents, assess needs, and maintain an accurate understanding of each resident's current condition. During interview, the MDS nurse reviewed the December 2025 MDS and confirmed that Section C was dashed and that a cognitive assessment was required for a quarterly MDS but had not been done. Further review showed Section C was also dashed on the resident's September 2025 assessment, and the resident's last BIMS assessment had been completed in June 2025. The NHA stated she was unaware that some MDS sections were incomplete, and acknowledged the deficiency.
Missed Care Plan Meetings After Required Assessments
Penalty
Summary
The facility failed to conduct care plan meetings after completion of comprehensive and quarterly assessments for multiple residents. Resident #1, who had been admitted since 2023 with stroke and dementia, had a comprehensive assessment with an ARD of 8/10/25 followed by a quarterly assessment with an ARD of 11/10/25. Record review showed a care plan meeting was scheduled on 8/6/25, but the resident’s family member did not answer the phone, a voicemail was left, and no other documentation was found showing that a care plan meeting was actually held after the comprehensive assessment was completed. Resident #2 was admitted in February 2024 with diagnoses including Parkinson’s disease and unspecified dementia. Review of the resident’s 2025 MDS assessment dates showed quarterly assessments on 1/23/25, 4/25/25, 6/10/25, and 12/11/25, and an annual assessment on 9/10/25. The record did not show evidence of care plan meetings held in September or December 2025. During interview, the social worker stated she had not yet met with the resident and confirmed that the last care plan meeting had been on 5/07/25, meaning the facility failed to hold two required care plan meetings after that date. Resident #47 stated during interview that they did not participate in a care plan meeting. Record review showed revisions to the resident’s care plan focus areas and goals with a revision date of 11/07/2025, but there was no documentation that the resident or representative participated in or were notified of a care plan meeting on that date. The most recent documented care plan meeting was on 09/03/2025, and no later documentation was found showing coordination of, notification of, or participation in a care plan meeting after that time.
Failure to Obtain Oxygen Order and Follow Up After Shortness of Breath
Penalty
Summary
The facility failed to obtain a physician's order for an increase in oxygen and failed to perform a follow-up assessment after a resident was treated for shortness of breath. The resident had diagnoses including COPD and dependence on supplemental oxygen, and the care plan indicated the resident required oxygen continuously at 2 liters/minute via nasal cannula. The resident's MOLST indicated do not attempt CPR. A progress note documented shortness of breath with an oxygen saturation of 90%, and staff provided three interventions: an as-needed inhaler, elevation of the head of the bed, and an increase in oxygen to 3 liters/minute. There were no subsequent progress notes describing the resident's response to these interventions, and there was no physician's order for the increased oxygen. The next documented progress note was written hours later and stated that the resident was expired and was observed without respirations or pulse. During interview, the DON confirmed that the resident had died at the facility, that there were discussions about hospice and palliative care but no documented decision or physician orders for a hospice consult, and that the record contained no evidence of the discussions. The DON also confirmed there was no order to increase oxygen or titrate oxygen and no evidence of staff follow-up to assess the resident's response after the interventions were provided.
Failure to Provide Ordered Pressure Injury Prevention and Skin Monitoring
Penalty
Summary
The facility failed to ensure that a resident at very high risk for pressure injuries received appropriate pressure ulcer prevention and treatment services. Resident #3 had a low air loss mattress ordered, but during observation the mattress control was set to the maximum firmness/weight setting even though the resident’s documented weight was 160.2 lbs. The facility’s wound nurse confirmed the setting was incorrect and stated it should have been set between 150 and 180 lbs. The medical record showed an order to ensure the low air loss mattress was on and in adequate working order, and the nurse explained that this included checking that the weight setting was appropriate. The resident’s record also showed a Braden Scale dated 5/2/25 indicating very high risk, with weekly skin checks ordered every Thursday on day shift. Although nurses signed the electronic treatment record indicating the skin checks were completed on five Thursdays in January 2026, only two weekly skin assessments were documented in the assessment section of the record. Review of the skin sheet binder and the medical record confirmed there was no documentation showing skin assessments were completed for three of the five scheduled days. The DON and wound nurse acknowledged the concern that the resident did not receive documented weekly skin assessments as scheduled.
Failure to Monitor Wanderguard Device
Penalty
Summary
The facility failed to monitor a resident's wanderguard safety device. Resident #51 was admitted with diagnoses including Alzheimer's disease, had an elopement assessment on 10/08/25 that identified a high risk for elopement, and was later assessed on 11/13/25 as severely cognitively impaired. A Minimum Data Set assessment dated [DATE] documented a significant change in condition related to new onset wandering behavior and indicated that a wanderguard device had been placed on the resident for safety. On 2/03/26, the resident was observed self-propelling in a wheelchair in the facility hallways, oriented only to self, and wearing a wanderguard around the right ankle. A review of the medical record at 12:02 PM found no documented evidence that the wanderguard was regularly monitored for placement and functionality. During interview, an agency nurse stated she checked the device and that the green light indicated sufficient battery, but she also said it was her first day at the facility and identified the TAR as the place where the check should be documented. The DON reviewed the record and confirmed there was no documentation that the wanderguard had been monitored. The facility policy required checking wander guard location and placement every shift, checking function daily, checking skin integrity every shift, and documenting all orders on the TAR.
Failure to Document Pain Assessment and Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to ensure pain management was provided according to professional standards of practice for two residents reviewed for pain management. For one resident, who was admitted in mid-2025 and reported that pain medications did not always help and that non-pharmacological interventions were not provided or attempted, the medical orders included a PRN pain medication and a pain assessment order requiring pain scoring, offering non-pharmacological interventions, and documenting interventions attempted before PRN medication administration. The resident’s January 2026 eMAR showed the PRN pain medication was given on 1/12/26 at 10:58 PM, but the corresponding progress note did not document the location of pain, and there was no documentation that non-pharmacological interventions were attempted before the medication was administered. For the second resident, who was admitted in November 2024 and had diagnoses including chronic respiratory failure and right-sided weakness from a stroke, PRN oxycodone was documented as administered on multiple days in early February 2026. The eMAR entries for those administrations listed the pain score as NA. Staff interviews indicated that a nurse was expected to assess the resident’s pain, attempt non-pharmacological interventions, document the resident’s pain location and level, and then document whether the medication was effective, but the DON confirmed there was no evidence that the nurse assessed the resident for pain or attempted non-pharmacological interventions before the PRN oxycodone doses were given. The DON reviewed the records and confirmed that for both residents there was no evidence of pain assessment documentation consistent with the facility’s expectations before PRN pain medication administration. For the resident with repeated oxycodone doses, the DON also confirmed that the entries for several days showed no evidence that pain had been assessed prior to administration. No additional evidence was provided by the end of the survey.
Missing Provider Response to Pharmacy Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen review (MRR) recommendations and identified irregularities had a documented provider response and rationale in the residents’ permanent medical records. For Resident #48, who was admitted after a hospitalization that included intensive care and had diagnoses including type 2 diabetes, heart failure, and malignant neuroendocrine tumors, the consultant pharmacist reviewed the insulin and fingerstick glucose orders and suggested the provider assess the need for adjustments and consider an endocrine consult. The pharmacy form contained a handwritten notation stating "No response required," but it was unsigned and undated, and the Director of Nursing confirmed this was not evidence of a physician review, response, or rationale. For Resident #3, the medical record contained consultant pharmacist progress notes showing MRRs for only six months in 2025, all stating no irregularities were identified. No documentation was found showing that MRRs were completed for the other months of 2025 or January 2026. The DON described the process as printing the pharmacist’s monthly report for provider response, then copying and scanning the completed report into the chart, but the record reviewed by surveyors did not show provider response to the 2/23/25 MRR recommendation. The DON provided a copy of the report, which had a provider signature but no date, and the top of the document showed it was faxed to the facility on 2/4/26 at 1:32 PM. Further review of Resident #3’s chart showed a provider progress note from a different medical provider that did not mention addressing the MRR recommendation. The facility policy stated that copies of drug/medication regimen review reports, including physician response, would be maintained as part of the permanent medical record. The NHA acknowledged the concern, and the DON confirmed she could not verify when the provider responded to the 2/23/25 MRR report.
Late Administration of Scheduled Insulin and Morning Medications
Penalty
Summary
The facility failed to administer medications timely for a resident with type 2 diabetes mellitus, heart failure, and malignant neuroendocrine tumors who required multiple medications, including significant doses of insulin before meals and as needed at bedtime. The resident was alert, oriented, and able to describe their medication regimen in detail. During an interview and observation, the resident stated they had received all morning medications together, including insulin that was supposed to be given before breakfast, even though they had not yet eaten breakfast and usually slept until around 11:00 AM. A review of the electronic medication administration record showed the morning medications were signed as given by an RN, but the actual administration times were not listed. The DON reviewed the medication audit and confirmed that medications scheduled for 7:30 AM, 8:00 AM, and 9:00 AM were signed as given at 11:37 AM. When asked what was considered timely administration, the DON stated it was within one hour before or one hour after the scheduled time and confirmed the medications were given late, stating this was a deficiency.
Failure to Perform Hand Hygiene and Maintain Sanitary Medication Storage
Penalty
Summary
The facility failed to ensure hand hygiene was performed during breakfast tray delivery and medication administration observations. On 02/01/2026 at 8:17 AM, Staff #5, a GNA, and Staff #7, an LPN, delivered meal trays to resident rooms 406, 409, 410, 411, 412, 414, 415, and 416 on the 400 hall and exited all 8 rooms without performing hand hygiene before entry or after exit. No alcohol-based hand sanitizer was observed on the meal cart, although wall-mounted hand hygiene dispensers were present in the hallway and inside each resident room. The facility also failed to maintain a sanitary medication storage environment. On 02/04/2026 at 10:45 AM, Staff #4, an RN, provided access to two medication storage areas behind the nursing station. In the area containing the Omni-Cell for resident medication storage, the surveyor observed disposable gloves, paper towels, sugar packets, and flip-top medication caps on the floor, and the floor was visibly soiled. The handwashing sink basin in the medication storage area was filled with packaging and wrapping debris and was not accessible for use. During medication administration observation on the 500 hall, Staff #6, an RN, failed to perform hand hygiene before and after administering medications to R#37 and failed to perform hand hygiene prior to administering medications to R#55. Staff #9, the Assistant DON and facility Infection Preventionist, stated that hand hygiene audits are conducted but could not provide documentation of completed audits, audit frequency, or evidence of staff education or reinforcement related to hand hygiene practices.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to staff and residents and failed to educate staff and residents regarding the COVID-19 vaccination. During the infection control task of the recertification survey, surveyors reviewed vaccination information for 7 staff members and 4 residents, and found no documented evidence that they had been educated about the COVID-19 vaccine or offered the vaccine. The staff members reviewed were Staff #6, #11, #12, #16, #17, #18, and #19, and the residents reviewed were Resident #2, #8, #48, and #51. An interview with the facility's infection preventionist, an RN, revealed that the new admission packet for residents included education sheets for COVID-19 vaccinations and a place to indicate consent, and that the facility ordered vaccines from the pharmacy and offered them to current residents who consented. She also stated that although the facility held a flu clinic each year for staff, it did not do this for the COVID-19 vaccine even though the vaccine was available, and she did not have evidence that staff had been educated about or offered the COVID-19 vaccine. The Nursing Home Administrator acknowledged that there was no evidence that the COVID-19 vaccine was offered to staff or residents.
Call Bell Not Accessible and Delayed Staff Response
Penalty
Summary
The facility failed to ensure that a working call system was accessible in a resident’s bathroom and bathing area. During observation on 02/01/2026 at 8:05 AM, the surveyor found Resident #45 in the room with the call bell cord partially disconnected from the wall outlet and out of reach while the resident was positioned near the edge of the bed and asking for assistance. The resident stated that delayed staff response to call light activation was not unusual and reported waiting up to one hour for staff to respond. The surveyor reconnected the call bell and instructed the resident to activate the adaptive pendant-shaped call button; although the signal was activated, no staff responded for approximately eight minutes.
Failure to Ensure Required Training for Agency GNAs
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants received required training. During the annual survey, the Nursing Home Administrator stated that approximately 80% of the facility’s staff were agency staff, and the staffing scheduler also reported that about 80% of scheduled GNAs were from an agency. The Human Resources Director said she was responsible for training facility-hired staff only and did not do anything for agency staff, including monthly training. When surveyors requested training records for two agency GNAs, the NHA said she could access the agency portal and would print what she could. The documents later provided for one GNA did not identify the instructor, the length of the training, or whether the GNA passed a test or was graded on the content, and no training evidence was provided for the other GNA. No additional evidence was provided by the end of the survey.
Failure to Secure Laundry and Mechanical Room Doors Resulting in Resident Injury
Penalty
Summary
Facility staff failed to ensure that the doors to the laundry room and mechanical/boiler room were locked when unattended, resulting in unauthorized access by a resident. On the evening of the incident, a Geriatric Nursing Assistant (GNA) was unable to locate a resident during evening care. After a search, the resident was found in the mechanical/boiler room, sitting on the floor near their wheelchair. The resident sustained a skin tear/laceration on the left shin and bruises on the left forearm and right elbow. The resident involved had a history of cognitive impairment, including diagnoses of Adjustment Disorder, Cognitive Communication Deficit, Delusional Disorders, and late-onset Alzheimer's Disease. The resident was assessed as high risk for elopement, with a severely impaired BIMS score. The resident used a wheelchair for mobility and had a care plan addressing elopement risk, wandering, and impaired safety. At the time of the incident, the resident could not recall how they entered the mechanical room and was disoriented, searching for a deceased spouse. Observations and interviews revealed that the laundry room doors were designed to lock automatically when closed, requiring a keypad code for entry, while the mechanical/boiler room door required a key from the laundry room side but did not automatically lock. Staff statements and maintenance inspection indicated that the doors were likely propped open, allowing the resident to access the unauthorized area. There was no evidence of mechanical malfunction with the door locks at the time of the incident.
Failure to Provide Appropriate Bariatric Beds and Supervision Resulting in Resident Injuries
Penalty
Summary
The facility failed to provide sufficient supervision, prevent avoidable accidents, follow appropriate safety procedures, and utilize the required number of staff during care for two residents who required bariatric beds and mattresses. In the first case, a resident with significant mobility impairments and a history of cerebral infarction, heart failure, and recent fractures was being provided incontinent care by a single aide. The resident was instructed to roll over and subsequently fell from the bed, resulting in multiple fractures. It was found that the mattress in use was too large for the bed frame, and staff had previously switched to a smaller bed frame without ensuring compatibility with the bariatric mattress. The care plan indicated the resident required maximum assistance and two staff for transfers, but this was not followed during the incident. In the second case, another resident with chronic respiratory failure, morbid obesity, and muscle weakness, who required substantial assistance with mobility and was at high risk for falls, was found on the floor with the mattress over them after turning in bed. This resident was using a standard mattress and bed despite documented requirements for a bariatric mattress and bed due to their height and weight. Staff interviews and documentation confirmed that the need for a bariatric mattress was communicated prior to admission, but the resident was not provided with the appropriate equipment at the time of the fall. The resident sustained acute fractures as a result of the incident. In both cases, there was a breakdown in communication and execution of safety protocols regarding the provision of appropriate beds and mattresses for residents with bariatric needs. Staff failed to ensure that the correct equipment was in place and did not follow established procedures for safe resident handling and supervision, directly leading to serious injuries for both residents.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, and not later than 24 hours to other officials, as required by federal and state regulations. In multiple instances, staff did not follow the facility's abuse prevention policy, which mandates prompt reporting of all alleged abuse, neglect, exploitation, or mistreatment. The deficiency was identified through interviews, observations, and record reviews for four residents who were reviewed for abuse. One incident involved a resident with chronic respiratory failure, COPD, morbid obesity, and chronic kidney disease, who was struck by objects during a disruptive event in the dining room. The incident was not reported to the state agency until several days after it occurred, despite the resident's family expressing concern and intent to press charges. Staff interviews confirmed delays in removing residents from the area and in notifying appropriate authorities. The administrator acknowledged that the abuse incident was not reported in a timely manner due to confusion over which agencies to notify. Other cases included a resident with severe cognitive impairment who was allegedly locked in a conference room by staff, with the incident not reported to the administrator or state agency until several days later. Another resident with dementia and Parkinson's disease was reportedly handled roughly by a staff member, but the allegation was not escalated to the administrator or reported to the state agency within the required timeframe. In each case, staff interviews and documentation revealed a lack of immediate reporting, despite facility policy and staff education on the required procedures.
Failure to Maintain Complete Abuse Investigation Documentation
Penalty
Summary
The facility failed to maintain complete documentation of an abuse allegation investigation involving a resident with dementia, Parkinson's disease, and delusional disorder. According to the facility's abuse prevention policy, all witness statements should be obtained in writing, signed, and dated, and the results of the investigation should be recorded on approved forms and provided to the Administrator. However, the investigation file for the incident included only one written statement from the Unit Manager, which was based on information reported by a staff member, and a handwritten, undated, and unsigned statement later identified as the resident's. There were no written or signed statements from the staff member who reported the abuse or from other staff present during the shift when the alleged abuse occurred. Interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed that the required staff statements were not obtained or maintained in the investigation file. The ADON acknowledged responsibility for conducting abuse investigations and stated that she should have collected statements from all staff involved, including the reporter, but was unable to locate them and had only begun to contact staff for statements after the deficiency was identified. The Administrator also confirmed that the investigation documentation was incomplete and that no further information was available regarding the abuse investigation.
Failure to Notify Health Department and Post Outbreak Signage
Penalty
Summary
The facility failed to adhere to infection control practices and guidelines by not notifying the local health department of a gastrointestinal outbreak and not posting appropriate signage to inform staff and visitors. During a tour of the facility, it was observed that several rooms had contact isolation signs with PPE available outside the doors. In one room, a resident was found with a basin in their lap due to nausea, indicating symptoms of the outbreak. The Assistant Director of Nursing (ADON), who also served as the Infection Preventionist, confirmed that approximately 24 residents were experiencing symptoms such as nausea, vomiting, diarrhea, coughing, and congestion over the past 24 hours. Despite recognizing the situation as a potential outbreak, the ADON had not notified the local health department, which is required when more than two residents are affected. Additionally, there was no signage at the facility's entrance to alert residents and visitors of the outbreak, further contributing to the deficiency.
Lack of Comprehensive Care Plan for Resident with Prosthetic Eye
Penalty
Summary
Facility staff failed to develop a comprehensive, resident-centered care plan for a resident with a prosthetic eye. The resident, admitted in July 2023, had diagnoses including late-onset Alzheimer's disease, neurocognitive disorder with Lewy Bodies, and age-related physical debility. The resident's medical records indicated the need for daily cleaning of the prosthetic left eye, which involved removing the eye from the socket, cleansing it with normal saline solution, drying it, and replacing it. However, the care plan did not address the specific needs related to the prosthetic eye, nor did it provide strategies for managing the resident's behaviors associated with Alzheimer's disease and Lewy Body Dementia. The care plan that was in place was not tailored to the resident's specific needs and lacked detailed approaches for handling the prosthetic eye care. It included general interventions such as anticipating and meeting the resident's needs, speaking in a calm manner, and diverting attention, but these were not specific to the resident's situation. The deficiency was confirmed during a review with the Director of Nursing, highlighting the absence of a resident-centered care plan for the prosthetic eye since the resident's admission.
Failure to Renew Prosthetic Eye Care Order
Penalty
Summary
The facility failed to renew the cleaning order for a resident's prosthetic eye after multiple hospitalizations. The resident, who was admitted in July 2023 with Alzheimer's disease and other neurocognitive disorders, had a left prosthetic eye since childhood. Initially, the resident's spouse managed the prosthetic eye care, but as the resident's condition deteriorated, the facility staff took over. The order for daily cleaning of the prosthetic eye was initially included in the resident's treatment plan but was not reinstated after the resident's hospitalizations. The Assistant Director of Nursing (ADON) discovered the omission during a chart audit and reinstated the order without notifying the physician or documenting communication with the resident's spouse. The ADON acknowledged that the order was never officially discontinued by the physician and was inadvertently left off the treatment record due to the resident's frequent hospitalizations. The issue was discussed with the Director of Nursing and the Nursing Home Administrator, but there was no documentation of corrective actions taken at the time of the report.
Failure to Adhere to Medication Parameters and Notify Physician
Penalty
Summary
The facility failed to maintain a resident's drug regimen free from unnecessary drugs by not adhering to physician-ordered parameters for medication administration and failing to notify the physician when the resident's blood pressure exceeded specified limits. The resident, who had hypertension, was prescribed Lisinopril and Clonidine, with specific instructions to hold Clonidine if the systolic blood pressure was greater than 150. However, the medication was administered on multiple occasions when the resident's systolic blood pressure was above this threshold, including readings of 155/63, 176/80, 156/61, and 164/74. Additionally, the facility did not notify the physician when the resident's systolic blood pressure exceeded 160, as required by the physician's order. Instances of elevated systolic blood pressure without physician notification were documented on several dates in January and February 2025, with readings such as 168/73, 176/80, 161/72, 189/85, and 170/84. The Director of Nursing confirmed these errors during a review of the medications and the Medication Administration Record.
Failure to Protect Resident from Inappropriate Restraint
Penalty
Summary
The facility failed to protect residents from inappropriate use of physical restraints, as evidenced by an incident involving a resident who was restrained against a wall in their wheelchair by facility staff. The resident, who had a history of muscle weakness, gait abnormalities, anxiety disorder, and dementia, was unable to move independently due to the table being pushed against them. Despite being severely cognitively impaired, the resident was participating in physical therapy and was documented as able to walk with supervision. The incident was observed by staff, who reported it to their supervisor, but the staff member involved continued to have access to other vulnerable residents. The facility's investigation revealed that two staff members had secured the resident in a manner that prevented them from moving. The resident was found restrained in the sunshine room, and the incident was documented in the facility's records. Interviews with staff indicated that the incident was reported to the nursing department, but the staff member involved was not immediately removed from duty. The facility's human resources director confirmed that the staff member had been rehired without knowledge of their previous history, and there was no documentation in the employee's file regarding the incident. Further investigation showed that the staff member continued to work in the facility, including in the area where the incident occurred. The facility's director of nursing and nursing home administrator were unable to provide documentation or a clear explanation for the continued employment of the staff member involved. The facility's failure to document and act on the incident led to a determination of immediate jeopardy, which was later abated, but the deficient practice remained a concern for the safety of other residents.
Failure to Address Changes in Resident Conditions
Penalty
Summary
The facility failed to recognize and address changes in the condition of residents, leading to immediate jeopardy. For Resident #127, the facility did not respond to a pharmacy alert regarding a morphine order that was outside the recommended dose or frequency. The morphine was administered routinely instead of as needed, which was a mistake made by the attending physician and not caught by the admitting nurse. This error was not communicated to the physician, and the resident's decline in condition, including decreased food intake and nonverbal status, was not properly documented or reported to the physician, family, or hospice care. Resident #921 experienced ongoing abdominal concerns, including pain, nausea, vomiting, and significant weight loss over several months. Despite these symptoms and a recommendation for a gastrointestinal consult, the consult was not ordered until much later, and the resident's condition continued to deteriorate. The resident was eventually sent to the emergency room with a change in mental status and was diagnosed with sepsis, shock, and circulatory failure, leading to their death shortly after. The facility's failure to promptly assess and address changes in residents' conditions, ensure proper medication administration, and follow up on necessary medical consultations contributed to the deficiencies identified by the surveyors. These oversights resulted in significant negative outcomes for the residents involved.
Deficient Care and Supervision Leading to Resident Injuries
Penalty
Summary
The facility failed to ensure that staff provided care in a manner that prevented injuries to residents, as evidenced by incidents involving two residents. In the first case, a resident sustained a 15-centimeter leg laceration during a transfer from a wheelchair to a bed. The incident involved two agency geriatric nursing assistants (GNAs) who were unable to explain how the injury occurred. The Director of Nursing (DON) speculated that the injury might have been caused by the resident's leg catching on a metal piece of the wheelchair, but this was not consistent with the nature of the wound. The facility's investigation revealed that the resident required a mechanical lift for transfers, but this information was missing from the Kardex due to a computer glitch, and the agency staff were not properly oriented to the facility's expectations. In the second incident, another resident fell out of bed during activities of daily living (ADL) care and sustained a hematoma. The resident, who required extensive assistance for bed mobility, was being bathed by a GNA who asked the resident to roll over. The resident rolled off the bed onto the floor, resulting in a hematoma on the forehead. The facility's investigation noted that the mattress was larger than the bed frame, and the GNA had inappropriately rolled the resident away from herself, not towards her, which contributed to the fall. Both incidents highlight the facility's failure to provide safe equipment and adequate supervision to prevent accidents. The facility frequently used agency staff without providing formal orientation, relying on them to access care needs through the Kardex, which was not always accurate or available. The lack of a formal process to ensure agency staff were aware of the facility's expectations and the absence of critical information in the Kardex contributed to the unsafe care provided to the residents.
Failure to Address Resident's Transfer Request
Penalty
Summary
The facility failed to provide appropriate discharge planning for a resident who requested a transfer to another facility. The resident, who was capable of making informed decisions, expressed a desire to return to a different facility shortly after admission, citing that their current placement was due to their daughter's preference for proximity. Despite the resident's clear requests communicated to the Social Worker on two separate occasions, there was no documentation or evidence that the facility staff took any action to address or facilitate the resident's transfer request. Interviews with the Director of Nursing and the Social Worker confirmed the resident's requests were acknowledged but not acted upon. The Social Worker admitted to recalling the resident's insistence on transferring but was unable to provide any documentation of actions taken to address the request. The facility's failure to document or act on the resident's transfer request was further highlighted when the Administrator could not provide any evidence of measures taken to arrange the transfer, resulting in a deficiency noted by the surveyors.
DON Overburdened with Dual Roles
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) was working in her capacity on a full-time basis. This deficiency arose because the DON was assigned additional duties as the Infection Prevention (IP) nurse after the previous IP nurse resigned without notice. The resignation occurred on 7/22/24, and since then, the DON has been fulfilling both roles. The DON acknowledged that she should not be performing the IP nurse duties due to her responsibilities as the DON. The facility is licensed for 80 beds, which requires the IP responsibilities to occupy 40% of a full-time equivalent. The Nursing Home Administrator (NHA) confirmed awareness of the issue and mentioned that another staff member is currently in training to assume the IP nurse role.
Failure to Conduct Annual GNA Performance Reviews
Penalty
Summary
The facility failed to conduct yearly performance reviews for Geriatric Nursing Assistants (GNAs) at least every 12 months, as required. This deficiency was identified during a review of personnel files and staff interviews, affecting five GNAs (Staff #29, #31, #32, #33, #34) who had been employed for more than 12 months. The surveyor found no documentation of annual performance reviews in the employee files of these staff members. The Director of Nurses (DON) confirmed that performance reviews and competency evaluations had not been completed since she assumed her role.
Deficiencies in Transfer/Discharge Procedures and Staff Training
Penalty
Summary
The facility administration failed to develop and implement procedures to ensure the highest practicable wellbeing of residents, as evidenced by deficiencies in transfer/discharge notices and discharge planning. Notices for several residents lacked essential information, such as the right to appeal the transfer/discharge, contact details for the state entity handling appeals, and guidance on obtaining and submitting appeal forms. Additionally, the notices included a proposed date for a post-discharge planning meeting that was set approximately 10 days after the residents' transfer or discharge, which caused confusion among residents and their representatives. The facility also failed to provide written notice of the bed-hold policy to residents and their representatives at the time of transfer to the hospital. This issue was identified in a previous survey, and although a plan was developed to correct it, the facility continued to rely on telephone notifications rather than written ones. Furthermore, the facility did not have an effective discharge planning process, as evidenced by the lack of discharge plans of care and assessments for residents' post-discharge needs. The social worker confirmed that no written protocol existed for discharge planning, and discharge plans were not formally documented. Additional deficiencies were noted in the facility's failure to ensure timely physician visits, with some residents not being seen by their attending physician within the required 60-day period. The medical records staff was unaware of the need to differentiate between visits by attending physicians and nurse practitioners. Furthermore, the facility did not provide required communication and behavioral health training to all staff, including new hires, as mandated by federal regulations. The human resources director and nursing home administrator acknowledged the lack of a comprehensive education plan for new hires, which contributed to these training deficiencies.
Recurrent Deficiencies in Quality Assessment and Assurance Program
Penalty
Summary
The facility failed to maintain an effective quality assessment and assurance program, as evidenced by the recurrence of deficiencies identified in previous surveys. During the recertification survey, it was observed that the facility did not implement effective processes to prevent repeat deficiencies related to reasonable accommodation of needs, pharmacy services, drug regimen free from unnecessary drugs, and medication error rates. These deficiencies were initially identified in the recertification surveys concluded in 2018 and 2019, but the corrective actions taken were insufficient, leading to the continuation of these issues in the current survey. The Nursing Home Administrator acknowledged the recurrence of these deficiencies during discussions with surveyors.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by several deficiencies. Staff did not don appropriate personal protective equipment (PPE) when providing direct care to residents with specific medical needs. For instance, a staff member assisted a resident with a central line for dialysis without wearing a gown, despite the requirement for Enhanced Barrier Precautions (EBP). Similarly, another staff member provided care to a resident with open wounds without wearing a gown, only using gloves, which is insufficient for infection control. Additionally, during medication administration, a Licensed Practical Nurse (LPN) was observed handling an exposed needle without proper infection control measures. The LPN placed the syringe with the exposed needle on a tissue box while performing hand hygiene, which poses an infection risk. This incident was acknowledged as a concern by the Director of Nursing (DON) during the survey. The facility also demonstrated inadequate infection control practices in their laundry processing and water management systems. The laundry room lacked physical separation between clean and soiled areas, and staff processed soiled laundry without appropriate PPE. Furthermore, the facility did not have a system to identify and prevent the growth of Legionella in the water system, as they had not studied the water flow to identify potential pathogen growth areas. The facility's infection prevention and control policies were outdated and not reviewed annually, failing to specify critical procedures for reporting communicable diseases and using isolation measures.
Lack of Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to include effective communications as mandatory training for direct care staff, as evidenced by a review of employee files for five staff members. The review revealed that none of the selected employees had documentation indicating they received effective communications training. This deficiency was identified during an extended survey, where the importance of effective communication in understanding and responding to residents was emphasized. The lack of training documentation was noted for staff members with various dates of hire, ranging from 2010 to 2022. Interviews with the Human Resources (HR) staff and the Director of Nurses (DON) revealed that there was uncertainty about how mandatory in-service training was previously tracked. The HR staff mentioned that training materials had been sent by the corporate office since early 2024, but there was no confirmation of effective communication training prior to that. The DON acknowledged that staff training had not been occurring until recently and that the corporate office had been providing monthly training materials since April 2024. Despite these efforts, the surveyor found no documentation in the corporate training materials or the Annual Education Fair binder to indicate that effective communication training had been provided to the facility staff.
Deficiency in Staff Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to ensure that required training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management was completed for several staff members. During the survey, it was found that three out of five staff members reviewed did not have documentation indicating they had received the necessary training. The Human Resources representative, Staff #10, was unable to confirm training that occurred prior to January 2024, and the Director of Nurses (DON) acknowledged that staff training had not been consistently conducted until recently. The facility had received training materials from the corporate office since April 2024, but there was no documentation to confirm that staff had received the training. Further investigation revealed that some staff members had incomplete or missing records of training. For instance, Staff #29 had an undated record indicating abuse training but no evidence of dementia training, while Staff #31 had no record of either training. Additionally, a review of the facility's active staff roster showed that several active GNAs and other employees had not received abuse training. Staff #41, who was terminated, also lacked documentation of completed abuse training. The DON and the Regional Director for Clinical Operations were made aware of these concerns but did not provide further comments.
Failure to Provide Mandatory Infection Control Training
Penalty
Summary
The facility failed to provide mandatory infection prevention and control training that included written standards, policies, and procedures for the program. This deficiency was identified during an extended survey, where a review of five randomly selected employee files revealed that four employees had no documentation of having received the required training. The employees in question, all GNAs, had hire dates ranging from 2010 to 2022, yet their files lacked evidence of infection control training. The only partial evidence found was for one staff member, whose record indicated attendance at a training session, but lacked a signature to confirm participation. Interviews with the HR staff and the DON revealed that the facility had not consistently tracked or conducted mandatory training sessions. The HR staff, who joined the facility in late 2023, was unaware of how training was previously documented and could not confirm any training prior to January 2024. The DON acknowledged that training had not been occurring until recently, with corporate training materials only being provided since April 2024. Despite the presence of a binder labeled Annual Education Fair, which contained some training records, there was no comprehensive documentation to confirm that all staff had received the necessary infection control training.
Deficiency in GNA Training and Performance Documentation
Penalty
Summary
The facility failed to provide documentation that Geriatric Nursing Assistants (GNAs) received the required in-service training of no less than 12 hours per year, including abuse prevention and dementia management training. Additionally, there was no evidence of annual performance reviews for GNAs who had been employed for more than 12 months. This deficiency was identified during a review of five randomly selected employee files, which revealed a lack of documentation indicating that the GNAs had received any training or education in the past year. The Human Resources (HR) staff, specifically Staff #10, acknowledged the absence of training records and performance evaluations, noting that the employee files were in place before her hire in late 2023. The Director of Nurses (DON) confirmed that staff training had not been occurring until recently, with the corporate office only starting to send monthly training materials since April 2024. However, the training materials provided were limited to Resident Rights and Transmission-Based Precautions, with no documentation of staff attendance or completion of training. Further review of the Annual Education Fair binder showed limited evidence of training for some staff, with undated or incomplete records of training topics such as abuse and dementia. Notably, there was no documentation for one staff member, Staff #31, indicating they had received any annual training. The DON and the Regional Director for Clinical Operations were informed of these concerns, acknowledging the lack of evidence for required in-service training and competency evaluations for GNAs.
Lack of Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory effective communication training for its direct care staff, as required by the facility assessment. During a survey, a review of five randomly selected employee files revealed that none of the employees had documentation indicating they received effective communication training. The employees in question were GNAs with varying dates of hire, ranging from 2010 to 2022. The absence of this training was confirmed through interviews with the Human Resources staff and the Director of Nurses (DON), who both acknowledged the lack of documentation and training. The Human Resources staff member, hired in late 2023, was unable to confirm any training that occurred prior to January 2024, as the previous tracking method was unclear. The DON indicated that training materials had been sent by the corporate office since April 2024, but a review of these materials did not show evidence of effective communication training. Additionally, a binder labeled Annual Education Fair contained limited training records for some staff but did not include effective communication training. Despite being made aware of these concerns, no further documentation was provided to the surveyor by the time of their exit from the facility.
Deficient Facility-Wide Assessment and Staff Training
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment, which is essential for determining the resources necessary to care for residents competently during both day-to-day operations and emergencies. The assessment lacked critical information, such as the facility's average number of residents, which is necessary for evaluating the facility's capacity and physical characteristics. Additionally, the assessment did not adequately address staff competencies required to provide the level and types of care needed for the resident population, which includes residents with behavioral health care needs, mental illness diagnoses, and dementia or Alzheimer's diagnoses. The facility's assessment also failed to evaluate the training program to ensure that training needs are met for all new and existing staff, contractual individuals providing services, and volunteers. This deficiency was evident as the facility did not have a system in place to provide staff with the required training and competencies. A review of employee files revealed that several GNA staff members had not received necessary training, such as abuse training, behavior management training, communications training, and infection control and prevention training. Furthermore, these staff members had not completed the required 12 hours of continuing education or received annual performance reviews. Moreover, the facility assessment did not include a facility-based and community-based risk assessment utilizing an all-hazards approach. This omission was identified during a Sufficient and Competent Nurse Staffing review and an extended survey review. The Director of Nurses and the Regional Director for Clinical Operations acknowledged these concerns when they were discussed with them, indicating a recognition of the deficiencies in the facility's assessment process.
Failure to Investigate Injuries and Allegations
Penalty
Summary
The facility failed to conduct thorough investigations for injuries of unknown origin and allegations of abuse and neglect for five residents. For one resident, bruises were discovered by a Geriatric Nursing Assistant (GNA) during routine care, but the facility did not complete the final report to the state agency, omitting the alleged perpetrator and a summary of the investigation. Additionally, the facility did not interview other residents who were under the care of the same GNA. Another resident experienced a fall with injury, but the facility lacked any documentation related to the investigation of this incident. In another case, a resident was restrained in the facility's sunshine room, but the facility failed to maintain the investigation and documentation in the employees' files. Furthermore, a resident's elopement was not properly investigated, lacking statements, interviews, and preventive education. Lastly, a resident with an injury of unknown origin was not investigated or documented in the medical record, despite the resident's complaint of being bumped during a transfer and later being diagnosed with a tibial fracture. The facility was unable to provide any investigation related to this incident reported to the Office of Health Care Quality.
Deficiencies in Physician Documentation and Medication Review
Penalty
Summary
The facility failed to ensure that physician notes were available in the medical record and that a comprehensive review of residents' total treatment was completed at each visit. This deficiency was identified during a complaint survey conducted alongside a recertification survey, affecting four out of six residents reviewed for quality of care. The issues included incorrect medication orders and discrepancies between hospital discharge orders and facility admission orders, as well as missing or delayed physician notes in the residents' medical records. For Resident #911, there were significant discrepancies in medication orders upon admission. The resident was prescribed an incorrect dosage of Lasix, receiving double the intended amount, and was also given the wrong dose of Synthroid for the first two days of their stay. The Medical Director attributed these discrepancies to the use of hospital electronic records that did not accurately reflect the medications the resident was receiving in the nursing home. This lack of accurate medication documentation and review contributed to the deficiency. Resident #921's records revealed a lack of timely and accurate physician notes, with medications not being reviewed or updated appropriately. The resident's progress notes contained outdated and incorrect medication lists, and there was a delay in documenting necessary medical interventions, such as a gastroenterology consult. Similar issues were found with Resident #9 and Resident #914, where physician and nurse practitioner notes were not uploaded to the facility's electronic medical record in a timely manner, hindering the staff's ability to provide informed care. These failures in documentation and medication review processes highlight the facility's deficiency in maintaining accurate and up-to-date medical records for its residents.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain residents' dignity during meal assistance, as observed by surveyors. On three separate occasions, staff members were seen standing over residents while feeding them, which is against the facility's policy. Specifically, a GNA was observed standing over a resident in bed, and two other GNAs were seen standing over residents in the dining room. Interviews with staff revealed a lack of awareness of the feeding policy, although they acknowledged the importance of maintaining eye contact with residents during feeding. The Director of Nursing was also unaware of the specific feeding policy but confirmed the expectation for staff to be seated and maintain eye contact while assisting residents with meals. The facility's policy, 'Assistance with Meals,' explicitly states that staff should not stand over residents during meal assistance.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives when residents were transferred to the hospital. This deficiency was identified during a survey, where it was found that three out of four residents reviewed for hospitalization did not receive written notice of their transfer. Specifically, Resident #924 was transferred to the hospital for evaluation of lethargy, low blood pressure, and low sodium levels, but there was no written notification provided to the resident or their representative. The facility's policy did not include a requirement for written notification, which contributed to this oversight. Similarly, Resident #45 was transferred to the hospital due to difficulty breathing and lethargy, and although an attempt was made to notify the representative by phone, no written notice was documented. Resident #33 was also transferred to the hospital, but again, there was no written notification provided. Interviews with the Director of Nursing and Assistant Director of Nursing revealed a lack of awareness regarding the requirement for written notification, further highlighting the facility's failure to comply with regulatory standards.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by multiple errors during medication administration observations involving four residents. The errors were identified across three different hallways and involved three staff members, including an agency certified medication aide, an agency LPN, and a staff LPN. The errors included administering medications at incorrect times, failing to document administered medications, administering incorrect dosages, and giving medications that were not ordered. For Resident #5, an LPN administered Finasteride at the wrong time and failed to document the administration of three other medications that were not observed to be given. Resident #476 received an incorrect dosage of calcium and had a medication administered without documentation. Resident #11 was given a lidocaine patch that was not ordered, and Resident #54 received two medications that were not ordered, while another medication was documented as given but not observed to be administered. The surveyor reviewed these concerns with the Director of Nursing, who confirmed discrepancies in documentation and administration. The errors were significant enough to result in a medication error rate exceeding the acceptable threshold, indicating a deficiency in the facility's medication administration process.
Failure to Notify Representatives and Physicians of Changes in Condition
Penalty
Summary
The facility failed to ensure timely notification of resident representatives and physicians regarding changes in condition and occurrences of falls. This deficiency was evident in the cases of three residents. One resident, admitted for aftercare related to a fall with fractures, was found on the floor in the bathroom, but their representative was not notified until 24 hours later. The resident was documented as alert and oriented to self only, with a designated medical power of attorney, yet the facility did not complete a change in condition notification as per their policy. Another resident complained of knee pain and was treated with Tylenol, but the family was not informed of the injury until days later, despite the resident's continued complaints of pain and an eventual x-ray. The physician was also not notified in a timely manner, even though the resident was crying in pain and had a visible knee deformity. Additionally, a third resident with a history of multiple sclerosis, dementia, and frequent falls experienced several falls without timely notification to the doctor and family. In one instance, the resident was sent to the hospital after an unwitnessed fall, but there was no evidence of an assessment or notification to the family and doctor. The facility's failure to follow their fall protocol was discussed in Quality Assurance Committee meetings, with staffing levels cited as a reason for the lapses.
Failure to Provide Required Transfer Information
Penalty
Summary
The facility staff failed to provide the minimal required information to the receiving provider at the time of transfer for a resident who was hospitalized. The deficiency was identified during a survey when it was found that a Hospital Transfer form was not present in the medical record of a resident who was transferred to the hospital for evaluation of lethargy, low blood pressure, and low sodium level. Although a nursing progress note indicated that some information, such as the resident's Medical Orders for Life-Sustaining Treatment (MOLST), capacity, current medication orders, and a copy of the bed hold policy, was sent with the resident, it did not include the resident's Comprehensive Care Plan goals, identification and contact information for the resident's representative, or the practitioner responsible for the resident's care. The surveyor's review of the facility's policy for Transfer or Discharge, Emergency, revealed that the policy did not specify the documentation required to be sent to the receiving facility at the time of a resident's transfer. The Director of Nursing and the Administrator confirmed the absence of the Hospital Transfer form and the lack of evidence that the required minimal information was sent to the hospital. This oversight was evident for one of the four residents reviewed for hospitalization during the survey.
Failure to Develop Elopement Care Plan
Penalty
Summary
The facility failed to develop a care plan addressing a resident's potential for elopement, which was identified through a completed elopement assessment. The assessment, conducted on 5/1/23, resulted in a score of 15, indicating a risk for elopement. Despite this, the resident actually eloped on 5/2/23, and no care plan was developed during the resident's two-week stay at the facility. This deficiency was confirmed during an interview with the current Director of Nursing on 7/25/24, who acknowledged that a care plan should have been created to address the elopement risk.
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 354 citations issued within 25 miles in the last 12 months — including the 5 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 Hagerstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Julia Manor Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 47 | 0 |
| Hagerstown Healthcare Center | 1.4 mi | ★★★★★ | 28 | 0 |
| Coffman Nursing Home | 3.2 mi | ★★★★★ | 16 | 0 |
| Western Md Hospital Center | 3.5 mi | ★★★★★ | 20 | 0 |
| Homewood Living Williamsport | 4.4 mi | ★★★★★ | 17 | 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 July 2026) and official state health department websites.