Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
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 Egle Nursing Home during CMS and state inspections, most recent first.
A resident was transferred to the hospital after a fall, but record review found no documentation that the resident or the resident’s representative received written transfer notice or a transfer summary. The DON stated the facility’s current process was not to provide transfer notices in writing, and there was no record showing written notification was given.
A resident with Alzheimer's disease and dementia was found with a right hip fracture of unknown origin. The facility's investigation included staff interviews and security footage review but did not include interviews with other residents. The DON acknowledged that interviewing other residents was not considered, which limited the ability to rule out abuse or improper staff handling.
A resident with dementia and severe cognitive impairment was observed in a wheelchair with a lap buddy positioned in front of him/her, and the resident repeatedly tried but was unable to remove it. The device was used to remind the resident not to stand up, but the record did not identify it as a restraint, did not include a pre-restraint assessment, and lacked documentation of ongoing monitoring and repositioning every 2 hours.
The facility failed to adequately monitor a resident receiving daily antianxiety medication for anxiety. Although the care plan directed staff to monitor and record medication effectiveness, side effects, adverse consequences, and behaviors, the MAR and TAR lacked documentation showing that staff monitored the resident’s behaviors or side effects related to the psychotropic medication. The RN stated behaviors and side effects were documented for all residents, but the DON reviewed the record and confirmed the documentation was missing.
Late Completion of Admission MDS Assessments: The facility failed to complete admission MDS assessments for two residents within required time frames. One resident’s MDS was completed 11 days late and another was completed 2 days late; an MDS nurse confirmed both assessments were late.
A resident’s quarterly MDS was not completed within the required timeframe. The resident had an admission MDS completed, but the next quarterly assessment was not found in the record when reviewed, and an MDS nurse stated she missed the scheduled assessment.
A resident’s MDS inaccurately coded anticoagulant use during the look-back period even though the MAR showed antiplatelet use and no anticoagulant documentation. An MDS nurse confirmed the coding error and stated that aspirin use should have been recorded instead.
Failure to provide activity programs that met a resident’s needs and preferences. A resident with dementia and severe impaired cognitive status was observed in bed and not engaged in activities, including calling out for help during one observation. The MDS documented preferences for music and going outside for fresh air when weather was good, but activity logs showed 1:1 visits, family visits, and music without evidence of outdoor activities matching the resident’s stated preference.
A resident with a pressure injury was found on an air mattress set at the max 450-lb setting, with no documented 2025 weight and no order or care plan direction for the mattress setting. Staff said maintenance set up the mattress and inflated it to max firm, while nursing did not know who determined the correct setting or how to verify it was appropriate for the resident.
A resident with urinary retention and an indwelling Foley catheter was observed in bed with the urine collection bag laying directly on the floor. An LPN later confirmed the bag was on the floor and then secured it to the bed frame. The resident's care plan included an intervention that tubing or any part of the drainage system should not touch the floor.
The facility failed to complete the resident Matrix accurately during survey. The DON presented a complete Matrix, but it did not show any resident receiving end-of-life, Comfort Care, or Palliative Care even though a resident's record documented terminal condition and a care plan for terminal/end stage condition. The DON confirmed the resident was receiving end-of-life care and should have been reflected in the Matrix.
A resident’s record contained duplicate and contradictory active MOLST forms in both the electronic chart and paper chart, including one form indicating CPR and two duplicate forms indicating no CPR. A unit nurse confirmed the conflicting forms and said she would honor the most current form if there was a discrepancy. The DON and ADON were interviewed and confirmed the facility did not have a specific process for voiding inactive MOLST documents, and the old forms were not handled according to the MOLST instructions.
QAA committee sign-in sheets showed monthly meetings, but documentation did not confirm that required attendees were present at all meetings. The Nursing Home Administrator was not documented as attending several meetings, and the DON was not documented as attending two meetings. Staff interviews were unable to provide proof that all required attendees participated in every meeting.
Improper Storage of Clean Linens in Dirty Linen Areas: Surveyors found clean folded bed pads stored in a dirty laundry area with no separation between clean and dirty sides, and clean personal bedding linens stored uncovered in a dirty linen room among soiled linen bins and bags. Staff confirmed clean linens should not have been stored in those areas, and the IP nurse later acknowledged the finding.
Failure to Document COVID-19 Vaccine Education and Offering: The facility failed to document screening, education, offering, and current COVID-19 vaccination status for a staff member who was eligible for the 2024-2025 COVID-19 vaccine. The IP nurse stated the facility did not offer COVID vaccines to employees due to insurance reimbursement, did not track staff vaccine status, and did not provide vaccine education, despite the facility policy requiring that residents and staff be offered the vaccine and that staff receive education on its benefits, risks, and side effects.
A resident in a shared room did not have full visual privacy because the overhead curtain for the resident’s bed was too short and left the foot of the bed open when fully extended. An LPN demonstrated the curtain during incontinence care and confirmed it did not cover all sides of the bed, and the DON agreed the curtain needed to be longer.
Failure to Provide Required Abuse Education: The facility failed to ensure staff were educated on abuse, neglect, exploitation, resident abuse prevention, and reporting procedures. Review of training records for the DON and four staff members showed no abuse training during onboarding or since February 2024, and the 2025 education calendar did not include abuse training. The DON confirmed the training had been missed and was not part of onboarding education.
The facility failed to ensure nurse aides received required in-service education on dementia management and abuse prevention. Record review and interviews showed the DON could not provide documented evidence that these topics were included in onboarding or annual education for nurse aides, despite the facility assessment stating that training must cover abuse prevention, dementia care, and the care of cognitively impaired residents.
Surveyors identified deficiencies in food storage and expiration date management at the facility. Uncovered pans of cooked food were found in the refrigerator, contrary to the facility's policy, and several canned food items lacked expiration dates. Staff struggled to determine expiration dates, requiring assistance from the food distributor.
The facility failed to review and revise care plans for two residents after assessments. One resident, with severe cognitive impairment and physical limitations, had a care plan that included bed rails, but the plan was not reassessed for effectiveness. Another resident, with severe cognitive impairment and behavioral symptoms, had multiple care plans that were not updated following the most recent MDS assessment. The MDS Coordinator and DON acknowledged these deficiencies.
A resident with a PEG feeding tube was not properly positioned during medication administration and feeding, as the head of bed was elevated only to about 10 degrees instead of the required 45 degrees. The staff member involved admitted to not following the care plan due to nervousness, and the DON confirmed the expectation for proper HOB elevation to prevent aspiration.
A GNA entered a resident's room without knocking or requesting permission, violating the resident's right to dignity and self-determination. The incident was reported to the DON, who noted that the GNA was confused because the door was usually open.
A facility failed to complete a comprehensive MDS assessment for a resident, omitting cognitive and mood evaluations. The MDS Coordinator confirmed the oversight, noting the Social Worker was responsible. The Social Worker acknowledged the error, citing an unrecognized change in the resident's health insurance requirements.
A facility failed to complete a Significant Change in Status MDS assessment within the required 14-day period after a resident experienced a significant decline in condition, including a left tibial plateau fracture. The MDS assessment was completed 24 days after the change was noted, and the MDS coordinator was unaware of the 14-day requirement.
Two residents' MDS assessments were inaccurately coded, leading to deficiencies. One resident's MDS failed to capture the diagnosis for antipsychotic medication use, despite available documentation. Another resident's MDS omitted a BIMS score assessed on the ARD, confirmed by the Social Service Director.
A resident with left hemiparesis due to a stroke did not receive the ordered palm protector to prevent worsening hand contracture. Despite an order for the device to be worn at all times, it was not observed in use, and staff interviews revealed a lack of adherence to the care plan due to oversight and workload issues.
A facility failed to explore alternatives and assess a resident's risk of entrapment before installing bed rails. The resident, with severe cognitive impairment and mobility issues, was unlikely to benefit from the rails. The facility also lacked ongoing evaluation and specific monitoring of the resident's use of bed rails, and did not conduct routine maintenance checks on bed equipment.
The facility failed to ensure timely documentation of physician visit notes for two residents. The EMRs showed that notes were dated after the actual visit dates, indicating a delay in documentation. The DON acknowledged the concerns but did not provide further comments.
A facility staff member failed to wear a gown while providing care to a resident with a PEG feeding tube, despite enhanced barrier precautions requiring both gloves and gowns. The resident needed extensive assistance, and signage indicated the need for these precautions. Interviews confirmed staff were trained and gowns were available, yet the deficiency occurred.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, relying instead on aides to report issues. This deficiency was identified during an observation of a resident with bed rails attached, and the maintenance director confirmed the lack of routine checks. The issue had the potential to affect all residents, and the nursing home administrator acknowledged the concerns.
A facility failed to provide full visual privacy for a resident in a shared room. The privacy curtain only extended to the length of the beds, which was inadequate for a resident using a bedside commode. The DON confirmed that the room's ceiling configuration prevented proper curtain installation.
The facility failed to maintain accurate medical records, including incorrect transcription of antipsychotic medication indications, lack of documentation for a wound evaluation, and missing records of a care plan meeting. These issues involved two residents, one with a Stage III pressure ulcer and another with mental health diagnoses.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide written notice of transfer to the resident or the resident’s representative for Resident #66, who was transferred to the hospital after a fall. A progress note documented that staff heard a loud thump, found the resident on the bathroom floor, determined the resident had fallen, and transferred the resident to the hospital following an assessment. The record review found no documentation showing that a written transfer notice or summary had been provided. A second review of the medical record also found no evidence that transfer information had been given to the resident or the resident’s representative. During interviews, the DON stated she was unsure whether written notices were provided and later stated that the facility’s current process was not to provide transfer notices in writing. The DON confirmed there was no record supporting that Resident #66 or the resident’s representatives were notified in writing of the hospital transfer.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin involving a resident with Alzheimer's disease, dementia, and muscle wasting and weakness. The resident was found sitting in a wheelchair with their right leg in an unnatural position, and a fracture was suspected. The resident was transferred to the hospital, where a right hip fracture was confirmed, requiring surgical intervention. The facility's investigation included interviews with all staff members involved in the resident's care and a review of security footage, which confirmed the resident remained in their room throughout the day. However, there was no evidence that any other residents were interviewed as part of the investigation. During interviews, the DON stated that her process for investigating injuries of unknown origin involved reviewing staff schedules and interviewing staff who had contact with the resident. She acknowledged that she did not consider interviewing other residents, even though this could have provided additional information about the incident. The surveyor noted that without interviewing other residents, the facility could not rule out possible abuse or determine whether staff handling may have contributed to the injury. The DON agreed that interviewing other residents would have been an important step in the investigation.
Failure to Recognize and Monitor Lap Buddy as a Restraint
Penalty
Summary
The facility failed to identify a lap buddy as a physical restraint, failed to complete a pre-restraining assessment for its use, and failed to provide ongoing monitoring and evaluation for continued use for one resident. The resident was observed sitting in a wheelchair beside the bed with a lap buddy positioned in front of him/her, and the resident was seen attempting to remove it but was unable to do so. Later observations showed the resident remained in the wheelchair with the lap buddy in place, with no documented opportunities for repositioning or release of the device for mobility. The resident had severe cognitive impairment due to dementia and had a post-fall assessment after a fall that recommended a lap buddy on the wheelchair when up and out of bed for safety because of repeated attempts to stand unassisted. The attending provider also ordered a lap buddy for safe positioning and stability while seated, but the review did not identify it as a restraint or include a pre-restraining assessment. The facility’s restraint policy stated that restrained residents must be repositioned at least every two hours, but the record lacked documentation of ongoing monitoring, including repositioning at least every two hours. Staff stated the lap buddy was used to remind the resident not to stand up and that no specific assessment was completed for its use as a restraint.
Lack of Monitoring for Antianxiety Medication Use
Penalty
Summary
The facility failed to ensure that one resident’s medication regimen was free from unnecessary psychotropic medication use by not adequately monitoring the resident for behaviors, side effects, or adverse consequences related to antianxiety medication use. Resident #8 received antianxiety medication daily for anxiety, and the care plan included interventions to monitor and record drug effectiveness, side effects, adverse consequences, and behaviors per protocol, with quantitative and objective documentation of behaviors. A review of the resident’s MAR and TAR from August through October 7, 2025, did not show evidence that staff monitored changes in behaviors that supported the use of the antianxiety medication or documented side effects related to the medication. An RN stated that staff documented behaviors and side effects in the MAR or TAR for all residents, but the record for Resident #8 lacked such documentation. The DON also reviewed the MAR and TAR and confirmed that the record lacked documentation of monitoring for behaviors and side effects related to the antianxiety medications.
Late Completion of Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive MDS assessments for 2 of 34 residents reviewed within the required regulatory time frames. The report states that the admission MDS is a federally mandated assessment tool used to gather information about each resident’s strengths and needs, and that the information collected drives care planning decisions. It also states that the admission MDS must be completed by the end of day 14, counting the admission date as day 1. For Resident #8, the admission MDS had an ARD of 3/18/2025 and was due to be completed by 3/24/2025, but it was not completed and signed in sections V0200B2 and Z0500B until 4/4/2025, 11 days late. For Resident #61, the admission MDS had an ARD of 6/20/2025 with an admission date of 6/16/2025 and was due by 6/29/2025, but it was completed and signed in section V0200B2 on 7/1/2025, 2 days late. During an interview on 10/9/2025, the MDS nurse confirmed that both admission MDS assessments were completed late.
Missed Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a Quarterly MDS assessment for one resident within the required regulatory time frame to keep the assessment record current and support care planning. Resident #61 had been residing in the facility since June 2025, and the admission MDS dated [DATE] was completed on 7/1/2025. The resident’s next MDS assessment was due by 9/20/25, but the record review on 10/7/2025 did not show that staff had completed or submitted the quarterly MDS, leaving 109 days since the last OBRA MDS assessment was completed. During an interview on 10/9/2025 at 8:28 AM, an MDS nurse stated that she missed completing Resident #61’s quarterly MDS assessment, which had been scheduled for 9/23/2025.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to ensure that an MDS assessment was accurately recorded for one resident reviewed for resident assessments. The resident’s MDS dated [DATE] documented anticoagulant drug use during the observation period, but review of the August 2025 MAR showed documentation of antiplatelet use and no documentation of anticoagulant use during that same look-back period. The record therefore did not reflect the resident’s actual medication use on the MDS, as aspirin was given during the observation period and should have been documented as antiplatelet use. During interview, the MDS nurse stated that anticoagulant use had been recorded in error on the MDS and that antiplatelet use should have been documented.
Failure to Provide Activities Matching Resident Preferences
Penalty
Summary
The facility failed to provide activity programs to meet Resident #8’s needs and preferences. Resident #8 had diagnoses of dementia and severe impaired cognitive status. Observations on 10/1/2025 and 10/2/2025 showed the resident lying in bed and not involved in any activity, and on the second observation the resident was calling out, “Help me, help me.” The MDS assessment documented activity preferences that were very important to the resident, including listening to preferred music and going outside for fresh air when the weather was good. However, review of activity logs for August 1 through September 30, 2025 showed activities such as 1:1 visits, family visits, and music, and did not show the resident participating in outdoor activities consistent with the documented preference to go outside for fresh air.
Pressure Injury Care and Air Mattress Setting Not Properly Monitored
Penalty
Summary
The facility failed to ensure that a resident with a pressure injury received appropriate treatment and prevention services. Resident #43, who had been in the facility since 2023 and had diagnoses including dementia, muscle wasting, and adult failure to thrive, was identified in the facility matrix as having a pressure injury/ulcer. The resident was observed sleeping in bed on an air mattress, and the mattress control was set to the max weight setting of 450 lbs. The resident’s record contained no documentation of a 2025 weight, and the medical orders and care plan did not indicate what the air mattress weight setting should be. Staff interviews showed that the nursing staff checked that the mattress was functioning and not deflated, but maintenance staff set up the air mattress and inflated it to the max firm setting before notifying nursing that it was ready. The charge nurse and another LPN stated they did not know who instructed maintenance on the proper setup or how to determine whether the mattress setting was appropriate for the resident. When the resident was later observed again, the air mattress had been changed to 130 lbs, and the DON acknowledged that the facility would audit resident weights against mattress settings. The DON and NHA were informed that the resident’s air mattress had not been assessed and monitored to ensure the setting was appropriate for treatment and prevention of pressure injuries/ulcers.
Urine Collection Bag Left on the Floor
Penalty
Summary
The facility failed to ensure a resident with urinary retention and an indwelling urinary catheter had the urine collection bag secured and kept off the floor. Resident #4 was admitted in mid-2025 with a diagnosis that included urinary retention, and the resident had a Foley catheter in place for urine drainage. On 10/1/25 at 10:47 AM, the resident was observed in bed with the urine collection bag laying directly on the floor. The observation was discussed with the assigned LPN at 11:07 AM, who checked on the resident and confirmed that the bag was on the floor. The staff member then entered the room and secured the bag on the resident's bed frame. A later review of the resident's care plan showed an intervention stating that tubing or any part of the drainage system should not touch the floor.
Inaccurate Resident Matrix
Penalty
Summary
The facility failed to complete the residents' Matrix accurately during the recertification survey. After the initial entry on 10/1/25, the DON presented a complete Matrix for all residents, but the survey team found that it did not reflect all residents as of the day of the survey. The Matrix showed no resident receiving end-of-life care, Comfort Care, or Palliative Care. However, Resident #4's medical record included an attending provider note dated 9/30/25 stating the resident was in terminal condition, and the care plan included a focus titled Terminal/End stage condition created on 9/30/25. In an interview on 10/2/2025 at 1:30 PM, the DON stated she was unsure why Resident #4's end-of-life care information did not transfer from the EHR to the Matrix and confirmed that Resident #4 was receiving end-of-life care and should have been reflected in the Matrix.
Duplicate and Contradictory MOLST Forms in Resident Record
Penalty
Summary
The facility failed to ensure that resident records were accurate for one resident who had duplicate and contradictory active Maryland MOLST forms in both the electronic record and the paper chart. A review of the resident’s electronic chart showed three separate active MOLST forms in the scanned records portion, including one form indicating the resident should have CPR and two duplicate forms indicating the resident should not have CPR. The same three MOLST forms were also found in the resident’s paper chart. During interview, a unit nurse confirmed the presence of duplicate and contradictory active MOLST forms in the record and stated that if there was a discrepancy between two MOLST forms, she would honor the most current form. The DON and ADON were interviewed about the facility’s MOLST process and stated that the ADON was responsible for MOLST forms. The DON described that an inactive form should have a line drawn through it, but did not identify the requirement to write VOID or include a signature and date. The ADON stated that when a resident’s MOLST was updated, the old document should be lined through and scanned into the electronic record, and confirmed the facility did not have a specific process for voiding inactive MOLST documents. The DON later confirmed that the facility did not follow the proper process for inactive MOLST documents.
QAA Committee Attendance Documentation Missing
Penalty
Summary
The facility failed to ensure that the required attendees participated in its Quality Assessment and Assurance (QAA) committee meetings at least quarterly. Review of QAA committee sign-in sheets from August 2024 through August 2025 showed that meetings were held monthly, but the documentation did not show the Nursing Home Administrator attended meetings in November 2024, January 2025, April 2025, May 2025, and September 2025. The review also did not show that the Director of Nursing attended the meetings in March 2025 and April 2025. During an interview on 10/9/2025 at 10:51 AM, the current QA Nurse and former QA nurse were unable to provide documentation confirming that all attendees were present at all meetings, and no additional evidence was provided before the survey ended.
Improper Storage of Clean Linens in Dirty Linen Areas
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed that the facility failed to properly store clean linens in two of two soiled laundry areas. In the first laundry room, one side contained two washing machines identified as the dirty area and the other side contained two dryers identified as the clean area, but there was no separation between the clean and dirty sides of the room. Directly across from the washing machines, a cart with a pile of folded bed pads that Staff #7 identified as clean and ready for resident use was stored in the dirty linen area, and Staff #8 confirmed clean linens should not have been stored there. Surveyors also observed a separate dirty linen room across the hall that contained a large bin of blue plastic bags with dirty linens ready for pickup by the laundry service, along with smaller dirty linen bins used to transport soiled linens from the nursing units. On the back wall of that room, an uncovered linen cart held what Staff #7 identified as clean folded personal bedding linens belonging to a deceased resident and intended for donation, and both Staff #7 and Staff #8 confirmed those clean linens should not have been stored in the dirty linen room. The infection preventionist nurse later confirmed the finding during interview and stated she would be conducting training with laundry staff, and the DON later stated there would be improvements made to the laundry area and linen storage.
Failure to Document COVID-19 Vaccine Education, Offering, and Status
Penalty
Summary
The facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for staff. During the infection control task portion of the recertification survey, 2 staff were reviewed for COVID-19 immunizations, and one staff member was identified as eligible for the 2024-2025 COVID-19 vaccine. A review of that staff member’s health record did not reveal any evidence that she was screened, educated, or offered the 2024-2025 COVID-19 vaccine. During interview, the infection preventionist nurse stated that the facility did not offer COVID vaccines to employees due to insurance reimbursement and that it was not the facility’s practice to track employee COVID-19 vaccine status or provide education on the COVID-19 vaccine. The facility later provided its policy titled Policy on Resident and Staff COVID-19 Immunizations, Education, and Reporting, which stated that when COVID-19 vaccine is available, each resident and staff member is offered the vaccine unless medically contraindicated or already immunized, and that all staff members are provided education on the benefits, risks, and potential side effects before the vaccine is offered. The infection preventionist nurse confirmed the facility did not follow the regulation or its own policy, and the DON acknowledged the deficiency.
Incomplete Privacy Curtain Coverage in Shared Room
Penalty
Summary
The facility failed to provide full visual privacy to a resident in a non-private room. During an initial room inspection, Resident #4’s room was observed to have two occupied beds with overhead privacy curtain rails, but the curtain for the resident’s bed on the window side only covered one side of the bed and left the foot of the bed completely open when fully extended. When the charge nurse was asked to demonstrate how privacy would be maintained during incontinence care, she pulled the curtain and confirmed that it was not long enough to cover all sides of the bed. The DON later inspected the curtain and agreed that the railing and hooks appeared sufficient, but the curtain itself needed to be longer.
Failure to Provide Required Abuse Education
Penalty
Summary
The facility failed to ensure that staff were educated on abuse, neglect, exploitation, and resident abuse prevention, as well as the procedures for reporting abuse, neglect, exploitation, or misappropriation of resident property. During review of the facility assessment, the surveyor found that the facility’s stated staff training expectations included education on these topics upon hire. However, when the surveyor requested employee training records, the DON stated that abuse training was part of the annual education program, but the records for the DON and Staff #10, #11, #12, and #13 showed no evidence of abuse training during onboarding or since February 2024, approximately 20 months earlier. The surveyor also reviewed the facility’s 2025 monthly education document, which listed completed and projected education topics, and abuse training was not included. When questioned further, the DON confirmed that abuse training had been missed because the social worker who typically conducted it had been out of work, and she stated that abuse training was not part of onboarding education. The NHA and DON later acknowledged that they needed a consistent education calendar to ensure abuse training occurred annually and upon hire.
Missing Dementia and Abuse Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received in-service education that included dementia management and abuse prevention. Record review showed that the facility assessment dated January 2025 stated employee education protocols included abuse, neglect, exploitation, and misappropriation training, as well as care and management for persons with dementia and resident abuse prevention, and that nurse aide education must be no less than 12 hours per year and include dementia training and resident abuse prevention training. The deficiency was identified for 2 of 5 staff reviewed under the Sufficient and Competent Staffing task, specifically Staff #12 and #13. During the survey, the DON stated that staff receive some training upon hire and monthly one-hour courses, and provided a monthly education document listing training completed since January 2020 and projected through the end of 2025. However, the surveyor was unable to find evidence that dementia management or abuse training had been included in the nurse aide training. When the concern was raised, the DON confirmed there was no documented evidence of training related to dementia management or abuse prevention, and the NHA and DON agreed the facility had not included those topics in onboarding or annual education for nurse aides.
Deficiencies in Food Storage and Expiration Date Management
Penalty
Summary
The facility staff failed to properly store food items in the kitchen's walk-in refrigerator and did not have a process in place to determine the expiration date of food procured from vendors. During an initial tour of the kitchen, surveyors observed uncovered pans of cooked potatoes and rice pudding in the refrigerator, which were not loosely covered as required by the facility's policy for cooling food products. Staff #7, the Certified Dietary Manager, acknowledged that the pans were uncovered because the food was cooling, but later confirmed that the policy required pans to be loosely covered during cooling. Additionally, the surveyors found several canned food products in the dry storage room that were not labeled with a manufacturer's expiration date or a production date. Staff #7 was unable to determine the expiration dates of these products and had to contact the food distributor for assistance. Although some expiration dates were eventually determined, Staff #7 and Staff #13 were still in the process of verifying the expiration dates for certain products, such as canned apricots and applesauce, at the time of the survey. The Nursing Home Administrator was made aware of these concerns.
Failure to Review and Revise Care Plans
Penalty
Summary
The facility failed to review and revise care plans for residents after each assessment, as required. This deficiency was observed in the cases of two residents. For the first resident, who had severe cognitive impairment and physical limitations, the care plan included the use of bed rails as enablers. However, the resident was unable to utilize the bed rails due to their dependency on maximum assistance for mobility. Despite this, the care plan was not reassessed to determine the effectiveness of the interventions, such as the need for a bed alarm or assistance with toileting, and the necessity of the bed rails was not reevaluated. In the case of the second resident, who had severe cognitive impairment and exhibited behavioral symptoms, the facility failed to update the care plans following the resident's most recent MDS assessment. The resident's care plans addressed various issues, including behavioral symptoms, cognitive loss, communication, psychotropic drug use, pain management, and pressure ulcers. However, there was no documentation of care plan evaluations or revisions after the assessment, indicating a lack of evaluation of the resident's progress or the effectiveness of current interventions. The MDS Coordinator acknowledged the concerns regarding the failure to evaluate and revise care plans following the MDS assessments. The Director of Nurses was also made aware of these issues. The lack of timely review and revision of care plans for these residents highlights a deficiency in the facility's compliance with regulatory requirements for resident care planning.
Failure to Elevate Head of Bed for PEG Feeding
Penalty
Summary
The facility staff failed to ensure proper elevation of the head of bed (HOB) for a resident during medication administration and infusion of a percutaneous endoscopic gastrostomy (PEG) feeding. This deficiency was identified for one resident who was reviewed for tube feeding. The resident had a PEG feeding tube due to difficulty swallowing, as documented in their care plan. The care plan, initiated in December 2020, included an intervention to keep the HOB elevated at 45 degrees at all times. An attending provider's order from April 2023 also specified that the HOB should be elevated 45 degrees every shift. During an observation in May 2024, the resident was found lying on their back with the HOB elevated to only about a 10-degree angle while a staff member administered medications and resumed PEG feeding. The staff member confirmed that the HOB was not elevated to the required 45 degrees and admitted to elevating it only to about 15 degrees due to nervousness. The Director of Nursing stated that the expectation was for nurses to follow the provider's order to reduce the risk of aspiration, and acknowledged that the staff member had reported the failure to elevate the HOB correctly.
Failure to Respect Resident's Privacy
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not treating them with respect and dignity. This deficiency was identified when a Geriatric Nursing Assistant (GNA) entered a resident's room without knocking or requesting permission. The incident occurred during an interview with the resident, whose room door was closed at the time. The Director of Nurses (DON) was informed of the incident and acknowledged that the GNA had reported being thrown off by the door being closed, as it was usually kept open.
Incomplete MDS Assessment for Resident
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident, specifically omitting the assessment of cognitive patterns and mood. This deficiency was identified during a review of the resident's medical record, which showed that the annual assessment with an Assessment Reference Date (ARD) was not fully completed. The MDS is a federally mandated tool used to ensure that each resident's individual needs are identified and addressed through a standardized assessment process. During an interview, the MDS Coordinator confirmed that the cognitive and mood assessments for the resident had not been completed, attributing the responsibility to the Social Worker. The Social Worker acknowledged the oversight, explaining that a recent change in the resident's health insurance provider, which required completion of these assessments, had not been realized at the time of the assessment.
Failure to Timely Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required 14-day period following a significant decline in a resident's condition. This deficiency was identified during a recertification survey for one resident. The resident, who was admitted to the facility in June 2019, experienced a significant change in condition when they complained of left knee pain and swelling on February 13, 2024. An X-ray was ordered, and it was later determined that the resident had a left tibial plateau fracture on February 15, 2024. Despite the significant change in the resident's condition being identified on February 13, 2024, the Significant Change in Status MDS assessment was not completed until March 7, 2024, which was 24 days after the change was noted. The MDS coordinator, during an interview, acknowledged that she was unaware of the requirement to complete the assessment within 14 days of determining a significant change in a resident's condition. This oversight led to the facility's failure to comply with the federally mandated timeline for MDS assessments.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents. For Resident #64, the MDS assessment did not capture the diagnosis of delusions and hallucinations, which was the indication for the use of an antipsychotic medication. Although a physician's order report signed by an attending provider documented these diagnoses, the MDS coordinator forgot to record them in the MDS assessment. This oversight occurred despite the availability of the necessary documentation prior to the completion of the MDS. For Resident #35, the MDS assessment did not include the Brief Interview for Mental Status (BIMS) score, which was assessed on the same date as the Assessment Reference Date (ARD). The BIMS score of 15/15 was documented in a social service progress note, but it was not captured in the MDS assessment submitted four days later. The omission was confirmed by the Social Service Director, indicating a failure to include all relevant assessment information available during the lookback period.
Failure to Provide Ordered ROM Treatment
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the necessary treatment and services to prevent further decline. Resident #43, who was admitted with left hemiparesis due to a stroke, required extensive assistance for self-care and had functional limitations in both upper and lower extremities. An order was in place for the resident to wear a left upper extremity palm protector at all times, except during bathing and hand hygiene, to prevent worsening of hand contracture. However, during an observation, the resident was found without the palm protector, and staff interviews revealed that the device was not consistently used as required. Staff interviews indicated a lack of adherence to the care plan, with a licensed practical nurse unaware of the palm protector's location and a geriatric nurse aide admitting to not checking for the device due to being too busy. The occupational therapy team confirmed the importance of the palm protector in preventing contracture worsening, yet it was not observed in use. This deficiency highlights a failure in the facility's responsibility to provide ordered treatments and services to maintain the resident's range of motion.
Failure to Assess and Monitor Bed Rail Use
Penalty
Summary
The facility failed to identify and use appropriate alternatives before installing bed rails for a resident, and did not assess the resident's risk of injury or entrapment prior to their use. The resident in question had severe cognitive impairment, dementia, hemiplegia, and hand contractures, and was dependent on assistance for all activities of daily living and mobility. Despite these conditions, the facility did not document any exploration of alternatives to bed rails or assess the risks of entrapment before installation. The resident's medical record included a physician's order for bed rails and a signed informed consent form from the resident's representative, acknowledging the risks and benefits of bed rail use. However, the facility did not provide evidence of ongoing evaluation to ensure the bed rails met the resident's needs or that specific monitoring and supervision were provided during their use. The physical therapist confirmed that the resident was unlikely to benefit from the bed rails due to their dependency and inability to grasp the rails. Additionally, the facility lacked a regular maintenance program to inspect bed frames, mattresses, and bed rails, relying instead on reports of issues to address problems. This lack of routine maintenance was acknowledged by the Maintenance Director and discussed with the Nursing Home Administrator, who recognized the concerns raised by the surveyors.
Failure to Document Physician Visit Notes Timely
Penalty
Summary
The facility staff failed to ensure that physician progress notes were written, signed, and dated at each required visit for two residents. For one resident, the electronic medical record (EMR) and paper medical record showed discrepancies in the dates of the physician's visit notes. The notes were dated after the actual visit dates, indicating a delay in documentation. The Director of Nurses (DON) was informed of these concerns and acknowledged them, believing that the physician dictated the notes on the day of the visit. Similarly, for another resident, the EMR revealed that the physician's visit notes were not documented on the day of the visit. The notes were dated several days after the actual visit dates. The DON was made aware of these issues and acknowledged the concerns but did not provide further comments. This deficiency was identified during a review of residents for unnecessary medications.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control protocols by not wearing the required personal protective equipment (PPE) when providing direct care to a resident with a percutaneous endoscopic gastrostomy (PEG) feeding tube. Specifically, during an observation, a geriatric nurse aide was seen giving a bed bath to the resident while only wearing gloves, neglecting to wear a gown as mandated by the enhanced barrier precautions. These precautions are essential for reducing infection transmission during high-contact care activities for residents with medical devices such as feeding tubes. The resident in question required extensive assistance for all self-care needs and was on enhanced barrier precautions, as indicated by signage on the resident's door. Despite the availability of gowns in the resident's room and staff training on these precautions, the nurse aide did not comply with the requirement to wear a gown. Interviews with the staff, including the director of nursing, confirmed that all staff were expected to follow these precautions, yet the deficiency occurred, highlighting a lapse in adherence to infection control protocols.
Failure to Conduct Regular Bed Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which is a crucial part of their maintenance program to prevent potential entrapment risks. This deficiency was identified during an observation of a resident lying in bed with bilateral bed rails attached. The maintenance director confirmed that no routine maintenance checks were performed on the beds or bed rails, and the facility relied on aides to report any issues to maintenance for further inspection. The deficiency was evident for one resident reviewed for accidents, but it had the potential to affect all residents in the facility. The maintenance director stated that the facility's protocol involved aides assessing the beds and notifying maintenance if there were any problems. However, there was no structured routine maintenance program in place to ensure the equipment was inspected and maintained according to the manufacturer's recommendations and requirements. The nursing home administrator acknowledged the concerns when they were discussed.
Failure to Provide Full Visual Privacy in Shared Room
Penalty
Summary
The facility failed to provide full visual privacy for a resident residing in a non-private room. This deficiency was identified during a recertification survey for a newly admitted resident who occupied a bed in a shared room. The privacy curtain between the two beds only extended to the length of the beds, failing to provide complete visual privacy. The resident used a bedside commode in the room for bowel and bladder elimination, which further necessitated the need for adequate privacy. The Director of Nursing confirmed the observation and noted that the room's ceiling configuration prevented the installation of a track for suspended curtains, unlike other rooms in the facility.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for its residents, as evidenced by several deficiencies. For one resident, the facility did not accurately transcribe the indication for the use of the antipsychotic medication Seroquel. The medication was prescribed for dementia with psychosis and specific behaviors, but the psychiatric progress note indicated the primary diagnoses as adjustment disorder with anxiety and depressed mood, generalized anxiety disorder, and delusional disorder, with Seroquel continued for delusional disorder. This discrepancy was confirmed by the Director of Nurses during the survey. Additionally, the facility did not document a wound evaluation for the same resident who had a Stage III pressure ulcer on the left ankle. Although the wound was assessed during a dressing change, the evaluation and measurements were not recorded in the electronic health record. Furthermore, another resident's medical record lacked documentation of a care plan meeting following a Minimum Data Set assessment. The Social Service Director and Director of Nursing could not provide evidence of the meeting in the medical record, although an email indicated it occurred.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 285 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lonaconing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Moran Nursing And Rehabilitation Center | 5.8 mi | ★★★★★ | 4 | 0 |
| Frostburg Rehab Center | 6.8 mi | ★★★★★ | 54 | 0 |
| Mountain City Rehab Center | 7.2 mi | ★★★★★ | 33 | 0 |
| Keyser Healthcare Center | 9.3 mi | ★★★★★ | 19 | 1 |
| Complete Care At Dawnview Llc | 11.4 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.