Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Frederick Villa Healthcare during CMS and state inspections, most recent first.
A resident with chronic genital cellulitis and severe groin pain repeatedly reported 10/10 pain, but nursing documentation showed ineffective and incomplete pain management. Staff applied podofilox, a medication for genital warts rather than pain relief, and a lidocaine order was not administered because it had not arrived from the pharmacy. The MAR also lacked documentation of PRN Tylenol use, and facility leaders confirmed pain scale documentation and pre/post PRN assessments were not being properly recorded.
Failure to provide escort staff for an outside physician appointment. A resident with dementia, CVA with right-sided weakness, immunodeficiency disease, chronic pain syndrome, expressive aphasia, and genital herpes had a scheduled ID physician visit cancelled because the facility could not provide a CNA to accompany the resident. The resident had severe cognitive impairment and was observed in pain, while the office and facility scheduler confirmed the cancellation was due to no available nursing aide.
A resident with dysuria had urine testing ordered, and the lab later reported culture results showing the organism was resistant to Ciprofloxacin. Facility staff did not promptly notify the ordering practitioner of the culture result, and the resident continued receiving Ciprofloxacin before the MD was informed and changed the antibiotic to Keflex.
Failure to obtain ordered infectious disease and urology consults: A resident with dementia, stroke-related weakness, immunodeficiency, chronic pain, and genital HSV had severe cognitive impairment and complained of groin pain while moaning with movement. An ID appt was cancelled by facility staff because no CNA was available to accompany the resident, and a urology order for penile cellulitis and chronic HSV/condyloma remained without consult documentation or explanation for why it had not been discontinued.
A resident’s chart showed that staff were only initialing ordered lung sound checks and pacemaker checks without documenting the required lung sound parameters or obtaining a result showing the pacemaker was functioning properly each shift. The DON and regional clinical educator stated the resident goes out to the cardiologist for pacemaker checks, the facility has equipment to perform the test, and the pacemaker had last been checked months earlier, while the resident and family also reported ongoing groin pain and ineffective pain medication.
A resident admitted with STEMI, CHF, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure had anticoagulant therapy changed from Eliquis to Xarelto per the hospital discharge summary, and Xarelto was ordered by the physician on admission. However, the baseline care plan created within 48 hours did not list the anticoagulant among current medications and did not include a care plan for anticoagulant therapy. The DON confirmed the resident was receiving Xarelto at admission and that it should have been included in the baseline care plan.
Facility staff failed to develop a comprehensive, person-centered care plan for a resident admitted with paraplegia, severe malnutrition, and multiple Stage IV pressure ulcers. The existing care plan included only general goals and basic interventions such as repositioning and nonspecific wound/dressing care, without specifying dressing types or frequencies. It omitted key interventions to prevent worsening heel ulcers (e.g., heel elevation or heel boots), did not address the ordered wound vac or required monitoring for seal integrity, infection, bleeding, or fluid leakage, and did not specify the type of mattress needed. During review, the DON acknowledged that the care plan was not comprehensive for the resident’s pressure wounds.
A resident admitted after a cerebral infarction with hemiplegia and hemiparesis had been diagnosed with a UTI in the hospital and started on Amoxicillin 500 mg TID, with instructions on the discharge summary to continue the antibiotic for five additional days. On review, the MAR contained no documentation that the Amoxicillin was administered after admission. During interviews, the DON reported having reviewed the discharge summary but believed the antibiotic had been completed in the hospital, and another staff member explained that the facility’s second-day chart check process for new admissions likely failed to identify and implement the ongoing antibiotic order.
A resident with a history of STEMI, CHF, A-fib, chronic embolism/DVT, and hypertensive heart disease was discharged from the hospital with instructions to switch from Eliquis to Xarelto, including a loading dose followed by a maintenance dose. Although Xarelto was ordered on admission, multiple erroneous Eliquis orders were entered by the pharmacy and verified by an LPN supervisor, then repeatedly discontinued by an RN Unit Manager who recognized that only Xarelto was intended. Despite these actions, Eliquis continued to appear on the MAR, and an LPN ultimately administered Eliquis 5 mg together with Xarelto 15 mg during a morning med pass, resulting in both anticoagulants being given concurrently and increasing the resident’s risk for bleeding.
Surveyors found that the facility failed to maintain complete and accurate medical records for two residents. One resident with paraplegia, multiple stage 4 pressure ulcers, a colostomy, and severe malnutrition had missing weekly wound care notes after an EMR system change, incomplete documentation of ordered colostomy output monitoring, and no nursing notes of nausea or vomiting despite staff recollections and a PRN ondansetron order. The same resident’s change-in-condition documentation omitted reported respiratory issues that were later reflected in hospital records and by the RN who sent the resident out. For both this resident and another recently admitted resident, there were care plan invitation letters but no corresponding documentation in the EMR that required care plan meetings after admission actually occurred, as confirmed by the regional social worker.
A deficiency was identified when ongoing pest infestations, including roaches, mice, ants, spiders, and other insects, were repeatedly documented in multiple care areas and common spaces. Despite the use of a pest management company, the NHA confirmed the continued presence of pests, and a complaint was filed regarding the issue. Surveyor review of logs and staff interviews confirmed that the facility's pest control program was not effective.
The facility failed to designate a qualified IP responsible for the infection prevention and control program. The DON stated that a regional ADON/IP was only serving as a resource person until IP training was completed and came to the facility once a month. Staff confirmed she was covering the vacancy from a regional role, and the DON later acknowledged that the facility did not have an IP onsite.
The facility did not ensure timely reporting of multiple allegations of abuse, neglect, and theft to the appropriate authorities. Several residents reported rough treatment, derogatory comments, delayed care, and missing property, but these incidents were not consistently documented or reported as required. Leadership interviews confirmed lapses in recognizing and reporting these events, resulting in noncompliance with regulatory standards.
Multiple residents reported staff being rough, making inappropriate comments, or providing aggressive care, but the facility did not conduct timely or thorough investigations or document required assessments. In several cases, allegations were not immediately reported, investigated, or followed up with resident assessments, and staff interviews and protective measures were lacking.
The facility failed to keep resident care plans current, hold or document quarterly care plan conferences, and ensure required IDT participation. A resident with ongoing dental pain and an active extraction referral had an outdated care plan, while other residents had quarterly MDS assessments without matching care conference documentation or with meetings spaced far apart. One care conference record also lacked documentation of nursing, dietary, or physician attendance.
Infection control deficiencies were identified when a resident with COVID-19 did not have consistent isolation signage posted, another resident’s ordered antiviral medication was not started on time because it was awaiting pharmacy delivery, and a laundry staff member handled soiled linens without required PPE. The DON and EVS Director confirmed the concerns, and the laundry policy required gloves, gowns, and face protection when handling contaminated linens.
Surveyors found that two residents experienced persistent pest infestations, including flies and gnats, in their rooms, with complaints also referencing ants and mice. Maintenance staff did not routinely check rooms unless issues were reported, and pest control measures were insufficient to resolve the problem. Additionally, another resident's room was observed to have longstanding maintenance issues, such as unpainted walls, a corroded faucet, loose plaster, a displaced ceiling tile, and a non-functioning light, all of which contributed to an environment that was not safe, clean, or homelike.
A staff member used a resident's bank card and account information to withdraw funds for personal use, with multiple unauthorized transactions identified through a police investigation. The administrator was unaware of the extent of the staff member's actions and could not confirm if the resident received the withdrawn funds, despite facility policy prohibiting such conduct.
A resident's discharge paperwork was found to be incomplete, with missing information in several sections of the discharge planning tool, including responsible party details, physician information, required signatures, and the medication list. Staff interviews confirmed that all sections should have been completed prior to discharge, but this was not done, and the DON acknowledged the concern.
Surveyors identified that two residents did not have baseline care plans, including medication lists, properly provided or documented within 48 hours of admission. In both cases, required signatures and evidence of delivery to the resident or their representative were missing, and documentation was not present in the EHR as expected. Staff interviews confirmed the deficiencies in the care plan process.
A resident lost the ability to perform activities of daily living (ADLs) without a documented medical reason, as the facility did not ensure that such declines only occurred when medically necessary.
Three residents did not receive appropriate pain management, including lack of pain monitoring, failure to schedule pain management appointments, and improper administration of PRN pain medications without following pain scale parameters or attempting non-pharmacological interventions. Pain medications were sometimes given when pain was not present, and documentation was incomplete or missing.
Two residents did not have complete or accurate documentation in their medical records. One received a one-time dose of Narcan that was not recorded on the MAR, and another had a therapeutic boot recommended by an orthopedist, but its use was not documented on the Treatment Administration Record. These actions resulted in incomplete medical records, contrary to professional standards.
A GNA began caring for residents before completing mandatory training in abuse prevention, dementia care, and infection control, with required education not finished until nearly two months after hire. The NHA confirmed that essential training should have been completed during orientation, but the staff member worked with residents prior to receiving this education.
A resident was observed eating breakfast in bed while a urinal about one-third full of urine was hanging on the bedrail at the bedside. The resident said the urinal had been used earlier and was still there when breakfast was served. A GNA entered the room but did not remove it, and an LPN later confirmed staff should have emptied the urinal when breakfast was served.
Facility staff failed to obtain and maintain required physician certifications of incapacity and Advance Directive documentation for two residents. One resident had only a single physician certification in the chart despite being cognitively impaired with a BIMS of 00, and another resident's EHR lacked documentation showing that AD information was obtained or addressed as required.
Failure to notify the POA and physician of resident events: A resident fell out of bed and the POA was not notified, and the record showed the resident—not the POA—was listed as notified. The same resident also missed a post-op appointment after transportation failed to arrive, and there was no documentation that the attending physician was notified of the cancelled appointment.
A resident had scheduled and PRN antianxiety medications ordered, but the facility had no documentation showing that the resident’s behavior was monitored to support appropriate psychotropic medication use. When the surveyor asked for behavior monitoring records, the DON confirmed the chart did not contain documentation and stated that behaviors were expected to be documented every shift.
Incorrect MDS Diagnosis Coding: A resident’s MDS assessments incorrectly coded schizophrenia as an active diagnosis in Section I even though the medical record and psychiatry note did not corroborate it. The resident had an order for Olanzapine for depression, and the MDS nurse confirmed that schizophrenia and schizoaffective disorder are distinct diagnoses and that schizophrenia should only be coded when supported by a recent hospital diagnosis.
A resident with a J-tube did not have ordered tube feeding, residual checks, and flushes documented on two shifts, and the complaint stated the tube became clogged after not being flushed and the resident had pain at the J-tube site. Another resident with an order for Modafinil 200 mg daily missed doses for several days because staff were waiting on pharmacy delivery and processing a C2 form.
Pressure ulcer care was not provided consistently for two residents. One resident with multiple wounds was not seen promptly by the wound team, had gaps in wound treatment orders, and had only limited wound provider documentation. Another resident’s sacral wound treatment changes were delayed, nutrition was not addressed when the wound developed, and the care plan did not include key interventions such as T&R, a pressure-reducing mattress, or updated wound treatments.
Incomplete Incontinence Assessment and No Care Plan: A resident who was incontinent of bowel and bladder reported waiting 2 to 3 hours to be changed and being completely soaked. Record review showed the bowel and bladder assessment was incomplete, with most questions unanswered and several sections blank, and there was no incontinence-related care plan in place. The DON and UM both verified the assessment was incomplete and that no care plan had been established.
The facility failed to complete annual performance reviews for three GNAs. Their employee files contained no performance appraisals for 2022 and 2023, and the HR Manager confirmed the reviews were missing. The DON stated that GNAs should have an annual performance evaluation and agreed the missing appraisals were a concern.
A resident was given Prostat three times daily for wound healing even though the MDS, weekly skin checks, and nursing notes showed intact skin and no wounds. The nurse, acting unit manager, wound nurse, and DON all confirmed the resident had no wounds, yet the MAR/TAR still reflected the unnecessary medication order.
Expired medications, biologicals, and patient supplies were found in med carts and storage areas on multiple units, including expired protein supplements, expired COVID-19 test kits, expired wound culture and infusion supplies, and an unlabeled, sticky bottle of valproic acid solution that an RN could not identify. Surveyors also found expired items in an unlocked cabinet near the nurses' station, and facility policy required medications and biologicals to be stored in locked compartments with labels including expiration dates and resident names when available.
Failure to Arrange Dental Services for Two Residents: Two residents had documented dental pain and/or broken teeth, with physician-ordered dental consults and referrals for extractions, but the facility did not timely schedule the appointments or arrange transport. One resident’s urgent consult was delayed while staff searched for a dentist because of lack of insurance, and the other had no documented evidence of a scheduled dental appointment despite a referral for oral surgery and extractions.
Improper Storage of Dry Food Items: The surveyor observed two bins in the dry storage area lined with ripped, stained plastic bags and not labeled with the contents or a date. The Dietary Director identified the items as flour and sugar and stated she had placed brand new bags into dirty containers and forgot to label them, acknowledging the bins were not clean.
Incomplete Antibiotic Stewardship Monitoring Records: The facility failed to collect all necessary information for its antibiotic stewardship program. Review of the antibiotic tracking spreadsheets showed missing details for infection type diagnosis, last treated, organism identified, and whether minimum criteria were met. The DON said weekly stewardship meetings were held, but the additional EMR order listing report also lacked criteria details, organism identified, and start and end dates, and the surveyor determined the program did not adequately monitor antibiotic use.
A resident admitted in 2022 had no record of a pneumococcal vaccine during an immunization review. A unit manager said unit managers are supposed to monitor flu, pneumonia, and COVID-19 immunization status on admission, but staff could only produce a declination form dated later showing refusal of flu, Pneumovax23, and COVID-19 vaccines. No additional documentation was found to show the pneumonia vaccine had been offered at admission, and the regional clinical educator validated the concern.
The facility failed to document COVID-19 vaccine education for a resident who refused the vaccine and failed to maintain COVID-19 vaccination records for two staff members. A unit manager stated she had educated the resident’s family but did not document it, and the DON and HR director confirmed that the two employees’ health files were missing required vaccination documentation.
Failure to Provide and Document Effective Pain Management
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident who repeatedly complained of severe groin and genital pain. During an interview, the resident moaned with movement and the family member stated the resident was in constant pain and that the medications being provided were not working. The resident had a history of chronic genital cellulitis and had previously been hospitalized for the condition. The attending physician documented chronic pain and noted that the resident had tried several other medications, including NSAIDs, OTCs, and topical pain relievers without improvement. On 05/02/26, a nursing note documented the resident reporting severe chronic groin/genital pain rated 10/10, with swollen and tender genitals on assessment. The nurse applied podofilox 0.5% gel, which is used to treat genital warts and is not a pain-relieving medication; the resident’s pain remained 10/10 after application. The nurse notified the nursing supervisor and provider, and a verbal order was received for lidocaine cream to the genitals, but the medication was not administered that day because it had not been delivered from the pharmacy. The nurse also documented giving Tylenol later that day. Record review showed the resident had an order for Tylenol 325 mg, 2 tablets every 4 hours as needed for pain, but the May 2026 MAR did not show documentation of PRN Tylenol administration between 05/01/26 and 05/04/26 at 11:00 am. The facility’s pain management policy required individualized pain management, pain assessment, documentation of pain scale use, interventions, response, and follow-up. Interviews with the DON and regional clinical nurse educator confirmed the expectation for numerical pain scale documentation and pre/post assessment for PRN pain medication, but the educator stated the nursing staff were only signing off a pain assessment order without documenting the resident’s verbal or non-verbal response because the supplemental documentation tab had not been included in the system order.
Failure to Provide Escort Staff for Outside Physician Appointment
Penalty
Summary
The facility failed to obtain the staff needed to escort a resident to an outside infectious disease physician appointment. Resident #1, who was admitted with diagnoses including dementia with behavioral disturbance, stroke with right-sided weakness, immunodeficiency disease, chronic pain syndrome, papillomavirus, expressive aphasia, and genital herpes, had a physician order on 03/17/26 to be seen by a local infectious disease physician. The resident had severe cognitive impairment, with a BIMS score of 3/15, and during an interview on 05/04/26 at 11:07 am, the resident complained of groin pain and moaned with movement while seated. The resident’s family member stated that the resident was in constant pain and that the medications being provided were not working. The resident’s appointment for 05/04/26 at 9:30 AM was cancelled because the facility could not send a staff member, identified as a CNA, to accompany the resident. The clinical record showed the appointment had been cancelled and needed to be rescheduled. The infectious disease physician’s office confirmed that the facility called at 8:16 am to cancel the appointment because it could not send a CNA, and the office was told the resident could not go without a staff member. The facility scheduler confirmed that the appointment was cancelled because there was no available nursing aide to go with the resident.
Delayed Notification of Urine Culture Results
Penalty
Summary
The facility failed to promptly notify the ordering physician or clinical practitioner of a laboratory result for one resident. The resident had been assessed by the attending physician for discomfort during urination, declined a genitourinary examination, and was ordered to have a urinalysis and urine culture obtained. Nursing staff collected the urine specimen and sent it to the lab, and the urinalysis results were forwarded to the facility and later reported to the attending physician, who then ordered Ciprofloxacin for cystitis. The urine culture results were forwarded to the facility and showed abnormal findings, including that Ciprofloxacin was resistant to the organism identified. A nursing progress note later documented that the attending physician was made aware of the urine culture results, and the physician discontinued Ciprofloxacin and started Keflex for a urinary tract infection. The resident received additional doses of Ciprofloxacin after the facility had already been notified by the lab that the organism was resistant to that antibiotic.
Failure to Obtain Ordered Infectious Disease and Urology Consults
Penalty
Summary
The facility failed to follow a physician’s order to obtain timely infectious disease and urology consults for a resident with multiple complex diagnoses, including dementia with behavioral disturbance, stroke with right-sided weakness, immunodeficiency disease, chronic pain syndrome, papillomavirus, expressive aphasia, and genital herpes. During an interview, the resident complained of groin pain and moaned with movement while seated, and a family member stated that the resident was in constant pain and that the medications being provided were not working. The resident’s BIMS score was 3/15, indicating severe cognitive impairment. A physician ordered an infectious disease evaluation, and an appointment was scheduled, but the facility cancelled it the morning of the visit because staff said there was no available nursing aide to accompany the resident. The outside office reported that the facility cancelled the appointment because it could not send a CNA and stated the resident could not go without one. The record also contained a physician order to schedule a urology consult for penile cellulitis and chronic HSV infection with condyloma acuminata, but the scheduler could not produce urology consult notes and could not explain why the order had not been discontinued by the attending physician.
Failure to Document Ordered Lung Sounds and Pacemaker Checks
Penalty
Summary
Nursing staff failed to follow physician-ordered parameters when documenting lung sounds and failed to obtain a resident’s pacemaker check every shift for proper functioning. For one resident reviewed during the complaint survey, the chart contained an order from 11/25/25 to document lung sounds once daily using specific values for clear, rales, rhonchi, or wheezing, and another order from 11/25/25 to obtain a pacemaker check every shift for proper functioning. Review of the April and May 2026 MARs and TARs showed staff were only initialing that both tasks had been completed, without documenting the ordered lung sound results or obtaining a result showing the pacemaker was functioning appropriately each day. During interview, the resident and a family member reported groin pain, and the family member stated the resident was in constant pain and that the medications being provided were not working. The DON and regional clinical educator stated the resident goes out to the cardiologist’s office for pacemaker checks and that the facility has the equipment to perform the test there, but does not use the telephone method to check pacemaker function. They also stated the resident’s pacemaker had last been checked in July 2025 and was scheduled to be rechecked on 05/13/26.
Baseline Care Plan Omitted Resident’s Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident’s baseline care plan reflected the resident’s current medications at the time of admission. The resident was admitted with diagnoses including ST elevation myocardial infarction (STEMI), congestive heart failure, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure. The hospital discharge summary documented that the resident’s anticoagulant therapy had been changed from Eliquis to Xarelto, with a loading dose of Xarelto 15 mg twice daily starting on 12/7/2025 and a planned transition to Xarelto 20 mg daily on 12/29/2025. Upon admission, the physician orders at the facility included Xarelto as an anticoagulant medication. Record review showed that the resident’s baseline care plan, dated 12/10/2025, did not list anticoagulant medication among the resident’s current medications and did not include any care plan addressing anticoagulant therapy. During an interview, the DON confirmed that the resident was taking Xarelto at the time of admission and acknowledged that the anticoagulant medication should have been included in the baseline care plan. This omission occurred despite the requirement that the baseline care plan, provided within 48 hours of admission, detail the components of care the facility intends to provide, including current medications.
Failure to Develop Comprehensive Care Plan for Resident With Stage IV Pressure Ulcers
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered care plan for a resident admitted with extensive Stage IV pressure ulcers. The resident was admitted with paraplegia due to a motor vehicle accident, Stage IV pressure ulcers to the left buttock, sacral region, and left ankle, a local infection of the skin and subcutaneous tissue, and unspecified severe protein-calorie malnutrition. A pressure ulcer care plan was created and initiated with a goal that the resident would be free from signs of infection and that the ulcers would improve by the next review date. The listed interventions included carefully drying between toes without applying lotion between them, positioning the resident off affected areas, changing position every two hours and as needed, and a general directive for wound/dressing care "as order" with instructions to observe and change dressings and record observations at a frequency to be specified. The care plan was not comprehensive or resident-centered for the type and severity of the resident’s pressure ulcers. It did not specify the types of wound dressings or the frequency of dressing changes and observations. The plan omitted interventions to prevent further worsening of heel ulcers, such as elevating the heels or using heel boots. It also failed to include any information about the ordered wound vac, including monitoring for an intact seal, assessing for infection, bleeding, or fluid leakage. Additionally, the care plan did not address the type of mattress the resident should use. During review of the pressure ulcer care plan with the DON, the DON acknowledged that the care plan was not comprehensive for the resident’s pressure wounds present on admission.
Failure to Continue Prescribed Post-Hospital Antibiotic Therapy
Penalty
Summary
Facility staff failed to provide ordered treatment and care by not administering a prescribed antibiotic following a resident’s hospital discharge. The resident was admitted with hemiplegia and hemiparesis after a cerebral infarction affecting the left dominant side and had been diagnosed with a urinary tract infection in the hospital, for which Amoxicillin 500 mg three times daily was initiated. The hospital discharge summary specified that this Amoxicillin regimen was to be continued for an additional five days after discharge. Review of the resident’s January 2026 MAR showed no evidence that the Amoxicillin was administered upon admission. During interviews, the DON acknowledged reviewing the discharge summary and initially believing the antibiotic had been given in the hospital, and another staff member stated that the facility’s process includes a second-day chart check for new admissions and believed the antibiotic order was missed.
Concurrent Administration of Eliquis and Xarelto Due to Medication Order Errors
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors when both Eliquis and Xarelto were ordered and administered contrary to the hospital discharge instructions. The resident was admitted with diagnoses including STEMI, congestive heart failure, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure. The hospital discharge summary documented that Eliquis had been changed to Xarelto, with a loading dose of Xarelto 15 mg twice daily starting on 12/7/2025 and a planned transition to Xarelto 20 mg daily on 12/29/2025. Upon admission, Xarelto was ordered as directed; however, multiple Eliquis orders were subsequently entered and then discontinued on 12/10/2025, 12/11/2025, and 12/15/2025. The DON stated that the Eliquis order was stopped and restarted to change the indication from DVT to atrial fibrillation. The LPN supervisor reported that the Eliquis orders were created by the pharmacy and verified with the provider, but he could not explain why they were created. The Unit Manager RN acknowledged that the resident was supposed to be on Xarelto per the hospital discharge orders and identified the Eliquis orders as errors on multiple dates, contacting the provider to verify the correct Xarelto order and discontinuing Eliquis each time. Despite these discontinuations, Eliquis continued to appear on the MAR. Review of the December 2025 MAR showed that on 12/16/2025 at the 9:00 AM medication pass, the resident received Eliquis 5 mg along with Xarelto 15 mg, resulting in the administration of both anticoagulants. LPN #18 confirmed administering both medications as documented. The DON later confirmed, upon review of the MAR, that the resident received both Xarelto and Eliquis during that medication administration, and that the resident should have remained on Xarelto per the hospital discharge orders. The administration of both anticoagulant medications increased the resident's risk for bleeding.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident with paraplegia, multiple stage 4 pressure ulcers, local skin infection, and severe protein-calorie malnutrition, the medical record initially contained only a few wound notes despite weekly wound care visits. The wound care NP reported that the facility changed electronic systems and that prior wound notes had not transferred into the EMR; the DON later produced printed wound notes that had not been in the record. For the same resident, a change-in-condition note documented hypotension and critical labs with normal respiratory rate and oxygen saturation and no mention of breathing problems, while hospital records from the same day documented shortness of breath and use of a non-rebreather mask at 15 L/min. The RN who sent the resident out stated the resident was having respiratory issues and acknowledged he failed to document this. Additional documentation gaps for this resident included incomplete GNA task records for colostomy output, despite an order to monitor bowel movements every shift. Several shifts in December, January, and February lacked documentation of bowel movements, and the DON stated that if tasks were not signed off, they were not done. A complaint alleged the resident could not keep food down; although there was a PRN order for ondansetron for nausea and vomiting and staff and the physician both recalled an episode of vomiting, there was no nursing documentation of nausea or vomiting in the medical record. Another complaint alleged the facility failed to hold mandated care plan meetings; while there was a letter inviting the family to a care plan meeting on a specific date, there was no documentation in the medical record that the meeting occurred, and the regional social worker confirmed there were no social work notes and that the meeting should have been documented in the assessment section. For a second resident admitted in October 2025, the medical record did not contain documentation that a care plan meeting was held after admission. The EMR’s miscellaneous section contained only a care plan invitation letter for a meeting scheduled in January 2026, with nothing documented for the months immediately following admission. The regional social worker confirmed there was no documentation related to a post-admission care plan meeting for this resident and that only the January meeting notes could be found. These omissions collectively demonstrate that the facility did not maintain complete, accurate, and properly filed medical record documentation for assessments, treatments, changes in condition, and care plan meetings for the residents reviewed.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple documented sightings of roaches, mice, ants, spiders, water bugs, flies, and gnats in various patient care areas, medication rooms, break rooms, laundry, conference rooms, and shower rooms. The pest problem logs reviewed by the surveyor showed repeated entries of pest infestations over several months, including in resident rooms and critical care areas. These logs indicated that the issue was ongoing and widespread throughout the facility. During interviews, the Nursing Home Administrator acknowledged the presence of roaches and rodents in the facility, attributing the problem to the building's age and its location near woods and water. Despite the facility having a pest management company, the logs and staff interviews confirmed that pest sightings continued to occur, and a complaint had been filed regarding the infestation. The surveyor verified and confirmed the presence of pests during the investigation, establishing that the facility's pest control measures were not effective in preventing or addressing infestations.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the infection prevention and control program. During an interview, the DON stated that Staff #29, the regional Assistant DON and Infection Preventionist, was collaborating as the IP for the facility, but also clarified that until she completed IP training, Staff #29 was only a resource person who came to the facility once a month. In a phone interview, Staff #29 confirmed that she was an employee of a regional company serving as a resource person to cover the vacancy of a qualified IP, that she began this role at the end of March 2025, and that she came to the facility once a month and was available when the DON needed help. In a later interview with the DON and NHA, the DON confirmed that the facility did not have an IP onsite.
Failure to Timely Report Alleged Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse, neglect, exploitation, or mistreatment of residents to the appropriate authorities, as required. Multiple residents reported incidents of staff being rough, making hurtful statements, refusing care, and other forms of mistreatment. In several cases, residents reported these concerns to staff or surveyors, but there was no documented evidence that the facility initiated timely investigations or reported the allegations to the Office of Health Care Quality (OHCQ) within the required timeframes. For example, two residents alleged that a nurse was rough and had a poor attitude, but the concerns were not reported to OHCQ, and there was no documentation of a timely investigation. Another resident reported that a GNA made derogatory comments about their weight and delayed providing care, but these incidents were not reported as abuse or neglect to OHCQ, and the actions taken were only documented as customer service issues. Additionally, the facility failed to report an incident of alleged theft in a timely manner. A resident's cellphone went missing, and although staff were notified on the day of the incident, the report to OHCQ was not made within the required 24-hour period. In another case, a resident alleged being pushed into bed by a GNA, but the initial self-report to OHCQ was not made within the mandated 2-hour window. Furthermore, a resident reported ongoing issues with a roommate to a GNA, but the allegation was not reported to the state agency, and the facility only addressed the issue internally by arranging a room change. Interviews with facility leadership, including the DON and NHA, revealed a lack of consistent understanding and execution of reporting requirements. In several instances, staff acknowledged that incidents were not reported as abuse or neglect, and documentation was either lacking or delayed. The facility's failure to recognize, document, and report these allegations in a timely manner resulted in noncompliance with regulatory requirements for reporting suspected abuse, neglect, or theft.
Failure to Timely Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of abuse in a timely manner for multiple residents. In several instances, residents reported that staff were rough, mean, or made inappropriate comments during care. For example, two residents reported that a nurse was rough and had a poor attitude, but there was no evidence that the facility conducted a timely or thorough investigation after these concerns were reported to a unit manager and later to the Director of Nursing (DON). The only documentation provided was a single statement form, with no further evidence of interviews, assessments, or protective measures taken while the investigation was pending. Another resident reported that a Geriatric Nursing Aide (GNA) made hurtful comments about the resident's weight and was rude during care. Although the incident was documented as a concern, there was no evidence that the facility conducted a thorough investigation, assessed the resident, or interviewed staff and residents in a timely manner. The Nursing Home Administrator (NHA) acknowledged that the incident was not treated as abuse and that the GNA was only verbally instructed not to return to the resident's room. Additional incidents included a resident calling 911 to report being aggressively grabbed by a nurse, with a significant delay in conducting required assessments after the NHA was notified. In another case, a family member reported aggressive care by a GNA, but the resident's assessment was not completed until the following day. The DON confirmed that immediate assessments and investigations were not performed as required in these cases.
Missing and Incomplete Care Plan Reviews and IDT Participation
Penalty
Summary
The facility failed to review and revise resident care plans as required, failed to hold or document interdisciplinary team (IDT) care plan meetings at the time of quarterly revisions, and failed to ensure participation in the care planning process by required IDT members. These findings were identified for 7 residents reviewed during the survey investigation, including residents with dental concerns, fall-related issues, and long-term care residents whose quarterly MDS assessments were completed without corresponding care plan conference documentation. For one resident, the record showed a dental exam identifying missing restoration on tooth #30 and poor restorability and mobility on teeth #12 and #13, with a referral for extraction of those teeth. The resident later reported a broken tooth and pain, and staff stated they were not aware of any scheduled dental appointment. The resident’s care plan, which had been initiated earlier for oral pain and coordination of dental care, was not updated to reflect the active dental referral and tooth pain for approximately 11 months. For other residents, the records showed quarterly and annual MDS assessments but missing or delayed care plan conference documentation. One resident stated awareness of no care plan meeting and the chart contained only one documented care conference despite multiple quarterly and annual assessments. Another resident had care plan meetings documented nine months apart despite multiple quarterly MDS assessments. For another resident, care conference notes were present only in January and July 2025, with no evidence of a meeting after the April 2025 quarterly MDS assessment, and the resident confirmed no April meeting occurred. In a separate case, a July 2023 care plan meeting record for another resident did not show attendance by a nurse, nurse aide, physician, or dietary representative, and the NHA confirmed that no nursing or dietary staff or physician were documented as attending.
Infection Control Deficiencies With COVID-19 Precautions, Delayed Antiviral Medication, and Laundry PPE Lapses
Penalty
Summary
The facility failed to maintain the environment of resident care in a manner that minimized the potential spread of infection. For a resident diagnosed with COVID-19 on 8/14/25 and ordered contact and droplet precautions through 8/24/25, an isolation sign was not consistently posted on the room door. During survey observations, staff removed the EBP signage from the door and stated the resident no longer needed any type of precaution, and a later observation showed EBP signage present but no contact and droplet precaution signage. The DON confirmed that contact precaution signage should have been placed for the resident immediately after diagnosis. The facility also failed to ensure timely administration of antiviral medication for another resident who tested COVID-19 positive on 8/10/25 and was ordered antiviral medication twice daily for 5 days starting that same day. The MAR showed the resident did not receive the medication until 8/12/25, and documentation stated the dose was not given because pharmacy delivery was pending. In addition, during a laundry room observation, a staff member was seen placing soiled linens into the washer without a gown or face protection. The EVS Director stated staff were required to wear PPE when handling soiled linens, and the facility policy required tear-resistant gloves, gowns, and face protection.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyor observations and resident interviews revealed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents. In two separate rooms, residents reported persistent issues with flies and gnats, which were also directly observed by the surveyor at multiple times during the facility tour. A complaint had previously documented problems with pest control, including ants, fruit flies, gnats, and mice. The Maintenance Director confirmed that routine checks of resident rooms were not performed unless an issue was reported, and that fly traps and spraying were not permitted in resident rooms. The Administrator acknowledged the ongoing pest issue and indicated that pest control services were in place, but could not specify the frequency of visits or provide immediate evidence of effective pest management. Despite some pest control measures, the presence of flies and gnats persisted in resident rooms at the time of the survey. In a separate incident, a complaint and subsequent observation of another resident's room revealed that the room had not been painted in years, with visible old paint where items had been removed from the walls. The bathroom faucet was corroded, plaster on the walls was loose and flaky, a ceiling tile was ajar, and the light above one bed was not functioning due to a missing bulb and pull cord. The resident confirmed the light had not worked for some time. The Nursing Home Administrator agreed that these conditions did not constitute a comfortable, homelike environment.
Staff Misappropriation of Resident Funds
Penalty
Summary
Facility staff failed to protect a resident from misappropriation of property when a Geriatric Nursing Assistant (GNA) used the resident's bank card and account information to access funds for personal benefit. The GNA admitted to withdrawing $100 at the resident's request, but denied making other withdrawals. However, a police investigation revealed 28 transactions over several months, with the GNA's name associated with withdrawals via a cash app. Bank records showed two significant withdrawals to the GNA's cash app prior to his termination. The resident confirmed that the staff member used their bank card and stated there had been no further incidents since the last event. The facility administrator was unaware of the GNA's actions until after the staff member's termination and could not confirm whether the withdrawn funds were given to the resident. The administrator also did not know the reason for the GNA's termination and was unable to provide a clear policy regarding staff obtaining money for residents. Facility policy prohibits misuse or abuse of nursing home funds, dishonesty, theft, and misrepresentation, but the events indicate that these policies were not effectively enforced in this case.
Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to ensure that discharge documentation for a resident was fully completed. Upon review of the resident's closed medical record, it was found that several sections of the Engage Discharge Planning Tool were left blank, including responsible parties' information, primary physician information, staff and resident or responsible party signatures, and the medication list. Additionally, the section regarding whether a pharmacy printout of the medication regimen was attached was not completed, and no medication list or indication of its status was present in the record. Interviews with facility staff revealed that the discharge paperwork is typically initiated by the social worker and completed by various disciplines, including the physician, nurse, rehab, activities, and dietician. The unit manager stated that medication lists are not routinely printed out, and new prescriptions are provided to residents on paper. The social worker confirmed that all sections of the discharge planning tool should be completed before the resident or responsible party receives the paperwork. The Director of Nursing acknowledged the concern when informed of the incomplete documentation, and no additional documentation related to the resident's discharge was provided.
Failure to Provide and Document Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan (BLCP), including a current list of medications, was provided to residents and/or their representatives and documented in the medical record within 48 hours of admission. For two residents reviewed, there was no evidence in the electronic health record (EHR) that the BLCP was present under the designated section, nor was there documentation that the BLCP had been provided to the resident or their representative. In one case, a resident with severely impaired cognition, as indicated by a BIMS score of 0, had a BLCP signed by the resident instead of the representative, contrary to facility expectations. The Director of Nursing (DON) confirmed that the required documentation and signatures were missing and that the BLCP was not properly scanned into the EHR. In another instance, a resident with dementia and a BIMS score of 2 had a BLCP with missing signatures from both the staff and the resident or representative, and there was no evidence that the BLCP or medication list had been provided. The DON and Regional Director of Clinical Operations (RDCO) verified that the required fields were incomplete and that the documentation process had not been followed as expected. These findings were based on medical record reviews and staff interviews conducted during the recertification survey.
Failure to Prevent Unjustified Decline in ADL Abilities
Penalty
Summary
Residents experienced a decline in their ability to perform activities of daily living (ADLs) without a documented medical reason to justify the loss. The facility failed to ensure that residents maintained their ADL abilities unless a medical condition necessitated the decline, as required by regulations.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents, as evidenced by lack of pain monitoring, failure to schedule necessary pain management appointments, and improper administration of pain medications. One resident, following hospital discharge, was recommended to follow up with a pain management clinic and spine specialist. Although physician orders and a pain care plan were in place, there was no evidence that pain was monitored or recorded every shift, and the resident did not have a scheduled appointment with the pain specialist until after surveyor intervention. The resident continued to experience pain and was unaware of any scheduled follow-up, indicating a breakdown in communication and care coordination. Another resident was administered PRN pain medication even when their pain level was documented as zero, and there was no evidence that non-pharmacological interventions were attempted prior to medication administration. The physician's order did not include non-pharmacological interventions, and the Medication Administration Record did not reflect their use. The DON confirmed that pain medication should not be given when pain is absent and that non-pharmacological interventions should be implemented, but these standards were not followed. A third resident with chronic pain and opioid dependence had PRN orders for both acetaminophen and oxycodone without specific pain scale parameters. Review of records showed inconsistent pain management, with medications given for pain scores that did not align with best practices (e.g., oxycodone for a pain score of 1). There was also no documentation of non-pharmacological interventions prior to medication administration. Staff interviews confirmed that pain medications should be administered according to pain severity and that non-pharmacological interventions should be attempted and documented, but these practices were not consistently followed.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by professional standards. In the first instance, a resident who had returned from a leave of absence was administered a one-time dose of Narcan after exhibiting unresponsiveness and excessive drowsiness. Although the administration of Narcan was documented in the nursing progress notes, the Medication Administration Record (MAR) for the month did not include documentation of the Narcan administration. Additionally, there was no documented evidence that the resident’s behavior was being routinely monitored following the event. In the second instance, another resident was admitted with a therapeutic boot and had an orthopedist consultation recommending continued use of the boot for weight bearing as tolerated. However, there was no evidence in the clinical record that nursing staff documented the use of the boot on the Treatment Administration Record, despite the expectation that such recommendations would be followed. These omissions resulted in incomplete and inaccurate medical records for both residents.
Failure to Provide Timely Abuse Education to Newly Hired GNA
Penalty
Summary
The facility failed to provide required abuse education to a geriatric nursing assistant (GNA) upon hire, as evidenced by a review of staff training records and administrative interviews. One GNA, who was later falsely accused of sexual abuse by a resident, was hired and began caring for residents before completing mandatory training in infection control, dementia care, and abuse prevention. The training was not completed until nearly two months after the hire date, despite facility policy requiring such education during orientation. The Nursing Home Administrator confirmed that the staff member worked with residents prior to completing the required training.
Dignity Failure: Urinal with Urine Left at Bedside During Breakfast
Penalty
Summary
Facility staff failed to treat Resident #49 in a dignified manner by leaving a urinal containing urine hanging on the resident’s left upper bed rail during breakfast. During observation, the resident was sitting in bed eating breakfast while the urinal, about one-third full of clear yellow urine, remained attached to the bedrail at the bedside. The resident stated that the urinal had been used a while back and that when staff served breakfast, the urinal containing urine was still hanging on the bedrail and had not been emptied. A GNA entered the room to pick up trays but left without removing the urinal. When interviewed, the GNA stated she was not assigned to the resident and acknowledged it was not appropriate for the resident to be eating breakfast with a urinal containing urine next to him/her. The resident’s nurse later validated the observation and stated staff should have emptied the urinal when breakfast was served. The DON stated she was aware of the observation and had done education/training with staff.
Missing incapacity certifications and Advance Directive documentation
Penalty
Summary
Facility staff failed to ensure that two physicians' certifications of incapacity were obtained and that Advance Directives were completed in accordance with the Health Care Decisions Act before allowing resident representatives to make informed health care decisions on a resident's behalf. For Resident #8, the medical record showed the resident had been in the facility for more than 10 years, but only one physician certification was signed and filed, despite the resident's BIMS score being 00 since admission. Staff interviews confirmed that two physician certifications are required and should be maintained in the paper chart, but the resident's record did not contain the second certification. The facility also failed to provide written information to residents concerning the right to formulate an Advance Directive. For Resident #11, the medical record did not contain documentation showing that Advance Directives were obtained or addressed as required. Interviews with the RDCO and social work staff indicated that Advance Directive documents should be present in the EHR and discussed during admission and care plan meetings, but no documented evidence was found in the record to show that this had occurred for the resident.
Failure to Notify POA and Physician of Resident Events
Penalty
Summary
The facility failed to notify the resident’s POA after the resident fell out of bed. Complaint intake #337221 and record review showed that the resident was found on the floor on 8/26/25 at 10:15 AM and stated s/he was trying to reach for something on the floor by the bedside. No pain or injury was noted. The medical record did not show that the POA was notified of the fall incident. During interview, the DON stated that if a resident has a POA, the POA is notified, but the incident document later produced showed the resident, not the POA, was listed as notified. The facility also failed to notify the attending physician when the resident missed a scheduled post-op appointment related to repair of a fractured tibia. The appointment on 10/30/23 was rescheduled after the facility’s transportation vendor did not show up, and staff stated the consulting doctor was made aware of the cancellation, but it was unclear whether the attending physician was notified. Review of the medical record did not show documentation that the attending physician was notified, and the DON later confirmed there was no proof of such notification.
Lack of Behavior Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide documented evidence that Resident #74 was free from unnecessary medication administration. On review of the medication list, the resident had orders for a scheduled antianxiety medication once daily and a separate antianxiety medication every 6 hours as needed. However, there was no documentation showing that the resident’s behavior was adequately monitored to support appropriate administration of psychotropic medications. When the surveyor requested behavior monitoring documentation, the DON reviewed the chart and stated that there was no documentation to support that the facility monitored the resident’s behavior. The DON acknowledged that the resident’s behaviors were expected to be monitored and documented every shift.
Incorrect MDS Diagnosis Coding
Penalty
Summary
The facility failed to accurately code a diagnosis in the Minimum Data Set (MDS) for Resident #15, who was reviewed for antipsychotic medication use and related diagnosis. The record showed an order for Olanzapine 5 mg at bedtime for depression and a psychiatry progress note dated 05/28/2025 with active diagnoses that did not include schizophrenia. Despite this, the resident’s MDS assessments for 06/30/2024 and 09/30/2024 listed schizophrenia as an active diagnosis in Section I. Review of the medical record did not corroborate the schizophrenia diagnosis, and the MDS nurse stated that schizophrenia should only be coded if obtained from a hospital within the last six months. The MDS nurse also stated that schizoaffective disorder and schizophrenia are distinct diagnoses and that a resident with schizoaffective disorder should not be coded as schizophrenia on the MDS. The incorrect schizophrenia coding on the two MDS assessments was confirmed by Staff #30, and the DON was made aware of the concern on 08/28/2025.
Missed Tube Feeding Care and Delayed Medication Administration
Penalty
Summary
The facility failed to provide ordered tube feeding care for a resident with a J-tube. The resident’s physician orders required enteral feeding with Osmolyte 1.2 at 55 mL/hour, flushing with water every 4 hours, aspirating stomach contents each day shift, and flushing the tube before and after medication administration and between medications. Review of the March 2024 MAR and TAR showed that on the evening/night of 3/21/24 and the night of 3/22/24, the tube feeding, residual check, and tube flushes were not signed off, and there were no notes explaining why the entries were left blank. The complaint also stated the resident had pain at the J-tube site, had multiple issues when the tube became clogged because it was not flushed, and was later taken to the hospital and diagnosed with a clogged J-tube. The facility also failed to ensure a resident received a prescribed medication for several days. The resident had an order for Modafinil 200 mg by mouth daily for stay awake. Review of the MAR showed the medication was not given on two consecutive days in January 2024, and nursing notes documented that staff were waiting on pharmacy delivery, then sent a C2 form to the NP, and continued waiting for pharmacy to bring the medication the following day. The DON was informed that the resident did not receive the medication for 3 days because it took that long to be delivered by pharmacy.
Pressure Ulcer Care and Care Plan Deficiencies
Penalty
Summary
The facility failed to provide timely, consistent pressure ulcer care for two residents with wounds. One resident was admitted with diagnoses including multiple sclerosis, generalized muscle weakness, aphasia, dementia, and an unstageable pressure ulcer of the right ankle present on admission. The DON stated residents with pressure ulcers would automatically be seen by the wound team and that the wound NP came on Tuesdays or Thursdays, with the wound doctor on Fridays. However, the resident was admitted on a Friday and was not seen by a wound provider until the following Thursday, and only three wound provider notes were available for the admission period. For that same resident, wound treatment orders for the sacral wound and right ankle wound were discontinued and not reordered for three days even though the wounds had not resolved. The MAR/TAR showed treatment orders that stopped and then restarted later, creating a gap in wound care. The DON stated she could not determine why the treatment orders fell off and confirmed that residents with pressure ulcers should have treatment orders in place. A second resident had a worsening sacral pressure area with weekly skin checks documented. The wound NP changed the sacral wound treatment, but the prior treatment continued for four days after the new recommendation, and the new order was not started until several days later. The resident’s record also showed no nutritional intervention related to the sacral wound when it developed, and the dietician stated she was not notified of the wound until later and had not been consulted at the time it occurred. In addition, the resident’s care plan for the sacral wound did not include interventions for turning and repositioning, use of the pressure-reducing mattress, or the updated treatment changes, and the wound care nurse confirmed the care plan was not updated with those interventions.
Incomplete Incontinence Assessment and No Care Plan
Penalty
Summary
The facility failed to adequately assess urinary incontinence and failed to implement a care plan to restore continence to the fullest extent possible for Resident #107, who was documented as incontinent of bowel and bladder. During an interview, the resident stated he/she had been waiting 2 to 3 hours since early morning and was completely soaked, and reported that staff said no one was there yet. The resident also stated that waiting to be changed occurred often. Record review showed that a bowel and bladder assessment completed three days after admission was incomplete. Although the assessment documented incontinence of bowel and bladder in Section A, only Section A and one question in Section B were completed; the remaining questions in Section B were not answered, and Sections C, D, and G were blank. The record also showed there was no plan of care related to incontinence. The DON stated incontinent residents are to be on either a toileting program or a two-hour check and change schedule, and that both a comprehensive bowel and bladder assessment and an incontinence-related care plan must be established. The Unit Manager also verified that the bowel and bladder assessment was incomplete and that no plan of care had been established related to incontinence.
Missing Annual Performance Reviews for GNAs
Penalty
Summary
The facility failed to perform annual performance reviews for Geriatric Nursing Assistants (GNAs) #38, #43, and #44. Review of their employee files showed no performance appraisals for 2022 and 2023. During interview, the Human Resources Manager confirmed that the annual GNA performance appraisals for those years were missing and stated that if the appraisals were not in the files, then they were not done. The DON also stated that GNAs should have an annual performance evaluation and agreed that the missing performance appraisals for 2022 and 2023 were a concern.
Unnecessary Prostat Given for Wound Healing Without an Active Wound
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary medications. Resident #49’s record showed an Annual MDS with an ARD of 5/26/2025 indicating no pressure ulcer or skin issues, and weekly skin documentation from May 2025 through August 2025 showed the resident’s skin was intact with no wounds present. A nursing progress note dated 7/15/2025 documented that a wound CNP completed a skin sweep and noted no areas, with the RP and MD notified. Despite the absence of wounds, the resident had an active physician order dated 11/2/2024 for Prostat three times daily for wound healing, and the August 2025 MAR and TAR showed the resident was still receiving Prostat three times a day for wound healing. The resident’s nurse and the acting unit manager both confirmed the resident had no wounds, and the acting unit manager reviewed the record and verified that the resident should not have been receiving Prostat for wound healing. The wound nurse also validated that the resident had no wounds.
Expired and Improperly Labeled Medications and Supplies Found in Locked and Unlocked Storage Areas
Penalty
Summary
Facility staff failed to safely store medications and dispose of expired medications and patient supplies on two of three nursing units observed during the medication storage and labeling review. On Unit 2, surveyors found an opened box of COVID-19 at-home test kits with an expiration date of 4/14/2025, three test packs in the box with one opened, and a bottle of Pro-Stat Wild Cherry Punch that was about one-third full and expired on 8/6/2025. During a separate observation on Unit 2, surveyors found a bottle of Pro-Stat concentrated liquid protein medical food expired on 7/10/2025 and a sticky bottle of Valproic Acid solution 250/5 mL that was about one-third full, with a faded label and no visible resident name or expiration date; the RN stated she could not identify which resident it belonged to and confirmed the substance on the cart was spillage from that bottle and that it should have been discarded and/or relabeled. On Unit 1, surveyors observed the medication storage room behind the nurses' station and found expired supplies including five ESwab Collection and Transport System items expired on 12/29/2024 and one Port Access Infusion Set expired on 7/31/2025. In an unlocked bottom cabinet next to the med-storage room, surveyors found two Disposable Virus Specimen Collection Tubes expired on 8/1/2022 and four Sterile Normal Saline collection tubes expired on 1/13/2023. The UM verified the items were expired. The facility policy stated medications and biologicals are to be stored in locked compartments, and labels are to include expiration date and resident name when available; it also stated outdated or deteriorated medications or biologicals are to be handled through the dispensing pharmacy and that containers with missing or incomplete labels are to be addressed through the pharmacy.
Failure to Arrange Timely Dental Consults and Transportation
Penalty
Summary
The facility failed to assist residents in obtaining dental services, including making appointments and arranging transportation, for 2 of 3 residents reviewed for dental services. Resident #5 reported right mouth gum pain that interfered with eating, and the physician ordered a dental consult in the evening of 8/10/2025. The resident continued to report gum pain on 8/11/2025, and on 8/14/2025 staff observed the lower dental implants detaching from the gums, prompting an urgent dental consultation. The resident again reported tooth pain on 8/15/2025, and on 8/18/2025 a note stated the unit secretary was looking for a dentist because the resident lacked dental insurance. Staff interviews showed that the facility’s process was for the physician order to be sent to medical records, which would then schedule the appointment, and that the facility would cover the cost if the resident had no dental insurance. However, no appointment had been documented until after surveyor intervention, when a dental appointment was scheduled for 8/21/2025. Staff later stated that the urgent dental consultation had been delayed because the resident lacked insurance, and confirmed that the appointment was made only after the surveyor’s involvement. Resident #10 reported having a broken tooth and pain, with several broken teeth and a history of prior dental evaluation. A review of the dental exam showed missing restoration on tooth #30 and poor restorability and mobility on teeth #12 and #13, with a referral for extraction of those teeth. A later progress note documented a referral for dental consult at the University of Maryland Medical Center for oral and maxillofacial surgery and extraction, but there was no documented evidence that the resident was scheduled for the recommended dental services. Staff interviews confirmed that the referral process should include notification, scheduling, and transportation arrangements, but Staff #12 was not aware of any dental appointment for Resident #10.
Improper Storage of Dry Food Items
Penalty
Summary
Food items were not stored under sanitary conditions in the dry storage area during the recertification/complaint survey. On 8/19/25 at 8:17 AM, the surveyor observed two large bins lined with white plastic bags, and both bags had ripped areas with brown and black stains. Neither bin was labeled with the item inside or a date. During a dual observation at 8:21 AM, the Dietary Director identified the contents as flour and sugar and acknowledged that the bins were not labeled. She stated she had put the items in the bins that morning and forgot to return to label them, and when asked if the bags and bins were clean, she stated they were not. She also stated she had placed brand new bags of flour and sugar into dirty containers because she was trying to get it all done.
Incomplete Antibiotic Stewardship Monitoring Records
Penalty
Summary
The facility failed to collect all necessary information for monitoring its antibiotic stewardship program. During review of all seven months of antibiotic stewardship records from January 2025 through July 2025, the surveyor found that the facility used spreadsheets to track antibiotic use with resident name, infection type diagnosis, last treated, organism identified, Rx date, Rx duration, antibiotic name, dose, and whether minimum criteria were met. However, the forms did not contain detailed information for infection type diagnosis, last treated, organism identified, or whether minimum criteria were met. During interview, the DON, who was also the Infection Preventionist, stated that the facility held weekly antibiotic stewardship meetings with qualified staff to discuss antibiotic use. When the surveyor reviewed the spreadsheet with the DON, the surveyor stated that the documentation did not include all necessary information to monitor antibiotic use. The DON stated that other documentation was used during the antibiotic stewardship meetings. Later, the DON and the Regional educator provided an EMR order listing report that included resident name, antibiotic order summary, order category, revision date, and supply last order date, but it did not include criteria details, organism identified, or start and end dates. The surveyor informed them that the antibiotic stewardship program did not adequately monitor antibiotic use, and they validated the concern.
Failure to Offer Pneumococcal Vaccine on Admission
Penalty
Summary
The facility failed to offer a resident a pneumococcal vaccine upon admission. During review of five residents' immunization records, Resident #68, who was admitted in October 2022, had no record of receiving the pneumococcal vaccine. A unit manager stated that unit managers are supposed to monitor residents' influenza, pneumonia, and COVID-19 immunization status upon admission. The regional clinical educator later produced a vaccine declination form dated 10/10/24 showing the resident refused influenza, Pneumovax23, and COVID-19 vaccines for personal reasons, and stated that staff had reviewed the resident's paper chart and found the form. However, when asked for documentation showing the pneumonia vaccine had been offered at admission in October 2022, no additional evidence was found in the paper chart, and the unit manager could not indicate where the declination form had been located. The surveyor shared concerns with the regional clinical educator, who validated them.
Failure to Document COVID-19 Vaccine Education and Staff Vaccination Status
Penalty
Summary
The facility failed to document education about the benefits, risks, and potential side effects of the COVID-19 vaccine for a resident who refused the vaccine after admission in July 2025. A surveyor reviewed the resident’s immunization record and found that although the resident refused the COVID-19 vaccine, the record did not show that education had been provided. During interview, a unit manager stated that she had offered the vaccine and educated the resident’s family, but she failed to document the education by not clicking the education box. The Nursing Home Administration later validated this finding. The facility also failed to maintain COVID-19 vaccination documentation for two staff members, both of whom were hired in 2024. A surveyor reviewed staff immunization records and found that the two employees did not have COVID-19 vaccination records in their health files. The DON and HR director confirmed that this documentation was required for new hires, and the HR director stated, “I just missed them,” which was validated by the surveyor.
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 1,833 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 Catonsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridgeway Rehab Center | 0.4 mi | ★★★★★ | 28 | 0 |
| Forest Haven Nursing And Rehabilitation Ctr | 0.9 mi | ★★★★★ | 54 | 0 |
| Westgate Hills Rehab & Healthcare Ctr | 1.1 mi | ★★★★★ | 10 | 0 |
| Autumn Lake Healthcare At Catonsville | 1.1 mi | ★★★★★ | 41 | 0 |
| Little Sisters Of The Poor | 1.5 mi | ★★★★★ | 5 | 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.