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 Elkton Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to follow physician-ordered BP parameters for Midodrine administration for three residents with hypotension and orthostatic issues. One resident with recent hospitalization, deconditioning, and high fall risk received Midodrine when SBP was above the ordered hold threshold and had a dose held when SBP was below that threshold, both before and after a dose change. Another resident with an order to hold Midodrine for SBP above a specified level repeatedly received the drug despite SBP readings over that limit. A third resident, ordered Midodrine TID with a lower SBP hold parameter, also received doses when SBP exceeded the ordered limit and did not receive the drug when SBP was below it. The medical director confirmed that staff did not follow the ordered parameters and voiced concern about these out-of-parameter administrations.
A resident admitted with pneumonia did not receive multiple physician-ordered medications and treatments as evidenced by missing documentation on the MAR. Orders lacking documented administration included PICC line flushes, inhaled acetylcysteine every 6 hours, nebulized albuterol every 6 hours, and IV piperacillin every 6 hours for pneumonia over several shifts. Review of the MAR with the DON confirmed that these medications and treatments were not documented as given for this resident during the complaint survey review.
A resident with a Stage 3 right heel pressure ulcer and multiple comorbidities, including diabetes with neuropathy and severe protein-calorie malnutrition, had physician and wound care orders for continuous heel offloading using boots, pillows, and pressure-reduction measures, with the TAR showing heel boots signed off as applied each shift. However, on multiple observations the resident was found in bed with heels resting directly on the mattress, wearing only slipper socks and without heel boots in place, and the DON confirmed that no heel boots were present in the room despite documentation indicating their use.
A resident with multiple comorbidities, recent falls with head injury, orthostatic hypotension, and documented high fall risk was not provided with consistent fall-prevention interventions as outlined in the care plan. On observation, the resident’s call bell was under the bed and unreachable, the urinal was placed several feet away on a nightstand drawer handle, there were no fall mats by the bed, and the bed was not kept in the lowest position. The care plan required that the bed be in low position and that the urinal and common items be within reach, and therapy staff described the resident as impulsive and likely to try to get out of bed if needs were not within reach. Additionally, Midodrine was administered despite a systolic BP above the physician-ordered hold parameter, and the medical director confirmed it should have been held.
Surveyors found that staff failed to obtain ordered lab tests for two residents. One resident with diabetes and anemia had physician orders for a CBC, CMP, and magnesium level to be drawn on a specific date, but the medical record showed no lab results and no nursing documentation explaining the omission, which the DON confirmed. Another resident with pneumonia was seen by a PA for abnormal labs, and a repeat CBC was ordered and acknowledged in a nurse’s note, yet no labs were drawn before the resident was discharged, which the DON also confirmed.
A resident with impaired mobility and a care plan requiring Hoyer lift transfers with two-person assistance was not transferred according to protocol. Instead, a GNA attempted to assist the resident without the required equipment or help, leading to the resident attempting to transfer independently, falling, and sustaining a displaced distal femur fracture.
A resident receiving hospice care for a terminal illness experienced unmanaged pain due to staff failing to administer scheduled and as-needed morphine as ordered. Documentation on the MAR did not match the narcotic log, and there were significant gaps in medication administration. Staff and family reported the resident suffered a pain crisis, and facility leadership was unaware of the incident until after the fact.
A resident was denied the right to manage their own finances after the facility became their Representative Payee without proper notification or documentation of incapacity, despite assessments showing cognitive intactness. The resident was not given access to their funds or statements, and staff actions were based on an outstanding bill rather than a documented change in capacity. Additionally, residents could only access their funds during limited business hours, with no access after hours or on weekends, and there were occasions when the facility ran out of petty cash.
Resident council concerns were not consistently acknowledged, resolved, or communicated back to residents. Residents reported that grievances and meeting concerns were not addressed timely, grievance forms were not available outside social services, and the process for after-hours grievances was unclear. Council minutes did not show review of prior resolutions, and surveyors also observed staff entering rooms without knocking, flies and ants in the facility and resident rooms, and snacks kept behind the nurses' station instead of being given to residents.
Poor housekeeping and maintenance were observed throughout the facility, with dirty sticky floors, wax buildup, stains, peeling paint, cracks, damaged walls, missing signage, and shower areas used for storage. Residents and a family member reported that spills were not cleaned up and floors were not cleaned daily. The facility also failed to account for a resident’s wallet and important documents after hospital returns, and there was no inventory documentation for the later re-admissions.
Meal tickets and actual trays did not match prescribed diets or resident preferences. A resident with DM and another with renal diabetic diet orders received incorrect items, including regular syrup, missing items, and foods inconsistent with fluid restrictions and dislikes. Other residents also reported missing or substituted foods, and tray line observations showed entree and side discrepancies between the ticket, posted menu, and what was served.
Surveyors found that the kitchen did not consistently follow the posted menu or provide the required protein portion at lunch. A ham bruschetta entrée appeared to contain only a thin amount of meat instead of the posted 4 oz serving, and the RD later acknowledged it was only a 2 oz portion. Staff also reported that substitutions were sometimes made when there was not enough meat, and the RD could not identify who was responsible for ensuring menu nutritional adequacy. In addition, meal tickets did not match trays for residents, with missing items such as broth, ice cream, French fries, and coleslaw, and residents reported ongoing inconsistencies with food served.
Food and drink were not kept at safe and appetizing temperatures. Surveyors observed incomplete temperature logs for hot menu items, milk held out of refrigeration at 48.6F, and food served on cold plates because the plate warmer was not in use even though a replacement unit was available. An RDM acknowledged the temperature recording and milk temperature concerns, and a resident reported that food was sometimes cold.
Kitchen sanitation, storage, and food handling practices were not maintained. Surveyors observed missing freezer temp logs, an unreadable refrigerator thermometer, leaking coffee and sink equipment, dirty floors and equipment, food carts and ice service items placed near dirty dish carts, food stored on the floor or without labels/dates, expired and undated items in a nourishment refrigerator, food stored in a shower room, personal beverages on a food prep surface, a dietary aide handling eyeglasses while gloved and then returning to tray assembly, and uncovered resident trays transported through the hallway.
The facility failed to ensure all required individuals participated in the Facility Assessment. A Direct Care Representative was not involved in completing the assessment, and the Administrator and/or staff could not show that processes for adequate supplies, maintenance and replacement needs, plant operational review, preventative maintenance, and administrative rounding were being completed or effective. The assessment also did not include an evaluation of building maintenance capital improvements or structures.
Dietary services failed to follow professional standards and resident diet orders. Contracted dietitian and dietary manager communications showed ongoing concerns about incorrect diets, missing fluid restrictions, and incomplete diet audits. During meal observations, a resident with DM received incorrect breakfast items, including regular syrup and cold cereal, and staff confirmed the error. Another resident reported not receiving the correct diet or fluids, and meal tickets did not match the resident’s renal diabetic diet, fluid restriction, or food dislikes. Additional tray checks showed menu and tray ticket mismatches for ravioli entrees.
Dishwashing System Not Maintained in Safe Operating Condition: Surveyors observed pooling water on the kitchen floor, a bucket catching leaks from the dishwasher, and an empty sodium hypochlorite jug attached while the machine was operating in chemical sanitization mode. The machine’s placard required a 140F wash tank minimum and 50 ppm available chlorine, but the wash temperature was observed at 134F and the facility log showed multiple instances of sanitizer ppm above the acceptable range with no documented action taken. The DM reported the machine had been leaking for months and that without the chemical present it would not effectively sanitize dishes.
Surveyors found that several residents were denied their rights to dignity and self-determination, including a resident who missed medical appointments due to transportation issues with a replacement wheelchair, was not properly informed about changes to their Social Security payee status, and lacked support for discharge planning. Staff were repeatedly observed entering rooms without knocking or seeking permission, despite resident complaints. Additionally, some residents lacked access to personal clothing on weekends due to ongoing laundry staffing shortages.
Surveyors observed persistent pest issues, including flies, gnats, and ants, in multiple units and resident rooms. A resident reported flies landing on their head, food, and bed, and staff confirmed the ongoing presence of pests despite regular pest control visits. The deficiency was evident through direct observation and resident interviews.
Smoking paraphernalia was found at the bedside or in the rooms of multiple residents who were supposed to be supervised while smoking, including cigarettes, lighters, and a vape pen. In several cases, smoking screens and care plans did not match the resident’s current smoking status, with some residents listed as independent despite scores indicating supervision was needed, and others documented as smokers or supervised smokers without corresponding updates in the record. The DON acknowledged concerns when the surveyor identified the mismatches and paraphernalia.
Medication storage and labeling were not maintained properly in several areas. Surveyors found an unlocked supply room with accessible injectable meds and needles, an unlocked treatment cart with multiple topical meds, unlabeled fluticasone in resident belongings, and an unlabeled insulin FlexPen used during med pass. They also observed a blood glucose strip bottle without an open date, blank refrigerator temperature log entries, an expired medication set, opened product without discard dating, and returned meds left in the med room awaiting pharmacy pickup.
A resident on a mechanically altered diet with dysphagia was served breakfast that did not match the ordered consistency. The meal ticket called for pureed toast, but the tray contained regular toast; an LPN confirmed the mismatch, and the RD and DOR stated there had been no diet upgrade and that the resident was to remain on the mechanically altered diet.
An LPN failed to perform hand hygiene and cleaned point-of-care testing equipment between residents, and another LPN did not clean hands after resident contact before medication administration. A resident on enhanced barrier precautions had an uncapped PICC line handled without a gown, with no swab caps present and a dressing lacking date and time documentation. Staff also mishandled clean linen, the laundry chute was backed up with unbagged soiled items, laundry vents were uncovered and dirty, hand soap was unavailable at floor 2 sinks, and respiratory supplies were stored close to a visibly dirty floor.
Unsafe and unkempt exterior and common areas were observed, including a laundry room vent covered with grey matter, weeds around generator equipment, peeling paint and ceiling disrepair in the laundry room, and a gutter filled with leaves and debris. Near the dining hall, an emergency fire blanket had about 15 cigarette butts on top of it, and the area also contained carts, broken furniture, a nightstand, a geriatric chair, an upside-down table, and four mattresses.
A resident was physically abused by a GNA, who was witnessed slapping the resident on the face while assisting them off an elevator. The incident was observed by a laundry staff member and confirmed through the facility's investigation. The resident was evaluated at a hospital and returned to the facility, with the abuse substantiated by both witness accounts and internal review.
Two residents were not provided with full participation in their care planning process, as care plan meetings were conducted only with Social Services staff and lacked involvement from the required Interdisciplinary Team (IDT). Residents reported that their concerns were not addressed, and documentation confirmed the absence of other disciplines during these meetings.
Three residents experienced failures in receiving medically-related social services, including lack of support for discharge planning, missed medical appointments due to transportation issues, unaddressed concerns about personal funds and documentation, and insufficient assistance with guardianship changes, despite being cognitively intact and expressing clear preferences.
A resident missed multiple medical appointments over an extended period because the facility did not provide appropriate transportation arrangements after the loss of their original wheelchair. The replacement wheelchair was too large for the contracted taxi service, and although the resident was approved for a power wheelchair, delays in the facility's billing process prevented its delivery. Staff did not pursue alternative transportation options, and the resident's requests for help were not effectively addressed.
Surveyors identified multiple instances where the facility failed to maintain accurate and consistent medical records, including incorrect documentation of decision-making authority, missing or delayed documentation of a PICC dressing change, outdated or conflicting smoking assessments and care plans, and inconsistent recording of a resident's fall. These deficiencies involved several residents and were confirmed through observation, record review, and staff interviews.
A resident’s dog was observed in the Dining Room during family visits, and staff later confirmed there were no vaccination records on file for the animal. The facility policy stated that all animals, including resident animals and therapy service animals, must have vaccination records on file, but the dog was still permitted into the controlled environment.
A resident’s chart contained conflicting advance directive and end-of-life orders, including 5 Wishes forms with a DNR preference, a physician note stating the resident requested Full Code, and multiple MOLST forms with mixed and voided code statuses. Staff acknowledged the inconsistency in the record and were unsure whether the chart had been audited for advance directives.
A facility failed to document written transfer notices and bed hold info for a resident’s hospital transfers, failed to show timely Ombudsman notification for multiple residents’ hospital transfers, and failed to document the clinical rationale for returning a resident to the hospital. The DON stated one resident required 1:1 care the facility could not provide, but the record lacked a progress note explaining the transfer decision and lacked documentation of Ombudsman and hospital notification.
A resident who returned after hospitalization for a fall with a right femur fracture and surgical repair had an inaccurate quarterly MDS. Section J-Health Conditions did not indicate a major surgical procedure in the prior inpatient stay and did not check the item for fracture repair, and MDS staff confirmed the coding should have reflected the resident’s status.
A resident with tracheostomy, anoxic brain damage, persistent vegetative state, and contractures had an activity care plan that required 1:1 activities, but it did not identify resident-specific activities, measurable objectives, or staff interventions tied to the resident’s needs. The AD acknowledged the concern that the plan did not reflect the resident’s current activity status.
A resident with multiple foot wound care orders had missed treatment documentation on several days, and ordered ID and vascular consults were not scheduled. The resident reported dressing changes were not being done as ordered due to staffing shortages and that staff had not arranged the specialist appointments, while the ADON and DON acknowledged missing documentation and unscheduled consults.
Failure to provide appropriate incontinent care and services was identified for a resident who was frequently incontinent of bladder and bowel. The resident was observed in a wheelchair wearing a brief saturated with urine and stool, while the bed mattress was uncovered, saturated with urine and stool, and in poor condition. The room floor around the bed was also observed with heavy dirt accumulation, and the resident stated staff removed the sheets but did not clean the bed.
Incorrect Oxygen Delivery and Monitoring: A resident with COPD had orders for O2 at 3L via NC with SpO2 monitoring, but was repeatedly observed on lower settings, including 1.5L and 1L. Staff confirmed the concentrator was not set correctly and at times stated it was broken, while the resident appeared winded when speaking and said they should be on 3L.
Controlled drug handling was not accurately maintained for a resident receiving Diazepam, Hydromorphone HCL, and Methadone. The facility failed to start new controlled substance log pages when new inventory arrived, had inaccurate tablet counts and missing dual-signatures during shift counts, and did not always document administration in the log book and MAR at the time meds were given. Records also showed the resident’s controlled meds repeatedly ran down to the last dose or zero before new supply was received.
Medication administration errors exceeded the allowed rate after surveyors observed multiple LPN errors during med passes. Errors included giving insulin from an unlabeled pen, administering pre-meal insulin after a resident had already eaten, omitting one ordered medication from a 12-med pass while charting it as given, and preparing polyethylene glycol incorrectly after an LPN used Google instead of the bottle directions; the DON stated Google was not the facility expectation.
The facility failed to ensure the person supervising food and nutrition services was a qualified dietetic service supervisor. Staff confirmed the Dietary Manager was running kitchen operations, but the RD did not oversee diets or the kitchen, and the Dietary Manager stated they were not a certified dietary manager and were still in training. The Administrator confirmed the training was not yet completed, while a regional supervisor only visited the facility about twice weekly.
Dietary orders were not followed for multiple residents. A resident with dislikes for gravy received mashed potatoes covered in gravy, another resident with shellfish and fish allergies was served a meal ticket listing fish and received a tray that did not match the ticket, and a third resident on a renal diabetic diet with double portions ordered did not receive the ordered portions and was also served fish despite listed allergies. Residents also reported cold, tasteless food, missing extras, and denied snacks.
Surveyors identified widespread environmental and equipment deficiencies, including stained and missing ceiling tiles, damaged molding, holes in walls, and torn or missing wheelchair and Geri-chair armrests. Several residents were affected by these issues, with one resident expressing a need for a replacement armrest and another's room found with tube feeding stains and dirty, ripped fall mats. Staff confirmed awareness of these problems, but many remained unresolved at the time of the survey.
Facility staff did not accurately code MDS assessments for several residents, resulting in failures to document significant weight loss, falls, and the administration of medications such as antibiotics, opioids, hypoglycemics, antiplatelets, and pain relievers. These discrepancies were confirmed through medical record reviews and staff interviews, showing that the MDS did not consistently reflect the care and clinical events experienced by residents.
The facility did not ensure residents received care according to professional standards, including sending a resident with heart failure and seizures to the ER unescorted, failing to document and assess after a resident's fall, not performing required neuro checks after unwitnessed falls, and delaying hospital transfer for a resident with a history of brain hemorrhage. Staff interviews and record reviews confirmed these lapses.
The facility did not consistently monitor and document vital signs as required by physician orders before administering blood pressure medications to three residents. Medications were given outside of prescribed parameters, including instances where heart rate or blood pressure readings should have resulted in holding the medication. The DON and nursing staff confirmed these findings during interviews.
Surveyors observed persistent flies and gnats in multiple facility areas, including resident rooms, hallways, the kitchen, and the rehab gym. A resident reported flies in their room for at least a week, and a fly was seen on a resident in bed with the DON present. Despite regular pest control services and fly lights, staff acknowledged the issue worsened with seasonal changes, indicating the pest control program was not effective.
Staff did not maintain resident dignity in two cases: one resident was fed while staff stood over them instead of sitting at eye level, and another resident with a Foley catheter had their catheter bag left uncovered and visible from the hallway, despite a care plan intervention requiring a privacy bag.
Facility staff did not inform a resident's representative when a new antipsychotic medication, Seroquel, was ordered and administered for depression in a resident with dementia. The lack of notification was confirmed by the DON after review of the medical record showed no evidence of communication regarding the medication change.
A resident's electronic medical record was left open and visible on an unattended medication cart in a hallway, exposing private medication information. An LPN acknowledged the error when informed by a surveyor, and the incident was reported to the DON.
A resident's PlayStation 5 went missing after being placed in facility storage during a hospital transfer. Despite assurances that belongings were secured, the device was not found upon the resident's return. Staff were aware of the loss, but no formal grievance or self-report was documented, and the resident ultimately replaced the item at personal expense.
Failure to Follow Midodrine Blood Pressure Parameters for Multiple Residents
Penalty
Summary
Facility staff failed to ensure residents’ drug regimens were free from unnecessary drugs by not following physician-ordered blood pressure (BP) parameters for Midodrine administration for three residents. One resident with a history of orthostatic hypotension, recent hospitalization for acute metabolic encephalopathy, infection, acute kidney injury, significant deconditioning, impaired mobility, chronic pain, nutritional deficits, and high fall risk was ordered Midodrine 5 mg, three tablets by mouth three times daily for hypotension, to be held for systolic blood pressure (SBP) greater than 120. The Medication Administration Record (MAR) showed Midodrine was administered on multiple dates when SBP readings were above 120, and on one date it was held when SBP was below 120, contrary to the order. After this resident returned from a hospital stay, the Midodrine order was changed to 10 mg three times daily with the same hold parameter, yet the MAR documented another administration when SBP exceeded 120. The DON later acknowledged awareness of these out-of-parameter administrations when they were brought to her attention. A second resident had a physician’s order for Midodrine 5 mg once daily for hypotension, to be held for SBP greater than 120, but the December and January MARs documented repeated administrations on days when SBP readings were above 120. A third resident had a physician’s order for Midodrine 5 mg three times daily for hypotension, to be held for SBP greater than 110, yet the December and January MARs showed numerous doses given when SBP exceeded 110. Additionally, on one occasion this resident’s SBP was below 110 and Midodrine was not administered, despite the order indicating it should have been given. During interview, the medical director confirmed that staff failed to follow the ordered parameters and expressed concern about Midodrine being administered outside of those parameters.
Failure to Administer Ordered IV Antibiotics and Respiratory Treatments
Penalty
Summary
Facility staff failed to administer medications and treatments as ordered by the physician for Resident #302, who was admitted with pneumonia. Review of the resident’s January 2026 Medication Administration Record on 1/29/26, conducted with the Director of Nursing, showed no documentation that multiple ordered medications and treatments were given. Specifically, there was no documentation that the PICC line was flushed every shift as ordered on the night shift of 1/7/26 and the day shift of 1/10/26. In addition, there was no documentation that Acetylcysteine solution 10 ml by inhalation every 6 hours was administered on 1/8, 1/9, and 1/10/26 at 6 AM, on 1/11/26 at 12 PM and 6 PM, and on 1/12/26 at 6 PM. There was also no documentation that Albuterol sulfate 3 ml via nebulizer every 6 hours was administered on 1/8, 1/9, and 1/10/26 at 6 AM, or that Piperacillin 4.5 grams IV every 6 hours for pneumonia was administered on 1/8, 1/9, and 1/10/26 at 6 AM. In an interview on 1/29/26 at 10:28 AM, the Director of Nursing confirmed these findings. These omissions were identified for 1 of 5 residents reviewed during a complaint survey and demonstrated that the resident did not receive medications and treatments according to physician orders as required.
Failure to Implement Ordered Heel Offloading for Resident With Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment and preventive services for a resident with an existing right heel pressure ulcer. The resident was admitted with a right heel pressure ulcer and diagnoses including a left pubis fracture, type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia, and severe protein-calorie malnutrition. An admission nursing note documented the presence of the right heel pressure ulcer, and a medical progress note directed staff to offload the right heel continuously with boots and pillows and avoid pressure on the affected area. A subsequent skin and wound note identified the right heel ulcer as Stage 3 and recommended floating the heels while in bed using pillows or boots and ongoing pressure reduction and turning/repositioning precautions per protocol. The January Treatment Administration Record contained a physician’s order to offload heels with green boots as tolerated every shift, and documentation showed the boots were signed off as worn each shift on 1/28/26. Despite these orders and documentation, multiple observations on 1/29/26 showed the resident’s heels were not offloaded as ordered. During the first observation, the resident was in bed on his/her back eating breakfast with both feet lying directly on the mattress, wearing gray slipper socks and no heel boots. When asked, the resident stated that staff sometimes elevated his/her feet but that there was nothing in place at that time. A second observation later that morning again showed the heels resting directly on the mattress without heel boots. A third observation showed a pillow under the bottom of the resident’s legs, with the resident still wearing gray slipper socks and no heel boots present. The DON, upon observing the resident and being informed that staff had been signing off that heel boots were being worn despite no heel boots being in the room, confirmed the finding.
Failure to Implement Fall-Prevention Interventions and Follow Medication Parameters for High-Risk Resident
Penalty
Summary
Facility staff failed to ensure that safety interventions were consistently in place for a resident with a known high risk for falls and fall-related injury. The resident had multiple significant diagnoses, including a left pubis fracture, diabetes with neuropathy and hyperglycemia, altered mental status, severe protein-calorie malnutrition, anemia, and orthostatic hypotension, and had a recent history of falls with head injury, concussion, transient loss of consciousness, and memory impairment. Medical notes documented that the resident was disoriented, had impaired mobility, chronic pain, and was considered a high fall risk, with instructions to maintain fall precautions and optimize the environment, including keeping the urinal and call bell within reach. Despite these documented risks and care plan interventions, observations on the survey date showed the resident lying in bed with the call bell under the bed and not within reach, and the urinal hanging from a nightstand drawer handle approximately four feet away from the bed, also not within reach. There were no fall mats next to the bed, and later observation with the DON showed the bed in a medium-high position rather than in the lowest position as care planned. The resident reported difficulty standing and a history of multiple serious falls with fractures and skull injuries. The LPN present in the room acknowledged that the call bell was under the bed and expressed uncertainty about who was responsible for placing it on the bed. The resident’s care plan identified the resident as being at risk for falls and fall-related injury related to weakness, diabetes, orthostatic hypotension, pain, anemia, and use of cardiovascular and psychotropic medications, with specific interventions such as ensuring the urinal and common items were within reach, keeping the bed in the lowest position, and reminding the resident to use the call light for assistance. Additionally, the physician’s order for Midodrine specified that the medication should be held if the systolic blood pressure was greater than 120, yet the MAR showed the medication was administered when the systolic blood pressure was 128, outside the ordered parameters. The medical director confirmed that the Midodrine should have been held. Therapy staff described the resident as a fall risk, impulsive, and more sedated than previously, and indicated that if the resident could not reach needed items, the resident would attempt to get out of bed despite knowing it was unsafe.
Failure to Obtain Ordered Laboratory Tests for Two Residents
Penalty
Summary
Facility staff failed to obtain ordered laboratory tests for two residents as identified during a complaint survey. For one resident admitted in January 2026 with diagnoses including diabetes and anemia, physician orders dated 1/5/26 directed that a CBC, CMP, and magnesium level be completed on 1/6/26. Review of the medical record on 1/29/26 showed no laboratory results for that date and no nursing documentation explaining why the ordered labs were not completed. In an interview on 1/29/26 at 1:45 PM, the Director of Nursing confirmed that staff did not obtain the physician-ordered laboratory tests for this resident. For another resident admitted with a diagnosis including pneumonia, the medical record showed that a Physician Assistant evaluated the resident on 1/7/26 for abnormal laboratory results and documented an order to repeat a CBC in the morning. A nurse’s note later that night stated that labs from 1/7/26 were reviewed by the Physician Assistant and that the resident already had an order for a CBC in the morning. However, review of the laboratory results revealed that no labs were drawn on 1/8/26. This resident was discharged on 1/13/26 without the repeat CBC having been completed. In an interview on 1/29/26 at 10:28 AM, the Director of Nursing confirmed that the ordered CBC was not obtained for this resident.
Failure to Use Required Hoyer Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who required a Hoyer lift with two-person assistance for all transfers due to impaired mobility, was not transferred according to their care plan. The resident had a documented need for maximal assistance with transfers and was unable to ambulate. Despite these requirements, a Geriatric Nursing Assistant (GNA) failed to identify and follow the resident's transfer status, attempting to assist the resident without a Hoyer lift or a second staff member. The GNA did not consult the resident's medical chart or seek clarification from nursing staff regarding the appropriate transfer method. During the transfer, the resident attempted to stand and move independently, resulting in a fall and a displaced fracture of the distal femur, as confirmed by radiology. Interviews and documentation revealed that the GNA was present but did not intervene to prevent the resident from transferring unsafely, nor did they seek additional help. The resident reported attempting to transfer from a wheelchair to bed, referencing recent therapy sessions but ultimately being unable to move their feet and falling. The Director of Nursing and Director of Rehabilitation both confirmed that the resident required a Hoyer lift with two-person assistance at the time of the incident, and that the staff member failed to follow established protocols for safe transfers.
Failure to Follow Hospice Pain Management Orders Resulting in Resident Harm
Penalty
Summary
Facility staff failed to follow hospice pain management orders for a resident admitted with a terminal illness, resulting in unmanaged pain and harm. The resident had active orders for scheduled and as-needed morphine, with instructions to administer the medication every four hours, including waking the resident if asleep. Despite these orders, there was a significant gap of approximately 18 hours and 39 minutes during which no morphine was administered, as confirmed by a review of the medication administration record and the facility's narcotic log. Documentation inconsistencies were found, with doses recorded on the MAR but not on the narcotic log, and some doses not matching the prescribed amount. Staff interviews revealed that the resident experienced a pain crisis, characterized by symptoms such as tremoring, foaming at the mouth, minimal responsiveness, and moaning. Multiple staff members, including nursing and hospice personnel, acknowledged that the resident's pain was not managed according to the orders, and that the family expressed concern about the lack of pain control. The narcotic log showed crossed-out and rewritten orders, missing RX numbers, and a lack of proper documentation for medication administration. Staff also reported that no action was taken to address the failure in medication administration or to prevent recurrence. Leadership interviews indicated a lack of awareness and oversight regarding the incident. The DON and ADON were not informed of the pain crisis, and upon review, the DON confirmed that procedures for documenting and administering controlled medications were not followed. The DON also acknowledged that pain should have been controlled for a resident receiving hospice services and that the facility's procedures were not adhered to, as evidenced by the discrepancies between the MAR and narcotic log.
Failure to Honor Resident Financial Rights and Provide Ongoing Access to Personal Funds
Penalty
Summary
The facility failed to honor a resident's right to manage their own financial affairs and did not obtain written authorization to act as a fiduciary for the resident's funds. One resident reported that their Social Security payments stopped being deposited into their personal bank account after a facility physician signed a statement indicating the resident could not handle their finances. The resident was not informed about the change, denied access to their funds and statements, and was unable to obtain necessary documents or legal assistance. Record review showed that the resident was assessed as cognitively intact and had multiple physician certifications indicating adequate decision-making capacity, including for financial matters. However, the facility submitted an SSA-787 form stating the resident was incapable of managing funds, resulting in the facility being assigned as Representative Payee without proper communication or documentation of a change in capacity. Interviews with facility staff revealed that the decision to pursue Representative Payee status was based on the resident's outstanding unpaid bill, not on a documented change in mental capacity. The Business Office Manager and physician confirmed that no additional assessments or consults were conducted to support the claim of financial incapacity. The resident was not provided with statements or timely access to their funds until after surveyor intervention, and there was no evidence of communication to the resident regarding the change in management of their Social Security benefits. Additionally, the facility did not have a system in place to allow residents ongoing access to their personal funds. Residents could only withdraw money during business hours on weekdays, and there was no provision for access after hours or on weekends. There were also instances when the facility ran out of petty cash, further restricting residents' ability to access their funds as needed.
Resident Council Concerns Not Timely Addressed
Penalty
Summary
The facility failed to maintain a system to ensure that resident council concerns were acknowledged and addressed in a timely manner, that resolutions were communicated, and that interventions were effective. During an interview with resident council representatives, residents stated that concerns discussed in council meetings were not addressed timely, the resolutions were often unclear because the issues continued to occur, and they felt that little was being done to address most of their concerns. A review of resident council minutes for July 15, August 12, and September 16, 2025, showed that the minutes did not include a review of administrative resolutions or what had been resolved from the prior meeting. The record also showed concerns that residents were unsure of the process for filing grievances outside regular business hours, and grievance forms were not available outside the social services office. The DON stated that concerns from resident council meetings were forwarded to the appropriate department for resolution and then returned to activity staff to be discussed at the next meeting, while the DOR stated that grievances were entered into a computer system and grievance summaries were attached to resident council minutes. During the survey, the AIT was informed that grievances from resident council were not reported on the same date they were recorded, were not addressed timely, resolutions were not always communicated to the resident council, and interventions were not monitored for effectiveness. Surveyors also observed staff failing to knock or ask permission before entering resident rooms, flies and ants in the facility and resident rooms, and snacks placed behind the nurses' station on Unit 2 rather than being passed out to residents.
Poor Housekeeping, Maintenance, and Missing Resident Belongings
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable homelike environment. During the initial tour and subsequent environmental rounds, surveyors observed multiple areas of disrepair and poor cleanliness throughout resident rooms and common areas, including missing or damaged room signage, walls with missing paint, cracks, holes, separated cove molding, exposed materials within walls, uncovered cable cords, dirty and sticky floors, black buildup on linoleum, stained ceiling tiles, soiled floor mats, rusted or unsecured fixtures, and shower rooms with cracked or crumbling surfaces. Surveyors also observed dead insects and thick cobweb-like material in windows, brown and black stains on floors and ceilings, and shower stalls being used for storage, with some stalls unavailable for resident use. Facility leaders, including the housekeeping director and maintenance director, acknowledged the conditions during rounds and stated they were working on repairs. Resident interviews and surveyor observations confirmed that the poor environmental conditions were ongoing. One resident and a roommate stated that floors were not cleaned daily and were sticky. Another resident stated that food and NGT feeding spills were not cleaned up by nursing or housekeeping staff. A family member expressed concern that spills happened frequently and were not cleaned up. The housekeeping director stated that resident floors were expected to be cleaned every day and that only one housekeeping staff member was available on evening shift and none on night shift. Surveyors also observed dirty floors, wax buildup, missing or damaged wall surfaces, and bathroom areas with buildup of black-brown substance, peeling paint, and unsecured or broken fixtures in multiple resident rooms and shower areas. The facility also failed to protect a resident's belongings from loss. Resident #3 reported that a wallet containing important credentials, a driver's license, an insurance card, and a social security card was missing after a hospital visit and return to the facility. An anonymous source reported that other residents entered the room and messed with the resident's belongings. Facility documentation provided to surveyors included only one inventory sheet from the resident's initial admission, with no inventory sheets for later re-admissions and no documentation showing the wallet or cards were accounted for. The DON stated that an admission assistant typically completed inventory sheets when residents returned from hospitalization, and the admission assistant later confirmed there was no inventory sheet completed for the missing items and no wallet had been locked up for the resident. The resident's identification, social security card, and insurance card were later found scanned into the medical record.
Meal tickets and prescribed diets did not match food served
Penalty
Summary
The facility failed to ensure residents received the correct prescribed diet orders and that meal tray tickets matched the food actually served. During breakfast observation, one resident with a documented diabetic diet order and a diagnosis of Type 2 diabetes mellitus was served a tray ticketed for diabetic breakfast items, but the tray contained cold cereal instead of hot cereal, regular table syrup instead of diet syrup, and no coffee. Staff confirmed the ticket information and stated the resident should not have been receiving regular syrup or sugary cold cereal, but that was what the kitchen sent. A second resident reported not receiving the correct diet and stated that food and drinks were often not what was ordered, including concerns about fluid intake. Review of that resident’s meal tickets showed a regular breakfast, lunch, and dinner ticket despite a medical record documenting a renal diabetic diet with thin liquids, double protein, and a 1500 mL/day fluid restriction, along with Type 2 diabetes mellitus and end stage renal disease on dialysis. The resident’s breakfast ticket also listed pork as a dislike, but there was no documentation of a substitute for that item. The Dietary Manager stated the kitchen used paper meal tickets to plate food and that there had been problems with consistency of correct food being served. Additional observations showed meal tray and ticket mismatches for other residents. One resident stated the meal ticket did not always match what was served and that preferred items were sometimes missing; the tray observed lacked broth and had pudding-like food instead of ice cream. Another resident stated the food was cold and unappetizing, and the tray observed did not include French fries or coleslaw listed on the ticket. During tray line observations, one resident’s ticket listed no cheese, yet cheese ravioli and meat sauce were served, and another resident’s ticket listed beef ravioli in sauce while cheese ravioli in meat sauce was observed. The posted menu in the kitchen listed beef ravioli in sauce as the planned entree.
Menu Portions and Meal Ticket Mismatches
Penalty
Summary
The facility failed to ensure the food service department followed the posted menu and failed to ensure the lunchtime menu met the required serving size of protein. During observation of the kitchen serving line, surveyors saw a ham bruschetta entrée that appeared to contain only a very thin serving of shaved meat on a small piece of white bread with a tomato slice, which did not appear to be a 4 oz portion as posted on the kitchen menu. A kitchen staff member stated that sometimes food different from the menu had to be served because there was not enough, such as ham and pork chops, and the dietary manager later stated that if food orders were placed and census fluctuated, that was causing the issue with not having enough meat. Surveyors interviewed the regional RD, who initially stated the menu was nutritionally adequate because meat sauce was served at dinner, but the menu she presented had been altered and was not the same menu posted and served in the kitchen. When questioned, she acknowledged that the bruschetta ham entrée had only been a 2 oz portion instead of 4 oz and that meat sauce had been added. The dietary manager later stated she did not know who was responsible for ensuring nutritional adequacy of resident diets and the menu. A resident also reported that one day they were supposed to have chicken and were given pork instead. The facility also failed to ensure menus and food preferences were followed according to meal tickets. One resident reported that the meal ticket did not always match what was served and that preferred items were sometimes missing. During tray observation, the resident’s ticket called for broth and ice cream, but the tray had no broth and instead had a cream-colored pudding-like item; the resident said broth had not been received for about a week. Another resident’s meal ticket listed an alternate entrée, French fries, coleslaw, cake with icing, apple juice, and chocolate milk, but the tray contained a different meat-like entrée, mashed potatoes, spinach, cake with icing, apple juice, and chocolate milk, with no French fries or coleslaw. The dietary manager acknowledged ongoing issues with staff ensuring meal tickets and meal trays matched and that residents had verbalized concern about consistency.
Food Temperatures and Plate Warming Not Maintained
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature. During review of the kitchen on 10/9/25, the surveyor observed 10 hot food items on the steam table, including cheese ravioli, rice, mixed vegetables, meat sauce, cream of rice, alfredo garlic meat sauce, plain puree sauce, pureed meat, white sauce, and pureed mashed potatoes. The written food service temperature log showed temperatures recorded for only 7 of the 10 hot food items and did not identify which specific items had been temperature tested. When the concern was discussed, the Regional Dietary Manager acknowledged that it was not appropriate to fail to record temperatures for each item served. During tray line observation, milk was being held out of the refrigerator in containers of ice water, with some cartons resting on top of the ice. Temperature testing of the food test tray after residents had been served showed a carton of milk at 48.6F, and the Regional Dietary Manager stated that this temperature was not acceptable and expressed concern about it. During the initial kitchen tour on 9/28/25, the surveyor also observed that the plate warming system used to hold plates was not lit and the plates were cold to the touch. Staff reported that the plate warming system was broken, and although a replacement system was available, it was not plugged in or being used. The surveyor observed food being served onto cold plates, and a resident later reported that the food was sometimes cold.
Kitchen sanitation, storage, and food handling deficiencies
Penalty
Summary
Food service sanitation and storage practices were not maintained in accordance with professional standards throughout the kitchen and nourishment areas. During the initial kitchen tour, the freezer temperature log showed no morning temperature documentation from September 23 through September 28, and the exterior thermometer on the walk-in refrigerator was covered with duct tape and could not be read. The surveyor also observed a plastic pitcher under the coffee machine spout with a thick layer of light and dark brown film, soiled wet linens on the floor under the coffee station, and the coffee machine drainage area leaking onto the floor. The handwashing sink near the food serving line and the three-compartment sink faucet were both difficult to turn off and were left running, and the three-compartment sink faucet was leaking water into the sink. The kitchen environment was observed to be unclean in multiple areas. Dark thick brown material was present on the floor under the food prep table, and a rolling dish pushcart near the food prep station had a wooden board and a food chopping board screwed to it, with rubber gloves stored inside and thick black material on the floor underneath and around it. In the dishwashing area, caulk-type material was detached from the wall molding and sitting in a pool of water, with dark debris along and under the area. The dishwasher exterior had a layer of film and debris, a metal cord with dark debris was loosely affixed to the booster heater with visible wiring, and dish carts had food matter and brown and black debris on them, including one cart with a plastic container of red oily food debris liquid that had reportedly been left from the prior shift. Food storage and transport practices were also observed to be deficient. Dirty dish carts were placed directly next to the clean ice cooler, with one cart touching the cooler and the dirty carts positioned near the clean ice scooper. Bread loaves and rolls were stored in plastic crates directly on the kitchen floor, other food crates were only about 2 inches off the floor, and a sugar container had an uncovered handled scoop resting on top of it. The dry storage floor had sticky residue and brown and black debris, the cove molding was separated from the wall, and wall openings were present. Beverage nozzles were lying on the floor, a juice machine sprayer nozzle and cords had debris on them, and food items in the walk-in refrigerator and freezer were improperly stored or unlabeled, including breaded meat patties with no label, juice cups in a crate on the refrigerator floor, diced green peppers on the freezer floor, and an open bag of hash browns with no date that was discarded after surveyor intervention. In the nourishment room, the ice cooler cart had a dirty resident tray on top of it, the ice scoop was covered by a trash bag, and the refrigerator contained expired or undated items including dialysis bags, cheese and meat slices, blueberries, and a sub sandwich with torn and stained wrapping. Additional observations showed food prep and service practices were not sanitary. Multiple food items were stored in plastic bins inside a second-floor shower room. A prep employee had personal beverage cups on the food prep surface, and a dietary aide wearing gloves reached into a pocket, removed eyeglasses, put them on, and then continued assembling a resident tray while still wearing the same gloves. An open uncovered sheet pan rack carrying resident food trays with uncovered silverware was pushed through the resident hallway, with the lowest tray only about 4.5 inches from the floor, and tray passing continued after the concern was shared. The Administrator later acknowledged extensive process problems surrounding the kitchen.
Facility Assessment Missing Required Participation and Physical Plant Evaluation
Penalty
Summary
The facility failed to ensure that all required individuals participated in the Facility Assessment. During review of the Facility Assessment and interview on 10/08/2025 at 1:00 PM, it was found that there was no Direct Care Representative involved in completing the Facility Assessment dated [DATE]. The Administrator and/or staff #16 were unable to provide or show that the facility's process for ensuring adequate supplies, appropriate maintenance and replacement needs/services, plant operational review, established preventative maintenance processes, and administrative rounding was being completed or was effective. Review also found that the Facility Assessment did not include an evaluation of building maintenance capital improvements or structures, and stated that any capital facility needs would be addressed through the capital budget.
Dietary services failed to follow resident diet orders and tray tickets were inaccurate
Penalty
Summary
The facility failed to ensure that outside contracted food and nutrition resources followed professional standards in providing dietary services. Surveyor review of correspondence between the contracted dietitian and dietary manager showed repeated concerns about diet audits, incorrect diets, missing fluid restrictions, and lack of access to the electronic clinical system used to verify resident diet orders. The documentation also showed communication about Resident #14’s report of not receiving double portions as ordered and going to bed hungry at night. During observation of meal service, Resident #172 was found eating breakfast from a tray ticket that listed a diabetic diet with thin liquids, hot cereal, waffles, syrup, sausage links, orange juice, milk, and coffee, but the tray actually contained cold cereal instead of hot cereal, regular table syrup instead of the listed diet syrup, and no coffee. Staff confirmed the ticket and stated the resident should not have been receiving regular syrup or sugary cold cereal, but that was what the kitchen sent. Resident #172’s record showed a diabetic diet order with double protein and a diagnosis of Type 2 DM with diabetic neuropathy. Resident #52 stated that the correct diet was not being provided and that fluids were not being served correctly. Review of meal tickets for that resident showed a regular diet with thin liquids and no documentation of a substitute for a listed pork dislike, even though the medical record showed a renal diabetic diet with thin liquids, a 1500 ml/day fluid restriction, double protein, Type 2 DM with diabetic neuropathy, and ESRD with dialysis. Additional tray ticket observations showed mismatches between the posted menu and what was served, including cheese ravioli and meat sauce being served when the ticket listed beef ravioli in sauce, and another tray ticket listing beef ravioli in sauce while cheese ravioli in meat sauce was observed on the tray.
Dishwashing System Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure the dishwashing system was maintained in safe operating condition. During observation, surveyors found a large area of pooling water on the kitchen floor in the dishwashing area and a plastic bucket placed under a mechanical component of the dishwasher to catch dripping water; the bucket was approximately 80% full of cloudy liquid. The dishwasher was observed operating in chemical sanitization mode with an empty sodium hypochlorite jug attached to the system. The manufacturer’s placard on the machine indicated that chemical sanitization required a wash tank minimum temperature of 140F and 50 ppm available chlorine. The dish machine was observed again in operation with the hypochlorite solution still empty and the wash temperature at 134F. The facility’s temperature log stated to notify a supervisor if the wash temperature was below 120F or sanitizer ppm was not within the acceptable range of 50-100, but the log also showed that on approximately 6 occasions during September 2025 the ppm was recorded above the acceptable range and there was no documentation in the column for action taken if out of range. The Dietary Manager reported that the dish machine had been leaking for several months and confirmed that if the chemical was not present, the machine would not be effectively sanitizing the dishes. The Administrator later stated that the dishwasher would be replaced with a new piece of equipment.
Failure to Ensure Resident Dignity, Self-Determination, and Access to Services
Penalty
Summary
Surveyors identified multiple deficiencies related to residents' rights to dignity, self-determination, and communication. One resident reported that care plan meetings were held at bedside with only a social worker present, and that they received only a care plan report and grievance form without meaningful discussion or support from other staff. The resident also experienced missed medical appointments for over a year due to the facility providing a replacement wheelchair that was too large for available transportation, despite being approved for a power wheelchair that was never received due to unpaid facility bills. The resident further reported a lack of support in discharge planning to return to their home state, loss of access to personal funds after the facility became their Social Security Representative Payee without proper communication or documentation, and an inability to obtain personal documents or legal assistance due to lack of funds. Record reviews confirmed the resident was cognitively intact and had decision-making capacity, yet the facility initiated the payee process citing incapacity, and failed to provide statements or timely access to personal funds. Surveyors also observed staff repeatedly entering residents' rooms without knocking or requesting permission, despite previous resident complaints and administrative awareness of the issue. Multiple residents confirmed that staff often failed to announce themselves before entering, and this concern had been reported to facility administration but remained unresolved. Direct observations by surveyors corroborated these reports, with staff entering rooms unannounced during the survey period. Additionally, residents reported not having access to their personal clothing, particularly on weekends, due to ongoing staffing shortages in the facility's laundry services. One resident was found to have no clothing in their room except for the outfit they were wearing, which they had slept in, while another was observed wearing a hospital gown and expressed a preference for personal clothing. The Director of Housekeeping confirmed that the position responsible for laundering personal items on weekends had been unfilled for months, resulting in extended wait times for laundry return and residents lacking appropriate clothing.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests such as flies, gnats, and ants in multiple areas. During observation rounds, a resident's room was found to have numerous black insects flying near and on the resident, their bed, and privacy curtain. The resident reported that flies were landing on their head, food, and bed. Additional observations on subsequent days revealed that the issue persisted, with several insects still present in the same room. Staff were made aware of the situation during these observations. Further inspection of other units revealed flies and gnats in hallways and shower rooms, as well as a trail of ants in another resident's room, attracted to food particles on the floor. These findings were confirmed by facility staff, including a GNA and a Unit Manager. Interviews with residents also indicated ongoing issues with flies and gnats throughout the building. The Director of Maintenance later confirmed that a pest control company visits the facility weekly, but the presence of pests remained evident during the survey.
Smoking paraphernalia left with residents needing supervision and smoking assessments not kept current
Penalty
Summary
The facility failed to maintain smoking paraphernalia for residents who required supervision with smoking and failed to keep smoking assessments and care plans aligned with residents’ current smoking status. The report identified multiple residents on the smokers list who required supervision, yet cigarettes, lighters, vape devices, or other smoking items were observed in their rooms or at the bedside. Facility policy stated that smoking paraphernalia for residents needing supervision would be maintained by the center and that supervised smokers would not keep possession of those items. Resident #33 was identified as needing supervision based on a smoking safety screen score of 10 and a care plan calling for supervised smoking, yet the resident told the surveyor that smoking items were kept in the room in a pocket of clothing. Resident #119 was also listed as needing supervision, with a smoking safety screen score of 25 and a care plan for supervised smoking, but cigarettes were observed in the nightstand and later on the over-bed table. Resident #42 was observed with three boxes of cigarettes in the bedside table, and the smoking safety screen score of 15 indicated supervised smoking was required. Resident #45 was listed as requiring supervision, had a smoking safety screen score of 10, and was observed with a vape pen in the room and in hand; the resident stated the vape pen was used in bed and had been used that day. Resident #2 was observed in bed on oxygen with cigarettes and a lighter at the bedside, while the smoking assessment initially scored the resident as 0, indicating unsupervised smoking, despite the resident being on oxygen. The report also described failures to update smoking assessments and care plans when residents’ smoking status changed or when the assessment did not match the resident’s condition. Resident #4 was listed as an independent smoker, but the smoking safety screen score was 10 and the care plan still reflected supervised smoking. Resident #55 was listed as an independent smoker, but the smoking safety screen stated the resident did not smoke, while the care plan addressed smoking and independent smoking. Resident #37 was documented on the smokers list as requiring supervision, but the smoking screening assessment identified the resident as a smoker without supervision and no updated care plan was found at the time of review. The report stated that eight residents reviewed for smoking had the potential to be affected by these issues.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure secure storage of medications and failed to appropriately label and store drugs and biologicals in accordance with accepted professional principles in multiple areas, including supply rooms, medication carts, resident belongings, and the medication refrigerator area. During the initial tour, the second-floor biohazard soiled utility room door was observed ajar, allowing free access to the second-floor supply room, where multiple boxes and bags of Apomorphine Hydrochloride Injection and boxes of needles were visible in an unlocked area. An RN confirmed medication should not have been stored there, and a GNA stated the supply room did not require a code to enter and that the lock had been broken for approximately two to two and a half years. Surveyors also observed an unlocked treatment cart in the freely accessible supply room containing multiple topical medications, including Lidocaine ointment, Clobetasol topical solution, Clotrimazole, Santyl, Calcipotriene, Tacrolimus, and Triamcinolone. The facility’s Director of Maintenance stated staff had removed the lock mechanism for convenience. In another area, fluticasone nasal spray without resident identification was found in resident belongings stored in the unlocked second-floor shower room. The Administrator observed and acknowledged the unlabeled medication, and the ADON responded to the concern. During medication administration, an LPN dispensed insulin to a resident from an unlabeled Insulin Aspart Injection FlexPen and stated the label had fallen off, adding that this was the only resident using that FlexPen medication. Surveyors also observed a bottle of blood glucose test strips without a visible open or discard date. In the Station 2 medication room, the refrigerator temperature log had blank entries, the sink area was obstructed by storage bins and supplies, an expired secondary medication set was present, an opened activated charcoal product lacked an open or discard date, and returned medication packs were piled on a bedside table and medication cart awaiting pharmacy pickup. Staff interviews showed conflicting understanding about who was responsible for completing the temperature log.
Incorrect Food Consistency Served to Resident on Mechanically Altered Diet
Penalty
Summary
The facility failed to ensure that a resident receiving a therapeutic mechanically altered diet was served food in the correct consistency according to the physician's order. During a tour of the 2nd floor nursing unit, the surveyor observed Resident #100 with breakfast on the bedside table. The resident stated they had drunk some of the supplement shake and were not interested in the tray. The breakfast tray contained hot cereal, scrambled eggs, and a slice of toast cut in half with margarine, while the meal ticket indicated hot cereal, scrambled eggs (fork mashable), and toast that was to be pureed with jelly and margarine. The surveyor reviewed the resident's record and found a physician's order for a regular diet with dysphagia, mechanically altered texture, and thin liquids. An LPN confirmed the tray did not match the meal ticket, and the RD stated the resident should not have had regular toast because the toast should have been pureed per the diet order. The DOR also stated there had been no upgrade to the resident's diet and that speech therapy notes indicated the resident was to remain on a mechanically altered diet due to dysphagia. The Regional Dietary Manager was informed that the resident received regular toast despite the documented diet requirements.
Infection Prevention and Control Failures During Resident Care and Environmental Handling
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during resident care and medication administration. During observation of medication pass, an LPN donned and doffed gloves but did not perform hand hygiene after fingerstick testing or insulin administration, and returned the glucometer to the medication cart without cleaning it. The same LPN then retrieved the glucometer for another resident before cleaning it, and another LPN was observed entering a resident room to adjust an oxygen nasal cannula and then proceeding to medication administration without performing hand hygiene between resident interactions. In another resident care observation, an LPN entered a resident’s room under enhanced barrier precautions and handled the resident’s uncapped PICC line without wearing a gown. The resident’s PICC dressing had no date or time documented, no swab caps were present on the connectors, and the resident reported concern that the uncapped lines were dragging along the counter and could contact the food tray. The resident also had a pressure-relieving boot with crusted brown, black, and red matter on the surface where the wound area would contact it, and the boot was observed sitting on a plastic basin on the floor. Environmental and housekeeping observations also showed infection control failures in linen and supply handling. An admission assistant dropped clean linen on the hallway floor and then used that linen to make a bed. In the laundry room, the chute was backed up with dirty loose clothing and linen, and clear bags were not tied before being tossed into the chute. A laundry assistant was observed folding clean linen so that it touched the uniform and, on another occasion, the floor, contaminating the blankets. The laundry room ceiling vents were uncovered and covered with debris, soiled laundry was overflowing from the chute, hand soap was unavailable at a floor 2 bathing room sink and nearly empty at another sink, and respiratory supplies were stored about 2 inches from a visibly dirty floor.
Unsafe and Unkempt Exterior and Common Areas
Penalty
Summary
The facility failed to ensure a safe functional environment based on observations of the exterior grounds and related areas. Surveyors observed the exterior vent for the laundry room covered with several inches of grey matter, overgrown weeds surrounding the generator equipment, an area of ceiling disrepair with peeling paint extending several feet across the ceiling in the laundry room, and an exterior gutter near the laundry room filled with leaves and debris. Near the resident dining hall, surveyors observed an emergency fire blanket on the wall with approximately 15 cigarette butts sitting on top of it. In the same area, surveyors observed two carts on their sides, a piece of broken furniture, a nightstand, a geriatric chair, an upside-down table, and four mattresses. The concerns were shared with facility leadership during the observation.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A facility failed to protect a resident from physical abuse perpetrated by an employee. The incident involved a Geriatric Nursing Assistant (GNA) who was observed by a laundry department staff member slapping a resident on the right cheek while attempting to assist the resident off an elevator. The resident was later reported by hospital staff to have stated being hit on the left side of the face by a staff member while at the facility. The incident was witnessed and reported by the laundry assistant, and the facility became aware of the event on the same day it occurred. Following the incident, the resident was sent to the hospital for a CT scan of the head, which was negative, and subsequently returned to the facility. The facility's internal investigation confirmed the physical assault by the GNA. The surveyor reviewed the incident through medical records, administrative records, interviews, and direct observation, confirming that the facility did not protect the resident from physical abuse as required.
Failure to Ensure Resident Participation and IDT Involvement in Care Planning
Penalty
Summary
The facility failed to ensure that residents were able to participate in the development, review, and revision of their care plans as required. For two residents reviewed, care plan meetings were conducted only at the bedside and attended solely by Social Services staff, without participation from the full Interdisciplinary Team (IDT). Residents reported that these meetings were not helpful, as the Social Worker present was unable to answer questions about medical care or business concerns, and residents were simply given a copy of their care plan and a grievance form. Documentation reviewed confirmed that only Social Services staff and the resident signed the care plan meeting sign-in sheets, with rare attendance by other disciplines. No evidence was found that the required IDT members participated in these meetings. Additionally, residents expressed dissatisfaction with the process, stating that their concerns, such as those related to depression or facility policies, were not addressed during the meetings. The Director of Social Services confirmed that the IDT was invited but did not usually attend bedside meetings, and no further documentation was available to support full IDT involvement. The lack of comprehensive team participation and inadequate opportunity for residents to discuss their care needs led to the deficiency.
Failure to Provide Adequate Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary for residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. One resident reported that care plan meetings were only attended by the social worker, with no other staff present to discuss care or address multiple concerns. The resident experienced missed medical appointments for over a year due to the loss of a wheelchair that fit into available transportation, and the replacement wheelchair was too large for the facility's only taxi service. Although the resident was approved for a power wheelchair, it was never received due to an unpaid bill. The resident also reported a lack of support for discharge planning to return to their home state and was not provided assistance in recovering lost personal documents or accessing personal funds after the facility became the resident's representative payee. Documentation showed the resident was cognitively intact, yet the facility submitted paperwork to Social Security indicating the resident was incapable of managing finances, without corresponding progress notes or communication to the resident about this change. Another resident expressed a desire to return to the community but was unable to do so due to lack of access to personal funds and was not informed about available programs such as the Waiver Program. The social services staff indicated that the resident's family was receiving survivor's benefits and paying privately, but no further assistance or documentation was provided to support the resident's expressed interest in community discharge. The care plan noted the need to assess the resident's preference for community return, but there was no evidence of follow-up or action taken in response to the resident's requests. A third resident, who had a court-appointed guardian, reported dissatisfaction with the guardian's support and expressed a desire for their granddaughter to become their power of attorney or guardian. The resident stated that requests for assistance in changing guardianship were met with dismissals about excessive paperwork. Documentation confirmed the resident was cognitively intact and had communicated their wishes, but there was no evidence of effective social services intervention to facilitate the requested change. These findings collectively demonstrate the facility's failure to provide adequate social services to support residents' rights, preferences, and access to necessary resources.
Failure to Assist Resident with Transportation for Medical Appointments
Penalty
Summary
The facility failed to assist a resident in making appropriate transportation arrangements to and from laboratory services outside of the facility, resulting in multiple missed medical appointments. The resident reported missing appointments for over a year due to the loss of their original wheelchair, which was compatible with the facility's contracted cab service. The replacement wheelchair provided by the facility was larger and could not fit in the available taxi, and the resident had not received an approved power wheelchair due to delays in payment processing. Despite the resident's repeated requests for assistance, including communication with the Social Worker, no effective solution was provided, and the resident was only given grievance forms without resolution. Record reviews confirmed that the resident missed several appointments because the available transportation could not accommodate the larger wheelchair. Staff interviews revealed that the facility was limited to scheduling with a single taxi service, which could not transport the resident's current wheelchair, and alternative transportation options were not pursued. The Director of Rehab Services confirmed that the resident was approved for a power wheelchair, but the facility's billing process delayed payment, preventing the resident from receiving the necessary equipment. Communication between facility staff and regional business offices showed ongoing delays in processing the invoice for the power wheelchair, with no payment status available at the time of the survey.
Failure to Maintain Accurate and Consistent Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records for several residents, as evidenced by multiple discrepancies and omissions in documentation. For one resident, the care plan sign-in sheet and face sheet incorrectly listed a family member as the power of attorney for health care decisions, despite documentation showing the resident had decision-making capacity and the power of attorney was only for financial matters. The care conference invitation was also misaddressed, and the error was only identified after surveyor intervention. Another resident's peripherally inserted central catheter (PICC) dressing was observed without a date or time, and there was no documentation of a dressing change in the medical record, even though the change was reportedly performed. Additionally, two residents' smoking status assessments and care plans were not updated to reflect their current abilities and preferences. One resident was listed as an independent smoker on the facility's list, but the medical record and care plan still indicated the need for supervision, while another resident's assessment failed to indicate they smoked, despite care planning for independent smoking. A further deficiency was noted in the documentation of a resident's fall. Progress notes contained conflicting dates and times regarding when the fall occurred, with some notes indicating different days and times for the same incident. Staff confirmed that only one fall had occurred, but the medical record did not accurately reflect this, leading to confusion and inconsistency in the resident's documentation.
Unvaccinated Resident Dog Allowed in Dining Room
Penalty
Summary
The facility failed to ensure reasonable clinical and safety restrictions under its policies and procedures by allowing an unvaccinated animal into the controlled environment. Surveyors observed a dog in the 1st floor Dining Room brought in by family, and the dog was later identified as belonging to resident #115 and visiting weekly. During interview, the Director of Recreational Therapy provided the facility policy stating that all animals, including service animals used for therapy and resident animals, are to have vaccination records on file. However, during follow-up interview, staff stated there were no vaccination records on file for resident #115’s dog and that the facility would need to obtain them from the family.
Advance Directive Records Were Conflicting and Not Current
Penalty
Summary
The facility failed to ensure that a current copy of a resident’s advance directive was maintained in the medical record. During record review, the resident’s code status was shown as CPR (Full Code) through a hyperlink, but the linked advance directive documents included two 5 Wishes forms with a DNR preference dated earlier in the record. The chart also contained a Nursing Home H&P note signed by a physician stating that the patient had capacity to make decisions and requested full code, including tube feeding and blood transfusion except dialysis. The record further showed a history of five Maryland Orders for Life Sustaining Treatment (MOLST) forms, with the most current reflecting Attempt CPR and four prior forms voided, including DNR/I and other conflicting entries. During interviews, staff acknowledged the conflicting advance directives and end-of-life orders in the chart and stated that charts are audited for advance directives, though it was unclear whether this resident’s chart had been audited. After surveyor intervention and provider discussion with the resident, the advance directives were changed to Full Code status, and the 5 Wishes packet on file was voided in the medical record.
Failure to document hospital transfer notifications, bed hold information, Ombudsman notice, and transfer rationale
Penalty
Summary
The facility failed to provide written notification to resident representatives of hospital transfers and the facility’s bed hold policy, and failed to ensure the local Ombudsman was notified timely on a monthly basis of facility-initiated hospital transfers. For Resident #153, the record showed transfers to the hospital on 9/8/2025 and 9/29/2025, but the electronic and paper record did not contain documentation that the resident representative received written transfer notification or bed hold information for either transfer. The record also did not show that the local Ombudsman was informed of those hospital transfers at the time they occurred. For Resident #5, the electronic medical record showed hospital transfers on 8/23/2025 and 8/29/2025, but there was no documentation in the record that the local Ombudsman was notified of either transfer. The DON stated that social services sends monthly emails to the local Ombudsman regarding discharges, admissions, and transfers to the hospital, but the facility could not initially provide documentation to verify notification for the resident’s August transfers. The emails later provided to the surveyor were sent after surveyor intervention, and the resident was listed on the August notification. For Resident #174, the DON stated the resident was admitted from the hospital and then discharged back to the hospital because the resident was not an appropriate admission and required 1:1 service for the remainder of life, which the facility said it could not provide for an extended period. However, the surveyor could not find clinical documentation in the medical record explaining the reasoning for the discharge back to the hospital, and the DON stated there was no nursing progress note documenting the decision-making process. The DON also could not provide documentation that the Ombudsman was notified of the resident’s discharge to the hospital, and the record did not show that the hospital was notified of the pending transfer.
Inaccurate MDS Coding for Resident After Femur Fracture Surgery
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for Resident #5, who had been hospitalized after a fall that resulted in a right femur fracture, underwent surgical repair, and returned to the facility on 8/28/2025. A quarterly MDS assessment completed on 9/21/2025 did not accurately code Section J-Health Conditions to reflect the resident’s status after the hospital stay and surgery. During record review, the surveyor found that J2100 was not marked yes to indicate the resident had a major surgical procedure during the prior inpatient hospital stay that required active care during the SNF stay. The assessment also failed to check J2510 for repair of fractures of the pelvis, hip, leg, knee, or ankle. In interview, both MDS Coordinators stated that J2100 should have been answered yes and J2510 should have been checked to accurately reflect the resident’s status on the quarterly assessment.
Incomplete Resident-Centered Activity Care Plan
Penalty
Summary
The facility failed to develop a resident-centered activity care plan for Resident #9 that addressed the resident’s physical, mental, and psychosocial needs with personalized goals, measurable objectives, and interventions. Record review showed the resident had diagnoses including tracheostomy, anoxic brain damage, persistent vegetative state, and contractures, and had communication problems due to the condition. The activity-focused care plan stated the resident required 1:1 activities because the resident was unable to participate in other activities, with a goal that the resident would be satisfied with 1:1 activities provided through the review period. The care plan also included an intervention to provide 1:1 activities in the room or location of the resident’s preference as needed, but it did not identify resident-specific activities, measurable objectives, or interventions implemented by staff to help the resident reach the stated goal. During interview, the Activity Director acknowledged the concern that the resident did not have a resident-centered activity care plan addressing current activity status and stated he would look into the care plan and revise it to reflect the resident’s current activity status.
Missed wound care and unscheduled specialist consultations
Penalty
Summary
The facility failed to ensure timely consultations were scheduled and wound care was consistently performed for Resident #3, who had multiple wound care orders for foot wounds during September 2025. During interview, the resident stated that dressing changes were not occurring at the ordered frequency because there were not enough nursing staff available to perform them, and that specialist appointments for foot care had not yet been arranged even though staff told the resident they were handling the scheduling. Record review showed six wound care orders in place for the resident’s foot wounds during September 2025. The September 2025 Treatment Administration Record showed no nursing sign-off for ordered wound care on one dayshift treatment on 9/6/25, two dayshift treatments on 9/13/25, and two dayshift treatments on 9/28/25. Active orders also included an infectious disease consultation ASAP for the right foot dated 9/25/25 and a vascular consultation related to right lower extremity stenosis dated 7/28/25, but the ADON later confirmed that neither appointment had been scheduled. The ADON and DON both acknowledged gaps in documentation, and the DON stated that the unsigned wound care treatments could not be confirmed as completed because they were not documented.
Failure to Provide Incontinent Care and Maintain a Clean Bed Area
Penalty
Summary
Failure to provide appropriate incontinent care and services was identified for one resident who was documented as frequently incontinent of both bladder and bowel. During observation rounds, the resident was found sitting in a wheelchair near the room window wearing a brief saturated with urine and stool. The resident’s bed mattress had no fitted sheet and was observed to be over 75% saturated with a wet yellow and brown substance with a strong odor of urine and stool; the mattress was worn, faded, discolored, lumpy, and in poor condition. The flooring around the resident’s bed and throughout the room was noted to have a thick layer of sticky dark spots of dirt accumulation. When interviewed, the resident stated that staff had taken the sheets off the bed but did not clean the bed. A later observation found the mattress and room floor in the same condition. The DON was informed of the observations and agreed with the condition of the mattress, stating that a new mattress would be obtained.
Incorrect Oxygen Delivery and Monitoring
Penalty
Summary
The facility failed to ensure Resident #77 received respiratory care in accordance with professional standards of practice, the resident’s care plan, physician’s orders, and the resident’s choice. Resident #77 had a diagnosis of COPD and orders for oxygen at 3L via nasal cannula to keep SpO2 at or above 92% with shift monitoring. The care plan also directed oxygen at 3L, monitoring for respiratory complications, and administration of oxygen as ordered. During multiple observations, the resident was found on incorrect oxygen settings, including 1.5L and later 1L, despite the ordered 3L. On one occasion, oxygen tubing was observed on the floor and was replaced by staff after the surveyor notified them. On another observation, the resident was in the dining room with the nasal cannula in place but the concentrator set at 1.5L; staff confirmed the setting was incorrect and stated the concentrator was broken and would not go to 3L. On a later observation, the resident was again noted with the concentrator set at 1L and the humidified bottle not flowing, and staff stated the concentrator was not working. The resident was observed appearing winded when speaking and stated, "I should be on 3L, but I often feel winded when speaking."
Controlled Drug Records, Counts, and Supply Management Failures
Penalty
Summary
The facility failed to provide pharmaceutical services to meet each resident’s needs and to employ or obtain the services of a licensed pharmacist, as shown by multiple problems with controlled drug handling for one resident. During review of the controlled substance log book, surveyors found that when new inventory of Diazepam, Dilaudid, and Methadone was received, the facility did not start a new page for the medication supply. A review of Methadone records also showed an inaccurate transfer between pages, including a last entry showing 46 tablets on hand, 4 tablets used, and 42 tablets left, followed by a new page entry showing a transfer of 38 tablets. The DON confirmed that the expected practice was to start a new page for each new controlled drug supply from the pharmacy. Surveyors also found repeated failures in controlled drug shift counts and documentation. The controlled substance log book for the resident showed numerous shift changes between 8/11/2025 and 10/7/2025 where only one signature was present or no signatures were present for the required count. The DON confirmed that two nurses are expected to complete a controlled drug count at every 8-hour shift change, even if one nurse is working a double shift. In addition, two controlled substance sheets for Methadone contained overlapping accountability records for the same dates and both documented a dose given on 8/8/2025, but with different tablet counts on hand and remaining. The facility also failed to document controlled medication administration immediately and failed to maintain a sufficient supply of controlled medications. An LPN was observed documenting Methadone after it had already been given earlier that day, and the LPN confirmed the medication should have been documented in the controlled substance log book at the time of administration. Another review showed Hydromorphone HCL doses documented in the controlled substance sheets on several dates that were not documented on the MAR. The resident stated the facility was constantly running out of Methadone, and the record review showed periods when Methadone, Diazepam, and Hydromorphone HCL reached zero or the last dose before new supplies were received, including instances where the last tablet or last doses were administered before replacement medication arrived.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent during 33 observed medication administration opportunities, resulting in a 12.12% error rate involving 4 of 5 residents observed. During insulin administration for one resident, an LPN dispensed insulin from an unlabeled Insulin Aspart FlexPen and stated the label had fallen off, while also acknowledging that a labeled replacement should have been requested from pharmacy. During another insulin pass, an LPN obtained and recorded a fingerstick of 140 after the resident had already eaten breakfast, then administered pre-meal insulin despite the meal having already been consumed. Additional medication administration errors were observed with two other residents. For one resident receiving 12 medications, an LPN removed all medications from the cart but failed to include calcium carbonate in the medication cup, administered only 11 medications at the bedside, and then charted all 12 medications before later retrieving and giving the omitted dose after surveyor intervention. For another resident, an LPN prepared polyethylene glycol 3350 incorrectly by searching measurements on Google, despite the bottle labeling indicating the dose should be measured using the cap filled to the line; the LPN measured the powder into a medicine cup, mixed it in a drinking cup with water, and administered it before the resident refused the medication. The DON stated that using Google was not the facility expectation for medication reconstitution.
Unqualified supervision of food and nutrition services
Penalty
Summary
The facility failed to ensure that the staff member assigned supervisory responsibilities for food and nutrition services was a qualified dietetic service supervisor. During the surveyor’s initial kitchen tour, staff confirmed that the Dietary Manager was the full-time supervisor in charge of kitchen operations. The Regional Registered Dietitian stated that they did not provide oversight to the facility’s diets or kitchen. The Dietary Manager reported having supervised and run the kitchen for ten years but confirmed they were not a certified dietary manager and were still in training. The Administrator later provided a dietary manager continuing education course registration form and confirmed that the Dietary Manager had not completed the educational training and was still in the course. A Regional Dietary Manager also stated they were a regional supervisor who visited the facility approximately two times per week.
Dietary Orders, Allergies, and Portion Needs Not Followed
Penalty
Summary
The facility failed to ensure that residents received foods that matched their dietary orders, allergies, intolerances, and stated preferences. Resident #58 was observed eating lunch in bed with a tray ticket listing a regular heart healthy diet with thin liquids, baked pork chop, Italian blend vegetables, dinner roll, and diet ice cream, along with instructions/dislikes noting tomato products, tomatoes, and gravy. The actual tray contained a white meat-like item, green bean-like vegetables, mashed potatoes with a generous amount of brown gravy-like substance, and apple juice, with no roll or ice cream shown on the tray and no substitution indicated. The resident stated there was no variety, limited vegetables, too many carbs, and wrong timing. Resident #117 had dietary orders for a heart healthy diabetic diet with thin liquids and allergies to shellfish and fish, yet the meal ticket for lunch listed baked fish, French fries, coleslaw, and cake. The tray observed did not match the ticket and included a brown meat-like substance with gravy, mashed potatoes with gravy, green bean-like pieces, apple juice, coffee, coleslaw, and cake. Resident #117 stated the food was always cold, tasteless, and not enough, and said extra portions and an evening snack were requested but not received. Resident #14 had orders for a renal diabetic diet with thin liquids, double portions, and allergies to shellfish and fish, but the meal ticket listed baked fish, rice, coleslaw, and cake. The tray observed did not include the ordered double portions or rice and included a fish patty-like substance despite the listed allergy. The DON stated the resident was not really allergic to fish, only shellfish, and preferred fish they had caught, and no corrected meal tickets were provided before the end of survey.
Environmental and Equipment Deficiencies Impact Resident Comfort and Safety
Penalty
Summary
Facility staff failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by multiple environmental deficiencies observed during a complaint survey. On two of three nursing units, surveyors noted numerous stained and missing ceiling tiles, missing or damaged molding around over-the-bed tray tables, and exposed or damaged wall areas. In several resident rooms, there were holes in the walls, spackle left unpainted, torn wallpaper, and gaps in base molding. These issues were observed throughout the second-floor nursing unit, as well as in administrative offices, indicating a widespread lack of maintenance and housekeeping. Additional deficiencies were observed in resident equipment and furnishings. Several residents were found using wheelchairs with missing or damaged armrests, exposing foam or padding, and in one case, a resident expressed a desire for a replacement armrest. In the dining room, a resident's Geri-chair had a torn armrest with exposed padding. In another room, tube feeding stains were present on the floor, and fall mats were dirty, ripped, and had exposed padding. These conditions were confirmed by staff during the survey. Interviews with the Maintenance Director revealed that the facility was aware of the ceiling tile issues, which were attributed to a malfunctioning rooftop air conditioning unit causing condensation and leaks. The Maintenance Director also described ongoing efforts to replace damaged tray tables and repair wheelchairs, relying on reports from staff and a maintenance program. However, as of the time of the survey, many of these environmental and equipment deficiencies remained unaddressed, directly impacting the residents' living conditions.
Inaccurate Coding of MDS Assessments for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, as evidenced by discrepancies between the MDS documentation and the residents' medical records. In several cases, the MDS did not reflect significant clinical events or medication administration, such as substantial weight loss, falls, and the use of specific medications including antibiotics, opioids, hypoglycemics, antiplatelets, and pain relievers. For example, one resident experienced a weight loss of over 20 pounds, but the MDS did not indicate a 10% or greater weight loss. Another resident had two documented falls, but the MDS assessment stated no falls had occurred during the relevant period. Additional deficiencies were noted in the failure to accurately document medication administration. Several residents received medications such as insulin, antibiotics, opioids, antiplatelets, and pain medications, but these were not captured in the corresponding MDS assessments. In one instance, a resident received both scheduled and PRN pain medications, as well as topical antibiotics, but the MDS failed to record these treatments. Similarly, another resident received a PPD injection for tuberculosis screening, which was not documented in the MDS. These inaccuracies were confirmed through interviews with MDS coordinators and review of medication administration records (MARs). The findings indicate that the facility did not consistently ensure that the MDS assessments accurately reflected the residents' clinical status and care provided during the assessment periods, as required by federal regulations.
Failure to Provide Care and Timely Response After Falls and Medical Events
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for multiple residents. In one instance, a resident with chronic congestive heart failure, seizures, diabetes, and anxiety was ordered by a physician to be sent to the emergency room for fluid overload and seizure activity. The resident was transported via non-emergency taxi without an escort, resulting in the resident waiting 20 minutes outside the emergency room before being assisted inside. Staff interviews revealed inconsistent practices regarding escorts for non-emergency transports, and the physician was not aware that the resident was unescorted. In another case, a resident who fell off the bed did not have the incident documented in the medical record on the day of the fall, and there were no follow-up assessments or timely physician notification. The first documentation occurred at least 12 hours after the fall, and vital signs recorded did not correspond to the time of the incident. The facility's policy required immediate notification and monitoring after a fall, which was not followed. The LPN involved admitted to forgetting to document the incident and not being familiar with the process at the time. Additional deficiencies included failure to conduct and document neurological checks after unwitnessed falls for two residents, despite facility policy requiring specific intervals for such assessments. In one case, neuro checks were not performed at all after four unwitnessed falls, and in another, the checks were completed at incorrect intervals and with inaccurate data. Furthermore, a resident with a history of intracerebral hemorrhage and recent skull surgery was not sent to the emergency room in a timely manner after a fall, despite an order for immediate transfer for imaging. These findings were confirmed through medical record reviews and staff interviews.
Failure to Monitor Vital Signs Prior to Medication Administration
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not adhering to physician orders regarding the monitoring of vital signs prior to medication administration. For one resident prescribed Carvedilol for hypertension, the physician's order required holding the medication if the heart rate was less than 50, but there was no documentation that heart rate was consistently monitored before administration. Similarly, another resident receiving Hydralazine for hypertension had an order to hold the medication if systolic blood pressure was less than 110, yet the medication was administered when the blood pressure was 100/62. In both cases, the Director of Nursing confirmed that the required monitoring was not performed as ordered. A third resident, with a history of orthostatic hypotension, was prescribed Midodrine with specific parameters to hold the medication if blood pressure exceeded certain thresholds. The medication was administered multiple times outside of these parameters, as documented in the Medication Administration Records. Interviews with nursing staff and the Director of Nursing confirmed that medications were given even when vital signs were outside the prescribed limits, and that the required monitoring and documentation were not consistently performed.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous flies and gnats throughout multiple areas. Surveyors observed flies and gnats in the conference room, first-floor hallways, resident rooms, the kitchen, the rehab gym, and the conference room over the course of a week. In one instance, a resident reported that flies had been present in their room for at least a week and found them to be annoying. Additionally, a fly was observed on a resident while they were lying in bed with the DON present. Flies were also seen in the kitchen, including on storage racks and around the serving table during food plating. Staff interviews revealed that fly lights had been installed in the hallways and kitchen for the past two years, and pest control services were provided approximately twice a month, including spraying and treating drains. Despite these measures, staff acknowledged that the fly problem typically worsened at the beginning of summer. Pest control invoices confirmed regular service visits, but the persistent presence of pests indicated that the program was not effective in preventing or controlling infestations during the survey period.
Failure to Maintain Resident Dignity During Feeding and Catheter Care
Penalty
Summary
Facility staff failed to uphold residents' rights to dignity and privacy in two observed instances. In the first case, a geriatric nursing assistant was observed feeding a resident while standing over them, rather than sitting at eye level, which did not promote a dignified dining experience. In the second case, a resident with a Foley catheter, who had recently been admitted from the hospital with a urinary tract infection, was observed in bed with the catheter bag hanging visibly from the bed frame and not placed in a privacy or dignity bag, despite the resident's care plan specifying the use of a catheter privacy bag. Both deficiencies were directly observed by surveyors and confirmed with facility leadership.
Failure to Notify Resident Representative of New Medication Order
Penalty
Summary
Facility staff failed to notify a resident's representative when a new medication, Seroquel, was ordered for the resident. The resident, who had a diagnosis including dementia, was admitted in November 2024. On 12/18/24, the physician ordered Seroquel 25 mg in the morning and two tablets at bedtime for depression. There was no documentation in the medical record indicating that the resident's representative was informed of this new medication order. The medication was administered on 12/18/24 and 12/19/24, and subsequently discontinued after the resident was seen by the physician on 12/19/24. The Director of Nursing confirmed that the representative was not notified of the medication order.
Failure to Maintain Resident Medical Record Confidentiality
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of a resident's medical records when an electronic medical record was left open and visible on a computer screen atop an unlocked and unattended medication cart in a hallway. The unattended cart, located outside a resident's room, displayed the resident's medications and allowed access to additional information. This lapse was observed by a surveyor, and the responsible LPN acknowledged leaving the computer screen open by mistake. The incident was brought to the attention of the Director of Nursing.
Failure to Safeguard Resident's Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property from misappropriation. When the resident was transferred to the hospital, facility staff packed the resident's belongings and placed them in storage, assuring the resident that the items were secured. Upon the resident's return, the PlayStation 5 was missing. Multiple staff members, including the social work director and the ADON, were aware of the missing item, and a building search was conducted, but the device was not found. The resident ultimately replaced the PlayStation 5 at personal expense after waiting for a facility response. Interviews with staff and the resident's roommate confirmed that the PlayStation 5 had been missing since the resident's hospitalization, and the issue had been reported through various channels, including the Ombudsman. The current NHA was unable to locate a self-report or grievance related to the incident and could not determine a timeline or confirm the existence of the device. Documentation provided by the resident showed proof of purchase for a replacement PlayStation 5. The facility did not maintain adequate records or follow up on the reported loss, resulting in a failure to safeguard the resident's property.
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 260 citations issued within 25 miles in the last 12 months — including the 8 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 Elkton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurelwood Healthcare Center | 1.7 mi | ★★★★★ | 16 | 0 |
| Exceptional Care For Children | 5.2 mi | ★★★★★ | 0 | 0 |
| Newark Manor Nursing Home | 7.2 mi | ★★★★★ | 7 | 0 |
| Jeanne Jugan Residence | 8.4 mi | ★★★★★ | 4 | 0 |
| Encore At Parkside | 9.4 mi | ★★★★★ | 27 | 1 |
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.