Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Fairfield Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment was started on Seroquel 25 mg BID for agitation and mood stabilization without documented consent from the resident’s representative. Review of the medical record and MARs showed the antipsychotic was administered over multiple weeks, including a restart after a brief hold, with no evidence of obtained consent. In interviews, the prescribing physician and the DON confirmed that staff did not secure representative consent for this change in treatment.
Staff failed to maintain a clean, sanitary, and orderly room for a resident, resulting in persistent fruit flies, dirty surfaces, and unresolved maintenance issues. A complaint about fruit flies led to observations of multiple food trays with leftover food left in the room, visibly dirty bedside tables and dresser drawers, debris on the floor, and peanut butter jars with residue on the outside. On a subsequent visit, numerous fruit flies were counted in the bathroom and on walls and the sink, large cobwebs were present around closet doors, and the room still had dirty drawers and uncontained peanut butter jars. Additional issues included a constantly running toilet, an unused open-ended pipe near the toilet, cracked drywall around the sink, and old drill holes under the television, all confirmed by the DON.
Staff failed to follow physician orders for two residents, resulting in missed wound care and improper preoperative management. One resident with a non-pressure sacral wound did not receive the ordered daily silver sulfadiazine and calcium alginate dressings for several weeks after the wound physician initiated and reaffirmed these orders. Another resident scheduled for an outpatient vascular procedure received food and fluids despite NPO instructions, did not have Eliquis stopped as ordered, and did not receive the permitted morning doses of Aspirin, Metoprolol, Vimpat, and Gabapentin, leading to rescheduling of the procedure. The DON confirmed these failures to follow the consultant and vascular physicians’ orders.
Unsafe and Poorly Maintained Resident Areas: Surveyors observed multiple resident room and common-area maintenance issues, including marred and chipped furniture, loose baseboards, broken drawers, damaged walls, a missing window blind, a hole in a wall, and a damaged shower room door with a gap at the frame. In one resident room, drywall dust was found on the headboard and the wall behind the bed had significant scrapes in the paint and drywall; maintenance staff said they were not aware of the damage when shown.
Unlabeled and undated food items were found in kitchen refrigeration and freezer storage, including personal lunch items, leftovers, opened dairy and meat products, and mixed foods in containers that did not match their labels. The surveyor also noted missing freezer temp checks and a reused Gatorade bottle with an unidentified milky white substance in a nourishment refrigerator; the CDM and UM were unable to identify several items.
Incomplete resident medical records were found for several residents when surveyors reviewed the EMR and found missing provider, psychiatry, and psychology notes despite ongoing follow-up plans. The DON and UM confirmed that some notes were still in a backlog of paper/faxed records awaiting upload, and additional notes had to be obtained from Medical Records or providers because they were not present in the EMR.
A resident was not informed when a prescribed ointment was discontinued after a hospital return. The resident said staff told him/her the ointment could no longer be given, and the DON was unsure whether the resident had been involved in the decision. The resident confirmed not being told why the ointment was stopped and stated he/she had used it his/her whole life.
Failure to document GDR attempts or contraindication for psychotropic meds. Two residents receiving psychotropics, including an atypical antipsychotic and other psych meds, had records showing continued use for mood, agitation, and psych symptoms, but the chart lacked clear rationale for why GDR was not done or supporting documentation of a failed GDR. MDS entries noted ongoing antipsychotic use and no GDR attempted, while psych notes stated the residents were stable or on minimal medication without documenting the required basis for skipping dose reduction.
Inaccurate MDS coding affected three residents. One resident had a documented fall with a right tibia and fibula fracture, but the MDS listed the fall as no injury and omitted the fractures from active diagnoses. A second resident had documented falls, but the Quarterly MDS also coded the falls as no injury. A third resident had psychiatric diagnoses, including schizophrenia, that were not entered in the active diagnosis section of the MDS.
A resident’s care plan was not reviewed and revised after changes in splint use and therapy guidance. The resident had left-sided weakness from a CVA, a left UE contracture, and a splint order, but OT had last seen the resident long before and had recommended a resting hand splint for limited daily use with skin monitoring. The resident said the splint had not been worn for 1 to 2 years because it was too rigid and uncomfortable, yet the care plan did not reflect the current recommendations or the resident’s refusal.
Failure to provide appropriate respiratory care for a resident with a PRN O2 order was identified when surveyors observed an O2 concentrator and emergency tank in the room, a humidifier bottle dated 9/16, and no O2 signage posted on the room door. The RN Unit Manager confirmed the resident had a PRN O2 order and stated that O2 signs should be posted when O2 is in resident rooms. The resident stated he/she had not used O2 in a while.
Expired medications and therapeutic nutritional supplements were found in a medication cart during surveyor review with an LPN. The expired items included several blister-packed meds stored between the locked med box and a drawer divider, showing a failure to follow professional standards for medication disposition.
A resident was served a lunch tray that did not match the preplanned menu. The tray lacked nectar thick tomato juice and a pureed fresh baked roll, even though both were listed on the meal ticket. The CDM confirmed the juice was not available and stated the kitchen does not puree rolls.
Missed Hand Hygiene Between Resident Encounters: During a med pass, an LPN exited a resident's room and began preparing meds for another resident without performing hand hygiene. The LPN stated hand hygiene should be performed after each resident encounter, and hand sanitizer was present on the med cart. The DON acknowledged the missed opportunity.
A resident at risk for falls had a mattress that did not fit the bed frame properly, leaving a gap between the mattress and footboard. Staff placed a pillow and later a foam cushion in the gap, but the cushion was not secure and did not stay in place. The DON and Maintenance Assistant observed the issue, and the resident’s record noted recent falls.
Call Light System Not Functioning and Not Accessible: A resident's call button did not activate the hallway indicator, and staff were unable to identify the source of the call because the monitor was being rebooted. In a separate observation, another resident's call light device was found on the floor next to the bed and out of reach, and the RN unit manager acknowledged that call light devices should be within residents' reach.
Unsafe and poorly maintained resident and facility areas were observed, including an inoperable toilet in a resident room, an uncovered electrical outlet with a silver object in the prong, stained and broken ceiling tiles in the laundry area, and a large pothole in the parking lot. The resident with the broken toilet was incontinent at times and used a urinal at bedside; the DON, RN UM, maintenance staff, and NHA acknowledged the concerns.
A resident in a wheelchair was observed using a hall handrail near the kitchen hallway while a staff member assisted the resident to the requested destination. Surveyors also found no hallway handrails in the front lobby or in the hallway past the dining area toward the Atlantic units, and the NHA agreed residents use these areas.
Failure to Post Current Nurse Staffing Information: Surveyors observed that the nurse staffing posting in the lobby was not current and was still dated several days earlier when they entered the facility. The DON stated the Nursing Supervisor was responsible for posting the daily staffing sheet, including weekends, and acknowledged that the current sheet should have been posted. The report notes the required posting includes the facility name, current date, resident census, and RN, LPN, CNA, GNA, and CMA staffing hours.
The facility did not follow professional standards for medication administration, including giving a resident a medication that was supposed to be held, leaving medications and an insulin pen in a resident's room, and repeatedly documenting medication administration late for several residents. Nursing staff confirmed that high workload and lack of support staff contributed to delays in both administering and documenting medications.
Multiple residents requiring substantial or total assistance with bathing did not receive showers as ordered, with documentation showing extended periods between showers and no records of refusals. Staff and resident interviews attributed missed showers to staffing shortages and high resident-to-GNA ratios, resulting in inadequate hygiene care, including infrequent changing and turning. Facility leadership confirmed the expectation for twice-weekly showers and proper documentation, but these standards were not met.
A complaint investigation revealed that the call bell system on one unit was not functioning properly, as call lights illuminated but no audible alert was heard in the hallway or at the nurse's station. A resident was observed repeatedly pressing the call bell without response, and staff confirmed they could not hear the alerts. The issue was traced to the speaker system being turned off, and leadership was unaware that this could occur.
Surveyors identified unsafe and unsanitary conditions in two outdoor areas, including dilapidated planter boxes, broken and uneven concrete, scattered rocks, a moldy sheet, loose boards, a large hose on a picnic table, and deteriorating bird houses. Both the Maintenance Director and the NHA confirmed the poor condition of these areas.
A resident's call light was found on the floor and out of reach, contrary to the care plan directive to keep it accessible at all times. The resident relied on a hand bell or yelling for assistance, and staff did not respond to the hand bell. When the call bell was finally activated, a GNA responded after several minutes.
A resident with dysphagia experienced a significant weight loss, dropping from 213 to 191 pounds between two MDS assessments. Despite this, staff incorrectly coded the MDS to indicate no substantial weight loss, a mistake later confirmed by the MDS Coordinator.
A resident returned to the facility after a six-week hospital stay and underwent a comprehensive MDS assessment, but the facility did not hold a required care plan meeting to discuss the resident's treatment and prognosis. This oversight was confirmed by the Social Work Director during a complaint survey.
Facility staff failed to provide prescribed wound care for two residents, including one with a venous leg wound and another with a diabetic toe ulcer. In both cases, nursing staff did not follow updated physician orders, resulting in missed or improperly documented treatments, as confirmed by facility leadership.
A resident admitted with a sacral pressure ulcer did not receive the wound care team's prescribed treatment plan, as nursing staff failed to communicate and enter the correct orders into the system. Instead, a different wound care regimen was documented and provided, resulting in a deficiency in pressure ulcer care.
A resident with dysphagia experienced significant unplanned weight loss over several months due to staff failing to promptly follow the dietitian's recommendations for nutritional supplements and appetite stimulants, and not notifying the provider of continued weight loss. Despite monthly assessments, no further interventions were implemented, and the provider remained unaware of the ongoing decline.
A resident did not receive required face-to-face visits from a physician, PA, or NP within the mandated 60-day interval, with a gap of 76 days between documented visits. Staff confirmed the absence of provider notes during this period.
A resident with multiple complex medical conditions did not receive prescribed Tramadol for several scheduled doses due to the medication not being available. Interviews with the ADON, RN unit manager, and an LPN indicated that the pharmacy could have delivered the medication within hours if contacted, but there was no documentation that the physician was notified or that appropriate steps were taken to obtain the medication.
A resident with multiple diagnoses, including hypertension, was prescribed three antihypertensive medications with physician-ordered parameters to hold doses if blood pressure was below a certain threshold. Blood pressure was only consistently documented for the morning dose, with no documentation for the afternoon and evening doses of one medication. The MAR lacked designated spaces for recording required blood pressure readings, and this omission was confirmed by nursing leadership during the survey.
Surveyors found that staff failed to keep medication carts locked and unattended, left pre-poured medications unlabeled, and did not date or properly refrigerate opened medications such as inhalers and insulin pens. These actions were not in accordance with facility policy or manufacturer instructions.
A resident with dysphagia and recent significant weight loss reported issues with ill-fitting dentures. Although the concern was communicated to nursing management and a dental hygienist documented the need for a dental evaluation, the resident was not seen by a dentist as scheduled and did not receive the required follow-up dental services.
Two residents with orders for mechanical soft, ground meat diets due to swallowing and aspiration risks were served meat in cubed and chunked forms rather than ground, as required by their dietary orders. Staff and dietary leadership confirmed the meals were not prepared according to the prescribed consistency.
A resident with multiple chronic conditions and cognitive impairment had significant gaps in meal consumption documentation by GNAs, with numerous days missing records for breakfast, lunch, and/or dinner. This incomplete documentation prevented validation of the resident's food intake, and facility leadership confirmed the deficiency.
A resident with advanced cancer and a history of unsuccessful radiation treatment requested hospice care, with both the resident and family expressing this wish. Although the PCP was notified and directed staff to contact hospice, there was no documentation of a hospice order or initiation of services during the resident's stay. Staff interviews revealed inconsistent processes for handling hospice requests, and hospice care was only arranged after the resident was discharged home.
Required nurse staffing data, including staff names and actual hours worked, was not posted at the start of each shift in the facility's lobby or nursing units. Observations over two days found outdated or incomplete information, and interviews with the ADON and HR Director confirmed that postings were not maintained during the scheduler's absence.
The facility failed to conduct and document timely care plan meetings for several residents, as evidenced by missing documentation and staff interviews. A resident had a care plan conference upon admission, but no subsequent meetings were documented. Another resident reported not having care plan meetings, and their records lacked documentation despite multiple MDS assessments. A third resident's care plan meeting was canceled and not rescheduled promptly, with no documentation found. These deficiencies indicate a systemic issue in the facility's care planning process.
The facility failed to maintain a safe environment, as two residents were observed with safety hazards in their rooms, including a high bed position and debris on the floor. Additionally, a medication cart was found unlocked, and multiple building doors were unsecured, allowing surveyors to enter without alarms or staff presence. The Administrator acknowledged the broken locks but had not implemented alternative security measures.
A surveyor found that the facility failed to store food according to professional standards, with numerous opened and unlabeled food items in the kitchen's storage areas. The Certified Dietary Manager was unaware of the facility's food safety policy, and despite being informed, the facility did not remove or discard the identified items, posing a potential risk to residents.
The facility failed to ensure a functional call light system for residents, affecting their ability to summon assistance. Multiple residents reported non-functional call lights, with no alternative devices provided. Maintenance logs lacked documentation for repair requests, and staff interviews confirmed a lack of awareness and implementation of protocols for alternative communication methods.
A resident reported not receiving showers for two years, only bed baths, despite preferring showers. The DON and ADON stated the resident was informed to request showers and believed the resident refused them, but no refusals were documented in the chart. The DON acknowledged the need for documentation of refusals.
The facility failed to ensure residents were offered the opportunity to complete Advance Directives upon admission, affecting three residents. The Social Work Director acknowledged that documentation might have been missed due to staffing changes, contributing to the deficiency.
A staff member failed to keep a resident's medical information private by leaving a medication packet with the resident's name and medication list on top of a locked medication cart. This breach of confidentiality was observed during a medication administration task.
The facility failed to provide written notification to two residents or their representatives regarding hospital transfers, as required by policy. One resident was transferred due to a dislodged Foley catheter with bleeding, and another was transferred twice for altered mental status and hypoxia. The facility's records lacked documentation of written notifications, and the Social Worker confirmed that the required notices were not provided.
Facility staff did not develop baseline care plans for a resident within 48 hours of admission, as required. Despite having care plan conferences on later dates, the initial baseline care plan was missing from the clinical record. The DON and ADON were informed of this deficiency but did not provide an explanation or present the missing care plan to the surveyor.
The facility failed to provide a resident-centered activities program for three residents, impacting their mental and psychosocial well-being. One resident was unclear about being encouraged to leave their room and had limited engagement with activities. Another resident's family reported a lack of activities, with the last assessment dated months prior. A third resident's preferences were not assessed in recent years, and activity documentation was insufficient. The Activities Director admitted to documentation backlogs and inconsistent engagement efforts.
Facility staff failed to reposition a resident to maintain or improve their range of motion and mobility. The resident was observed lying on their back in bed on multiple occasions over several days. The DON and ADON could not explain the resident's positioning and stated they would investigate.
Two residents reported issues with the dietary provisions, including consistently cold food, limited entree choices, and lack of variety in breakfast options. One resident kept personal cereal due to hunger concerns. A cook confirmed a standard breakfast menu with limited alternatives and acknowledged food supply issues.
Failure to Obtain Representative Consent for Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to obtain consent from a resident’s representative before initiating an antipsychotic medication. The resident was admitted in October 2025 with dementia with psychotic disturbance and was assessed on 10/29/25 with a BIMS score of 6/15, indicating severe cognitive impairment. On 12/23/25, a physician (Staff #16) ordered Seroquel 25 mg twice daily, and on 12/26/25 documented that the resident was agitated, not tolerating nursing or therapy care, and that a short course of Seroquel would be started for mood stabilization. Review of the resident’s paper and electronic medical record showed no documentation that consent was obtained from the resident’s representative for the administration of Seroquel. Medication Administration Records showed that the resident began receiving Seroquel on 12/23/25 at 9:00 PM and continued to receive it twice daily through 1/27/26, when the medication was placed on hold for seven days. The February 2026 MAR showed that Seroquel 25 mg was restarted on 2/4/26 at 9:00 AM and continued until 2/6/26 at 9:00 AM. During interviews, Staff #16 confirmed that facility staff failed to obtain consent for the administration of Seroquel, and the Director of Nursing confirmed that staff failed to obtain consent from the resident’s representative for this change in treatment.
Failure to Maintain a Clean, Sanitary, and Well-Maintained Resident Room
Penalty
Summary
Facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for one resident. A complaint from January 2026 alleged a fruit fly infestation in this resident’s room. On 3/17/26, a surveyor observed several fruit flies in the room, along with two food trays left behind the resident’s door: one from the previous day’s dinner with leftover pasta, carrots, milk, and ice cream containers, and another from that morning’s breakfast with food crumbs. The bedside table in front of the resident was visibly dirty, dresser drawers were visibly dirty, debris was present on the floor by the window, and two peanut butter jars on the shelves had peanut butter on the outside of the jars. The resident’s toilet was noted to be constantly running. When asked, the resident agreed to have housekeeping clean the room, remove the food trays, and place the peanut butter jars in a sealed container. The DON later accompanied the surveyor and confirmed these observations, including seeing a fruit fly in the room. On 3/18/26, the surveyor returned and counted 15 fruit flies in the resident’s bathroom, 2 fruit flies on the wall where the food trays had been observed the previous day, and 1 fruit fly on the sink. Large cobwebs were observed around both closet doors, dresser drawers remained dirty, and the peanut butter jars still had peanut butter on the outside and were not in a sealed container. Additional maintenance issues were noted, including an open-ended pipe next to the toilet protruding from the wall that did not appear to be in use, dry wall around the sink with large cracks, and old drill holes in the wall under the television. The resident again stated willingness to have a scheduled cleaning time. The DON again accompanied the surveyor and confirmed these observations.
Failure to Follow Wound Care and Preoperative Physician Orders
Penalty
Summary
Facility staff failed to follow consultant physician orders for two residents, resulting in missed and incorrect treatments. For one resident who returned from the hospital and was seen by a wound physician, the wound doctor identified a non-pressure sacral wound and ordered daily application of silver sulfadiazine and calcium alginate dressings starting on 1/28/26, with reaffirmed orders on 2/3/26 and 2/10/26. Review of the resident’s January 2026 medication and treatment records showed that these ordered sacral wound treatments were not initiated until 2/18/26, resulting in a 21-day delay in implementing the prescribed wound care. The DON confirmed that staff did not provide the ordered sacral wound treatments during this period. For another resident admitted from the hospital and scheduled for an outpatient vascular procedure on 12/12/25, the vascular physician’s office sent preoperative instructions specifying that the resident should have nothing by mouth after midnight before the procedure, that Eliquis should be stopped two days prior, and that Aspirin, Metoprolol, Vimpat, and Gabapentin could be taken the morning of surgery with a small sip of water. The medical record showed the resident was given food and fluids after midnight on the day of the scheduled procedure. The December 2025 MAR further showed staff did not stop Eliquis two days prior and did not administer the allowed morning medications (Aspirin, Metoprolol, Vimpat, and Gabapentin) on the day of the procedure. The resident’s outpatient vascular procedure was subsequently rescheduled, and the DON confirmed staff failed to follow the preoperative instructions.
Unsafe and Poorly Maintained Resident Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, homelike environment in 6 of 33 resident rooms and common areas reviewed. During a tour, surveyors observed multiple items that were not in good repair, including a bedside dresser that was marred and chipped, a loose baseboard behind a bed, a bedside dresser with two broken drawers not affixed to the tracks, a severely marred and chipped wall behind a bed, a closet curtain not affixed to the curtain rod, marred baseboard molding with chipped paint, no window blinds, a hole in the wall behind a door knob, a marred and chipped shower room door with a gap between the door and frame, and a hole in the hallway wall above the baseboard by the hallway phone. In a separate observation, surveyors noted drywall dust on the top of the headboard in Resident #69's room and significant scrapes in the paint and drywall behind the headboard. Maintenance staff stated they were not aware of that damage at the time it was shown to them and explained that nurses either call or write needed repairs in a book at the nurses station. The Maintenance Director acknowledged that some of the observed items needed repair and stated he had already begun fixing some of them, and the Administrator acknowledged the damaged wall behind the bed and stated the facility would fix it.
Unlabeled and Improperly Stored Food Items
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards. During an initial kitchen tour, the surveyor observed multiple unlabeled or undated items in walk-in refrigerator #2, including a takeout container with a chili-like substance, a piece of cake in a see-through container, an opened jelly jar, a fast-food soft drink cup with ice, lunch bags with no name or date, baked beans labeled 11/9/25 with no use-by date, ziti labeled 11/8/25 with no use-by date, and sandwiches in baggies with no label or date. The surveyor also observed a cardboard box of ground beef packages, including one opened package with an open date of 11/14/25 and no discard date, with the potential for juices to leak into the box. In the walk-in freezer, the surveyor found an opened box labeled onion rings containing three different food items that were not labeled and did not appear to be onion rings, as well as a bag of what appeared to be chicken tenders with no label. The surveyor also noted missing freezer temperature checks for multiple shifts on several days. In a room outside the freezer, a yellow container labeled eccolab was stored on a shelf near a tray containing multiple bread bags. On the Atlantic unit nourishment refrigerator, the surveyor observed a reused Gatorade bottle containing a milky white substance with no label identifying the contents. The surveyor reviewed these findings with the CDM and UM, who were unable to identify some of the items and acknowledged that personal food items should not be stored in the kitchen refrigerator.
Incomplete resident medical records and missing provider documentation
Penalty
Summary
The facility failed to maintain complete medical records in accordance with accepted professional standards and practices for four residents reviewed. During record review, surveyors found missing or incomplete provider documentation in the electronic medical record (EMR), including physician and psychiatric notes that were expected to be present based on the residents’ ongoing treatment plans and follow-up schedules. For one resident with a current admission, no physician notes were found in the EMR. The DON confirmed the surveyor was looking in the correct location and stated the facility had not uploaded the provider notes from the current admission. Twenty provider notes dated from early September through mid-November were later produced from faxed documents kept in the Medical Records office, and the DON acknowledged the EMR did not include those notes and that there was a backlog of records awaiting upload. For two residents with psychiatric and psychological histories, the EMR contained only limited notes despite plans for ongoing follow-up. One resident had diagnoses including vascular dementia, psychotic disturbance, mood disturbance, anxiety, and cognitive communication deficit, but only a few psychiatric and psychological notes were available for 2025 even though the notes stated the resident should be seen monthly or more often. Another resident with schizophrenia, vascular dementia, psychotic disturbance, anxiety, OCD, and bipolar disorder had only one psychiatry note in the EMR until additional notes were later provided; those notes also showed ongoing planned visits that were not fully represented in the record. For a fourth resident, the last provider note in the EMR was from September 2025, and additional provider notes were later obtained from Medical Records; the ADON stated those notes had been faxed from provider visits but had not yet been scanned into the EMR.
Resident Not Informed of Ointment Discontinuation
Penalty
Summary
The facility failed to involve and inform a resident about a change in treatment regimen when the resident’s prescribed ointment was discontinued. Resident #39 stated that he/she had requested the ointment and was told by staff that he/she could no longer have it. During follow-up interviews, the DON stated that the resident had returned from the hospital and was evaluated as not needing the ointment, but she was not sure whether the resident had been involved in or aware of the decision to discontinue it. When interviewed with the surveyor, Resident #39 confirmed that he/she had not been informed of the decision to stop the ointment and stated that he/she had used it his/her whole life and did not understand why it was discontinued.
Failure to Document GDR Attempts or Contraindication for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) or document a contraindication rationale for psychotropic medication use for 2 residents reviewed for unnecessary medications. Resident #10 had diagnoses including vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, emotional deficit following cerebral infarction, and cognitive communication deficiency, and was prescribed Seroquel for mood and agitation. The psychiatric notes reviewed showed recommendations to continue Seroquel and statements that no GDR was recommended, but the notes did not document why a GDR was clinically contraindicated. The MDS for Resident #10 also documented regular antipsychotic use, no GDR attempted, and no documentation that a GDR was clinically contraindicated. Resident #33 had diagnoses including schizophrenia, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, obsessive compulsive disorder, and bipolar disorder, and was prescribed Mirtazapine and Risperdal. The psychiatric notes reviewed documented no medication changes, that the resident wanted medications discontinued because they were excessive and reported sleeping excessively, and that the resident was on the bare minimum amount of medication with a recent failed GDR; however, the documentation did not include when the last GDR was attempted and failed. Another note stated the resident was stable and that further reduction would lead to a change of symptoms and psychosis as in the past. The MDS documented regular antipsychotic use, no GDR attempted, and a physician-documented contraindication date, but there was no supporting documentation showing the prior GDR attempt.
Inaccurate MDS Coding for Falls and Active Diagnoses
Penalty
Summary
The facility failed to accurately document MDS assessments for three residents by not correctly coding falls and active diagnoses in the MDS. For Resident #4, the surveyor observed fall mats on both sides of the bed and the resident stated he had had two falls in the past. Record review showed a fracture of the right tibia and fibula from a fall on 7/6/2025, but the Discharge MDS coded the fall as "No injury" in Section J1900 and did not list the fractures in Section I8000. For Resident #3, the surveyor observed fall mats on both sides of the bed and reviewed documentation showing falls on 5/29/2025 and 6/8/2025. The Quarterly MDS coded Section J1900 as "No injury" despite the documented falls. The MDS coordinator reviewed the record and stated the assessment was coded inaccurately because the resident had falls that should have been reflected differently in the MDS. For Resident #33, record review showed a history that included schizophrenia, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, obsessive-compulsive disorder, and bipolar disorder. The MDS assessment did not include psychiatric or mood disorders in Section I for active diagnoses. When the MDS coordinator was shown the schizophrenia diagnosis in the record, she stated it should have been coded and that it was missed in error.
Care Plan Not Updated for Splint Use and Resident Refusal
Penalty
Summary
The facility failed to review and revise a resident’s care plan after the resident’s condition and care needs changed. Resident #10 had a care plan for ADL self-care performance deficit related to muscle weakness, left-sided weakness from a CVA, and a left upper extremity contracture requiring a left upper extremity splint. The care plan was initiated on 10/2/23 and last updated on 10/30/25, but it did not reflect the resident’s actual splint use status or the most current therapy guidance. Record review and interviews showed that OT had last seen the resident in January 2023, and the OT discharge notes recommended passive range of motion to the left digits/wrist before splint application, wearing a resting hand splint up to 2 hours daily, and monitoring for redness or irritation. A later order dated 12/15/23 directed that the left hand splint be worn for 6 to 8 hours as tolerated for contracture management and to monitor for skin breakdown. The resident stated the splint was in the room but had not been worn for the last year or two because it was too rigid and not comfortable. The DON was interviewed after the concern was reviewed, and the care plan was noted not to reflect the actual recommendations or the resident’s refusal.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for Resident #42, who had a current physician order dated 10/27/2025 for oxygen via nasal cannula at 2 liters per minute as needed for shortness of breath. During a tour of the LTC unit on 11/17/2025, the surveyor observed the resident in bed with an oxygen concentrator and an oxygen emergency tank in the room, but there was no oxygen signage posted on the room door. The oxygen humidifier bottle in the room was dated 9/16. When interviewed, the RN Unit Manager confirmed the resident had a PRN oxygen order, observed the oxygen equipment and lack of signage, and stated that oxygen signs should be posted on resident room doors when oxygen is in the room. The resident stated that he/she had not used oxygen in a while.
Expired Medications and Supplements Found in Medication Cart
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to follow professional standards of practice for medication disposition. During surveyor review of a medication storage cart with an LPN, expired medications were found in blister packs lodged between the locked medication box and a drawer divider, including gabapentin 100 mg, glimepiride 2 mg, carvedilol 6.25 mg, pantoprazole 40 mg, dexamethasone 2 mg, and trazodone 100 mg. Expired therapeutic nutritional supplements, Suplena and Boost, were also found on the cart. The deficiency was identified in 1 of 2 medication carts reviewed for medicine storage.
Meal Tray Did Not Match Predetermined Menu
Penalty
Summary
The facility failed to ensure that a resident was served a meal according to the predetermined menu. During lunch observation, Resident #10’s tray did not include nectar thickened tomato juice or a pureed fresh baked roll, even though both items were listed on the meal ticket. When asked, the resident stated those items were not on the tray and said he/she would have wanted them if they were available. The surveyor then reviewed the scheduled lunch menu, which listed breaded fried fish, stewed tomatoes, a fresh baked roll, cream pie, and a macaroni & cheese cup. In an interview, the CDM confirmed that nectar thick tomato juice was not available and stated that the kitchen does not puree rolls.
Missed Hand Hygiene Between Resident Encounters
Penalty
Summary
The facility failed to perform hand hygiene between resident encounters during a medication pass. During observation on 11/20/2025 at 8:32 AM, an LPN exited Resident #72's room and began preparing medications for another resident without performing hand hygiene. When asked about the facility policy for hand hygiene between residents, the LPN stated, "I am supposed to perform hand hygiene after each resident encounter." A bottle of hand sanitizer was observed on the medication cart. The DON acknowledged the missed opportunity for hand hygiene during an interview on 11/20/2025 at 9:30 AM.
Incompatible Mattress and Bed Frame Created a Bed Gap
Penalty
Summary
The facility failed to ensure that a resident’s environment was free from accident hazards related to the compatibility of the resident’s mattress and bed frame. During the initial tour, Resident #12 was observed in bed with a gap between the end of the mattress and the footboard of the bed frame, and a long blue pillow was placed in that gap. The resident was identified in the record as being at risk for falls and having recent falls. The resident’s weight was documented as 137 lbs. and height as 70 inches (5 feet 8 inches). Later observations showed a plastic foam cushion placed between the end of the mattress and the footboard to fill the gap, but it was not secure and did not stay in place on the bed frame. The DON observed the bed, mattress, and pillow and acknowledged the concern. The Maintenance Assistant also observed that the mattress did not fit the bed frame properly and stated he had been told by Nursing to change the bed for the resident. A subsequent observation showed the resident had a new bed, with a compatible mattress and bed frame and no gap between the footboard and the end of the mattress.
Call Light System Not Functioning and Not Accessible
Penalty
Summary
The facility failed to ensure that a resident's call system was functioning properly. During observation, the surveyor asked Resident #25 to push the call button, and the unit manager entered the room. The unit manager stated she had heard a call light at the nurse's station but was not sure whose call light it was, and no light was on in the hallway above Resident #25's room. When the unit manager pushed the call button, no light came on in the hallway. Resident #25 stated that the call light does not work. The nursing home administrator and director of nursing later stated that the call light monitor normally gives the location of a call light request, but the system was being rebooted, and staff were unaware of which resident was requesting help. The facility also failed to keep a call light device accessible for Resident #42. During a tour of the LTC unit, the surveyor observed Resident #42 in bed, alert and oriented, and in no distress. The call light device was lying on the floor next to the bed, and Resident #42 was unable to reach it to call for staff assistance. The RN unit manager observed the device on the floor with the surveyor and stated that call light devices should be in reach for residents to call for staff assistance.
Unsafe and Poorly Maintained Resident and Facility Areas
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff in multiple areas. In one resident room, the toilet in the bathroom was observed inoperable: it was not attached to the sewer hole/line, was resting next to the sewer opening, and a cloth was stuck in the hole in the floor. The resident was sitting in a wheelchair in the room and stated the toilet had been broken since the prior week and that maintenance was working on it. The DON and RN Unit Manager acknowledged the concern, and the LNHA later stated the toilet had been out of operation since 11/12/2025, that the resident was incontinent, and that the resident had been offered but refused a temporary room transfer. The resident’s record showed the resident was continent of bladder and bowel but had occasional bladder and bowel incontinence and used a urinal at bedside. Additional environmental concerns were identified in other areas of the facility. In another resident room, an electrical outlet was observed without an outlet cover, and a silver object was noted in the lower right prong of the outlet. In the laundry area, a bulging, stained ceiling tile was observed over a washing machine, along with other stained and broken tiles in the surrounding area; staff stated the roof had leaked previously and that the tile was damaged from an old leak. In the parking lot, surveyors observed a large pothole measuring 70 inches long, 38 inches wide, and 2 inches deep. The maintenance assistant and the NHA acknowledged these concerns.
Missing Handrails in Resident-Used Hallways
Penalty
Summary
The facility failed to ensure that all corridors had firmly installed handrails on each side. During observation, a resident in a wheelchair was seen grasping both hands on the hall handrail adjacent to the kitchen hallway while a Human Resource Director staff member assisted the resident off the handrail and wheeled the resident to the requested destination. The surveyor also observed that there were no hallway handrails in the front entrance hallway or in the hallway past the dining area toward the Atlantic units, and the resident was observed between these two areas. When the surveyor reviewed these observations with the NHA and DON, the NHA agreed that there were no handrails in the front lobby or in the hallway leading to the dining room areas and acknowledged that residents use these areas.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to display the current posted nurse staffing information in a timely manner. On the initial tour, when surveyors entered the facility at 7:00 AM on 11/17/2025, the nurse staffing posting displayed on the receptionist desk in the lobby was dated 11/14/2025 rather than the current date. The report states that nursing facilities are required to post daily nurse staffing information, including the facility name, current date, resident census, and the total number and actual hours worked per shift for licensed and unlicensed nursing staff responsible for resident care, and to keep staffing data available for survey review for at least 18 months. The DON was interviewed on 11/20/2025 and stated that the Nursing Supervisor was responsible for posting the nurse staffing sheet daily, including weekends. When informed that the staffing sheet observed on 11/17/2025 was still dated 11/14/2025, the DON acknowledged that the current nurse staffing sheet should have been posted by the Nursing Supervisor. No additional information was provided by the facility at the time of survey exit.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for multiple residents, as evidenced by direct observations, interviews, and medical record reviews. One resident was given Metformin despite a physician's order to hold the medication for two days following a procedure. The resident reported that the nurse left the medication in the room without ensuring it was taken and also left an insulin pen labeled for another resident. The same nurse was previously documented for attempting to administer Metformin when it was not scheduled and for administering another resident's insulin to the wrong individual. A review of medication administration records (MARs) for several residents revealed a consistent pattern of late documentation and possible late administration of medications. Medications such as Gabapentin, Hydralazine, Acetaminophen, Aspirin, Eliquis, Phenytoin, Amlodipine, chlorhexidine gluconate, and Humalog insulin were frequently signed off hours after the scheduled administration times. In many cases, it was unclear whether the medications were actually given late or if the documentation was completed later in the shift, raising concerns about the accuracy and timeliness of medication administration and record-keeping. Interviews with nursing staff confirmed that medications were sometimes administered or documented outside the required one-hour window due to workload and staffing issues. Staff acknowledged that when a medicine aide was unavailable, nurses were responsible for a higher number of residents, which led to delays in both medication administration and documentation. Facility leadership agreed that these practices were a concern and did not meet professional standards of quality.
Failure to Provide Required Showers and Hygiene Care Due to Staffing Shortages
Penalty
Summary
Facility staff failed to provide showers twice weekly to multiple residents who required assistance with activities of daily living, as evidenced by medical record reviews, observations, and interviews. Several residents with significant medical conditions, such as systemic lupus erythematosus, chronic pain, heart failure, hemiplegia, and cognitive deficits, were documented as needing substantial or total staff assistance for bathing and showering. Despite physician orders specifying shower days, records showed that these residents often received only bed baths or went extended periods without showers, with no documentation of refusals. Interviews with staff and residents revealed that the lack of showers was not due to resident refusals but rather staffing shortages and time constraints. Staff reported high resident-to-GNA ratios, sometimes as high as 27 residents per two GNAs, which limited their ability to provide showers and even basic hygiene care such as changing and turning residents. Residents and their representatives confirmed that showers were missed and that refusals were not the cause, with some residents stating they were only changed once per shift and not turned as frequently as required. Observations further supported these findings, with one resident noted to have a strong odor of feces and visibly dirty hair, and documentation confirming missed showers over multiple weeks. Facility leadership acknowledged the expectation for twice-weekly showers and the need to document refusals but admitted that this was not being done. The deficiency was identified for five residents during the complaint survey, with consistent evidence of missed showers, lack of documentation, and inadequate hygiene care.
Failure to Maintain Audible Call Bell System in Resident Rooms
Penalty
Summary
The facility failed to maintain a working call bell system on one of its nursing units, as evidenced by multiple observations and interviews during a complaint survey. Family members reported that the call bell in a specific room did not illuminate in the hallway, and staff informed them that the call bell was either not working at the desk or the volume was turned down. Upon investigation, the surveyor found that while the call light illuminated over the doorway when activated, there was no audible sound in the hallway. This issue was confirmed by staff present at the time, who also could not hear the call bell. Additional rooms were tested, and in each case, the call lights illuminated but no audible alert was heard. A resident was observed repeatedly pressing the call bell button without any response, and resorted to using a hand bell, which also could not be heard at the nurse's station. Staff at the nurse's station confirmed they did not hear any call bells ringing. The Director of Maintenance later discovered that the speaker system was turned off, as indicated by a muted speaker icon on the computer screen. The Assistant Director of Nursing and the RN unit manager were unaware that staff could turn off the call bell sound and needed to investigate the cause. The deficiency was communicated to the Director of Nursing and the Regional Representative during the exit conference.
Unsafe and Unsanitary Outdoor Areas Identified During Complaint Survey
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in two outdoor areas accessible to residents, visitors, and staff. During a complaint survey, observations revealed that the courtyard where residents were permitted to smoke contained dilapidated wooden flower bed planter boxes that were falling apart, as well as multiple areas of broken, crumbled, and chipped concrete, creating uneven walking surfaces. Additionally, rocks of various sizes were scattered throughout the area. The Maintenance Director confirmed that the flower beds had not been used in 6 to 7 years and stated that repairs to the concrete would require a contractor. Further inspection of another courtyard adjacent to the dining room, which was also accessible to residents and visitors, revealed a wet, moldy sheet bunched up on a window radiator, two boards propped against a brick wall, a large hose placed on top of a picnic table, and dilapidated bird houses barely hanging on a post. The Nursing Home Administrator acknowledged and confirmed the poor condition and unattractiveness of these areas during the survey.
Failure to Ensure Call Light Accessibility per Care Plan
Penalty
Summary
Surveyors determined that the facility failed to ensure a resident's call light was within reach as required by the individualized care plan. During observation, the resident was found lying in bed with a hand bell on the tray table and the call bell cord on the floor, out of reach. The resident reported using the hand bell or yelling for assistance because staff did not respond to the bell. When the surveyor tested the hand bell, there was no response, but when the call bell was activated, a geriatric nursing assistant responded after several minutes. The care plan for the resident specifically documented the intervention to keep the call light within reach at all times, which was not followed.
Inaccurate Coding of MDS Assessment for Resident Weight Loss
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) assessment for a resident with a diagnosis of dysphagia. Medical record review showed that the resident's weight decreased from 213 pounds to 191 pounds between two MDS assessments, representing a 22-pound or 10.3% weight loss over the period. Despite this significant weight loss, staff coded the MDS Section K0300 as 'No' for weight loss, indicating that the resident had not experienced a loss of 5% or more in one month or 10% or more in six months. The MDS Coordinator confirmed during interview that this coding was inaccurate and should have reflected the weight loss.
Failure to Hold Care Plan Meeting After Resident's Return from Hospitalization
Penalty
Summary
The facility failed to hold a care plan meeting following the completion of a comprehensive MDS assessment for a resident who had recently returned from a six-week hospital stay. After the resident experienced a change in condition and was transferred to an acute care hospital, they returned to the facility, and an MDS assessment was completed. However, there was no documentation in the medical record indicating that a care plan meeting was held after this assessment. During an interview, the Social Work Director confirmed that a care plan meeting should have been conducted in the month following the resident's return but acknowledged that it was not held. The absence of this meeting was attributed to an oversight, as it "fell through the cracks." This deficiency was identified during a complaint survey and was substantiated by both medical record review and staff interview.
Failure to Provide Physician-Ordered Wound Care Treatments
Penalty
Summary
Facility staff failed to provide wound care treatment as prescribed by physicians for two residents reviewed during a complaint survey. For one resident with a history of systemic lupus erythematosus and venous thrombosis, the medical record showed a venous wound on the left calf with several changes in the treatment plan over time. Despite updated physician orders, the treatment administration record (TAR) indicated that wound care was only provided up to a certain date, with no documentation or explanation for the gap in care before the resident was sent to the hospital. Facility leadership confirmed that the treatment change was not carried out by the nursing staff. For another resident with polyneuropathies, chronic pain, and type 2 diabetes mellitus, the medical record documented a diabetic wound on the right first toe. The TAR showed two overlapping physician orders for wound care, with nurses signing off daily for both treatments. However, the Assistant Director of Nursing confirmed that the treatments were not performed correctly, as the first order was not discontinued when the second was entered, making it unclear whether both treatments were actually provided or if the documentation was inaccurate.
Failure to Follow Wound Care Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident admitted with a sacral ulcer. Upon admission, the resident had a sacral ulcer that was unstageable with slough, and later identified as a Stage 4 pressure wound. The wound care team established a specific treatment plan, including the application of Leptospermum honey, alginate calcium, and a secondary gauze dressing, all to be applied once daily for 30 days. However, the Treatment Administration Record (TAR) for February and March documented a different treatment regimen, involving cleansing with normal saline solution (NSS) and application of mepilex with a cover dressing, which was signed off by nursing staff over several weeks. An interview with the Assistant Director of Nursing (ADON) and the RN unit manager confirmed that the nurses failed to relay the wound care team's orders and did not enter them into the computer system. As a result, the prescribed wound care treatments were not implemented as ordered by the wound care team, leading to a deficiency in the facility's pressure ulcer care for the resident.
Failure to Timely Implement Dietitian Recommendations and Notify Provider of Ongoing Weight Loss
Penalty
Summary
Facility staff failed to follow the dietitian's recommendations in a timely manner and did not notify the resident's physician or nurse practitioner of ongoing weight loss. The resident, who had a diagnosis of dysphagia, experienced significant weight loss over several months. The dietitian initially recommended a nutritional supplement (Med Pass 2.0) twice daily after noting weight loss, and later increased the recommendation to three times daily, also suggesting consideration of an appetite stimulant. However, there was a delay of 20 days before the appetite stimulant was ordered, and no further interventions were implemented despite continued weight loss. Throughout this period, the resident's weight continued to decline, with documentation showing a total loss of 35 pounds over approximately one year. Despite monthly assessments by the dietitian, there was no evidence that the resident's physician or nurse practitioner was notified of the ongoing weight loss after the initial intervention. Interviews confirmed that the nurse practitioner was unaware of the continued weight loss and that facility staff did not timely communicate these changes or implement recommended interventions.
Failure to Ensure Timely Provider Visits
Penalty
Summary
Facility staff failed to ensure that a resident received required face-to-face visits from a physician, physician assistant, or nurse practitioner at least every 60 days. Medical record review showed that the resident, who was admitted in 2015 and later transferred to the hospital, was not seen by any of these providers for a period of 76 days between late April and early July 2025. Staff interviews confirmed the absence of documented visits during this interval, indicating that the required provider visits did not occur as mandated.
Failure to Timely Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to timely provide prescribed medication to meet the needs of a resident admitted for rehabilitation following an acute care stay. The resident had multiple diagnoses, including paralytic syndrome after cerebral infarction, pain, hypertension, dementia, restless leg syndrome, neuralgia/neuritis, and a sacral ulcer. A physician's order for Tramadol 50 mg to be administered four times daily was written, but the medication was not available and not administered at multiple scheduled times over several days, as documented in the Medication Administration Record (MAR). Interviews with the Assistant Director of Nursing (ADON), a Registered Nurse unit manager, and an LPN revealed that there was no valid reason for the delay in obtaining the medication, as the pharmacy could have delivered it within four hours if contacted. The LPN stated that the process required the doctor to call the pharmacy, but also mentioned that the resident's spouse did not want the medication administered due to concerns about drowsiness. There was no documentation that the physician was contacted when the medication was unavailable, and the LPN was unsure if this step had been taken.
Failure to Monitor Blood Pressure as Ordered for Antihypertensive Medications
Penalty
Summary
A deficiency was identified when a resident's drug regimen was not kept free from unnecessary drugs due to a failure to monitor blood pressure as required by physician orders. The resident, admitted for rehabilitation with diagnoses including paralytic syndrome following cerebral infarction, hypertension, and other conditions, was prescribed three blood pressure medications: Isosorbide Mononitrate, Lisinopril, and Hydralazine. All three medications had physician-ordered parameters to hold administration if the blood pressure reading was less than 100. While the Medication Administration Record (MAR) showed blood pressure monitoring at 9 AM for Lisinopril, there was no documentation of blood pressure readings for the 2 PM and 9 PM doses of Hydralazine. Further review of the electronic medical record's vital sign section revealed inconsistencies in recording blood pressures at the times Hydralazine was administered in the afternoon and evening. During an interview, the RN unit manager and the Assistant Director of Nursing confirmed that the MAR did not include a space to record blood pressure readings for all medications requiring such monitoring, corroborating the surveyor's findings.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Facility staff failed to ensure that medication carts were kept locked when unattended, as observed during a complaint survey. On one nursing unit, a medication cart was found unlocked and unattended in a hallway while the nurse responsible was inside a resident's room with her back to the door, leaving the cart out of her line of sight. The surveyor was able to open the cart and found a cup containing pre-poured medications with no resident name labeled. The nurse later stated that the medications were for a resident who was unavailable due to therapy. Further inspection of the medication cart revealed multiple deficiencies in medication labeling and storage. Several opened medications, including inhalers and insulin pens, were not dated as required by manufacturer instructions. Additionally, insulin pens that required refrigeration were found in the cart without being refrigerated, despite being labeled with refrigerate stickers. The facility's own medication storage policy requires that only authorized personnel have access to medications and that multi-dose medications be dated upon opening, but these procedures were not followed.
Failure to Obtain Follow-Up Dental Services
Penalty
Summary
Facility staff failed to obtain follow-up dental services for a resident who had a diagnosis of dysphagia and experienced a significant weight loss of 12 pounds in one month. The resident reported not having properly fitting dentures, and this concern was communicated to the nurse manager, who was to follow up with the dentist for a refitting. The resident was later examined by a registered dental hygienist, who noted the resident's dental pain and desire for dentures, and documented that the dentist would see the resident on a scheduled date. However, the resident was not seen by the dentist as planned, and as of the time of the survey, the resident still had not received the necessary dental evaluation or services.
Failure to Provide Prescribed Diet Consistencies to Residents
Penalty
Summary
The facility failed to provide two residents with their prescribed diets in the correct consistency during a lunch observation. Both residents were documented as requiring mechanical soft, ground meat diets due to risks such as choking, swallowing difficulties, aspiration, weight loss/gain, and dehydration. However, during the meal service, one resident received cubed chicken parmesan instead of ground meat, and the other received meat in chunks rather than ground, as specified in their dietary orders. These discrepancies were directly observed by the surveyor, who also confirmed the dietary requirements by reviewing the residents' tray tickets and medical records. When the issue was brought to the attention of staff present in the dining room, it was acknowledged that the meat was not prepared as ordered, with staff stating that this was the usual practice. The Food Service Director and the cook both confirmed that the meats should have been ground according to the residents' dietary needs. The deficiency was further discussed with facility leadership, confirming that the prescribed diet consistencies were not provided as required.
Failure to Maintain Complete and Accurate Medical Records for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. A complaint was received alleging that the resident was often not fed due to short staffing, and that the resident's spouse had to visit to ensure the resident was fed. The resident had multiple diagnoses, including systemic lupus erythematosus, chronic pain, heart failure, muscle wasting, and a cognitive communication deficit. A review of the resident's medical record revealed significant gaps in the documentation of meal consumption by geriatric nursing assistants (GNAs). Specifically, there were multiple days across April, May, and June where documentation for breakfast, lunch, and/or dinner was missing. The missing records included both partial and full days without any entries, making it impossible to validate the amount of food the resident consumed. Facility leadership reviewed and agreed with the findings that the documentation was incomplete.
Failure to Arrange Hospice Services Upon Resident Request
Penalty
Summary
A deficiency was identified when the facility failed to arrange hospice services for a resident who requested them. The resident, who had a two-year history of cancer with metastasis to the brain and had recently completed unsuccessful radiation treatment, expressed a desire for hospice care along with their family. Documentation in the medical record showed that the primary care physician was informed and directed staff to contact hospice. However, there was no evidence in the medical record of a verbal order for hospice services following this request, nor was there documentation of any action taken to initiate hospice care until nearly two weeks later, when the resident was seen for pain management and a palliative care consult was ordered. Interviews with facility staff revealed inconsistencies and confusion regarding the process for initiating hospice services. The Assistant Director of Nursing stated that requests for hospice are communicated to social work, who then contacts hospice, but the Director of Social Services indicated that sometimes orders were not consistently relayed. The resident was ultimately discharged home with hospice services arranged to begin upon arrival, but the facility did not arrange for hospice services during the resident's stay despite the explicit request and physician direction.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post required nurse staffing data at the beginning of each shift, including the total number and actual hours worked by nursing staff. Upon entry to the facility's lobby and on both nursing units, there was no visible signage displaying the names or hours of nursing staff working in the building. Observations revealed that the only available information was an outdated dry erase board on one unit, listing staff names from a previous date, and another board that listed names but not hours. Multiple observations confirmed the absence of required postings over two days. Interviews with the Assistant Director of Nursing and the Human Resources Director confirmed that the staffing information had not been posted, with the ADON attributing this lapse to the scheduler's absence and the HR Director acknowledging responsibility for posting the hours during this period.
Failure to Conduct and Document Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct and document timely care plan meetings for several residents, as evidenced by the review of clinical records and staff interviews. Resident #46 had a care plan conference upon admission, but no subsequent meetings were documented, and there was no evidence of invitations to care plan meetings. The Social Work Director confirmed the lack of meetings and documentation. Similarly, Resident #4's records showed the last care plan conference was held months ago, with no evidence of required subsequent meetings. The Director of Nursing and Assistant Director of Nursing were unable to provide clarification or documentation for these missing meetings. Resident #69 reported not having care plan meetings, and a review of their electronic medical record revealed no documentation of such meetings or care conference notes, despite multiple MDS assessments being completed. The Social Worker, responsible for setting up these meetings, confirmed the process but failed to provide evidence of completed meetings. The Administrator later provided a care conference note, but it was insufficient to cover the required meetings following the MDS assessments. Resident #21's care plan meeting was initially scheduled but canceled due to the Social Work Director's unavailability and was not rescheduled in a timely manner. The resident's medical record lacked evidence of a completed care plan meeting, and the Social Work Director admitted to not documenting the meeting notes or summary. The deficiency in timely care plan meetings and documentation was evident across multiple residents, indicating a systemic issue in the facility's care planning process.
Facility Fails to Maintain Safety and Security
Penalty
Summary
The facility failed to maintain a safe environment for its residents, as evidenced by multiple observations and interviews. Resident #4, who had a care plan to address fall risks, was repeatedly observed with their bed in a high position, contrary to the care plan's directive to keep it in a low position. Despite being informed, the nurse did not lower the bed. Additionally, Resident #14's room was found with debris on the floor, including food trays and a catheter bag, which posed a hazard. The fall mat intended for safety was not in place, and staff failed to address these issues promptly. The facility also failed to secure medication carts, as observed when a cart was found unlocked and accessible. A nurse was informed and locked the cart, but this incident highlighted a lapse in maintaining medication security. Furthermore, the facility did not implement adequate measures to secure building doors and patio gates after hours. Surveyors were able to enter the facility through multiple unlocked doors without alarms or staff presence, indicating a significant security breach. Interviews with staff confirmed that the keypad locks had been non-functional for months, and no alternative security measures were in place. The Administrator acknowledged the broken locks but had not taken steps to replace them or ensure staff used secure entry points. The lack of response to the identified security risks and the failure to lock the patio gate further demonstrated the facility's inability to protect residents from potential hazards. These deficiencies were evident for two residents, a medication cart, and multiple building entrances during the survey.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety, as observed during a surveyor's inspection. In the kitchen's dry food storage area, several opened and unlabeled food items were found, including a 25lb bag of sugar, flour, and whole grain brown rice stored in large containers on the floor. Additionally, an opened and unlabeled jug of teriyaki sauce, a container of mashed potatoes, soy sauce, peanut butter, and an expired bag of pancake mix were found on a shelving unit. In the walk-in refrigerator, the surveyor noted opened and unlabeled bags of salad, spinach, sliced onions, boiled eggs, bologna, walnut topping, and various other food items, some of which were expired. The walk-in freezer contained opened and unlabeled tubs of ice cream, sliced pepperoni, egg rolls, and mixed vegetables. The Certified Dietary Manager (CDM) was unaware of the facility's food safety and storage policy, which was later reviewed and indicated that packaged foods should be dated when opened and leftovers labeled and discarded after three days. Despite being informed of the deficiencies, the facility did not remove or discard the identified food items from the storage areas. The surveyor's findings were confirmed by the CDM, and the facility's failure to adhere to its food safety and storage policy was evident, as the unlabeled and expired food items remained in the kitchen, posing a potential risk to all residents consuming food prepared in the facility.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that the call light system was available, functional, and operational for all residents, as observed during a recertification survey. Six residents were identified as lacking access to a working call light system. For instance, Resident #15's call light was unplugged and out of reach, and the resident reported it had been broken for several days. Similarly, Resident #8's call light did not function, and the resident had stopped using it due to staff non-responsiveness. These issues were not isolated, as other residents, such as Resident #18 and Resident #22, also experienced non-functional call lights, with no alternative devices provided. The maintenance log review revealed discrepancies in the documentation of repair requests. Although Resident #15's call light was reported and repaired, there were no maintenance requests logged for Residents #8, #18, #22, and #36. Additionally, Resident #18's shared bathroom lacked a call light device, and no request for installation was documented. Interviews with staff, including the Unit Manager and Maintenance Director, confirmed the lack of awareness and documentation regarding these issues. The Maintenance Director noted that the facility's protocol was to provide hand bells when call lights were under repair, but this was not consistently implemented. The surveyors' findings highlighted a systemic issue with the facility's call light system, affecting multiple residents' ability to summon assistance. Despite the facility's protocol for alternative devices, such as hand bells, these were not provided to the affected residents. The lack of functional call lights and alternative methods for residents to communicate their needs to staff was a significant deficiency observed during the survey.
Failure to Offer Showers to Resident
Penalty
Summary
The facility staff failed to ensure that residents are offered two showers each week, as evidenced by the case of one resident out of a sample of 56. The resident, identified as Resident #28, reported during an interview that they have only received bed baths and have not had a shower in two years, despite expressing a preference for showers. A review of the resident's clinical record confirmed that only bed baths have been documented since the beginning of the year. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that the resident was initially informed that they needed to request showers, and it was believed that the resident preferred to refuse showers. However, there was no documentation of such refusals in the resident's chart, which the DON acknowledged should have been recorded. The DON stated that the resident's care plan included the right to refuse, but agreed that nursing staff should document refusals.
Failure to Offer Advance Directives to Residents
Penalty
Summary
The facility staff failed to ensure that residents were offered the opportunity to complete Advance Directives upon admission. This deficiency was identified during a clinical record review and staff interview, affecting three out of nine residents reviewed for Advance Directives. Specifically, the clinical records of these residents did not contain an Advance Directive, nor was there evidence that they had been offered the opportunity to complete one. The absence of documentation indicates a lapse in the facility's process for managing Advance Directives. During an interview, the Social Work Director explained that upon admission, a Maryland Order for Life Saving Treatment (MOLST) is completed by the primary physician, and residents are asked if they have an Advance Directive. If they do not, they are given a copy to complete. However, the Social Work Director was unsure about the documentation process and acknowledged that the social work histories might not have been completed due to staffing changes. This lack of documentation and follow-through contributed to the deficiency, as there was no further evidence provided to show that residents or their responsible parties were given the opportunity to complete an Advance Directive.
Failure to Maintain Resident's Medical Information Confidentiality
Penalty
Summary
The facility nursing staff failed to maintain the confidentiality of a resident's medical information. During an observation of medication administration, a staff member left a medication packet on top of a locked medication cart while entering a resident's room. The packet, which was visible, contained the resident's name and a list of their medications, including risperidone, Eliquis, Lasix, and potassium chloride. This incident involved one resident out of a sample of 56 and was observed by surveyors during their assessment of the facility's practices.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents or their representatives regarding hospital transfers, as required by their Discharge Notification Policy. This deficiency was identified during the annual survey's investigative portion, where it was found that two residents were transferred to the hospital without proper written notification. Resident #69 was transferred due to a dislodged Foley catheter with bleeding and returned after five days, while Resident #35 was transferred twice, once for altered mental status to rule out a stroke and another time for hypoxia, with no written notifications provided for these transfers. The surveyor's review of the electronic medical records and physical charts revealed the absence of documentation indicating that the residents, their representatives, or the Ombudsman were notified in writing about the hospital transfers. During an interview, the Director of Nursing was informed of this concern, and the Social Worker later provided copies of the Transfer/Discharge Notification forms. However, it was confirmed that these forms were not given to the residents, their representatives, or the Ombudsman, as required by the facility's policy.
Failure to Develop Baseline Care Plans
Penalty
Summary
The facility staff failed to develop baseline care plans for residents, as evidenced by the case of one resident out of six reviewed. The clinical record review revealed that the resident was admitted on a specific date and had care plan conferences on two subsequent dates. However, a baseline care plan, which should have been created within 48 hours of admission, was not present in the clinical record. Additionally, there was no comprehensive care plan within the same timeframe. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), they were informed of the absence of a baseline care plan, but no explanation was provided, nor was a baseline care plan shown to the surveyor before the exit.
Deficiency in Resident-Centered Activity Programs
Penalty
Summary
The facility staff failed to ensure that residents had the opportunity to participate in an activity program and did not provide an ongoing resident-centered activities program to improve or maintain the residents' mental and psychosocial well-being. This deficiency was evident for three out of five residents reviewed for activities. Resident #28 expressed uncertainty about being encouraged to leave their room and mentioned a preference for music. The Activities Director admitted to being backlogged with documentation and noted that the resident often refused activities after a short period. Observations revealed that the resident's television or radio was not on, despite claims that the television was turned on daily. Resident #46's family member reported that the resident was often in bed and believed activities were not brought to the resident. The last activity assessment for this resident was dated several months prior, with no evidence of activities being provided. The Activities Director claimed the resident enjoyed certain activities, but the survey team did not observe the resident outside the room or the television being on. The Administrator acknowledged missing documentation after being shown the clinical records. Resident #6 was observed in their room with a shared television on at a high volume, but no communication devices were present. The resident's Minimum Data Set (MDS) indicated preferences for books, music, and animals, but these were not assessed in recent years. Activity documentation was sparse and lacked specificity, failing to reflect personal activities or interests. The Activities Director stated efforts to engage residents daily, but the surveyor noted the absence of activity materials in the resident's room.
Failure to Reposition Resident
Penalty
Summary
The facility staff failed to ensure that a resident was repositioned to maintain or improve their range of motion and mobility. This deficiency was observed in one resident, who was repeatedly seen lying on their back in bed over several days. Specifically, the resident was observed on their back on four separate occasions: once on April 16, 2024, at 11:46 AM, again on April 18, 2024, at 1:54 PM while being fed lunch, on April 23, 2024, at 2:15 PM, and finally on April 24, 2024, at 12:30 PM. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unable to provide an explanation for the resident's positioning when interviewed on April 30, 2024, and stated they would investigate the matter.
Inadequate and Unvaried Dietary Provisions
Penalty
Summary
The deficiency involves inadequate and unvaried dietary provisions for residents, as identified through interviews and observations. Resident #30 reported that the food is consistently cold, with limited entree choices, and occasional unavailability of salad ingredients. This resident was observed to keep a personal stash of breakfast cereal due to hunger concerns. Resident #28 expressed dissatisfaction with the lack of variety in breakfast options and unfulfilled food preferences. Staff #8, a cook, confirmed the existence of a standard breakfast menu with limited alternatives and acknowledged issues with food supply and delivery, leading to insufficient food availability.
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 1,757 citations issued within 25 miles in the last 12 months — including the 11 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 Crownsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Future Care Annapolis | 4 mi | — | 0 | 0 |
| Autumn Lake Healthcare At Waugh Chapel | 4.1 mi | ★★★★★ | 1 | 0 |
| Complete Care At Severna Park Llc | 4.1 mi | ★★★★★ | 6 | 0 |
| Autumn Lake Healthcare At Crofton | 4.3 mi | ★★★★★ | 24 | 0 |
| Ginger Cove | 5.3 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.