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 Denton Nursing And Rehab during CMS and state inspections, most recent first.
Food storage and sanitation monitoring were deficient in the kitchen and resident refrigeration units. Surveyors found multiple opened, unlabeled, undated, or uncovered food items in the walk-in freezer and refrigerator, while resident refrigerators contained unlabeled or expired food and temperatures above the expected range. One resident refrigerator initially lacked thermometers, and another unit showed elevated temperatures. In the kitchen, sanitizer testing was done with expired strips that read below the expected level, and the dishwasher had no sanitizer documentation despite policy requiring recorded sanitizer checks.
Kitchen Equipment Not Maintained in Safe Operating Condition: A reach-in refrigerator had a missing handle with tape covering the opening, a dish sanitizer sink was leaking and overflowing, the walk-in freezer had ice buildup and leakage onto food, the ice machine showed leakage with an old filter, and the dish machine was washing at 118 degrees with a gauge noted to need attention. Staff and maintenance reported the issues had been ongoing, with repeated temporary fixes and delayed replacement or service.
Failure to offer written advance directive information was identified for four residents. Record review found no documentation that advance directives were offered or that education was provided to the residents or their representatives, and the LMSW confirmed the absence of such documentation while noting that residents or their RP are asked on admission about existing directives and given the Maryland AG advance directive packet if none is in place.
A resident had a topical antibiotic order continued for over six months without documented reassessment or a stop date, and another resident had enteral feeding supplies hanging without required labeling for start date and time. Multiple residents were also observed with unlabeled oxygen tubing and nebulizer equipment, including tubing and masks left on the floor or not stored as expected. RN and DON interviews confirmed the facility’s expectations for labeling and handling of these items.
The facility failed to ensure staff competency for 4 of 5 GNAs reviewed. Employee file review found no current skills competency records for the GNAs, and the DON stated the facility had not conducted the 2025 skills competency clinics, with 2026 clinics scheduled for later in the year.
The facility failed to offer and document COVID-19 vaccination for residents and staff. Several residents had no evidence of being offered the vaccine for months, and a newly admitted resident had no documented offer at all. Staff records for multiple employees showed only old COVID vaccine dates or an incomplete declination form, with no evidence of screening, education, offering, or current vaccination documentation. The ICP and ADON confirmed there was no active process in place during the transition period.
Surveyors found that several residents did not have functioning call bells or any other reliable way to summon staff. One resident’s call bell had been broken for an extended period and was observed alerting on its own, while two other residents in shared rooms had no call bell of their own and had to rely on roommates to ring for help. A fourth resident was also observed without a call bell, and staff interviews confirmed that room changes had left some residents without access to a working call system.
A resident alleged that no staff provided care during an overnight (11p–7a) shift, and the facility’s follow-up investigation confirmed that the assigned GNA did not enter the room to provide care. Review of GNA task documentation for that shift showed no entries for bathing, bed mobility, oral hygiene, toileting, barrier cream after incontinence care, bowel and urinary incontinence care, or use of foam ankle boots in bed as tolerated. The DON stated that all care, including refusals, must be documented and that blank spaces indicate a lack of support that care was completed.
A resident reported to an Emergency Department that night-shift staff frequently left them sitting in urine and ignored call bells, prompting the resident to call 911. The ED note containing this neglect allegation was uploaded into the facility’s records, but the Administrator was unaware of the complaint and no investigation was identified. The DON stated the admitting nurse should have reviewed the hospital discharge paperwork and noted the complaint. In a separate facility-reported incident, the same resident alleged being left in soiled conditions for an extended period; however, only the initial report to the state was available, and the DON and Administrator could not locate the required investigation file or supporting documentation.
Surveyors identified that quarterly care plan meetings were not consistently held for a resident, with documented gaps where required meetings were missed despite the expectation for regular interdisciplinary review. In addition, a resident with documented ongoing inappropriate sexual behavior had a care plan intervention for 1:1 supervision that was not being implemented; the resident was observed without 1:1 supervision, an RN reported the behaviors occurred daily and that 1:1 supervision had not been provided for an extended period, and the DON confirmed the absence of the ordered supervision.
Surveyors identified that nursing staff failed to provide quality care when an LPN administered medications to residents without explaining the medications or offering information, and an RN administered medications without drawing the privacy curtain in a shared room, allowing a roommate to observe. Policy required privacy during medication administration, and the DON stated residents should be offered information about their medications to support choice and refusal. Surveyors also found urinals filled with urine left on a nightstand and a bed, and a trash can under a sink partially filled with coffee-colored water and trash for several days, despite the Lead GNA stating that GNAs are responsible for emptying urinals every two hours and as needed.
A resident with ongoing inappropriate sexual behavior had a care plan calling for 1:1 supervision, but staff observed the resident on the unit without that supervision in place. An RN stated the behaviors continued daily and that 1:1 supervision had not been provided for about 2 months, and the DON acknowledged the resident was not presently receiving the supervision identified in the care plan.
Kitchen Manager Lacked Current CDM Certification: The facility failed to ensure the Kitchen Manager had a current CDM credential for food service management and safety. The Kitchen Manager reported she was running the kitchen but was not certified and needed to retake the exam, and the Administrator confirmed she did not have a current CDM. Records showed she had completed a pre-certification nutrition and foodservice training pathway, while the facility’s dietician was only part-time.
The facility failed to maintain a documented system to prevent and monitor Legionella and other opportunistic waterborne pathogens in the water system. The Maintenance Director could not verify prior Legionella testing records, and observations showed water delivered through a mixing valve with no thermometers on the water heater tanks to confirm tank temperatures. The facility also failed to ensure proper hand hygiene when an LPN changed gloves during wound care for a resident with two sacral wounds but did not clean hands between glove changes.
Failure to offer and document flu and pneumococcal vaccinations for multiple residents was identified during record review. One resident had documentation of an influenza vaccine offer and refusal, but four other residents had no documentation that vaccines were offered during the season, and one newly admitted resident had no vaccination status or admission documentation addressing flu or pneumococcal immunizations. Interviews with the ICP, ADON, and DON confirmed there was a transition period when the ICP role was vacant and no staff member was designated to monitor vaccination offers and documentation.
Two residents receiving Morphine Sulfate for pain management had discrepancies between the number of doses signed out and those documented as administered on the MAR, with several doses lacking documentation and no corresponding nursing assessments of effectiveness. Nursing staff were unaware of the missing documentation, and the facility's pain management policy requirements for documentation and monitoring were not met.
A dependent resident with quadriplegia and an above-the-knee amputation, who required two-person assistance for Hoyer lift transfers, was transferred by a single GNA. During the transfer, the Hoyer lift struck the bed, causing the resident to slip through the sling and fall, resulting in bilateral sacral fractures and an L2 compression fracture. Staff interviews and documentation revealed that short staffing contributed to the failure to follow the care plan, with GNAs sometimes performing Hoyer transfers alone.
A resident with quadriplegia suffered physical injury and worsened PTSD after a ceiling collapsed in their room when a pipe burst due to inadequate attic temperature control and lack of pipe insulation. The resident was trapped under water, insulation, and drywall until staff arrived, resulting in ongoing pain, a mild disc bulge, and increased psychological distress.
A resident with hemiplegia was found in bed without access to their call light, which was on the floor instead of within reach as required by their care plan. The resident stated that a staff member had removed the call bell due to frequent use, despite care plan instructions to keep it accessible and encourage its use for assistance.
Staff did not promptly notify a physician when a resident experienced a significant decline, resulting in delayed assessment and intervention. In a separate case, multiple medication changes for another resident were made without notifying the resident's representative, as confirmed by medical record review and facility leadership.
A resident with severe cognitive impairment was found with a swollen, bruised eye, and the facility did not report the injury of unknown origin to OHCQ within the required 2-hour window. The cause of the injury was unclear at the time it was discovered, and the delay in reporting was confirmed by facility leadership.
A resident alleged theft of money, a gift card, and gift certificates from their room. The facility's investigation included statements from GNAs, the previous DON, and leadership staff, but failed to obtain input from nurses, prior shift staff, housekeeping, maintenance, or dietary staff who had access to the room. The NHA and ADON acknowledged that more staff should have been interviewed.
Facility staff did not hold required quarterly care plan meetings for a resident, despite completing quarterly MDS assessments. The last documented care plan meeting was several months prior, and both staff and the resident confirmed that no meetings had occurred during the expected periods.
A resident with cardiac conditions received Metoprolol Tartrate on multiple occasions when either blood pressure or heart rate was below the physician-ordered parameters. Staff misunderstood the order, administering the medication when only one parameter was out of range, rather than holding it as directed. The physician later clarified the order should have been followed for either parameter.
A resident with a history of stroke and hemiplegia had incomplete and inaccurate medical records, including missing diagnoses and lack of documentation of care plan meetings and discussions about loss of nursing home level of care. Key information was not included in the official record, and some documentation was not properly uploaded.
The facility did not follow its plan of correction for three previously identified deficiencies, with one deficiency remaining out of compliance. Although monthly QA meetings were held, the QA team did not specifically discuss the citations or progress of the corrective actions, contrary to what was outlined in the plan. Ongoing concerns were also noted regarding a qualified social worker.
The facility failed to maintain sufficient staffing to meet the needs of its 81 residents, leading to issues such as delayed assistance with ADLs and call light responses. Residents and staff reported concerns about inadequate staffing, with some residents missing scheduled care and staff struggling to complete assignments. The DON and Regional Director acknowledged the staffing shortages and efforts to incentivize staff to cover shifts.
The facility did not complete annual performance reviews for five GNAs, potentially affecting the care of 80 residents. Personnel files showed that GNAs hired between September 2021 and March 2023 missed evaluations. Interviews with HR, administration, and nursing leadership confirmed the oversight, attributed to nurse leadership turnover.
The facility failed to serve food at a palatable and appetizing temperature, affecting all residents consuming meals from the kitchen. Residents with intact cognition reported dissatisfaction with the taste and temperature of meals, including unappetizing eggs and cold, tasteless food. Observations confirmed these issues, with meals lacking flavor and desserts being dry, contrary to the facility's policy on providing a nourishing and well-balanced diet.
The facility failed to maintain sanitary conditions in the kitchen, affecting food preparation and serving for all residents. Observations revealed unsanitary conditions around the ice machine and kitchen equipment, with a lack of adherence to cleaning schedules. Interviews indicated that maintenance tasks were not completed as required, and a dietary aide was found not wearing a facial hair restraint, violating FDA Food Code requirements.
The facility failed to maintain a sanitary garbage and refuse area, with disposable gloves and a trash bag with a hole found around dumpsters. The Dietary Manager, a housekeeper, and the Administrator had differing views on who was responsible for maintaining the area. The facility's policy required the area to be kept clean to minimize debris and pest attractions.
The facility failed to use appropriate PPE during catheter care for residents, with staff unaware of Enhanced Barrier Precautions (EBP) requirements. A resident with an indwelling urinary catheter and another with a drug-resistant UTI did not receive care with the necessary PPE, despite orders for EBP. Additionally, the facility lacked a water management program, increasing the risk of Legionella infection.
The facility did not provide the required 12 hours of in-service training for five GNAs, as mandated by their policy. Personnel files showed that GNAs with start dates from September 2021 to March 2023 had not completed the necessary training. Interviews with facility leadership confirmed the deficiency, which could affect the safety and care of 80 residents.
The facility failed to maintain a sanitary and comfortable environment, with black mold and structural damages observed in multiple rooms. Staff and residents reported that maintenance issues were not addressed, and the Regional Director of Maintenance confirmed the need for significant repairs.
The facility failed to implement its abuse policy for allegations involving a resident who reported rough care and threats by a GNA. The investigation was delayed, and the abuse was not reported immediately. Additionally, the facility could not account for missing narcotics involving two residents, with an incomplete investigation lacking resident and staff statements.
The facility failed to investigate allegations of abuse and missing narcotics for several residents. One resident reported rough treatment and threats from a GNA, but the investigation was delayed, and the GNA was not immediately removed from care. Missing narcotics for two residents were not thoroughly investigated, and a new injury for another resident was not investigated, leaving the cause undetermined.
A facility failed to notify a resident's responsible party when a new treatment was started for a Stage 3 pressure ulcer. The resident was readmitted with a pressure ulcer, and treatment orders were documented, but there was no record of notification to the responsible party. This was confirmed by the DON.
A resident was readmitted to the facility with a stage 3 pressure ulcer on the coccyx. Despite treatment orders being placed, the wound dressing was not started until several days later, resulting in a gap in care. This deficiency was confirmed by the DON.
The facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week, on four specific days. This deficiency was confirmed through staffing documentation and an interview with the Regional Director of Labor Management. Complaints from residents, staff, and families about low staffing were also reviewed during the survey.
The facility failed to maintain complete and accurate medical records for three residents, as care plan meetings were not included in their records despite being documented on paper. The Social Services Assistant admitted to keeping evidence of these meetings in her office and uploading them when possible, which was confirmed by the DON.
The facility failed to treat two residents with dignity and respect. A resident with cognitive intactness reported that staff did not knock or introduce themselves before entering her room, and a CMA was observed rolling her eyes at the resident. Another resident with severe cognitive impairment was left uncovered and exposed during care, despite expressing that she was cold. The Interim DON confirmed that staff should knock before entering rooms and cover residents during care.
A resident with morbid obesity was not provided with the appropriate size of incontinent briefs, despite her repeated requests and visible discomfort. The facility staff measured her for a large size but supplied a smaller size, leading to pain and difficulty in sitting. Staff interviews confirmed the resident's need for a larger size, but the facility did not address the issue adequately.
A resident's grievance about another resident's behavior was not promptly resolved due to a lack of follow-up and communication among staff. The grievance, documented during a resident council meeting, was forgotten after being handed to a former DON, leading to unresolved issues and potential for further grievances.
A facility failed to transmit a Death in Facility MDS assessment for a resident within the required timeframe. Although the assessment was completed on time, the MDS Coordinator sent it to corporate offices for batch transmission, and the exact submission date was unknown. The CMS manual requires transmission within 14 days of the MDS death date, which was not met.
A facility failed to create a care plan for a resident with an indwelling urinary catheter, leading to its use for seven months without a discontinuation plan. The resident, cognitively intact, was unsure of the catheter's purpose. Initially ordered for one-day use due to urinary retention, the catheter remained due to a lack of follow-up and delayed urology consultation. The medical record lacked a care plan, and the DON confirmed this oversight.
A facility failed to integrate hospice care into a resident's care plan and did not include all necessary interdisciplinary team members in care planning meetings. Additionally, the facility missed quarterly care plan meetings for several residents, indicating a lack of coordination and adherence to care planning protocols.
A resident with dysphagia experienced significant weight loss, prompting a physician's order for weekly weights. However, the facility failed to document weights on two specified dates, as confirmed by the Interim DON.
The facility failed to provide necessary grooming services for two residents, resulting in inadequate ADL care. One resident, with morbid obesity, was not offered showers due to size limitations of the shower equipment, while another resident, with stroke-related paralysis, did not receive scheduled showers due to equipment issues and staffing shortages. Both residents were dependent on staff for bathing, and the facility's lack of communication and maintenance follow-up contributed to the deficiency.
A facility failed to ensure the safety of a designated smoking area for a resident, as required by its policy. Observations revealed no protective cover over the area and a metal container for ashtrays filled with trash. The resident, who was cognitively intact and smoked regularly, had not experienced any accidents, but the conditions were acknowledged by staff as non-compliant and potentially unsafe.
A facility failed to manage urinary catheter care for a resident, leading to multiple UTIs and delayed urology consults. The resident's catheter was not removed promptly despite physician orders, and a voiding trial was not conducted. Additionally, another resident received improper catheter care, as staff did not follow the facility's policy. These deficiencies were confirmed by the facility's Interim DON.
Food Storage and Sanitizer Monitoring Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards in the kitchen and in resident refrigeration units. During a kitchen tour, multiple items in the walk-in freezer and refrigerator were found opened, unlabeled, undated, or uncovered, including cooked chicken, chicken nuggets, diced carrots, vegetable blend, biscuit dough, chicken meatballs, mayonnaise, an Arby's drink, and trays of cut cake. The Kitchen Manager stated that opened items should be labeled with an opening date, that the mayonnaise should have been dated and would be good for 30 days, that the cake should have been covered, and that the Arby's shake should not have been in the unit without a label. Facility policy required foods stored in the refrigerator or freezer to be covered, labeled, and dated. Resident refrigeration units were also found with storage and temperature problems. In the breezeway refrigerator used by residents from multiple units, the freezer had brownish and whitish frost buildup, the refrigerator temperature was 54 degrees Fahrenheit, and items inside included resident food without dates or names, an unlabeled salad, Chinese food for a resident without a date, and milk cartons with sell-by dates of 3/03/2026 and 3/08/2026. The ICP nurse stated resident food must be dated and removed after 3 days if not eaten, confirmed the temperature was too warm, and agreed the freezer and refrigerator needed cleaning. The breezeway refrigerator later showed temperatures of 49, 44, and 48 degrees Fahrenheit before being placed out of order. Additional resident refrigeration units were observed without thermometers or with elevated temperatures. The 500-unit resident refrigerator and freezer initially had no thermometer inside, and when thermometers were later placed in the unit, the refrigerator temperature was 50 degrees Fahrenheit. The memory unit refrigerator also showed 48 degrees Fahrenheit, and the Maintenance Director adjusted it to be cooler. In the kitchen, sanitizer testing was performed with expired test strips dated 09/2024, and the sanitizer water tested below the expected level three times. The dishwasher had no documentation of sanitizer levels, and the Kitchen Manager stated staff did not test the dishwasher sanitizer because they did not have testing strips, despite facility policy requiring sanitizer concentrations to be checked and recorded.
Kitchen Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure essential kitchen equipment was maintained in safe operating condition. During a kitchen tour, the reach-in refrigerator was observed with tape covering a hole on the left door where the embedded handle had been missing, and the inside of the door was exposed. The Kitchen Manager stated the handle had been missing for a long time, and the Maintenance Director reported prior attempts had been made to secure it with duct tape but that he had been unable to find a replacement handle. The sink used to sanitize dishes after washing was observed leaking steadily, with a large black bin placed underneath to catch the water and a wet floor sign nearby. On a later observation, the sink was still leaking and the bin had overflowed, spilling water onto the floor. The Kitchen Manager stated the sink had been leaking for a while and that staff had to keep refilling the sanitizer sink while doing dishes because water drained out from the bottom. The Maintenance Director stated the leak was at the base, that he had fixed it a few times over the past few months, and that it continued to leak again. Additional kitchen equipment concerns were identified with the walk-in freezer, ice machine, and dish washing machine. The walk-in freezer had towels under the freezing unit, an icicle coming from the rear of the unit, leakage onto a box of pumpkin pies, and a large chunk of ice under the food rack; a contractor later serviced the freezer and replaced insulation on the evaporator. The ice machine had whitish brown leakage between the machine and ice bin, and a service report noted the filter was very old and needed replacement. The dish washing machine was observed washing at 118 degrees Fahrenheit, below the Kitchen Manager’s stated minimum of 120 degrees, and the gauge continued to read 118 on repeat observation; a service report identified that the gauges needed attention.
Failure to Offer Written Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents were offered written information regarding advance directives. Medical record review showed no written documentation that advance directives were offered or that education about advance directives was provided to Residents #8, #10, #47, and #86 or to their resident representatives. During interview, the Regional Social Worker stated that residents or their responsible party are asked on admission whether an advance directive is in place, and if one is not in place, the facility provides the Maryland Attorney General's Office Advance Directive packet. She also reviewed the records with the surveyor and confirmed there was no written documentation showing that advance directives were offered or that education was provided to the residents or their responsible parties. She further stated that the IDT had recently discussed incorporating advance directive discussions into care plan meetings, particularly for long-term care residents.
Failure to Follow Professional Standards in Medication and Respiratory Care
Penalty
Summary
The facility failed to ensure services were provided in accordance with professional standards of quality during medication administration and related care observations for six residents. During an unnecessary medication review, Resident #28 was found to have an active order for Bacitracin External Ointment 500 UNIT/GM to be applied into both nostrils twice daily for dry/irritated nostrils, with a start date of 09/03/2025. The order had remained active for over six months with no documentation of reassessment, evaluation of ongoing need, or clinical justification for continued use, and the MAR showed the ointment was administered from September 3, 2025 through March 12, 2026. During enteral feeding observations in Resident #5's room, the surveyor observed an enteral feeding bottle and water flushing bag hanging without a start date or time labeled to show when the feeding was initiated. The Kangaroo water bag had no date and was labeled Levity, and the enteral feeding bottle was marked exp 48 hrs without a documented start date and time. RN #5 stated that feeding bags and water bags must be labeled with the date, name of the feeding, resident's name, rate, start time, and flushing schedule, and the DON stated that feeding bottles and water flush bags are expected to be properly labeled and changed every 24 hours. During unit rounds, the surveyor observed multiple residents with oxygen and nebulizer equipment that was not labeled or properly stored. Resident #28, Resident #44, and Resident #90 had oxygen tubing in use with no date or label. Resident #47 had a nebulizer treatment machine placed on a plastic container on the floor, with tubing and mask lying on top of the resident's clothes on the floor and no label on the tubing. Resident #90 was also observed with a nebulizer mask and tubing without labeling, Resident #91 had oxygen tubing lying on the floor and was assisted by GNA #7 who picked it up and placed it back on the resident's nose, and Resident #44 was observed with oxygen in use and no label on the tubing. RN #5 and the DON stated that oxygen tubing, nebulizer tubing, and masks are expected to be labeled, and the DON stated they should be stored in a plastic bag when not in use.
Missing GNA Skill Competency Records
Penalty
Summary
The facility failed to ensure staff were competent in their skills for 4 of 5 Geriatric Nursing Assistants reviewed for skill competency evaluations during the recertification and complaint survey. During a review of employee files, it was found that GNA #1, #2, #8, and #9 did not have current records of skills competencies. In an interview, the DON stated that the facility conducted skills clinics with return demonstrations and said she would obtain the records for the GNAs. Later, the DON reported that the facility had failed to conduct the skill competency clinics for 2025 and stated that 2026 skill competency clinics were scheduled for May and June of 2026.
Failure to Offer and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to ensure residents were offered and educated on COVID-19 vaccination. Record review on 03/11/2026 showed that Resident #15 had not been offered the COVID-19 vaccine since 04/12/2025, Resident #5 since 12/03/2024, Resident #47 since 02/18/2025, and Resident #81 since 12/05/2024. Resident #7, who was admitted in February 2026, had no documented evidence of being offered the COVID-19 vaccine. During interviews, the ICP reported starting in the role on 02/05/2026 and stated that the ADON had previously served as ICP. The ADON reported there was a transition period toward the end of 2025 when the ICP position was vacant, and that during this time residents may have been missed and some may not have been accounted for. The ADON stated the expectation was for nursing staff to offer vaccinations on admission, including education, consent, and documentation in the EHR, and that residents should be offered influenza, COVID-19, RSV, and pneumococcal vaccines as appropriate on admission. The facility also failed to maintain staff documentation of COVID-19 screening, education, offering, and current vaccination status. Record review on 03/13/2026 for GNA #1, #2, #6, #7, and RN #10 showed last COVID-19 vaccination dates from 2021 and 2022 for four staff members, while GNA #6 had an incomplete and undated declination statement. No recent documentation was found showing these employees had been offered the vaccine, educated about it, or given the opportunity to receive it. The ICP and ADON confirmed that no active process had been in place for offering COVID-19 vaccinations to staff, providing education, or obtaining declination forms, and they stated no documentation existed showing staff had previously been offered the vaccine or completed declination forms.
Missing or Nonfunctioning Call Bells for Multiple Residents
Penalty
Summary
The facility failed to ensure that residents had functioning call bells or an alternative means to summon staff in their rooms and bathing areas. Surveyors identified this concern for four residents during the recertification survey, including one resident whose call bell was reported as broken for about a year and was observed actively alerting at multiple times without the resident activating it. Staff interviews showed that the resident often used a phone instead of the call bell, and maintenance staff reported ongoing problems with the device and attempts to repair or reprogram it. Two other residents were observed without their own call bells after room changes had converted single rooms into shared rooms. In both rooms, only the roommate had a working call bell, and the residents without bells were reported to rely on their roommates to ring for help or to catch staff as they passed by. An LPN confirmed that one resident should have had a call bell or hand bell and notified maintenance after the missing device was identified. The DON stated that every resident should have a call bell and explained that the rooms had been changed from single to double occupancy. A fourth resident was also observed without a call bell or other device to call for assistance, while the roommate had the only call bell in the room. The Maintenance Director stated that the facility had made room changes and had not notified him. The facility policy stated that each resident should have access to a call light at the bedside and toilet, and that staff should report call light problems immediately and provide immediate or alternative solutions until the problem is remedied. The report also noted that all staff members who see or hear an activated call light are responsible for responding.
Failure to Provide and Document Required Overnight Care Resulting in Resident Neglect
Penalty
Summary
The deficiency involves a failure to ensure that a resident remained free from neglect when required care was not provided during an overnight shift. A facility-reported incident submitted to the Office of Health Care Quality documented an allegation by Resident #75 that no staff provided care during the 11 p.m. to 7 a.m. shift on a specific date. A follow-up investigation form in the facility’s incident folder confirmed that the assigned Geriatric Nursing Assistant (GNA) did not enter the resident’s room to provide care during that shift. Review of the GNA task documentation for that night showed no entries for multiple care tasks, including bathing, bed mobility, oral hygiene, toileting, application of barrier cream after incontinence care, bowel elimination, urinary incontinence care, or use of foam ankle boots in bed as tolerated. During an interview, the Director of Nursing stated that care provided during a shift must be documented by the GNA, that there should not be blank spaces on the GNA task documentation, and that refusals and all care-related activities should be recorded. She acknowledged that if a task was not documented, there was no support to show it was completed, and confirmed that if care had been provided to the resident on that night shift, it should have been documented and not left blank.
Failure to Investigate and Document Resident Neglect Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and respond to allegations of neglect made by a resident. Medical record review showed that a hospital consult report, uploaded into the resident’s chart on 12/13/2025, documented that the resident went to the Emergency Department and reported being constantly neglected by the 11 p.m. to 7 a.m. shift, frequently sitting in urine, and having call bells purposely ignored, leading the resident to call 911 for help. The Administrator stated he was not aware of this complaint or of any investigation related to it, despite confirming that such reports of neglect should be brought to his attention and investigated, and that the Emergency Department note had been uploaded by facility staff. The DON reported that the admitting nurse should have reviewed the discharge paperwork when the resident returned from the hospital and should have noted the resident’s complaint of neglect. A second deficiency component was identified through review of Facility Reported Incident #2690114, in which the same resident had reported an allegation of neglect and being left in soiled conditions for an extended period. The DON could only provide the initial incident report submitted to the Office of Health Care Quality and was unable to locate any additional documentation or an investigation file for this incident. She stated that a file containing interviews and evidence is normally maintained for each Facility Reported Incident and confirmed that such a folder should exist for this resident but could not be found. The Administrator similarly confirmed that investigation notes and interviews are kept in a folder in a file cabinet and that the previous DON had handled the investigation for this incident, but the investigation file could not be located.
Missed Care Plan Reviews and Failure to Implement 1:1 Supervision Intervention
Penalty
Summary
The facility failed to hold required quarterly care plan meetings for one resident and failed to implement a care plan intervention for another resident. For Resident #75, interview on 03/10/2026 revealed the resident denied having regular care plan meetings. Medical record review on 03/11/2026 showed documented care plan meetings on 12/04/2024, 09/17/2025, and 01/16/2026, with no additional meetings documented between 12/04/2024 and 09/17/2025. The Regional Social Worker confirmed on 03/11/2026 that no care plan meetings were held for this resident between 12/04/2024 and 09/17/2025 and acknowledged that meetings due in March and June 2025 were missed. For Resident #1, the facility did not implement a care plan intervention for inappropriate sexual behavior. Progress notes reviewed on 03/11/2026 documented multiple occasions of inappropriate sexual behavior. The resident’s care plan, reviewed the same day, included an intervention for 1:1 supervision related to this behavior. However, observation on 03/11/2026 at 10:33 AM found the resident on the unit without 1:1 supervision. In an interview on 03/10/2026, an RN stated the resident continued to display inappropriate behaviors with other residents daily and that 1:1 supervision had not been in place for “maybe 2 months.” On 03/13/2026, the DON acknowledged that the resident displayed inappropriate sexual behavior and did not currently have 1:1 supervision as specified in the care plan.
Failure to Provide Informed, Private Medication Administration and Basic Hygiene Care
Penalty
Summary
The deficiency involves failures in medication administration practices and basic care related to hygiene and environmental cleanliness. Surveyors observed an LPN administering medications to two residents without explaining the medications or offering the opportunity for the residents to be informed. In a separate observation, an RN administered medications to a resident in a shared room without providing privacy, as the privacy curtain was not drawn and the roommate was able to observe the process. Review of the facility’s medication administration policy showed that providing privacy is required, and the DON stated that staff are expected to offer residents the opportunity to be informed about their medications to support resident choice and the ability to refuse. Additional deficiencies were identified in the management of residents’ urinals and room cleanliness. Surveyors observed two urinals filled with urine on a nightstand in one resident’s room, and the resident reported that some aides empty the urinal and some do not, and that this situation happens all the time. In another room, a urinal filled with urine and a trash can were observed on the bed. During room rounds, a trash can under a sink was found to be approximately one-quarter full of coffee-colored water and trash, and a resident stated it had been there for a couple of days. The Lead GNA reported that GNAs are responsible for emptying residents’ urinals every two hours and as needed, confirming that ensuring urinals are emptied is part of their duties.
Failure to Provide Ordered 1:1 Supervision for Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to ensure supervision was provided to a resident who had a care plan intervention for 1:1 supervision due to inappropriate sexual behavior. Review of the resident’s progress notes showed multiple occasions of inappropriate sexual behavior, and the care plan specifically included 1:1 supervision as an intervention for that behavior. During observation, the resident was seen on the unit without 1:1 supervision in place. During interview, an RN stated the resident continued to display inappropriate behaviors with other residents and was not presently receiving 1:1 supervision, noting the last time it had been provided was about 2 months earlier. The RN also stated the resident had these behaviors daily over the prior 2 months. The DON later acknowledged that the resident displayed inappropriate sexual behavior and did not presently have 1:1 supervision as identified in the care plan.
Kitchen Manager Lacked Current CDM Certification
Penalty
Summary
The facility failed to ensure that the individual designated as the Kitchen Manager was certified for food service management and safety. During an interview, the Kitchen Manager reported that she was managing the kitchen but was not currently certified and did not hold a current Certified Dietary Manager (CDM) certification. She stated that she had completed training and taken the CDM test in October, but needed to retake it and was waiting for approval to do so. She also reported that the previous Kitchen Manager had left about a year earlier and that she had taken over the position from within the facility. The Administrator later confirmed that the Kitchen Manager did not have a current CDM certification and that the facility’s dietician was not full time, coming to the facility every Wednesday or every so often. Document review showed the Kitchen Manager completed Nutrition and Foodservice Professional Training Pathway I with the University of Florida on 8/05/2025, noted as a pre-certification course for CDMs.
Failure to Monitor Water Safety and Perform Hand Hygiene
Penalty
Summary
The facility failed to ensure measures were in place to prevent and monitor the growth of Legionella and other opportunistic waterborne pathogens in the building water system. During interview, the Maintenance Director stated that the facility followed a water management program and conducted in-house Legionella testing about once per year since around September 2022, with results photographed and uploaded into the TELS system. However, on follow-up, he was unable to locate any documentation of the in-house testing results and could not verify where they were stored. He confirmed that he had no additional documentation or evidence showing that testing for Legionella or other opportunistic waterborne pathogens had been completed. During observation of the boiler room, a mixing valve was seen in place and heated water was being delivered from the water heaters through the mixing valve to resident rooms. A thermometer on the outgoing water line to resident rooms read 112 degrees Fahrenheit. The Maintenance Director was unsure of the temperature in the tanks before the mixing valve and stated there were no thermometers present to monitor or display the tank water temperature. He later observed a water temperature of 108.5 degrees Fahrenheit directly from a hose connected to the water heater tank and reported that thermometers should be present on the exterior of the water heater tanks to monitor water temperature. He also stated that he believed the expected water temperature should be approximately 140 degrees Fahrenheit. The facility also failed to ensure appropriate hand hygiene during wound care. While observing an LPN provide wound care for a resident with two separately located sacral wounds, the LPN changed gloves between cleaning the wound and placing the clean dressing but did not perform hand hygiene between glove changes. The same omission occurred when the LPN changed gloves again before applying a clean dressing to the second wound. When interviewed immediately afterward, the LPN confirmed that hand hygiene should have been performed between changing gloves.
Failure to Offer and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to provide influenza and/or pneumococcal immunizations as required or appropriate for residents. During record review of five residents, there was no documentation that influenza or pneumococcal vaccines were offered during the 2025-2026 season for four residents, and one resident was documented as having been offered the influenza vaccine and refusing it. For one resident admitted in February 2026, there was no documentation of vaccination status or that influenza or pneumococcal vaccines were addressed upon admission. During interviews, the Infection Control Preventionist reported she began in the role on 02/05/2026 in a part-time capacity and stated that prior to her assuming the role, the ADON had been serving as the ICP. The ADON reported there was a transition period toward the end of 2025 when the ICP position was vacant and that ensuring residents were offered vaccinations may have been missed. The ADON stated the expectation was for nursing staff to offer vaccinations upon admission, provide education, obtain consent, and document this in the electronic health record, and that influenza vaccines should be offered annually during flu season. The ICP and ADON further stated that after the previous ICP left, no staff member had been designated to monitor and ensure residents were offered vaccinations, and the DON later confirmed awareness of the concern.
Incomplete Medication Documentation for Pain Management
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for two residents, as evidenced by discrepancies between the controlled medication utilization records and the medication administration records (MAR) for Morphine Sulfate. For one resident with diagnoses including anxiety, dementia, and atrial fibrillation, the pain management care plan required administration and documentation of analgesic medications as ordered, with monitoring and documentation of side effects and effectiveness every shift. However, a review of the resident's records revealed that 34 doses of Morphine Sulfate were signed out in November, but only 26 doses were documented as administered on the MAR. Several specific dates were identified where doses were not documented, and there was no corresponding nursing assessment of the medication's effectiveness in the progress notes. Similarly, for another resident with chronic pain, lumbar back pain, repeated falls, and muscle wasting, who was also receiving hospice services, the controlled medication utilization record showed 35 doses of Morphine Sulfate signed out over a specified period, but only 14 doses were documented as administered on the MAR. Multiple dates were identified where documentation was missing, and there was no evidence in the MAR or nursing progress notes of any assessment regarding the effectiveness of the administered medication. Interviews with nursing staff revealed a lack of awareness regarding the missing documentation for both residents. The staff nurse interviewed was not aware of the failure to sign off on administered doses and confirmed the existence of both standing and as-needed orders for Morphine Sulfate. The facility's pain management policy required collaboration with healthcare professionals and documentation of interventions, but the records reviewed did not reflect compliance with these requirements.
Failure to Follow Two-Person Hoyer Transfer Protocol Results in Resident Injury
Penalty
Summary
Facility staff failed to follow the established plan of care for a dependent resident with quadriplegia and an above-the-knee amputation, resulting in significant injury during a transfer. The resident, who was totally dependent for all activities of daily living and required a Hoyer lift with assistance from two staff members for transfers, was instead transferred by a single geriatric nursing assistant (GNA). The GNA used the resident's own sling but did not have a second staff member present, as required by the care plan. During the transfer from bed to chair, the wheel of the Hoyer lift struck the end of the bed, causing the resident to slip through the sling and fall to the floor, landing on the buttocks. Following the fall, the resident complained of back pain and was subsequently transferred to the hospital, where imaging revealed bilateral sacral fractures and an L2 compression fracture. The resident was alert but not at full baseline, likely due to pain and lack of sleep after spending the night in the emergency room. Staff interviews confirmed that the GNA was working alone at the time of the transfer, despite the care plan's requirement for two-person assistance. Other staff members reported that short staffing was common, and it was not unusual for GNAs to perform Hoyer transfers alone when the facility was understaffed. Documentation and interviews indicated that the unit was short-staffed on the day of the incident, with GNAs assigned to multiple units and responsible for a high number of residents, many of whom required total care. The nurse on duty and other GNAs corroborated that the transfer was performed by one person, and that this practice had occurred previously due to staffing shortages. The failure to adhere to the resident's care plan and provide adequate supervision during the transfer directly resulted in the resident's injuries.
Ceiling Collapse Causes Physical and Psychosocial Harm Due to Environmental Failure
Penalty
Summary
The facility failed to maintain a safe and functional environment, resulting in both physical and psychosocial harm to a resident. On the date of the incident, a pipe burst in the attic above a resident's room due to inadequate temperature control and lack of pipe insulation, causing the ceiling to collapse onto the resident. The resident, who has quadriplegia and fully intact cognitive function, was unable to move independently and was covered in water, insulation, and drywall until staff arrived several minutes later to remove them from the room. Medical records indicate that the resident was sent to the emergency room, where they were evaluated for injuries and subsequently diagnosed with cervical spine and lumbar strain, leading to ongoing pain management with various medications, including Oxycodone and later Suboxone. The resident continued to experience significant lower back pain, which was later associated with a mild disc bulge found on MRI. The incident also exacerbated the resident's pre-existing PTSD, as documented in psychological and psychiatric evaluations, with the resident expressing ongoing fear and trauma related to the event. Interviews with staff confirmed that the ceiling collapse was sudden and involved a large section of drywall, insulation, and water falling directly onto the resident. Staff described the resident as visibly upset and shaken after the incident. The resident later requested counseling and physical therapy services from providers not affiliated with the facility, citing feelings of unsafety and worsened PTSD symptoms following the event. The deficiency was directly linked to the facility's failure to maintain appropriate environmental controls to prevent pipe freezing and rupture.
Call Light Not Accessible to Resident with Hemiplegia
Penalty
Summary
A deficiency was identified when a resident with hemiplegia was observed lying in bed without access to their call light, which was found on the floor in front of the oxygen concentrator. The resident reported that the call bell was usually placed on the bed but had been removed by a staff member because the resident was using it frequently. The resident's care plan included interventions to encourage the use of the call bell for assistance and specifically directed that the call light be kept within reach on the resident's right side. Despite these documented interventions, the call light was not accessible to the resident at the time of observation, and the resident had to request assistance from the surveyor to retrieve a personal item.
Failure to Notify Physician of Change in Condition and Representative of Medication Changes
Penalty
Summary
Facility staff failed to promptly notify a physician when a resident experienced a significant change in condition. One resident with a history of traumatic brain injury, heart failure, and renal failure was noted as difficult to arouse and lethargic by a nurse, but no timely assessment or notification to the physician occurred. Multiple staff members, including a registered nurse and a geriatric nursing assistant, observed the resident to be unresponsive and reported that the assigned LPN had not taken immediate action or obtained vital signs. The resident was eventually found to have critically low blood pressure and was transferred to the hospital after emergency measures were initiated, but only after a significant delay and repeated prompting by other staff members. Additionally, the facility failed to notify a resident's representative when there were multiple changes to the resident's medication regimen. Medical record review showed several instances where antipsychotic and anti-anxiety medications were initiated or had their dosages increased, but there was no documentation that the resident's representative was informed of these changes. The Assistant Director of Nursing confirmed the lack of documentation regarding representative notification for these medication changes.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required 2-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). A staff nurse became aware of a resident with severe cognitive impairment who was found with a swollen, bruised left eye. The resident was unable to communicate the cause of the injury. The initial self-report to OHCQ was sent the following morning, more than 2 hours after the injury was discovered. Facility leadership confirmed that at the time, it was unclear whether the injury was due to a fall, being hit, or another cause.
Failure to Thoroughly Investigate Alleged Misappropriation of Property
Penalty
Summary
The facility failed to provide adequate documentation that an allegation of misappropriation of property was thoroughly investigated. Specifically, a resident reported that money, a gift card, and multiple gift certificates were stolen from their room during a specified time frame. The facility's investigation included written statements from three geriatric nursing assistants, the previous DON, and three other staff in leadership positions. However, the investigation did not include interviews or statements from nurses on duty, staff from previous shifts, housekeeping, maintenance, or dietary staff who also had access to the resident's room. During interviews, the NHA and ADON confirmed that additional staff should have been interviewed as part of the investigation process.
Failure to Hold Quarterly Care Plan Meetings
Penalty
Summary
Facility staff failed to conduct required quarterly care plan meetings for a resident, as evidenced by medical record review and staff interviews. The resident was admitted in November 2022, and while quarterly MDS assessments were completed in March and June 2025, there was no documentation or evidence of corresponding care plan meetings during those periods. The last recorded care plan meeting for the resident occurred in December 2024. Interviews with the Social Services Assistant and the Assistant Director of Nursing confirmed the absence of care plan meetings in March and June 2025. Additionally, the resident reported not having any care plan meetings during the year and had been requesting them.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication Administration
Penalty
Summary
A deficiency occurred when a resident with multiple cardiac and vascular diagnoses, including non-rheumatic aortic stenosis, hypertension, atrial fibrillation, and heart disease, received Metoprolol Tartrate despite physician orders specifying parameters for administration. The physician's order directed staff to hold the medication if the resident's blood pressure was less than 110/65 or if the heart rate was less than 65. However, medical record review revealed multiple instances over several months where the medication was administered even when the resident's blood pressure or heart rate was below the specified thresholds. Staff interviews confirmed a misunderstanding of the physician's order, with staff indicating they would only hold the medication if both blood pressure and heart rate were below parameters, rather than either one. The physician clarified during the survey that the medication should have been held if either parameter was below the threshold. The facility's failure to follow the physician's order resulted in the resident receiving unnecessary medication doses outside of the prescribed parameters.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a history of cerebral infarction and hemiplegia. Upon review, it was found that the resident's medical record did not include all relevant diagnoses, specifically omitting hemiplegia on the information sheet submitted for nursing home level of care appeal. Instead, the documentation listed a diagnosis of no residual deficit, which did not accurately reflect the resident's condition. Additionally, the documentation provided for the appeal did not include all of the resident's diagnoses, and the information sheet was incomplete. Further review revealed that the facility did not maintain up-to-date records of care plan meetings and discussions regarding the resident's loss of nursing home level of care. There was no evidence in the medical record of a care plan meeting after April, nor documentation of discussions with the resident and their representative about the loss of level of care. Although a care plan meeting was held in July, the documentation was kept in the Social Services Assistant's office and had not been uploaded to the medical record, resulting in incomplete official records.
Failure to Follow Plan of Correction and Monitor Quality Deficiencies
Penalty
Summary
The facility failed to correct and monitor previously identified quality deficiencies, as evidenced by a revisit survey that found noncompliance with three specific deficiencies (F610, F842, and S1320). Record review and staff interviews revealed that the facility did not follow its plan of correction for these deficiencies, with S1320 remaining out of compliance. The Director of Nursing identified the Administrator as the Quality Assurance (QA) contact person, and the Administrator confirmed that QA meetings were held monthly. However, when questioned, the Administrator stated that the QA team did not specifically discuss the citations or the progress of the plan of correction, despite the plan indicating that the QAPI team would review all audits. The surveyor noted ongoing concerns related to a qualified social worker.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its 81 residents, as evidenced by multiple observations and interviews with residents and staff. Several residents, including those identified as R15, R44, and R55, reported issues related to inadequate staffing, such as not receiving timely assistance with activities of daily living (ADLs) and delayed response to call lights. R15, who required assistance from two staff members, expressed concerns about the lack of staff, while R44 noted that she sometimes missed her scheduled baths due to insufficient staffing. R55 also highlighted difficulties in getting assistance on weekends. These issues were corroborated by the facility's Minimum Data Set (MDS) assessments, which indicated that these residents were cognitively intact and aware of the staffing deficiencies. Staff interviews further confirmed the staffing inadequacies, with Geriatric Nurse Aides (GNAs) and a Registered Nurse (RN) expressing concerns about their ability to complete assignments and ensure resident safety. GNAs reported being unable to monitor all residents effectively, especially when only one aide was assigned to a unit. The RN mentioned working double shifts and being the only nurse on duty during certain shifts, which heightened his anxiety about resident safety. The Director of Nursing (DON) and the Regional Director of Labor Management acknowledged the staffing shortages, noting efforts to incentivize staff to cover shifts, but admitted that the facility was struggling to maintain adequate staffing levels.
Failure to Conduct Annual GNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for five Geriatric Nurse Aides (GNAs), which could potentially impact the safety and care of all 80 residents. Personnel files revealed that GNAs with start dates ranging from September 2021 to March 2023 had not received their required annual evaluations. Interviews with the Human Resources Director, Administrator, Director of Nursing, Chief Nursing Officer, and President of Clinical Operations confirmed that the evaluations were not completed due to nurse leadership turnover. The Chief Nursing Officer had implemented a directive for annual evaluations in January 2024, but it was not followed, leading to the deficiency.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature, as observed during two meal tray observations. This deficiency potentially affected all 80 residents who consumed food prepared by the facility's kitchen. During the initial screening, several residents expressed dissatisfaction with the taste and temperature of the food. Interviews with residents revealed specific complaints about the quality of meals, including unappetizing eggs, hard meat, and half-baked toast. These residents had intact cognition, as indicated by their BIMS scores, which ranged from 13 to 15 out of 15. Further observations during a group meeting and review of resident council minutes highlighted ongoing issues with food quality. Residents consistently reported that meals were cold and tasteless. A tray observation revealed that while some items were warm, they lacked flavor, and the dessert was dry. The facility's policy on Food and Nutrition Services, revised in October 2017, stated that each resident should receive a nourishing, palatable, well-balanced diet, considering their preferences. However, the facility did not adhere to this policy, as evidenced by the residents' complaints and the observations made during the survey.
Sanitation Deficiencies in Kitchen and Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting the preparation and serving of food to all 80 residents. During an initial kitchen tour, it was observed that the ice machine compressor was covered with a white powdery substance, and the floor around it was littered with trash, debris, and spider webs. The ice scoop holder contained water with a brown, gritty appearance, and the ice chest had a blackish-brown substance. Additionally, the floor and baseboards around kitchen equipment were covered with a greasy, dark sticky substance, and the tile grout appeared discolored. The hood vent had not been cleaned since February 2024, despite being due for cleaning in August 2024, and had a visible buildup of grease. Interviews with the Dietary Manager and the Regional Director of Maintenance revealed a lack of adherence to cleaning schedules and maintenance responsibilities. The Dietary Manager stated that the maintenance director was responsible for the ice machine's cleanliness, while the Regional Director of Maintenance acknowledged that scheduled maintenance tasks were not completed as required. Furthermore, during a tray line observation, a dietary aide was found not wearing a facial hair restraint, contrary to FDA Food Code requirements. The facility's policy on ice machines emphasized the need for proper cleaning and maintenance to prevent microbial contamination, which was not being followed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a kitchen tour with the Dietary Manager (DM). Three green dumpsters were located on a grass pad, surrounded by disposable gloves and a clear plastic trash bag with a hole, containing gloves, napkins, and food wrappers. The DM indicated that maintaining the garbage area was a housekeeping task, although dietary staff would pick up trash if found. The cleaning schedule for dietary staff did not include responsibility for the garbage area. A housekeeper believed maintenance was responsible, but all staff should clean around the dumpsters. The Administrator thought both dietary staff and housekeeping were responsible. The facility's policy stated that the surrounding area should be kept clean to minimize debris and insect/rodent attractions, and garbage should not accumulate outside the dumpster.
Inadequate PPE Use and Lack of Water Management Program
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of personal protective equipment (PPE) during catheter care for residents. Resident 65, who was readmitted with a diagnosis of obstructive and reflux uropathy, was observed receiving catheter care without the appropriate PPE. The Geriatric Nursing Assistant (GNA) 4 only wore gloves and did not don a gown, contrary to the facility's Enhanced Barrier Precautions (EBP) policy. The Interim Director of Nursing (DON) confirmed that the necessary PPE was not available outside Resident 65's room, and staff were not aware of the EBP requirements for residents with indwelling urinary catheters. Similarly, Resident 11, who had a physician's order for EBP due to an indwelling urinary catheter, did not have the required signage or PPE available. Licensed Practical Nurse (LPN) 3 and GNA17 provided care without wearing gowns, and there was confusion about the status of the EBP order. Resident 33, diagnosed with a drug-resistant urinary tract infection, had signage and PPE available, but GNA6 did not use a gown during care, indicating a lack of awareness about the resident's infection control needs. Additionally, the facility lacked a water management program, which is crucial for preventing Legionella infections. The Regional Director of Maintenance confirmed the absence of such a program and was unaware of any concerns related to Legionella. This oversight places all residents at risk, highlighting significant gaps in the facility's infection control measures.
Failure to Provide Required In-Service Training for GNAs
Penalty
Summary
The facility failed to provide the required 12 hours of in-service training for five Geriatric Nurse Aides (GNAs), which is necessary to ensure their continuing competencies. This deficiency was identified through interviews, personnel files review, and policy review. The facility's policy mandates that 12 hours of in-service training be provided annually based on the employment date. However, the personnel files of GNAs with start dates ranging from September 2021 to March 2023 revealed that they had not completed the required training. Interviews with the Human Resources Director, Administrator, Director of Nursing, Chief Nursing Officer, and the President of Clinical Operations confirmed that the training was not being provided. This lapse had the potential to impact the safety and care of 80 residents in the facility.
Facility Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment, as evidenced by the presence of black mold and other maintenance issues across multiple rooms. During an environmental tour, several deficiencies were observed, including black mold in rooms 408, 410, 400, 307, and 205, as well as structural damages such as unpainted spackle, holes in walls, and missing base molding. Additionally, there were issues with rusted fixtures, chipped counters, and missing covers for smoke detectors and ventilation fans. These conditions were confirmed by the Regional Director of Maintenance during a tour. Interviews with staff and residents revealed that maintenance issues had been reported but not addressed. A staff member indicated that the maintenance personnel had not performed their duties the previous week, and a resident reported that complaints about mold were ignored by the Maintenance Director. The resident had even marked the mold location with a sticky note, highlighting the lack of response to maintenance requests. The Regional Director of Maintenance acknowledged the findings and the need for significant repairs.
Failure to Implement Abuse Policy and Investigate Missing Narcotics
Penalty
Summary
The facility failed to fully implement its abuse policy in response to allegations of physical and verbal abuse, as well as misappropriation of property, involving three residents. One resident reported that a Geriatric Nursing Assistant (GNA) was rough during care and made threatening statements regarding the resident's diaper. The resident, who was cognitively intact and dependent on staff for toileting, expressed fear and reported soreness in his arms and neck. Despite the resident's report, the facility's investigation was delayed, and the abuse allegation was not reported immediately as required by the facility's policy. The investigation into the abuse allegation was initiated after a written statement was found under the Director of Nursing's (DON) door. The DON was informed of the incident via text message the previous evening but did not take immediate action to report the allegation. The investigation included obtaining statements from the involved staff, but the facility was unable to substantiate the abuse claims due to contradictory statements and lack of physical evidence. The resident was placed on daily safety checks, but the investigation did not include comprehensive interviews with all potential witnesses or other residents. In a separate incident, the facility failed to account for missing narcotics involving two residents. The investigation into the missing medications was incomplete, lacking written statements from the affected residents or other staff. The facility conducted an audit and background checks but was unable to determine the cause of the missing narcotics. The administrative staff involved in the incident were no longer employed at the facility, and the Interim DON was unfamiliar with the case, indicating a lack of continuity in addressing the issue.
Failure to Investigate Abuse and Missing Narcotics
Penalty
Summary
The facility failed to investigate allegations of physical and verbal abuse, as well as misappropriation of property, in a timely and thorough manner for several residents. One resident reported an incident where a Geriatric Nursing Assistant (GNA) was rough during care and made threatening remarks. Despite the resident being cognitively intact and dependent on staff for toileting, the facility did not initiate a care plan for behaviors upon admission. The investigation was delayed, and the alleged perpetrator was not immediately removed from the resident's care, leaving the resident and others at risk. In another incident, the facility did not adequately investigate missing narcotics for two residents. The medications were unaccounted for, and the facility was unable to determine what happened. The investigation lacked written statements from the involved residents or staff, and the administrative staff at the time of the incident were no longer employed, leaving gaps in the investigation process. Additionally, the facility failed to investigate a new injury for a resident who was found with a hairline fracture and bruising on the hand. Despite the physician's documentation indicating no known cause for the injury, the facility did not conduct an investigation, as they believed it was related to a previous fall. This lack of investigation left the cause of the injury undetermined.
Failure to Notify Responsible Party of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to notify a resident's responsible party when a new treatment was initiated for a pressure ulcer. This deficiency was identified during a review of the medical records and staff interviews, specifically concerning a resident who had been readmitted to the facility after a hospital stay. Upon readmission, the nursing admission assessment noted the presence of a pressure ulcer on the coccyx, but the length, width, depth, and stage were initially undetermined. Subsequent documentation on a wound note indicated that the resident had a Stage 3 pressure ulcer, and treatment orders were placed to cleanse the area with a wound cleanser, apply medical-grade honey and calcium alginate to the base of the wound, secure it with bordered gauze, and change it daily. However, the medical record did not contain documentation that the responsible party was informed of the Stage 3 pressure ulcer and the treatment plan. This oversight was confirmed during an interview with the Director of Nursing.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide timely treatment and services to prevent or heal pressure ulcers for Resident #65. Upon review of the medical records and staff interviews, it was found that Resident #65 was readmitted to the facility with a pressure ulcer on the coccyx, which was initially unable to be determined in terms of length, width, depth, and stage. A subsequent wound note on 10/25/23 documented that the ulcer was a stage 3 pressure ulcer present on admission, and treatment orders were placed to cleanse the area with a wound cleanser, apply medical grade honey, calcium alginate to the base of the wound, secure with a bordered gauze, and change the dressing daily. However, the review of Resident #65's October 2023 Treatment Administration Record (TAR) revealed that the wound dressing treatment was not initiated until 10/28/23, indicating a gap in treatment from 10/17/23 to 10/28/23. This lapse in care was confirmed during an interview with the Director of Nursing on 10/31/24. The failure to provide timely treatment for the pressure ulcer represents a deficiency in the facility's care for Resident #65.
Failure to Maintain Required RN Staffing Levels
Penalty
Summary
The facility failed to maintain the required staffing levels by not having a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency was identified during an annual survey, where it was found that on four specific days, the facility did not have RN coverage as required. The days without RN coverage were January 26, 2024, January 28, 2024, October 5, 2024, and October 20, 2024. This was confirmed through a review of staffing documentation provided by the Regional Director of Labor Management and an interview with the same individual, who acknowledged the lack of RN coverage on these dates. Numerous complaints regarding low staffing from residents, staff, and families were also reviewed during the survey, highlighting the ongoing issue of inadequate RN staffing.
Incomplete Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as required by accepted professional standards. For Resident #19, the care plan meetings held in March and July 2024 were not included in the resident's medical record, despite evidence of these meetings being available on paper. The Social Services Assistant admitted to keeping evidence of care plan meetings in her office and uploading them to the medical record when possible. This was confirmed by the Director of Nursing, who acknowledged the omission of the March and July 2024 care plan meetings from the medical record. Similarly, for Resident #45, the June 2024 care plan meeting was not documented in the resident's medical record, although evidence was available on paper. The Social Services Assistant again stated that she keeps evidence of care plan meetings in her office and uploads them when she can. The Director of Nursing confirmed the failure to include the June 2024 care plan meeting in the medical record. For Resident #62, the September 2024 care plan meeting was missing from the medical record, despite being documented on paper. The Social Services Assistant's practice of keeping evidence in her office and uploading it when possible was again noted, and the Director of Nursing confirmed the omission of the September 2024 care plan meeting from the medical record.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the treatment of two residents. Resident 14, who was cognitively intact with a BIMS score of 15 out of 15, reported that staff did not knock or introduce themselves before entering her room. During an interview, a Certified Medicine Aide (CMA) entered Resident 14's room without knocking and placed a lunch tray without introduction. Additionally, Resident 14 expressed frustration over the CMA's behavior, including rolling her eyes, which was observed by surveyors. The Interim Director of Nursing confirmed that staff are expected to knock and wait for permission before entering a resident's room and should not roll their eyes at residents. Resident 65, who had a BIMS score of zero indicating severe cognitive impairment, was left uncovered and exposed during a bath and catheter care by a Geriatric Nursing Assistant (GNA). Despite Resident 65 expressing that she was cold multiple times, the GNA did not cover her with a blanket or sheet, leaving her exposed throughout the care process. The Interim Director of Nursing stated that staff are expected to cover residents during care to prevent exposure. These incidents demonstrate a failure to uphold the facility's policy on promoting and maintaining resident dignity.
Failure to Provide Appropriate Incontinent Briefs
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not allowing her to choose the appropriate size of incontinent briefs, which led to discomfort and potential skin issues. The resident, who was readmitted with a diagnosis of morbid obesity, expressed that the current size of briefs was too tight and painful, causing difficulty in sitting up. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the resident's repeated requests for a larger size over two months were not addressed by the facility. Interviews with staff revealed that the resident was initially measured for a large size, but was provided with a 3x size, which was deemed insufficient by the resident and some staff members. The Medical Records/Central Supply staff decided against providing a larger size after a trial, assuming the resident did not complain further. However, observations confirmed the resident's discomfort, and staff acknowledged the need for a larger size due to the resident's condition as a heavy wetter. The Interim DON acknowledged the issue but did not provide a reason for the failure to supply the correct size.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to promptly resolve a grievance voiced by a resident, R4, during a resident council meeting. R4, who was cognitively intact with a BIMS score of 15, expressed concerns about another resident, R34, being rude due to the toilet not being cleaned properly after use. The grievance was documented on a Council Concern/Recommendation Form, but the form was undated and unsigned, indicating a lack of follow-up. The Activities Director stated that the concern was forgotten because the Director of Nursing, who received the concern, was no longer employed at the facility. Interviews revealed that the Social Services Assistant, who was responsible for ensuring grievances were followed up on, had given the form to the former Director of Nursing and had not seen it since. The Administrator, who oversees all grievances, confirmed that she had not seen the concern from R4 and acknowledged that there should have been more follow-up. This lack of action and communication led to the grievance not being resolved, which had the potential to cause further grievances to remain unresolved for other residents in the facility.
Delayed Transmission of MDS Assessment for Deceased Resident
Penalty
Summary
The facility failed to ensure timely transmission of a Minimum Data Set (MDS) assessment for one resident, identified as Resident 75, out of 31 sampled assessments. The resident was admitted to the facility and subsequently died there. The Death in Facility MDS was completed on time, but the transmission of this assessment was delayed. The MDS Coordinator confirmed that assessments are sent to corporate offices for batch transmission, and she was unaware of the exact submission date, although she sent it immediately. According to the CMS Long-term Care Facility Assessment Instrument 3.0 User's Manual, the transmission should occur no later than 14 days after the MDS death date. The facility's policy also mandates adherence to federal and state submission timeframes.
Failure to Develop Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter, resulting in the catheter being in place for seven months without a plan for its discontinuation. The resident, who was cognitively intact, was unsure of the reason for the catheter's placement. The initial physician's order was for a one-day use due to urinary retention, but the catheter remained in place due to a lack of follow-up and a delayed urology consultation. The medical record lacked a care plan addressing the catheter's use and discontinuation, and the Director of Nursing confirmed the absence of such a plan. The resident's medical records indicated a history of urinary retention and recurrent urinary tract infections, with a urology consult initially ordered but not completed until seven months later. The attending physician and medical director acknowledged the lack of medical justification for the prolonged use of the catheter and the delay in attempting a voiding trial. The failure to develop a care plan with specific interventions and goals for the catheter's use and discontinuation was verified by the Director of Nursing, highlighting a significant oversight in the resident's care management.
Deficiencies in Care Planning and Coordination
Penalty
Summary
The facility failed to ensure that a resident receiving hospice care had an integrated care plan, as required by their policies. The resident, identified as R32, was readmitted with a diagnosis of dementia and was under hospice care. However, the care plan did not reflect hospice involvement, and the interdisciplinary team (IDT) meetings did not include all necessary members, such as a hospice nurse and a nurse aide. Interviews with facility staff confirmed these omissions, indicating a lack of coordination and communication in care planning. Additionally, the facility did not conduct quarterly care plan meetings for several residents, including Resident #19, #45, and #65. Resident #19's last care plan meeting was in July 2024, missing the October 2024 meeting. Resident #45 missed multiple quarterly meetings, with no documentation of attempts to hold these meetings without the resident's presence. Resident #65's care plan meetings were not held for nearly a year, with missed opportunities to reschedule when the family was unavailable. These deficiencies highlight a pattern of inadequate care planning and coordination within the facility, potentially affecting the quality of care provided to residents. The lack of timely and comprehensive care plan meetings, as well as the failure to include all relevant parties in the planning process, suggests systemic issues in adhering to care planning protocols.
Failure to Conduct Weekly Weights for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, received weekly weight monitoring as ordered by the physician. R3 was readmitted to the facility with a diagnosis of dysphagia and had experienced a significant weight loss of 14 pounds (11%) over 30 days. The Registered Dietitian recommended weekly weights for closer monitoring, starting on 10/14/24. However, a review of the electronic medical record (EMR) revealed that there was no documentation of weights being taken on 10/14/24 and 10/21/24, as required. This was confirmed during an interview with the Interim Director of Nursing, who acknowledged that the weekly weights were not completed as ordered.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide necessary grooming services for two residents, R15 and R33, as part of their activities of daily living (ADL) care. R15, who was readmitted with a diagnosis of morbid obesity, was observed with greasy hair and white flakes, indicating a lack of proper hair washing. Despite being dependent on staff for bathing and hygiene, R15 was not offered showers due to her size exceeding the capacity of the available shower chair and bed. The Interim Director of Nursing confirmed that R15 had not been offered a shower in the past month, and there was no evidence in the Plan of Coordination that showers were offered or declined. Resident R33, who was admitted with a history of stroke and left-side paralysis, was also not receiving showers as per the facility's schedule. The resident's medical records indicated total dependence on staff for bathing, yet documentation showed only bed baths were provided from June to October 2024. Interviews with staff revealed issues with the availability and functionality of bariatric shower beds and slings, contributing to the lack of showers. R33 expressed fear of falling during the shower process and noted that staff often cited short staffing as a reason for not providing showers. The facility's failure to provide adequate ADL care was further highlighted by the broken shower bed pin, which was not promptly addressed. Staff interviews revealed a lack of communication and follow-up regarding maintenance issues, with the broken pin only being fixed during the surveyor's visit. The DON was informed of the situation, and R33 reiterated a preference for showers during the day shift due to perceived excuses from the evening shift about staffing shortages.
Deficiency in Smoking Area Safety Measures
Penalty
Summary
The facility failed to ensure the designated smoking area was safe for a resident who was the only smoker in the facility. The facility's policy required that the smoking area be protected from weather conditions and have accessible metal containers with self-closing covers for ashtrays. However, during observations, it was noted that there was no protective cover over the smoking area, and the metal container intended for ashtrays was full of trash. This was confirmed by the Regional Director of Labor, the Maintenance Director, and the Administrator in Training, who acknowledged that the conditions did not comply with the facility's smoking policy and could be unsafe when the area was in use. The resident involved, who was cognitively intact and safe to smoke with or without supervision, reported smoking six cigarettes per day at designated smoking times. Despite the lack of accidents related to smoking, the absence of a protective cover and the presence of trash in the metal container were identified as deficiencies. The Administrator also confirmed these observations, agreeing that the metal container should be free of trash before the resident smoked, indicating a failure to adhere to the facility's safety measures for the smoking area.
Deficiencies in Urinary Catheter Management and Care
Penalty
Summary
The facility failed to appropriately manage the urinary catheter care for a resident, identified as R11, who experienced multiple urinary tract infections (UTIs) while having an indwelling urinary catheter. Despite a physician's order to discontinue the catheter and monitor voiding, the catheter was not removed until a later date. The resident had a history of urinary retention and was initially given a catheter due to complaints of not being able to empty the bladder. However, a voiding trial was not attempted earlier, and a urology consult was delayed for several months, which contributed to the prolonged use of the catheter and recurrent UTIs. Additionally, the facility did not provide a policy for urinary catheter use when requested by surveyors. The medical records revealed multiple instances of UTIs treated with antibiotics, and the attending physician expressed concerns about antibiotic resistance. The Medical Director noted that there was no medical indication for the prolonged use of the catheter and that a voiding trial should have been conducted earlier. In another instance, the facility failed to provide proper catheter care for another resident, identified as R65. During an observation, a Geriatric Nursing Assistant (GNA) did not follow the facility's catheter care policy, which included not cleaning the labia area properly and not changing the direction of the washcloth. This was confirmed by the Interim Director of Nursing, who acknowledged that the staff did not adhere to the correct procedures for catheter care.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 201 citations issued within 25 miles in the last 12 months — including the 3 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Denton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Caroline Nursing And Rehab | 1.4 mi | ★★★★★ | 5 | 0 |
| Pines Nursing And Rehab | 16.5 mi | ★★★★★ | 90 | 0 |
| Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase | 16.7 mi | ★★★★★ | 0 | 0 |
| Complete Care At Corsica Hills Llc | 17.5 mi | ★★★★★ | 21 | 0 |
| Delaware Veterans Home | 19.3 mi | ★★★★★ | 7 | 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.