Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Dennett Rehab Center during CMS and state inspections, most recent first.
Unqualified dietary leadership and no on-site dietician. The Kitchen Manager was observed directing kitchen staff and admitted she had not yet completed ServSafe or her CDM program. She reported only emailing a dietician twice weekly, and the NHA stated the certified dietician was never on site and acknowledged the Kitchen Manager lacked the training and qualifications for the role.
Food was not consistently palatable or served at an appetizing temperature. Residents reported tough chicken, small portions, overcooked meat, and food that was often cold and not good. During lunch observation, surveyors found a tray delivered about 40 minutes after leaving the steam table; the pork, rice, and vegetables were no longer warm and were not palatable in temperature or taste. Two residents in the dining room said they did not like the meal, and one said the rice was undercooked.
Unsanitary Kitchen Conditions and Unlabeled Food Items: Surveyors found food labels without dates, grease and food buildup on cooking equipment, debris in prep table tracks, contaminated steam table water, standing juice in the dispenser, buildup on vents, walls, and ceilings, and a wet mop left in a dirty bucket. Staff and the NHA/Kitchen Manager confirmed the conditions were a concern.
Unsafe Kitchen Steamer Equipment: The facility failed to keep a kitchen steamer operating safely. During kitchen observations, the steamer was found not heating, and the Kitchen Manager said it had not worked for quite a while and had been verbally reported to maintenance. On a later observation with the NHA, staff stated the unit still did not work right and that hot water spilled out when the door was opened.
Failure to maintain resident dignity: A resident was observed in bed unclothed, uncovered, and fully exposed with no direct care being provided and no curtain pulled for privacy. Three staff passed the open doorway while the resident remained exposed for about 15 minutes before the concern was brought to the attention of the NHA.
A facility failed to ensure monthly pharmacist drug regimen reviews were reviewed, communicated, and incorporated into physician orders and the MAR after provider response. Several residents had pharmacy recommendations related to antipsychotics, antidepressants, insulin, atorvastatin, and a PPI that were missing, lacked physician response or rationale, or were signed without corresponding order updates. Staff interviews confirmed accepted recommendations were expected to appear in orders and the MAR, but this was not consistently done.
A resident’s electronic chart was left open and visible on a computer screen at an unoccupied nurses’ station. An AD used the nearby printer while the resident’s name remained displayed, and the screen was only locked after the surveyor pointed out the exposure. The NHA later acknowledged the finding.
Failure to Implement Ordered Tubi Grip Stockings: A resident admitted for rehab had a physician order for Tubi grip stockings to be applied to both lower legs each morning and removed at night, but the stockings were not on the resident when observed by the surveyor. The RN could not locate them, GNA staff denied removing them, therapy staff said they did not remove them, and the TAR documented daily application despite the resident later stating the stockings were worn that day and the administrator acknowledging concerns that they had not been applied as ordered on previous days.
Controlled substance reconciliation was not accurately documented. Surveyors found that 2 of 3 narcotic count sheets did not reconcile properly, including one sheet where an LPN signed as both on-coming and off-going nurse before the shift ended, and another undated, unlabeled sheet that lacked off-going licensed personnel signatures on multiple dates. The DON confirmed the facility's narcotic reconciliation practice did not meet acceptable standards of practice.
A resident’s scheduled meds, including oxycodone, were observed left on a bedside tray table with no staff present, while the resident could not identify the pills and had no order to self-administer. In a separate finding, a locked med refrigerator contained lorazepam in an unaffixed compartment, contrary to the facility policy requiring controlled substances to be separately locked in a permanently affixed compartment.
Failure to communicate with hospice about resident changes: A resident on hospice had episodes of agitation and pain requiring PRN morphine and Ativan, and later had an unwitnessed fall, but the facility did not document notifying or updating the hospice agency about either event. Hospice staff also reported they did not attend care plan conferences, and a CNA was documented as stating the resident would likely come off hospice, although the hospice RN said a CNA could not make that determination.
Hand hygiene and EBP compliance were not followed during medication administration. An LPN was observed entering and exiting resident rooms, preparing and giving medications, and assisting a resident with care without proper hand hygiene or PPE use for EBP, and another LPN administered medications without washing hands before entering a resident room.
A resident with cerebral palsy and intellectual disabilities was subjected to verbal abuse by a GNA, who expressed frustration and made derogatory comments about the resident's behavior. This occurred in the presence of other staff and a cognitively intact resident. Despite having received training on abuse, the GNA failed to provide appropriate care, leading to a deficiency finding during a complaint survey.
A facility failed to secure residents' medications, leading to misappropriation by an LPN. Narcotic discrepancies were noted, and a family reported a medication mix-up. The facility's investigation linked the issues to the LPN, who forged signatures and was associated with missing narcotics. The LPN was terminated after the discrepancies were discovered.
Facility staff failed to follow infection control guidelines by not wearing the required PPE, including gowns, while providing care to a resident with a gastrostomy tube. The resident was uncooperative, and the staff, including an LPN and two GNAs, did not adhere to the Enhanced Barrier Precaution sign instructions, leading to a deficiency noted by a surveyor.
Two residents at risk for elopement left the facility unsupervised due to unsecured exit doors. One resident was found in the parking lot after exiting through an employee entrance without locks or alarms. Another resident, with a history of wandering, left through an improperly latched door and was found in the woods. The facility's failure to secure exits and supervise residents led to these incidents.
The facility was found to have insufficient nursing staff, with GNAs caring for 20 to 27 residents per shift, leading to delays in care and missed showers. Staff interviews revealed consistent understaffing, and the facility's staffing levels did not meet the state minimum standard of 3.0 PPD. Residents' ADLs documentation showed incomplete or missed showers, highlighting the inadequacy of care provided.
The facility failed to employ a full-time RD or qualified DM, affecting all 75 residents. The previous DM left in early November 2024, and the RD worked remotely without being onsite. The facility was attempting to hire a new DM, but no viable candidates had applied, leaving the Dining Services department without necessary guidance and oversight.
The facility failed to provide sufficient competent dietary staff, resulting in unsanitary kitchen conditions and delayed meal service. Observations revealed unclean kitchen equipment and late meal deliveries to various dining areas. Residents reported meals were often served later than scheduled, and a shortage of the main entree caused further delays. The Dietary District Manager acknowledged the need for proper staff training.
The facility failed to properly store and label food, maintain cleanliness of kitchen equipment and walls, and ensure food served to residents was covered and at appropriate temperatures. Observations revealed undated and uncovered food items, unclean kitchen equipment, and uncovered cookies on meal trays. Pudding was served at an elevated temperature, and the Dietary District Manager confirmed these deficiencies.
The facility failed to ensure a dignified dining experience by serving meals on disposable plates and not serving meals simultaneously to residents at the same table. Observations showed residents received cookies on paper plates despite available dishware, and some residents waited for meals while others at the same table were already eating. Staff acknowledged these practices as dignity issues.
The facility failed to provide palatable meals, as observed during a survey. Residents reported that food was often cold and lacked seasoning. A test tray review confirmed that meals were not prepared according to recipes, resulting in dry and bland dishes. The Dietary District Manager acknowledged that the chicken pot pie was too thick and dry due to not following the recipe, and the Visiting Dietary Manager confirmed that the country style tomatoes and mashed potatoes were not properly seasoned.
The facility failed to honor the preferences of two residents. One resident's bed and chair were moved against their wishes, disrupting their accustomed room setup. Another resident, at risk for falls, was unable to reach the call bell to request bathroom assistance, contrary to their care plan. These actions demonstrate a lack of consideration for resident needs and preferences.
Two residents in the facility were subjected to verbal abuse by staff members. One resident, with a history of stroke and depression, was verbally abused by a GNA, who used expletive language. Another resident with Alzheimer's disease was verbally abused by a staff member, as witnessed by a visitor. The facility confirmed both incidents, indicating a failure to protect residents from verbal abuse.
The facility failed to report an allegation of verbal abuse within the required 2-hour timeframe to the Office of Health Care Quality. A GNA was overheard cussing verbally at a resident, but the report was not sent until the following day, as evidenced by a failed fax confirmation sheet. The NHA and Regional Director confirmed the findings and were not employed at the time of the incident.
A facility failed to thoroughly investigate an alleged verbal abuse incident involving a resident. An LPN and a GNA overheard another GNA cussing at a resident. The investigation was incomplete, lacking additional staff or resident interviews. The NHA and Regional Director confirmed the lack of documentation and were not employed at the time of the incident.
A resident with COPD and chronic respiratory failure experienced a delay in receiving prescribed respiratory inhalers due to flagged allergy concerns. An LPN messaged the Medical Director, but a response was delayed as the Director was initially unavailable. A family member's inquiry led another LPN to contact the Medical Director directly, resulting in an order for Albuterol nebulizer treatments, which the resident found helpful. The facility's Administrator and DON confirmed the delay in medication administration.
A resident with dementia experienced significant weight loss, dropping from 110 to 99 pounds over several months. The facility staff failed to intervene promptly, with delayed assessments and minimal dietary recommendations. The current dietitian acknowledged the need for timely reweighing and interventions such as fortified foods and snacks.
A resident admitted with chronic pain did not receive timely pain medication due to a delay in clarifying physician orders. An LPN attempted to contact the Medical Director without success, resulting in the resident not receiving medication until the next shift. The resident's pain level remained moderately strong, and no further medication was given before their transfer.
A resident's MDS discharge assessment was inaccurately coded as a discharge to a hospital instead of an assisted living facility. The MDS Coordinator acknowledged the error, which was contrary to the RAI manual guidelines. The Social Services Director confirmed the correct discharge location, highlighting a lapse in accurate documentation.
A facility failed to implement a pressure ulcer care plan for a resident with a stage two ulcer on the left heel. The care plan required treatment and floating of heels, but these were not documented or communicated effectively, leading to non-compliance with physician's orders. Despite this, the ulcer showed improvement. The oversight was due to incorrect entry in the EMR, as confirmed by staff interviews.
A facility failed to store oxygen tubing and nasal cannula in a clean manner for a resident with COPD, as the equipment was found unbagged on the floor. The facility's policy did not address proper storage, and a nurse confirmed the tubing should be bagged when not in use.
The facility failed to follow infection control guidelines, including improper PPE use for residents on isolation and inadequate wound care procedures. Additionally, the Legionella Water Management Program policy had not been reviewed annually as required.
A baseboard heater cover in the East Wing was found to be sharp and protruding, posing a potential injury risk. A resident, who was cognitively intact, was in proximity to the hazard. The Maintenance Director was unaware of this specific issue but noted that all heaters had damage due to cart collisions. Previous requests for new covers were denied, and the Administrator was unaware of any injuries. Preventive maintenance checks had been conducted, but the problem remained.
The facility failed to submit required staffing data to CMS for the third quarter of 2024 by the deadline. The policy requires data to be reported quarterly through the PBJ system, but the facility missed the August 14 deadline. The Administrator was unaware of the missed submission, as the Regional Office handles reporting, leading to a noted deficiency.
Unqualified dietary leadership and no on-site dietician
Penalty
Summary
The facility failed to employ a qualified kitchen manager and/or a full-time dietician to carry out the functions of the food and nutrition service. During observation of the kitchen, the Kitchen Manager was seen directing and instructing other kitchen staff to perform kitchen tasks, and she identified herself as the Kitchen Manager. In interview, she acknowledged that she lacked qualifications and stated that she still had to complete ServSafe and her CDM program. She also reported that she communicated with a dietician twice a week by email on Tuesdays and Thursdays. The Nursing Home Administrator stated that the certified dietician was never on site because she was not local to the area, and acknowledged that the current Kitchen Manager lacked the training and qualifications for the role.
Food Served Cold, Overcooked, and Unappetizing
Penalty
Summary
Food and drink were not consistently palatable, attractive, or served at a safe and appetizing temperature. During resident interviews, one resident reported that the chicken was tough and difficult to cut, another reported that food portions were small and that the meat was overcooked, and the resident council president reported that concerns had been shared in council meetings that the food was often cold and not good. During lunch tray observation on 3/16/26, a tray was loaded onto the food cart at 11:46 AM, left the kitchen at 12:17 PM, and was delivered to the dining room at 12:26 PM, about 40 minutes after the food left the steam table. Three surveyors observed and tasted the meal of pork slices, rice, and a vegetable dish and found it was no longer warm and was not palatable in temperature or taste. In the dining room, two of three residents interviewed said they did not like the food; one resident said the rice was undercooked and did not taste good, and another did not like the meat, with most of the meat remaining on the plate.
Unsanitary Kitchen Conditions and Unlabeled Food Items
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, as shown during the kitchen survey by unsanitary conditions and unlabeled food items throughout the kitchen and storage areas. Surveyors observed color-coded labels marked with the acronym [NAME] for received, opened, and expired items, but none of the labels included dates. During the kitchen and storage area observation, Staff #16 acknowledged that most, if not all, items lacked dates for received, opened, and expired status. Additional findings included an approximate 4' x 4' patch of ice on the freezer floor, frozen condensation on the condensing unit, significant grease and food buildup on the oven and stovetop, food debris and trash in the tracks of the cook preparation table, contaminated water with food debris in both the primary and secondary steam tables, juice standing in the bottom of the automatic juice dispenser, grease and dust buildup on vent covers with one vent containing a lodged insect, brownish/greenish buildup on walls and ceilings, and a soaking-wet mop left in a dirty bucket in the mop sink with no drying hooks available. The NHA and Kitchen Manager later confirmed these conditions were a concern.
Unsafe Kitchen Steamer Equipment
Penalty
Summary
The facility failed to maintain safe operating kitchen equipment by allowing the steamer to remain out of service and unsafe during kitchen observations. On 3/11/26 at 10:04 AM, the steamer’s on indicator light was dark and no heat was coming from the unit. The Kitchen Manager confirmed it had not worked for quite a while and stated she had verbally reported the broken equipment to the maintenance director. On 3/12/26 at 8:06 AM, during another kitchen observation with the NHA, the steamer’s on indicator light appeared to be on, but Staff #16 stated it still did not work properly and that hot water spilled out when the door was opened. The NHA heard and acknowledged the concern.
Failure to Maintain Resident Dignity
Penalty
Summary
Resident #74's dignity was not maintained when the resident was observed in bed from the hallway on 03/15/26 at 8:20 PM unclothed, uncovered, and fully exposed. No direct care was being provided at the time, and no curtain was pulled for privacy or dignity. The surveyor observed from a distance as three facility staff passed the resident's open door, and the resident remained exposed until approximately 8:35 PM. The nursing home administrator was informed of the concern during an interview at 8:45 PM.
Pharmacy Recommendations Not Reviewed or Incorporated Into Orders
Penalty
Summary
The facility failed to ensure a system was in place to review, communicate, and implement pharmacy recommendations after physician response for monthly drug regimen reviews. This was identified for 5 of 6 residents reviewed for unnecessary medications, including residents receiving risperidone, antidepressants, insulin, atorvastatin, and a proton-pump inhibitor. The report states that the licensed pharmacist was to perform monthly drug regimen reviews, including the medical chart, following irregularity reporting guidelines in the facility’s policies and procedures. For one resident, the pharmacist’s monthly medication review identified risperidone use for dementia without a diagnosis to support the indication, and the physician documented “okay” and signed the recommendation. However, the psychiatric CRNP confirmed the recommendation was only documented in a progress note and was not transcribed into physician orders. The resident’s chart also contained a diagnosis of delusional disorder dated earlier, but the physician orders and MAR were not updated to reflect that diagnosis, and the indication was not available to the pharmacist at the time of the review. The consultant pharmacist confirmed accepted recommendations were expected to be reflected in physician orders and the MAR, and the DON confirmed the orders were not updated after acceptance. For other residents, the record showed pharmacy recommendations that were either missing from the chart, lacked physician response or rationale, or were signed without documented action. One resident had repeated pharmacy recommendations about risperidone with no recommendations found in several monthly reviews, and later produced forms showed requests for a clear diagnosis and a PPI dose reduction, with no physician response or rationale on some forms. Another resident had pharmacy recommendations for gradual dose reduction attempts for antidepressants and a change in insulin dosage, but the forms lacked physician signatures or responses, or were signed without rationale. A fourth resident had pharmacy recommendations identifying irregularities in the diagnosis for risperidone used for agitation, and staff interviews confirmed recommendations were expected to be completed within about a week, but there was no evidence the prescriber made changes related to the medication orders. The DON acknowledged the concerns regarding the prescriber’s undocumented actions on the pharmacist’s recommendations.
Resident Record Left Visible at Nurses’ Station
Penalty
Summary
The facility failed to keep resident records private and confidential when a resident’s electronic medical record was left visible on a computer screen at an unoccupied nurses’ station in the 600/700 hallway. During an evening observation, the surveyor saw Resident #37’s chart open and readable on the large screen. Shortly afterward, an Activities Director came to the nurses’ station, used the printer next to the computer while the resident’s name remained visible on the screen, and then returned the schedule to the wall. When informed that the resident’s information was exposed, she paused and then locked the screen so the information was no longer visible. The Nursing Home Administrator later acknowledged that the resident’s medical record had been visible on the computer screen at the nurses’ station.
Failure to Implement Ordered Tubi Grip Stockings
Penalty
Summary
The facility failed to ensure physician orders were implemented for a resident admitted for rehabilitation. The resident had no documented cognitive impairment and reported doing well with no complaints regarding care. A physician order dated 1/17/2026 directed staff to apply Tubi grip stockings to both lower legs in the morning and remove them at night every day shift, but on 3/12/2026 the resident was observed sitting up in bed fully dressed and not wearing the stockings. During the survey, Nurse Staff #17 confirmed the stockings were not on the resident and could not locate them in the room. The nurse stated the resident had been wearing them that morning and suggested GNA Staff #18 and GNA Staff #19 may have removed them, but both GNAs denied removing the stockings during care. Therapy staff reported providing treatment to the resident that day and stated they did not remove the stockings, and one therapy assistant reported not recalling ever seeing Tubi grip stockings on the resident. The TAR documented the stockings as applied every morning from March 1 through March 12, 2026, while the resident later stated the stockings were worn that day and that it was the first time wearing them. The administrator acknowledged concerns that the stockings had not been applied as ordered on previous days.
Controlled Substance Reconciliation Not Properly Documented
Penalty
Summary
The facility failed to establish systems to accurately reconcile controlled medications using acceptable standards of practice. During observation of the facility narcotic books, surveyors found that 2 of 3 narcotic count sheets did not accurately reconcile and document narcotic counts. The standard of practice described in the report required end-of-shift narcotic reconciliation by two licensed personnel, with the on-coming and out-going nurses verifying the count of all controlled medications by signature on the narcotic count sheet. On 3/11/26, an LPN and the surveyor reviewed the East unit narcotic count sheet and found that the on-coming nurse had signed at 7:00 AM and also signed as the out-going nurse at 6:30 PM. The LPN confirmed the count sheet had been signed prematurely. In an interview later that morning, the LPN acknowledged signing the narcotic count sheet early and stated, "I always sign early so that I don't forget." A second narcotic count sheet was also found to be undated and unlabeled, and it lacked off-going licensed personnel signatures on 3/5 and 3/9/26. The DON confirmed that the facility's narcotic reconciliation practice failed to accurately reconcile and document controlled medications using acceptable standards of practice.
Medications Left Unsecured at Bedside and Controlled Drug Storage Not Properly Secured
Penalty
Summary
Medications were not secured and accounted for when Resident #2’s scheduled 9:00 PM medications were observed left at the bedside on an overbed tray table. The resident had been readmitted after hospitalization for surgical repair of a fractured right hip and had diagnoses including right neck of femur fracture and mild intellectual disability. During the observation, the resident was seated in a wheelchair beside the bed with a bowl of pudding, an overturned medicine cup, and six pills scattered on the table. The resident could not identify the medications, and no staff were present in the room. The resident’s record showed orders for atorvastatin, montelukast, potassium chloride, oxycodone, and pudding to take medications, but the physician order did not include authorization for self-administration. The medication administration record documented that an LPN signed that the medications were administered in pudding at 9:01 PM, which conflicted with the survey observation of the pills left on the resident’s table. In a separate finding, a locked medication refrigerator on the unit contained lorazepam in a plastic box compartment that was not permanently affixed. The RN who accessed the refrigerator removed the compartment easily and stated it should be secured. The DON provided the facility policy stating controlled substances are to be separately locked in a permanently affixed compartment, and the DON and NHA confirmed the concern.
Failure to Communicate with Hospice About Resident Changes
Penalty
Summary
The facility failed to ensure communication and collaboration with the hospice agency regarding end-of-life care for a resident under Hospice of [NAME] County. The resident’s care plan stated that the facility would update hospice and the family about significant changes, falls, and uncontrolled pain or discomfort, and that the resident was receiving hospice services for coping support related to a terminal illness. However, a progress note documented that the resident was very agitated, yelling out in pain, and requesting to go to bed, and staff administered PRN morphine and Ativan along with a scheduled morphine dose. There was no documentation that the facility notified or updated hospice about this change in condition. A separate progress note documented an unwitnessed fall in which the resident was found partially on the floor and partially in bed, was assisted back to bed, and had stable vital signs with no new complaints of pain or discomfort. Again, there was no documentation that hospice was notified of the incident. During interview, hospice staff stated they were the resident’s case manager and reported that hospice staff did not attend the facility’s care plan conferences. The hospice RN also stated that a CNA attended a care plan conference and said the resident would likely be coming off hospice later that month, but the RN explained that a CNA could not make that type of determination. The resident’s record did not show evidence that the facility contacted, communicated with, or consulted hospice regarding the pain episode and fall.
Hand Hygiene and EBP Noncompliance During Medication Administration
Penalty
Summary
The facility failed to ensure that licensed personnel used proper hand hygiene during medication administration and failed to ensure use of Enhanced Barrier Precautions for a resident on EBP. On 3/11/26, LPN #23 was observed exiting a room, approaching the hall medication cart, retrieving medication, re-entering the room, and exiting again without proper hand hygiene. Later that day, LPN #23 assisted Resident #56 to the restroom and to bed, then prepared the resident’s medications, entered the room, administered the medications, and exited without hand hygiene or donning PPE, despite an EBP sign and PPE being hung on the door. The surveyor also observed LPN #23 prepare and administer medications to Resident #8 and Resident #2 without hand hygiene. During an interview on 3/11/26 at 4:42 PM, LPN #23 acknowledged that she had not performed proper hand hygiene or donned PPE for residents on EBP. On 3/12/26 at 8:39 AM, the surveyor observed LPN #25 prepare Resident #33’s medications, enter the room, and administer the medications without hand hygiene. In interview, LPN #25 stated, “I didn't know to wash before entering.”
Verbal Abuse of a Vulnerable Resident by Staff
Penalty
Summary
The facility failed to protect a vulnerable resident from verbal abuse, as observed during a complaint survey. Resident #39, who has cerebral palsy and unspecified intellectual disabilities, was seen repeatedly scooting on the floor or moving in a wheelchair throughout the day. During one such instance, a Geriatric Nursing Assistant (GNA #5) expressed frustration verbally in the presence of Resident #39 and another resident. GNA #5 made derogatory comments about Resident #39's behavior, suggesting that the resident should be confined to an office to prevent further disruption. This interaction was witnessed by other staff members, including a Licensed Practical Nurse (LPN) and another GNA. The incident was reported to the Director of Nursing (DON) and the Nursing Home Administrator (NHA) immediately. A review of Resident #39's medical records confirmed the resident's non-verbal status and intellectual disabilities. Additionally, GNA #5's employee file indicated that he had received annual in-service training on abuse, yet failed to apply this training appropriately in his interactions with Resident #39. The facility's inability to ensure respectful and appropriate care for Resident #39, as evidenced by GNA #5's actions, was discussed with the facility during the survey exit.
Medication Misappropriation and Documentation Issues
Penalty
Summary
The facility failed to ensure the security and proper maintenance of residents' medications, leading to misappropriation. This deficiency was identified through a review of facility-reported incidents, medical records, and staff interviews. Specifically, narcotic discrepancies and misappropriation were noted for two residents. A family reported that a sedative medication brought from home was replaced with a diabetic medication after the resident was discharged. The facility's investigation could not confirm a mix-up but identified a pattern of incorrect documentation, missing forms, and false documentation linked to a specific nurse, LPN #14. This nurse was found to have forged signatures and was associated with the disappearance of narcotic medications from two residents. The facility's investigation revealed that Tramadol and Gabapentin were taken from the residents. The discrepancies were primarily noted on days when LPN #14 worked, and the pharmacy sheets did not match. The DON and ADON discovered a questionable signature on a narcotic log, which led to further scrutiny and the eventual termination of LPN #14. The facility's failure to secure medications and prevent misappropriation resulted in a deficiency citation for past non-compliance.
Inadequate PPE Usage During Resident Care
Penalty
Summary
The facility failed to adhere to infection control and prevention guidelines when staff did not don the required personal protective equipment (PPE) before entering a resident's room and providing hands-on care. During a surveyor's observation, an LPN and two GNAs were seen interacting with a resident who required nutrition administration via a gastrostomy tube. The resident was uncooperative, and the staff members were attempting to manage the situation without wearing the appropriate PPE, which included gowns as indicated by the Enhanced Barrier Precaution sign on the resident's door. The incident involved a resident who was active and unresponsive to the LPN's requests during the administration of a fluid bolus. The staff's failure to wear the necessary PPE, despite being aware of the resident's potential behavioral challenges, was noted by the surveyor. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were informed of these observations during the survey and again at the exit meeting.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent two residents, who were assessed to be at risk for elopement, from leaving the premises unsupervised. In the first incident, a resident was found in the facility parking lot sitting in a truck after eloping through an employee entrance that was not secured with a lock or alarm. The resident's wheelchair was found in the hallway, indicating the path taken to exit the building. The lack of security measures on the employee doors allowed the resident to leave the facility unnoticed. In the second incident, another resident eloped from the facility and was later found in the woods by the police. This resident had a history of wandering and was wearing a wanderguard for safety. However, the exit door on the 700 unit was not properly latched after a delivery, which allowed the resident to leave the building. The alarm system did not activate because the door was not shut properly, highlighting a failure in the facility's security protocol. Both incidents demonstrate a significant lapse in the facility's ability to secure exit points and adequately supervise residents at risk for elopement. The facility's failure to ensure that all exit doors were properly secured and monitored contributed to these elopements, posing an immediate jeopardy to the safety of the residents involved.
Removal Plan
- Head count for all residents
- Placed alarms on all exit doors
- Reassessed all residents at risk for elopement
- Staff educated on elopement assessment and prevention
- Incident included in the facility's QAPI plan
- All facility entry and exit ways and windows checked for security, penetration and proper function
- Facility elopement binders checked for accurateness and in use wanderguards checked for function
- Maintenance educated on daily checks of entry and exit door ways for security, penetration and proper function
Insufficient Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as evidenced by nine out of twenty-one complaints reviewed by the Office of Health Care Quality (OHCQ). These complaints highlighted that geriatric nursing assistants (GNAs) were responsible for caring for 20 to 27 residents per shift, leading to delays in care, missed showers, and inadequate toileting. The Resident Census and Conditions CMS 672 form indicated that all 75 residents required assistance with daily activities, yet the facility's staffing levels were inadequate to meet these needs. Interviews with staff members revealed consistent understaffing issues, with GNAs and nurses frequently working short-staffed. GNAs reported being unable to complete necessary rounds and provide showers due to the high number of residents assigned to them. The facility's use of agency staff and a bonus program were mentioned as attempts to address staffing shortages, but these measures were insufficient to meet the state minimum standard of 3.0 PPD (per patient per day hours). The facility's actual worked nursing schedules for July and August 2024 showed that the state minimum was not met for the majority of days reviewed. The deficiency was further evidenced by the review of residents' activities of daily living (ADLs) documentation, which showed incomplete or missed showers and bed baths. Specific residents were noted to have received fewer showers than scheduled, with documentation often marked as partial or not applicable. The facility's assessment documented a range of resident needs, including medical management, behavioral symptoms, and reduced physical functioning, yet the staffing levels were inadequate to provide the necessary care. The Nursing Home Administrator and Director of Nursing were informed of these staffing concerns during the survey.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to oversee the food and nutrition services, which had the potential to affect all 75 residents. The facility's policy required the employment of sufficient staff with appropriate competencies and skill sets, including a qualified dietitian or other clinically qualified nutrition professional, either full-time or part-time. If not employed full-time, a director of food and nutrition services meeting specific qualifications should be employed. However, the facility did not have a DM since the previous manager's departure in early November 2024, and the RD worked remotely without being onsite since the DM left. Interviews with the Dietary District Manager (DDM) and the Administrator confirmed the vacancy of the DM position and the remote status of the RD. The DDM stated that the facility was in the process of hiring a new DM, but no viable candidates had applied. The Administrator reiterated the vacancy and the ongoing efforts to fill the position, highlighting the absence of a qualified individual to provide necessary guidance and oversight to the Dining Services department, as required by the facility's policy.
Deficiency in Dietary Staff Competency and Meal Timeliness
Penalty
Summary
The facility failed to provide sufficient competent dietary staff to ensure meals were prepared in a sanitary environment and served on time. During an inspection, the kitchen was found to be unclean, with food preparation and service equipment such as the mixer, convection oven, and grill spill pan having visible food debris or spilled liquids. Additionally, opened and leftover food was not labeled, dated, or covered when stored. The Dietary District Manager acknowledged that while cleaning schedules were available, staff were not completing them, and many staff members had been employed for less than six months and required proper training. The facility also failed to serve meals on time as scheduled. Observations revealed that resident evening meals were consistently delivered later than scheduled to various dining areas, including the main dining room and the Far East and East units. Interviews with Geriatric Nurse Aides confirmed the delays, and residents reported that meals, particularly lunch and evening meals, were often served later than scheduled. The Dietary District Manager confirmed the delays, and the facility administrator expressed an expectation for meals to be served on time. Specific incidents included running out of the main entree, Rancher's Chicken Thighs, during meal preparation, which caused further delays in meal service. The Visiting Dietary Manager noted that staff had production sheets to guide food preparation, but an error in using too many chicken thighs for pureed meat led to a shortage. This resulted in a delay in serving the last resident on the East unit, with meals being delivered 29 minutes later than scheduled.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to adhere to its food storage and preparation policies, as observed during a kitchen inspection. Several food items in the walk-in refrigerator and freezer were found undated, uncovered, or improperly stored, including bowls of fruit cocktail, pans of pudding, and a bag of parmesan cheese. Additionally, a scoop was improperly stored in a bin of flour, with its handle embedded in the flour. The Dietary District Manager (DDM) confirmed these observations, acknowledging that food should be covered, labeled, and dated, and that the scoop should not be stored in the flour bin. The cleanliness of the kitchen equipment and walls was also found lacking. The kitchen's mixer, grill top, convection oven, and reach-in refrigerator were observed with accumulations of food spills and debris. The wall next to the stove top was unclean with dried food splatters. The DDM confirmed these cleanliness issues, stating that equipment should be cleaned according to the kitchen's schedule or as needed, and that the wall should be kept clean by staff. Furthermore, during meal service, residents were served uncovered cookies on their meal trays, which were delivered from enclosed food carts to resident rooms. The DDM and the Administrator both stated that food on resident meal trays should be covered. Additionally, pudding served from the kitchen's tray line was found to be at an elevated temperature of 52.2 degrees Fahrenheit, above the required 41 degrees Fahrenheit or below. The Dietary Aide responsible for preparing the pudding did not monitor its temperature before serving, and the DDM confirmed that staff should have ensured the pudding was at the correct temperature before service.
Dignity Issues in Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for residents by serving meals on disposable plates and not serving meals simultaneously to residents seated at the same table. Observations revealed that residents on four hallways were served cookies on paper plates, despite the kitchen's dish machine being functional and regular dishware being available. The Dietary District Manager acknowledged that disposable products should only be used when the dish machine is not working or in emergencies, indicating a lapse in staff training and adherence to the facility's policy on dignity. Additionally, in the Far East dining room, residents seated at the same table received their meals at different times, causing some residents to wait while others were already eating. This was observed with several residents, who expressed dissatisfaction with the delay. The Assistant Director of Nursing and the Business Office Manager both recognized this as a dignity issue, as residents should not have to wait for their meals while others at the same table are served. The Administrator confirmed the expectation that meal trays should be delivered in sequence to avoid such situations.
Failure to Ensure Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to serve palatable food to residents, as observed during a survey. On one occasion, residents on a dysphagia advanced diet were served a scoop of dry, unidentifiable food, later identified as ground meat chicken pot pie. The Dietary District Manager (DDM) confirmed that the chicken pot pie was too thick and dry because the cook did not follow the recipe, which required moistening the dish with gravy or broth. This failure to adhere to the recipe resulted in unappetizing meals for residents. Two residents, identified as R16 and R59, expressed dissatisfaction with the meals served at the facility. R16, who was cognitively intact, reported that the food was often cold and unpalatable, with the quality varying depending on the cook. R59, also cognitively intact, stated that the food lacked seasoning and could be improved. These complaints were consistent with the findings from the test tray review conducted by the surveyors. During the test tray review, the surveyors found that the food served was not prepared according to the facility's recipes. The country style tomatoes tasted bitter, and the mashed potatoes were bland and lacked seasoning. The Visiting Dietary Manager (VDM) confirmed these findings and noted that the country style tomatoes were not prepared with sugar or flour as required by the recipe. The mashed potatoes were made with only water and margarine, as per the recipe, but still lacked flavor. These observations highlighted the facility's failure to ensure food quality and palatability as per their policy.
Failure to Honor Resident Preferences and Ensure Call Bell Accessibility
Penalty
Summary
The facility staff failed to honor the needs and preferences of two residents during an annual/complaint survey. For Resident #205, the facility moved the resident's bed and chair against the wishes of the resident and their representative. The resident had been accustomed to having the bed against the wall and the chair positioned to look out the window. Despite multiple requests from the resident's representative to revert the furniture to its original position, the facility did not comply for approximately one month. The decision to move the furniture was part of a trial initiated by the facility, but the resident and their representative were not involved in the decision-making process. For Resident #1, the facility failed to ensure the call bell was within reach, as required by the resident's care plan. The resident, who is at risk for falls due to paraplegia and cognitive deficits, was observed holding their private area and stating the need to use the bathroom. The call bell was found on the floor, out of the resident's reach, contrary to the care plan's intervention to maintain the call light within reach. A geriatric nursing assistant confirmed that the call bell should have been accessible to the resident when in the wheelchair.
Verbal Abuse of Residents by Facility Staff
Penalty
Summary
The facility staff failed to protect residents from verbal abuse, as evidenced by two incidents involving different residents. In the first incident, a resident with a history of cerebral infarction, chronic obstructive pulmonary disease, and depression was verbally abused by a geriatric nursing assistant (GNA). The GNA was overheard by other staff members using expletive language towards the resident, indicating a failure to maintain a respectful and abuse-free environment. The incident was documented, and the GNA involved was identified and suspended. In the second incident, a resident with Alzheimer's disease was verbally abused by a staff member, as witnessed by a visitor. The staff member was reported to have used harsh and inappropriate language towards the resident, who was unable to recall the incident due to poor cognition. The facility's investigation confirmed the verbal abuse, and the staff member was reported to the Board of Nursing. These incidents highlight a failure in the facility's duty to protect residents from verbal abuse by staff members.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse within the required 2-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). This deficiency was identified during a review of facility-reported incidents, specifically involving an incident where a geriatric nursing assistant was overheard cussing verbally at a resident. The incident occurred on 1/2/22, but the report was not sent until 1/3/22, as evidenced by a failed fax confirmation sheet and the date on the self-report form. There was no documentation of when the final 5-day report was sent to the state agency. The Nursing Home Administrator and the Regional Director of Clinical Operations confirmed the surveyor's findings and stated they were not employed at the facility at the time of the incident.
Incomplete Investigation of Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an incident of alleged verbal abuse involving a resident. On January 2, 2022, at 5:35 PM, an LPN and a geriatric nursing assistant (GNA) overheard another GNA verbally cussing at a resident as they exited the resident's room. The investigation into this incident, identified as MD00180784, was found to be incomplete during an annual and complaint survey. The investigative packet provided to the surveyor included written statements from the two staff members who overheard the incident, but there were no additional staff or resident interviews conducted to determine if the GNA in question had been verbally abusive to other residents or to gather more information about the incident. On November 19, 2024, the Nursing Home Administrator and the Regional Director of Clinical Operations confirmed to the surveyor that no further documentation was available and acknowledged that the investigation was incomplete. They also noted that they were not employed at the facility at the time of the incident.
Delay in Medication Administration Due to Allergy Concerns
Penalty
Summary
The facility staff failed to provide treatment and services in accordance with professional standards of practice for a resident admitted with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. Upon admission, the resident was prescribed four different respiratory inhalers, which were flagged for potential allergies. The LPN on duty messaged the Medical Director regarding these allergy concerns. However, there was a delay in receiving a response from the Medical Director, as he was initially unavailable and did not see the message until later. The delay resulted in the resident not receiving the necessary medication in a timely manner. A family member inquired about the resident's medications, prompting another LPN to review the situation and contact the Medical Director directly. The Medical Director then ordered Albuterol nebulizer treatments every four hours, which the resident reported as helpful. The facility's Administrator and Director of Nursing confirmed the delay in clarifying the physician orders and administering an alternative medication.
Failure to Timely Address Resident's Weight Loss
Penalty
Summary
The facility staff failed to intervene in a timely manner for a resident with weight loss, identified as Resident #205, during an annual survey. The resident, who was admitted in October 2021 with a diagnosis of dementia, experienced a significant weight loss from 110 pounds on October 23, 2023, to 102 pounds on November 1, 2023. Despite this notable weight loss, the resident was not assessed by the former dietitian until November 13, 2023, 12 days later, and the only recommendation made was to re-weigh the resident. The re-weigh did not occur until December 1, 2023, when the resident's weight was documented as 103 pounds. The resident was not reassessed by the dietitian until December 22, 2023, with no new recommendations made at that time. The resident's weight continued to decline, reaching 99 pounds by February 2, 2024. The former dietitian recommended a snack order but did not suggest any supplements. During an interview, the current dietitian, who began her position in August 2024, acknowledged that the resident should have been reweighed and assessed more promptly after the initial weight loss. The dietitian indicated that interventions such as fortified foods and snacks should have been considered initially, followed by supplements if necessary. The Regional Director of Clinical Operations confirmed the facility's failure to intervene timely for the resident's weight loss.
Failure to Administer Timely Pain Medication
Penalty
Summary
The facility staff failed to administer pain medications to manage a resident's pain in a timely manner. Resident #203 was admitted to the facility with a diagnosis of chronic pain and had a physician order for Hydrocodone-Acetaminophen 10-325 mg to be administered every 4 hours as needed for pain. Upon admission, the resident expressed upset over not receiving pain medication. LPN #5, who was responsible for the resident at the time of admission, sent the medication orders to the pharmacy but was informed that clarification from the physician was needed. Despite attempts to contact the Medical Director, LPN #5 was unable to obtain the necessary clarification and did not administer the pain medication. LPN #6, who took over the shift, managed to contact the Medical Director and subsequently the pharmacy, which confirmed that the required medication was available in the Ebox. LPN #6 then administered the pain medication to the resident. However, the resident's pain level was documented as moderately strong the following morning, and no further pain medication was administered before the resident was transferred from the facility. The facility's Administrator and Director of Nursing confirmed the failure to administer the pain medication in a timely manner.
Inaccurate MDS Discharge Assessment Coding
Penalty
Summary
The facility failed to ensure an accurate coding of the Minimum Data Set (MDS) discharge assessment for one resident, identified as Resident 73. The deficiency was identified through a review of the resident's records and interviews with facility staff. The resident was discharged to an assisted living facility, as documented in the Nursing Progress Note. However, the MDS discharge assessment was incorrectly coded as a discharge to a short-term general hospital. This error was confirmed by the MDS Coordinator, who acknowledged the mistake and stated that the coding should have reflected a discharge to home/community, as per the Resident Assessment Instrument (RAI) User Manual guidelines. Interviews with the facility's MDS Coordinator and Administrator revealed that the MDS Coordinator was responsible for coding the MDS assessments and was expected to follow the RAI manual. The Social Services Director also confirmed that the resident was discharged to an assisted living facility and that this information was communicated during Medicare Meetings. The incorrect coding of the discharge status was a result of the MDS Coordinator's oversight, despite having access to the correct information in the resident's progress notes and the RAI manual.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to implement a pressure injury intervention as per the physician's orders and care plan for a resident with a stage two pressure ulcer on the left heel. The resident, who was admitted with diagnoses including Alzheimer's disease, malnutrition, and osteoarthritis, had a care plan indicating the need for treatment to the left heel and to float the heels when in bed or a geriatric chair. However, the treatment was not documented as completed for several days, and the task of floating the heels was not included in the nurse aide care plan. Observations and interviews revealed that the resident was seen in a geriatric chair with heels resting on the footrest, contrary to the care plan's instructions. Registered nurses and geriatric nurse aides confirmed that the intervention to float the heels was not documented or communicated effectively, leading to the resident's heels not being floated as required. The Assistant Director of Nursing and the facility Administrator acknowledged the oversight, noting that the orders were not visible to the nurses due to incorrect entry in the electronic medical record. Despite the lack of documentation and implementation of the prescribed interventions, the resident's pressure ulcer showed signs of improvement. However, the failure to follow the care plan and physician's orders could have resulted in inadequate wound treatment and interventions for the resident. The facility's policies on wound care and comprehensive person-centered care plans were not adhered to, as evidenced by the lack of documentation and communication among the staff.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to ensure that oxygen tubing and nasal cannula were stored in a clean and sanitary manner for a resident who required respiratory care. The facility's policy on oxygen administration did not address the proper storage of nasal cannula and tubing when not in use. During an observation, it was noted that the resident's oxygen tubing and nasal cannula were unbagged and lying on the floor next to the bed, which was confirmed by a registered nurse. The nurse acknowledged that the tubing should not be on the floor and should be placed in a bag when not in use. The resident involved was admitted with a diagnosis of chronic obstructive pulmonary disease and had a physician's order for oxygen administration at 3 liters per minute via nasal cannula due to respiratory failure with hypoxia. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. Despite the resident's cognitive status, the improper storage of the oxygen equipment was observed, which could potentially lead to the equipment not being properly maintained.
Infection Control and Policy Review Deficiencies
Penalty
Summary
The facility failed to adhere to infection control and prevention guidelines, as evidenced by multiple observations and interviews. In one instance, a hospitality aide entered the room of a resident on droplet and contact precautions for COVID-19 without donning the required personal protective equipment (PPE). The resident had been diagnosed with paraplegia and asthma and was under strict isolation orders. Despite the presence of isolation signage and PPE supplies outside the room, the aide admitted to not wearing the necessary PPE, acknowledging the oversight during an interview. Another deficiency was observed during a wound care procedure for a resident with unspecified dementia. The licensed practical nurse (LPN) performing the procedure did not change gloves or wash hands after removing the old dressing and cleansing the wound. This failure to follow proper wound care protocol was acknowledged by the LPN, who admitted that the gloves should have been changed and hands washed to prevent infection. The infection preventionist and the administrator both confirmed the expectation for staff to adhere to infection control guidelines during such procedures. Additionally, the facility did not review its Legionella Water Management Program policy annually, as required. The policy had not been reviewed since 2018, and the maintenance director, who had been in the position for two years, could not recall any reviews being conducted. The administrator confirmed the lapse in policy review, noting it was scheduled for discussion at the next safety committee meeting.
Baseboard Heater Cover in Disrepair
Penalty
Summary
The facility failed to ensure that a baseboard heater cover was in good repair in the 100 Hall of the East Wing, which had the potential to cause injury to residents. Specifically, the metal cover of a baseboard heater outside the room of Resident 17 was observed to be sharp and protruding from the wall. Resident 17, who was cognitively intact with a BIMS score of 14 out of 15, was admitted to the facility on an unspecified date. The facility's policy titled 'Homelike Environment' emphasized providing a safe, clean, and comfortable environment for residents. The Maintenance Director, during an observation, acknowledged the issue and stated that he was unaware of the specific heater cover protrusion but had repaired many due to damage from carts. He mentioned that all baseboard heaters had damaged covers and that previous requests for new covers were denied by former facility owners. Despite daily preventive maintenance checks, the Administrator was not aware of any resident injuries related to the heaters. The Preventive Maintenance Checklist indicated that the heaters had been checked recently, but the issue persisted.
Failure to Submit Timely Staffing Data to CMS
Penalty
Summary
The facility failed to submit the required direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) for the third quarter of the federal fiscal year 2024. According to the facility's policy, staffing data should be reported electronically through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. The policy mandates that staffing information is collected daily and reported quarterly, with a submission deadline of 45 days after the end of each fiscal quarter. For the third quarter, covering April 1 to June 30, the deadline was August 14. However, a review of the facility's PBJ report from CMS revealed that the data was not submitted within the required timeline. During an interview, the Administrator stated that they were unaware of the missed deadline for the PBJ report submission. The Administrator mentioned that the Regional Office is responsible for handling the reporting of this information, and they did not have a record of when the report was submitted. This lack of awareness and oversight led to the failure in meeting the CMS reporting requirements, resulting in a deficiency being noted during the survey.
What surveyors are citing around you — mapped
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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 138 citations issued within 25 miles in the last 12 months — including the 1 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 Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakland Nursing & Rehabilitation Center | 1.1 mi | ★★★★★ | 40 | 0 |
| Garrett County Subacute Unit | 1.1 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Hopemont | 7.6 mi | ★★★★★ | 30 | 0 |
| Kingwood Healthcare Center | 16.2 mi | ★★★★★ | 6 | 0 |
| Moran Nursing And Rehabilitation Center | 18.9 mi | ★★★★★ | 4 | 0 |
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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.