Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Future Care Cold Spring during CMS and state inspections, most recent first.
Food storage and kitchen sanitation deficiencies were observed in the kitchen and nourishment rooms. Ceiling dripping was seen near the walk-in refrigerator/freezer with bread and spices stored nearby, leftover resident food trays were left on counters in two nourishment rooms, and a cell phone was observed on a prep table during meal assembly. The NHA confirmed personal items should not be in the kitchen during meal prep or assembly.
Incomplete and inaccurate documentation was found for multiple residents. Records were missing key details for an incident investigation, a change-in-condition evaluation, and a fall with an abrasion, and one resident’s PICC and wound care documentation was incomplete, including a blank PRN dressing entry and no timely documentation of a refusal of care.
Failure to maintain infection control practices occurred when a resident with a PICC line, foley catheter, multiple pressure ulcers, and an ostomy had EBP ordered but no door sign or clear indication for staff to use EBP during high-contact care. In addition, the laundry area was observed with the clean room door open, soiled laundry on the floor and in the shoot, PPE left on a dispenser, and caked chemical residue, while the EVS director stated staff were not aware the clean area door should be closed.
Ice machines were not maintained in adequate condition in two nourishment rooms. One ice maker had water on the floor beneath it and a tray filled to the top with water, while another had moist tan particles in the tray that smeared onto a paper towel when wiped. The RDON stated some white areas could not be removed by cleaning, and the NHA said maintenance serviced the floor ice machines every 4 months.
A staff member was reported to have physically and verbally abused a resident, with a witness observing the staff member strike the resident, causing them to stumble. The resident and a roommate provided statements supporting the occurrence of the incident, while the staff member denied the physical abuse but admitted to making a threatening statement. The incident was reported for further investigation due to conflicting accounts.
Staff did not notify the state agency within the required two-hour timeframe after becoming aware of alleged incidents involving two residents. In both cases, the incidents were reported late, as confirmed by record review and staff interviews, despite facility policy requiring prompt reporting by the Administrator, DON, or ADON.
Staff did not follow professional nursing standards when a nurse delayed completing and backdated a change in condition evaluation for a resident, and an LPN failed to notify the physician after a resident repeatedly refused suprapubic catheter care. The DON and Regional Clinical Service Manager confirmed that timely documentation and physician notification are required in these situations.
Staff failed to obtain and administer medications as ordered for two residents, resulting in missed doses due to unavailable medications and improper insulin administration for a diabetic resident. Errors included not performing required blood sugar checks before meals and administering insulin at incorrect times, contrary to facility policy and physician orders.
A resident reported that the facility removed the bed side rails and that he/she could not move in bed. The NHA confirmed the rails had been removed while reassessing need, even though the resident’s assessment recommended 1/4 siderail assist handles as an enabler to promote independence and PT documentation noted the resident had been bedbound for years due to weakness.
Failure to document AD status and offer: Two residents had no AD documentation in the chart, and the SS Director could not confirm that either resident had been asked about ADs or offered help to complete one. One resident’s note about AD outreach was entered only after the surveyor requested documentation, and the other resident’s EMR contained no record that ADs were addressed on admission.
A resident was ordered multiple psychotropic medications, including quetiapine for depression and PRN olanzapine for anxiety, without clear documented need and with inconsistent documentation of the doses and directions. Pharmacy review noted the PRN antipsychotic lacked the required stop date, and the order remained active even after review and psych input requested changes.
Failure to develop patient-centered comprehensive care plans for two residents. One resident’s care plan for impaired memory/cognition due to a neurological disorder contained bracketed placeholders instead of resident-specific details, and the DON, RCSM, and SW acknowledged the information needed to be patient-centered. Another resident, admitted after a fall with fractures, functional decline in ambulation and ADLs, and RUE weakness, had incomplete pain and fall care plans that were later updated with additional statements; the RCSM stated the original care plans were not person-centered and should have been specific to the resident’s plan of care.
Failure to provide ADL personal hygiene care for a dependent resident. A resident recently admitted after a fall with fractures and RUE weakness was observed with long fingernails and dark substance under the nails. ADL documentation showed the resident was dependent for personal hygiene with no refusals recorded, and staff confirmed fingernail cleaning was part of ADL care.
Unaddressed Significant Weight Gain: A resident with MDD, PVD, above-the-knee amputation, and dementia had repeated significant weight gain over several months. The RD documented triggers for weight gain, questioned scale discrepancy or fluid shifts, and noted mirtazapine as a possible appetite stimulant, but the record did not show that the ongoing weight gain was acknowledged in the care plan or that interventions were adjusted.
Unlabeled Tube Feeding Bag: Staff failed to label a resident’s tube feeding formula bag and flush bag with the resident’s name, formula type, date/time hung, and staff initials/name. An RN could not confirm what formula was in the bag or when it had been hung, and the resident’s enteral feeding order called for Jevity 1.5 to run overnight, yet the bag was still hanging the next morning.
A physician failed to acknowledge repeated dietitian concerns about a resident’s significant weight gain. The resident, who had dementia, PVD, major depressive disorder, and an above-the-knee amputation, gained substantial weight over two 6-month periods. The RD documented ongoing weight gain, questioned a possible scale discrepancy, and twice suggested considering discontinuing mirtazapine, but the medical record did not show that the physician addressed these recommendations.
Missing Annual GNA Performance Reviews: The facility failed to complete required annual performance reviews for two GNAs. Record review showed that the two GNAs did not have annual competencies or performance reviews for the prior two years, and the RCSM confirmed that no additional documentation was available and acknowledged that GNAs should have annual competencies/performance reviews.
A facility failed to respond to a consulting pharmacist’s recommendation for one resident’s PRN lorazepam order. The pharmacist asked for a documented rationale and duration date, but the order remained active for anxiety and agitation related to end of life care without an end date. The physician acknowledged the missing stop date, and the RCSM confirmed the issue on the record.
Delayed BMP Lab Redraw: A resident with dementia, behavioral disturbances, aphasia, and apraxia had a BMP cancelled because the specimen was missing a DOB identifier. RN documentation noted the provider was informed and a redraw was reportedly ordered, but no redraw order was found in the chart when reviewed, and the DON stated the communication order for the redraw had been missed.
Facility staff failed to ensure GNAs completed required dementia training and an annual evaluation. Record review showed one GNA hired in March 2025 had no dementia training, another GNA had no documentation of completing the course, and a third GNA who remained employed did not have a yearly evaluation after one year. Interviews confirmed the dementia course should be completed within the first 90 days of employment and that a yearly evaluation is required.
A resident with dementia and wandering behavior exited the facility due to a malfunctioning wander guard system at the main entrance. Documentation revealed lapses in medication administration and nursing care by an LPN, and discrepancies in staff accounts regarding the incident. Post-incident logs showed errors in wander guard checks, and there was no evidence of immediate repairs following the mechanical failure.
A review of Personal Funds revealed that the facility's surety bond amount was not sufficient to cover the total amount of residents' personal funds held. The Corporate Accounts Receivable Manager indicated that residents' funds were kept in separate accounts and covered by a surety bond. However, the Trial Balance document showed a total of $172,021.92 across 75 residents, while the surety bond amount was $170,000.00. The Nursing Home Administrator confirmed the discrepancy, acknowledging that the surety bond did not cover the total amount of funds held by the facility.
The facility experienced issues with ensuring that food served to residents was palatable and at a safe, appetizing temperature. Residents reported dissatisfaction with the food's taste, temperature, and quality. Observations revealed malfunctions in food service equipment, including a broken indicator light on the steam table and a missing indicator light on the plate warmer system. Temperature testing showed a turkey burger patty at 106.7°F and cool waffle fries, with additional issues such as soggy buns and dry fries noted during palatability testing.
The facility experienced deficiencies in three key areas of its infection prevention and control program. Urinary bags for a resident were observed touching the floor multiple times, indicating improper handling. The Infection Prevention Control policy manual was outdated, with no annual reviews or updates since 2021. Additionally, staff handling dirty laundry were not using appropriate PPE, such as masks and gowns, and lacked adequate training on infection control practices related to laundry handling.
The facility failed to ensure sanitary practices and proper food storage in the kitchen. Observations included staff not wearing hair restraints, food debris in the dishwashing area, and improper storage of food items. Temperature logs for refrigerators and freezers were incomplete or inaccurate, and unlabeled food items were found. Broken kitchen equipment and inadequate monitoring of the kitchen environment were also noted.
The facility experienced issues with the accuracy of MDS assessments and coding. One resident's discharge status was incorrectly coded as a short-term general hospital instead of home. Another resident's MDS lacked an updated assessment upon discharge, with the last assessment not reflecting the discharge. Discrepancies were found in the functional limitations coding for a resident with hemiplegia and hemiparesis, showing conflicting information on upper and lower extremity impairments. Additionally, a resident's MDS assessment did not reflect the presence of pressure ulcers documented in wound and skin notes.
The report identifies several instances where care plans did not align with physician orders or resident needs. For a resident with daily wound care orders, the care plan lacked these interventions, raising concerns about pressure ulcer management. Another resident's care plan did not address their pressure ulcer at all. Specialized care plans for hospice and palliative care were found to be insufficient, lacking person-centered details. A resident with a suprapubic catheter had no care plan for surgical wound care. Infection control measures were also deficient, with no care plan for a resident on contact precautions for C-diff and inadequate details for G-tube feeding care.
Several residents, including those with recent MDS assessments, did not have documented care plan meetings. The Unit Manager indicated that the social worker, responsible for these meetings, had been inconsistent due to staffing changes. The DON acknowledged missed records for some residents due to the absence of a social worker since March 2023.
The facility failed to ensure physician responses to pharmacist recommendations for three residents, including recommendations for medication adjustments and clarifications. The DON confirmed the absence of documented responses and acknowledged ongoing efforts to improve compliance.
A resident reported losing $57 left on their bedside table. The facility's investigative report claimed the resident was provided a key to their nightstand for safekeeping, but the resident stated that their nightstand did not have a lock. Upon inspection, it was confirmed that the nightstand had a circular hole for a lock but no actual lock was present. The administrator was initially unaware of this issue and later confirmed the absence of a lock, indicating a failure to provide the promised security for the resident's belongings.
The facility failed to maintain a safe, clean, comfortable, and homelike environment, with issues such as damaged walls, broken fixtures, and unaddressed maintenance concerns observed in two nursing units. The maintenance director was unaware of these issues, which were not documented in the maintenance book.
The facility failed to provide a secure storage space for residents' belongings, as evidenced by a resident's complaint about missing or damaged items worth $2,332. Observations showed a cluttered storage room with unlabelled boxes and no security measures. The DoN confirmed the absence of a safe storage policy and tracking process.
The facility staff failed to timely report an allegation of abuse/harassment and a resident elopement to the State Agency within the required time frame. In one case, a resident was found by EMS and brought to the ER, but the self-report was delayed by over 4 hours. In another case, the facility delayed reporting harassment allegations by over 3 hours after police were notified.
The facility failed to thoroughly investigate allegations of misappropriation of resident property and a resident's elopement. Investigations lacked proper documentation, interviews, and evidence of staff training. Discrepancies in nursing care and medication administration records were also noted.
Facility staff failed to provide correct notice and ensure the safe discharge of a resident. The social worker issued a premature Notice of Medicare Non-Coverage, and the physical therapy staff ended skilled rehabilitation services abruptly without proper discharge planning. The resident's caretaker prevented an unsafe discharge.
The facility failed to maintain safety by leaving a resident's bed elevated, did not reassess a resident's fall risk after a fall, and missed follow-up appointments for another resident. Staff confirmed the bed should be lowered to prevent falls, and the DON acknowledged the missed appointments and lack of fall risk reassessment.
The facility failed to perform physician-ordered wound treatments and provide timely wound consultations for two residents. One resident's wound deteriorated due to lack of documented treatment, and another resident's wounds worsened due to incomplete and delayed assessments.
The facility staff failed to provide required care to a resident's PEG site, as the Treatment Administration Record did not include PEG site care, and there was no evidence of completed care. The Director of Nursing confirmed the oversight.
A resident went on a leave of absence (LOA) and returned the same day without a physician's order for the LOA. The DON confirmed that a new order should have been obtained for the LOA on the day the resident actually left, but this was not done, resulting in a deficiency.
The facility staff failed to follow physician orders by administering PRN pain medication outside the prescribed parameters, resulting in unnecessary medication for two residents. One resident received Oxycodone for pain scores below the prescribed range on multiple occasions, while another resident was given Oxycodone for pain scores below the prescribed range in January and February 2024. The DON confirmed these findings and acknowledged the inappropriate administration of medication.
The facility staff failed to ensure that the call system in the 3A central bathing room was fully functional. Specifically, 2 of the 3 shower stalls and the call switch wall panel for the toilet did not have cords attached to the call system. Without the cords, residents would not be able to access the call system if they were lying on the floor, potentially compromising their ability to call for help in an emergency situation.
The facility failed to document, review, and provide written responses to resident council concerns, leading to ongoing issues with laundry, linens, and shower room conditions. Residents expressed dissatisfaction with the lack of follow-up and incomplete documentation of their grievances.
The facility failed to notify two residents in writing of the bed-hold policy upon transfer to an acute care facility. Documentation was missing or incomplete, and the DON confirmed the deficiency.
The facility failed to document opioid use accurately and did not ensure a nurse had the necessary competencies for dialysis care. Two residents had multiple instances of opioid administration not recorded in the MAR, and a dialysis resident was found bleeding due to improper post-dialysis care. The DON admitted to assuming agency nurses were competent without verification.
A facility failed to provide appropriate urostomy care for a resident with bladder cancer. The resident reported that nurses did not empty, monitor, or assess the urostomy. The medical record lacked specific orders and documentation for urostomy care, and the care plan did not include detailed interventions. Interviews with an LPN and the DON confirmed these deficiencies.
The facility failed to place a physician's order for the indication of Oxygen administration and did not develop a comprehensive care plan for a resident's respiratory care, including oxygen therapy. The resident was observed using 2 liters of Oxygen via nasal cannula without a proper care plan or indication for its use in the medical record. The DON confirmed the oversight.
A nurse failed to perform a timely post-dialysis assessment on a resident, leading to a delay in identifying bleeding from the resident's Arteriovenous Fistula (AVF). Staff interviews confirmed that post-dialysis assessments should be done immediately upon the resident's return.
A facility failed to ensure that a licensed nurse was competent to care for a dialysis resident, resulting in a serious incident where a resident returned from dialysis with an arterial needle and clamp left in their access point. The issue was discovered more than two hours later when the resident was found bleeding. The LPN involved admitted to not having received training in dialysis care, and the DON acknowledged assuming agency nurses were competent without verification.
The facility staff failed to monitor and document a resident's inappropriate behavior, despite orders from the Psychologist. The LPN confirmed that behavior should be documented every shift, but records showed no checklist or progress notes. The DON acknowledged the concern but did not provide a method to validate behavior monitoring.
The facility failed to ensure proper documentation and timely administration of narcotics and antibiotics for residents. Narcotics were removed without corresponding MAR entries, and a resident did not receive prescribed antibiotics on time due to staff oversight. These issues were confirmed by staff interviews and record reviews.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service and safety. During an initial kitchen tour, dripping from the ceiling was observed outside the walk-in refrigerator/freezer, with a bread cart next to the refrigerator/freezer door, a spice rack across from it, and two containers placed on the floor to collect the water. The Food Service Director stated he believed the dripping was condensation, while the Nursing Home Administrator later stated the leak was from a pinhole in the hot water return line and that the line had been fixed. The surveyor also observed food handling issues in two nourishment rooms and in the main kitchen. In the 3rd floor nourishment room, a resident's food tray that appeared to have been eaten from was left on the counter, and an LPN stated she would dispose of the contents. In the 2nd floor nourishment room, leftover resident food trays were again observed on the counter. During lunch meal assembly at the steam table line, a cell phone was observed on a stainless-steel table next to the coffee maker, and the Dietary Aide removed it when asked about it. The NHA confirmed that personal items such as a cell phone should not be in the kitchen during meal preparation or meal assembly.
Incomplete and inaccurate resident documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards by keeping complete and accurate documentation for 3 residents reviewed. For one resident, the staffing sheet for the shift when an alleged incident occurred showed a GNA assigned to the unit, but the Administrator stated the assignment had been changed and the staffing sheet should have been updated. The same resident’s Change in Condition Evaluation was also incomplete, with sections for pain, code status, and recent medication changes left blank. For another resident, the record for a fall with a forehead abrasion did not include documentation of the abrasion’s location or size, and the ADON confirmed that such details should have been documented. For a third resident with a PICC line and left posterior thigh wounds, the surveyor observed the PICC dressing dated several days earlier and found the thigh dressing off, leaving the wound exposed to the bed with drainage on the linen. The resident stated the dressing had come off after transfers the prior evening and that staff were aware but said they would re-dress it later. Review of the September TAR showed no order or place to document the PICC dressing change, and the PRN wound dressing change was left blank even though scheduled dressing changes were documented. The DON stated the nurse later reported the resident refused both the PICC dressing change and wound re-dressing, and the DON confirmed the nurse should have documented the refusal at the time and notified the provider.
Failure to Maintain Infection Control Practices
Penalty
Summary
The facility failed to maintain infection prevention and control practices related to Enhanced Barrier Precautions (EBP) for a resident with multiple indwelling medical devices and wounds. Resident #137 was observed with a PICC line in the right upper arm, a foley catheter, multiple pressure ulcers, and an ostomy, but there was no sign or indication to staff that EBP should be used during high-contact care. The resident’s September 2025 TAR included an order for EBP, yet the assigned LPN stated the resident was not in EBP and confirmed there was no sign on the door. The DON later confirmed the resident was in EBP and stated the door should have had a sign indicating the precautions staff should provide. The facility also failed to maintain cleanliness and infection control practices in the laundry area. During observation, the door to the clean laundry room was open, the laundry shoot was ajar with four bags of soiled laundry inside, three bags of soiled laundry were on the floor, and a yellow gown and goggles were on top of the paper towel dispenser. The chemicals used to clean the laundry were caked on the raised area where they were stored. When the clean laundry room door was closed, dust particles were seen floating in the air. The EVS Director stated they were not aware the door to the clean area was supposed to be closed and later stated staff would be in-serviced on keeping the laundry room clean, that bags of laundry should not be on the floor, and that the laundry area should be dusted and cleaned daily.
Ice Machines Not Maintained in Adequate Condition
Penalty
Summary
The facility failed to maintain adequate conditions of equipment, as shown by observations of the ice machines in the 3rd floor and 2nd floor nourishment rooms and the laundry room. In the 3rd floor nourishment room, water was observed on the floor beneath the ice maker and the ice machine tray was filled to the top with water. In the 2nd floor nourishment room, moist tan particles were observed at the bottom of the ice machine tray, and when the tray was removed and wiped, a tan substance smeared on the paper towel. The RDON stated she believed cleaning could not remove some of the white areas seen on the tray. The NHA stated that maintenance serviced the floor ice machines every 4 months and that EVS was responsible for cleaning the outside of the machine every day, while also acknowledging that the 3rd floor ice maker had a clog causing backup.
Staff-to-Resident Physical and Verbal Abuse Incident
Penalty
Summary
A deficiency occurred when a staff member, specifically a Geriatric Nursing Assistant (GNA), was reported to have physically and verbally abused a resident. According to the facility's investigation, a Maintenance Assistant witnessed the GNA pull back their hand and strike the resident on the left shoulder with enough force to cause the resident to stumble into a wardrobe. The resident's roommate did not see the incident but heard the resident yell and a stumble. The GNA denied hitting the resident but admitted to saying, 'I'm going to bop you.' The resident later stated that the GNA hit them with a key holder because they were not dressed. The investigation also noted that the GNA had a history of tardiness and absences from work. Further interviews revealed conflicting accounts, with the Regional Director of Operations stating the investigation was inconclusive, as the resident gave differing statements about where they were struck and described the contact as a 'tap.' The Maintenance Assistant maintained that they witnessed the GNA strike the resident. The incident was reported to the Maryland Board of Nursing for further investigation. The deficiency centers on the physical and verbal abuse of a resident by a staff member, as witnessed and reported by another employee, and corroborated by the resident's statements and the roommate's account of hearing the incident.
Failure to Timely Report Alleged Incidents to State Agency
Penalty
Summary
Facility staff failed to notify the state agency within the required two-hour timeframe after becoming aware of alleged incidents involving two residents. In the first case, staff became aware of an alleged incident at 6:50 AM and reported it to the state agency at 9:23 AM, exceeding the two-hour reporting window. In the second case, staff became aware of an alleged incident at 1:40 PM and reported it at 3:51 PM, again outside the required timeframe. These findings were confirmed through record review and staff interviews, which established that the Administrator, DON, or ADON are responsible for reporting such incidents, and that the facility's policy is to report allegations of abuse as soon as possible, within two hours.
Failure to Follow Nursing Standards for Timely Documentation and Physician Notification
Penalty
Summary
Facility staff failed to adhere to professional standards of nursing practice in two cases. In one instance, a registered nurse completed a change in condition evaluation for a resident 11 days after the change occurred and backdated the documentation. The Director of Nursing confirmed that such evaluations are expected to be completed before the end of the shift and that supervisors are responsible for ensuring timely documentation. In another case, a licensed practical nurse documented that a resident refused care of their suprapubic catheter on two separate occasions but did not notify the physician as required. The Regional Clinical Service Manager stated that staff are expected to re-offer care, involve the family, educate the resident, and notify the physician when care is refused.
Medication Administration and Insulin Sliding Scale Deficiencies
Penalty
Summary
Facility staff failed to obtain and administer medications according to procedures for two residents. For one resident, multiple medications, including Famotidine, Levothyroxine, and a nasal solution, were not administered as ordered because the pharmacy had not delivered them to the facility. Documentation in the Medication Administration Record (MAR) indicated these medications were coded as not given, with progress notes confirming the medications were ordered but unavailable. The facility's policy required medications to be administered within appropriate time frames, but this was not followed in these instances. In another case, staff did not accurately or safely conduct and apply the insulin sliding scale before meals for a resident with diabetes mellitus type 2. The nurse failed to perform a blood sugar (BS) check before breakfast and did not provide the correct insulin coverage, as the MAR had an incorrect time for the BS check that did not align with the actual meal time. The night shift nurse performed a BS check much earlier than the meal and administered insulin based on that reading, while the day shift nurse omitted the required pre-meal BS check and insulin coverage. These actions resulted in the resident not receiving insulin as ordered in relation to meal times.
Failure to Provide Side Rail Accommodation
Penalty
Summary
The facility failed to provide a resident with a reasonable accommodation of need when Resident #138 reported that the facility had recently removed the side rails from the bed and that he/she was not able to move in the bed. The resident’s family member was present during the interview. The Nursing Home Administrator confirmed that the facility had removed the side rails from the resident’s beds and was reassessing whether they were needed. Review of the resident’s side rail assessment, completed on 9/20/25, showed a recommendation for 1/4 siderail assist handles to serve as an enabler to promote independence. The resident’s physical therapy evaluation also documented that the resident had been bedbound for several years due to weakness, with treatment intended to decrease the level of assistance from caregivers. The Director of Nursing later confirmed that the side rails would be replaced.
Failure to Document Advance Directive Status and Offer
Penalty
Summary
The facility failed to determine whether two residents had Advance Directives (ADs) and failed to document that they were offered help to formulate one if they did not already have one. For Resident #138, the paper medical record did not contain any ADs, and when the Social Service Director was interviewed, she stated she had met with the resident but was not sure whether ADs had been discussed. She also stated she had recently received help from corporate social workers to review residents’ ADs. A progress note about reaching out for ADs was written only after the surveyor requested documentation, and no documentation was available at the time of exit showing the ADs had been addressed before the request. For Resident #4, who was admitted in the middle of August 2025, the paper record did not contain ADs, and the electronic record also had no documentation showing whether the resident had ADs that needed to be obtained or whether the resident was offered the opportunity to create an AD on admission. When the surveyor asked the Social Service Director whether Resident #4 had been asked about ADs or offered help to make them, she stated she would review her documentation and follow up. On follow-up interview, she confirmed there was no documentation to support that Resident #4 had been asked about ADs or offered the opportunity to create one.
Unnecessary Psychotropic Medication and Improper PRN Antipsychotic Order
Penalty
Summary
The facility failed to appropriately prescribe psychotropic medication for a resident without documented need for one. Resident #4 was admitted and was ordered quetiapine 50 mg at bedtime for depression, along with an additional order for quetiapine 25 mg twice a day for depression. The record also showed that the resident was seen by Physician #33, who noted the resident was on both olanzapine and quetiapine and requested psychiatry follow up. A psych consult note later listed incorrect medication doses and stated to continue the medications as ordered, with an addendum made later to correct the quetiapine orders, while olanzapine was still documented incorrectly as daily rather than as needed. The resident’s medication regimen review noted that the resident had been admitted on olanzapine as needed and stated that, per regulatory guidelines, as-needed antipsychotic medication must be limited to 14 days with no exceptions. The review requested that a stop date be added or the medication be discontinued, and the providers agreed. The psych NP later recommended discontinuing the quetiapine bedtime dose and tapering olanzapine over 5 days before discontinuation. The surveyor also found that the as-needed olanzapine order remained in place even after the pharmacy review requested a change and psychiatry requested a change, and the order was not adjusted until later.
Failure to Develop Patient-Centered Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement patient-centered comprehensive care plans for 2 residents reviewed during the annual survey. For Resident #1, a care plan problem related to impaired memory/cognition due to a neurological disorder contained bracketed placeholders instead of resident-specific details. During record review and interviews, the Regional Clinical Service Manager stated Social Services was responsible for the entry and that details should be documented when the care plan is written. The Social Worker acknowledged that the care plan should be patient-specific and that the bracketed information needed to be patient-centered, and the DON and RCSM also acknowledged the concern that the care plan was not patient centered. For Resident #4, the medical record showed the resident had been admitted after functional decline in ambulation and ADLs due to a fall with fractures and right upper extremity weakness. The care plan created for pain stated the resident had pain related to an incomplete statement, and a later care plan added that the resident was at risk for pain related to chronic physical disability. Another care plan created for falls stated the resident was at risk for falls related to an incomplete statement, and a later care plan added that the resident had an actual fall as evidenced by being observed on the floor. The RCSM stated the care plans created on 8/24/25 were not person-centered and should have been specific to the resident's plan of care.
Failure to Provide ADL Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a dependent resident. Resident #4 had recently been admitted after a functional decline in ambulation and ADLs due to a fall with fractures and right upper extremity weakness. During observation, the resident was seen in a lounge area in a reclining chair with long fingernails on all left fingers, each appearing about 1/2 inch long and containing a dark substance under them. Review of the ADL task documentation for September showed the resident was documented as dependent for maintaining personal hygiene, and no refusals were recorded. During interview, the Regional Clinical Service Manager confirmed that fingernail cleaning would be part of ADL care, and later stated that a regional nurse looked at the nails and described them as needing some care.
Unaddressed Significant Weight Gain
Penalty
Summary
The facility failed to maintain acceptable parameters of nutrition for one resident and did not address significant weight gain. Resident #8 was admitted in January 2024 and had a history of major depressive disorder, peripheral vascular disease, acquired absence of the leg above the knee, and dementia. The resident’s weights showed a marked upward trend over time, including an 11.13% gain over about 6 months from 10/3/24 to 3/6/25 and a 23.75% gain over about 6 months from 3/6/25 to 9/1/25. The record also showed multiple instances where weight changes were identified as significant or questionable, including triggers for weight gain and requests for reweights to confirm the changes. Dietary notes repeatedly documented concerns that the resident’s weight gain might be related to fluid shifts, scale discrepancy, or outlier weights, and the dietitian continued to monitor weights and labs. The notes also referenced mirtazapine as a possible appetite stimulant and suggested considering discontinuation, but the record did not show that the resident’s ongoing weight gain was acknowledged as part of the plan of care or that interventions were adjusted. At exit, no documentation was provided to the surveyor showing that the resident’s weight gain had been addressed through the care plan or that the repeated weight changes had been resolved.
Unlabeled Tube Feeding Bag
Penalty
Summary
Facility staff failed to ensure that a tube feeding bag was labeled for Resident #89, who receives daily enteral feedings. During an initial observation on 09/29/2025, both the tube feeding formula bag and the flush bag were hanging on the tube feeding pump, and neither bag had the resident’s name, the type of formula, the date and time the bag was hung, or the name/initials of the staff member who hung them. The formula bag was full and the flush bag was half full when observed. When interviewed, an RN stated she was not sure whether Resident #89 had received the tube feeding because another shift hangs the bag and night shift takes it down by 6:00 AM. She also stated she was not sure what formula was in the bag or when it had been hung because there was no label. The resident’s record showed an order for Jevity 1.5 at 35 ml/hour for 10 hours from 8 PM to 6 AM, or until a total nutrient volume of 350 ml was infused, with the tube feeding to be hung at 8 PM each day. The tube feeding was still hanging at 10:57 AM the next day. The ADON later stated that nurses should verify the order, perform hand hygiene, and label the tube feeding and flush bag with the resident’s name, formula type, date, time hung, and initials or name, and acknowledged that this procedure was not followed for Resident #89.
Physician Failed to Address Repeated Weight Gain Concerns
Penalty
Summary
The facility’s physician failed to acknowledge and/or address dietitian recommendations related to a resident’s significant weight gain. Resident #8, who had a history of major depressive disorder, peripheral vascular disease, acquired absence of the leg above the knee, and dementia, was admitted in January 2024 and experienced an 11.13% weight gain from 10/3/24 to 3/6/25 and a 23.75% weight gain from 3/6/25 to 9/1/25. The surveyor reviewed dietary progress notes showing repeated concern about the resident’s ongoing weight gain, including a 6/12/25 note questioning a +41 pound gain in 6 months and stating the provider was to be made aware by nursing. Dietitian #31 documented on 7/4/25 that the resident had weight gain over 6 months, questioned a possible scale discrepancy, and suggested considering discontinuing mirtazapine, which can stimulate appetite. A quarterly assessment on 8/13/25 again documented weight gain trending up and repeated the recommendation to consider discontinuing mirtazapine. During interview, the physician stated she was monitoring the weight gain through labs and a heart failure workup, but she did not have documentation addressing the weight gain or the dietitian’s recommendation. The record contained no documentation that these notifications or recommendations were addressed.
Missing Annual GNA Performance Reviews
Penalty
Summary
The facility failed to complete required annual performance reviews for Geriatric Nursing Assistants at least once every 12 months. During the annual survey, record review of three randomly selected GNA personnel files showed that GNA #22 and GNA #23 did not have annual performance reviews for 2024 or 2025. The last annual GNA performance review in Staff #22's file was dated 6/27/2023, and the last annual GNA performance review in Staff #23's file was dated 6/29/2023. When interviewed, the Regional Clinical Service Manager stated that the documentation provided was all that was available for these staff members and acknowledged that GNAs should have competencies/performance reviews annually.
Failure to Address Pharmacist Recommendation for PRN Lorazepam
Penalty
Summary
The facility failed to respond to recommendations made by the consulting pharmacist for 1 of 51 residents reviewed, Resident #12. During review of the monthly pharmacist recommendations, the pharmacist noted that the prescriber should document a rationale for use and a duration date for lorazepam. The physician reviewed and signed the recommendation, indicating they would refer the matter to an end of life consultant, but the active order for LORazepam Oral Concentrate 2 mg/mL remained as 0.25 mL by mouth every 6 hours as needed for anxiety and agitation related to end of life care, with no end date written. During interview, Physician #30 acknowledged that although the indication for end of life care had been noted, no stop date had been added as recommended by the Clinical Pharmacist. The RCSM also acknowledged that there was no stop date for the PRN medication and confirmed the record would be corrected. The DON was identified as responsible for following up with the Clinical Pharmacist recommendations.
Delayed BMP Lab Redraw
Penalty
Summary
The facility failed to obtain laboratory services in a timely manner for Resident #2, who had a history of dementia and behavioral disturbances and whose care plan identified a risk for complications related to aphasia and apraxia affecting response to care, as well as refusal of lab samples. During record review, RN #29 documented that a BMP result was cancelled because the specimen was missing a DOB identifier, and the provider was notified with a new BMP order reportedly given for the following Monday. However, when the resident’s orders were reviewed, no order was found for a redraw of the BMP, and the DON later stated that an order should have been placed to communicate the redraw but was missed.
Missing Dementia Training and Annual Evaluation for GNAs
Penalty
Summary
Facility staff failed to ensure that Geriatric Nursing Assistants received required dementia training and an annual employee evaluation. Record review showed GNA #17, hired in March 2025, did not receive dementia training, and GNA #18, hired on 07/08/24 and terminated on 04/04/25, had no documentation verifying completion of dementia training. A review of GNA #36’s employee record showed the GNA was hired on 04/24/24 and remained employed, but did not have an annual evaluation after one year of employment. During interviews, the Regional Director of Operations stated there was no evidence that GNA #17 received dementia training, the Regional Clinical Service Manager stated GNA #18 started but did not complete the dementia course and confirmed that a GNA is supposed to have a yearly evaluation, and the Director of Education stated dementia training must be completed within the first 90 days of employment in HealthStream and that facility staff are responsible for ensuring the training is completed.
Supervision and Elopement Prevention Deficiency
Penalty
Summary
The facility failed to ensure adequate supervision and prevent elopement for Resident #92, who had a history of dementia and wandering behavior, as documented in their care plan upon admission in 2021. Despite having a functional wander guard in place on the day of the incident, an equipment malfunction at the main entrance resulted in no alarm sounding as Resident #92 exited the facility on 1/26/22. The Medication Administration Audit Report for that day revealed lapses in documentation and delayed administration of medications and nursing care by Staff #63, a Licensed Practical Nurse (LPN). Staff #57, another LPN assigned to Resident #92 on the 3-11 pm shift, reported not seeing the resident and failing to notice their absence. Further investigation revealed discrepancies in staff accounts regarding the incident, with Staff #56, a Geriatric Nursing Assistant (GNA) assigned to Resident #92, denying seeing the resident on the day of elopement. The facility's documentation logs of wander guard checks post-incident showed an error in the number of days checked in February 2022. Despite upgrades made to the wander guard system after the elopement, there was no evidence of immediate repairs following the mechanical failure on 1/26/22.
Surety Bond Coverage Insufficient for Residents' Personal Funds
Penalty
Summary
The facility failed to ensure the amount of the surety bond was comparable to the total amount of residents' personal funds held, as revealed during a review of Personal Funds on 3/07/24. The Corporate Accounts Receivable Manager stated that residents' funds were kept in separate accounts and covered by a surety bond. However, a review of the Trial Balance document showed a total of $172,021.92 across 75 residents, while the surety bond amount was $170,000.00, indicating an insufficiency in coverage. The Nursing Home Administrator confirmed the discrepancy during an interview, acknowledging that the surety bond did not cover the total amount of funds held by the facility.
Food Temperature and Quality Concerns Due to Equipment Malfunctions
Penalty
Summary
The deficiency identified in the report pertains to the failure of the facility to ensure that food served to residents is palatable and at a safe, appetizing temperature. Multiple residents expressed dissatisfaction with the quality of the food, citing issues such as lack of taste, coldness upon arrival, and overall poor quality. Observations made during the survey revealed specific issues with the food service equipment, including a broken indicator light on the steam table holding turkey burgers and a missing indicator light on the plate warmer system. These equipment malfunctions likely contributed to the inconsistency in food temperature and quality experienced by the residents. Furthermore, the surveyor's temperature testing of a turkey burger patty and waffle fries from a test tray revealed that the food was not served at an appropriate temperature, with the turkey burger patty measuring at 106.7 Fahrenheit and the waffle fries being cool to the touch. The immediate testing of palatability conducted on the test tray highlighted additional issues, such as soggy buns, dry and chewy fries, and overall unappetizing food presentation.
Infection Control Deficiencies in Urinary Bag Handling, Policy Updates, and Laundry PPE Usage
Penalty
Summary
The deficiency identified during the survey pertains to three main areas within the facility's infection prevention and control program. Firstly, it was noted that the facility failed to appropriately hang a urinary bag for Resident #51, with the bag coming into contact with the bare floor on multiple occasions despite staff interventions. Secondly, the facility was found to have an outdated Infection Prevention Control program policy manual, last updated in 2021, with no evidence of annual reviews or updates. Lastly, staff handling dirty laundry were observed not using appropriate Personal Protective Equipment (PPE) such as masks and gowns, with inadequate training provided on infection control practices related to laundry handling.
Sanitary and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure sanitary practices were followed in accordance with professional standards for food service safety. Observations included dietary staff not wearing hair restraints, food debris in the dishwashing area, and improper storage of food items. Additionally, the soap dispenser at the staff handwashing sink was broken, and wet resident food trays were improperly stored. The ice dispenser and refrigerator in the nutrition rooms were also found to be unclean and improperly maintained. The facility also failed to store food in accordance with professional standards for food service safety. The walk-in refrigerator/freezer door was observed propped open, and temperature logs were inaccurately recorded. The temperature gauge on the walk-in refrigerator was taped over, and the thermometer inside read 60 degrees. Temperature logs for the ice cream freezer box and milk refrigerator box were incomplete or missing for several dates. Additionally, the temperature log for the reach-in snack/nourishment refrigerator had crossed-out entries. Furthermore, the facility failed to store, label, and monitor the expiration of food in accordance with professional standards for food service safety. Unlabeled and undated food items were found in the walk-in refrigerator, and staff were unsure of the expiration dates for these items. Broken and damaged kitchen equipment, such as a plastic container with a sharp edge and cook pans with scraped-away coatings, were also observed. The steam table and plate warmer system had broken indicator lights, and the facility's monitoring and oversight of kitchen equipment and environment were inadequate.
Inaccurate MDS Assessments and Coding Errors Identified
Penalty
Summary
The facility failed to ensure accurate assessments for residents #128, #93, and #291, as well as accurate coding of pressure ulcers for resident #89. For Resident #128, the MDS assessment incorrectly coded the discharge status as a short-term general hospital instead of home. Resident #93's MDS lacked an updated assessment upon discharge, with the last assessment dated 10/27/23 despite documentation of discharge. Resident #291's MDS showed discrepancies in functional limitations related to hemiplegia and hemiparesis, with conflicting information on upper and lower extremity impairments. In the case of Resident #89, the MDS assessment completed on 1/22/24 did not reflect the presence of pressure ulcers documented in wound and skin notes from 12/18/23 and 2/20/24.
Care Plan Deficiencies in Addressing Resident Needs
Penalty
Summary
The report details multiple instances where deficiencies were identified in the development and implementation of comprehensive care plans for residents in the facility. In the case of Resident #57, it was noted that despite physician orders for daily wound care and dressing changes, the care plan did not include these interventions. This lack of alignment between physician orders and the care plan raised concerns about the adequacy of care provided to address the resident's pressure ulcers. Similarly, for Resident #89, the care plan did not address the resident's pressure ulcer, indicating a gap in addressing the resident's needs effectively. Furthermore, the report highlighted issues with care plans for residents receiving specialized care, such as hospice services for Resident #47 and palliative care for Resident #91. In both cases, the care plans did not reflect the specific needs associated with these services, indicating a lack of person-centered care planning. Additionally, for Resident #101 with a suprapubic catheter, the care plan did not include this important aspect of the resident's care, highlighting a gap in addressing the resident's surgical wound care needs. The deficiencies extended to infection control measures as well, as seen with Resident #302 who had a contact precaution order for C-diff, but no care plan was initiated to address this infectious disease. Similarly, for Resident #297 with a G-tube, the care plan lacked specific details regarding tube feeding care, indicating a gap in addressing the resident's nutritional needs effectively.
Inconsistent Care Plan Meetings Due to Staffing Changes
Penalty
Summary
The facility failed to ensure that care plan meetings were conducted as required for several residents, including Resident #33, #82, #91, and #98. For example, Resident #91 had a quarterly MDS assessment completed on 11/21/23, but there was no documentation of a corresponding care plan meeting. The Unit Manager indicated that the responsibility for ensuring care plan meetings fell to the social worker, who had been inconsistent due to staffing changes. Similarly, Resident #98 had multiple MDS assessments completed, but care plan meetings were not documented after November 2022, with the Director of Nursing acknowledging missed records due to a lack of a social worker since March 2023.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's monthly drug regimen review recommendations were acted upon by the physician. For Resident #44, pharmacy recommendations were made on 11/06/23 and 12/08/23, but there was no documentation of the physician's response to these recommendations. The Director of Nursing (DON) confirmed the absence of physician response documentation and acknowledged that the facility was aware of the issue and working to improve compliance. Similarly, for Resident #98, multiple pharmacy recommendations from 7/14/23 to 2/09/24 were documented, but no physician responses were recorded. The DON reiterated that the Medical Regimen Review (MRR) should be reviewed by the physician, and responses should be documented and uploaded to the residents' medical records. Additionally, for Resident #37, a pharmacy recommendation made on 2/9/24 suggested a gradual dose reduction (GDR) of Seroquel or documentation if a GDR was clinically contraindicated. However, there was no physician response documented, and the DON confirmed that the GDR was not done. These deficiencies were identified during the facility's recertification survey and were evident for three of the six residents reviewed for psychiatric medications.
Failure to Provide Secure Storage for Resident's Belongings
Penalty
Summary
The facility failed to accommodate a resident's need and preferences regarding the safekeeping of personal property. Specifically, a resident reported losing $57 left on their bedside table. The facility's investigative report claimed the resident was provided a key to their nightstand for safekeeping, but the resident stated that their nightstand did not have a lock. Upon inspection, it was confirmed that the nightstand had a circular hole for a lock but no actual lock was present. The administrator was initially unaware of this issue and later confirmed the absence of a lock, indicating a failure to provide the promised security for the resident's belongings.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by multiple deficiencies observed in two of the four nursing units reviewed. During an abbreviated tour with the maintenance director, several issues were identified, including trash and a broom in a dirty, nonfunctioning electronic jet tub, a shower stall without a light, and water puddles in another shower stall. Additionally, there were holes punctured through the wallboard in the bathing room, and an unfinished repair with white spackle and scrapes on the wall. The maintenance director was unaware of these concerns, and they were not documented in the maintenance book. In a resident's room, significant damage was observed, including a caved-in wall with missing pieces, a damaged bathroom door veneer with an opening into the hollow space of the door, and protruding screws from the wood door frame. The maintenance director confirmed the damage and mentioned that a contractor was hired to fix and repair. Other issues included a busted jagged hole in the handrail in the 3rd-floor corridor, a broken plastic corner molding strip in another room, and irregular discolorations on the walls of the shower stalls in the 2A central bathing room. These environmental concerns were confirmed by the maintenance director and reviewed with the nursing home administrator.
Failure to Provide Secure Storage for Residents' Belongings
Penalty
Summary
The facility staff failed to provide a safe and secure storage space for residents' personal belongings, as evidenced by the case of one resident out of sixteen reviewed for self-reported incidents. The resident had complained about missing or damaged items and expected reimbursement of $2,332. The facility's investigation could not clarify how the belongings went missing or were damaged. Observations revealed that the storage room was cluttered with large trash bags and unlabelled boxes, making it difficult to access. The Director of Nursing (DoN) confirmed that there was no safe storage space policy, no security cameras, and no process to track items in and out of the storage room.
Failure to Timely Report Abuse and Elopement
Penalty
Summary
The facility staff failed to timely report an allegation of abuse/harassment and a resident elopement to the State Agency within the required time frame. For the first incident, the Executive Director was notified at 5:45 PM that a resident was found by EMS walking in the facility neighborhood and brought to the emergency room. However, the self-report was not sent to the Office of Health Care Quality until 9:55 PM, approximately 4 hours and 10 minutes after the notification. Additionally, there was a lack of documentation for the resident's care and behavior monitoring during the 3-11 PM shift on the day of the incident, with some tasks being documented over 32 hours later. In the second incident, the facility staff failed to report an allegation of harassment within the required time frame. The resident's family notified the facility about harassing texts in the morning, and the local police were contacted and arrived at the facility by 10:40 AM. However, the initial self-report to the State Agency was not sent until 1:59 PM, 3 hours and 19 minutes later. The Director of Nursing confirmed the delay in reporting and was unable to provide the exact time of the initial email notification from the resident's family.
Incomplete Investigations of Misappropriation and Elopement
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of resident property and elopement. For two residents who reported missing personal property, the investigations were incomplete. The interview statements did not identify the persons completing them, and there were no statements from other residents or evidence of staff training post-incident. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were informed of these deficiencies but provided no additional information to address the concerns raised by the surveyor. In the case of a resident's elopement, the facility's investigation was also found to be lacking. The initial self-report indicated that the resident was found by EMS and brought to the emergency room. However, the investigation did not include documentation of the equipment malfunction that allowed the resident to exit the facility, nor did it confirm the functionality of the wander guard system. There were no interviews with maintenance staff or other relevant personnel, and no hospital records or video surveillance were included in the investigation file. The surveyor noted discrepancies in the documentation of nursing care and medication administration, with some entries being backdated. The surveyor communicated these concerns to the facility staff, including the Administrator, DON, and Corporate Director of Operations. Despite these discussions, no further clarification or additional documentation was provided to address the deficiencies in the investigation. The facility's failure to conduct thorough investigations and maintain accurate records was evident in the cases reviewed during the survey.
Improper Notice and Unsafe Discharge
Penalty
Summary
Facility staff failed to provide correct notice and ensure the safe discharge of a resident. The resident was admitted for skilled rehabilitation therapy, which was ordered four times per week for 12 weeks. However, the social worker issued a Notice of Medicare Non-Coverage (NOMNC) prematurely, indicating that the resident would be liable for their stay or had to accept discharge, despite the resident still receiving skilled rehabilitation treatment and not having achieved treatment goals. Additionally, the social worker did not secure a suitable outpatient dialysis center or arrange home health services before attempting to discharge the resident, leading to an unplanned and unsafe discharge attempt that was only prevented by the resident's caretaker's advocacy. Further review revealed that the physical therapy staff documented the resident's deterioration and need for more assistance using stairs just two days before abruptly ending skilled rehabilitation services without indicating that the resident had returned to their prior functional level. The discharge order for rehabilitative services was not obtained until six days later. The administrator acknowledged these failures, including the premature issuance of the NOMNC and the lack of proper discharge planning and continuation of skilled rehabilitation treatments.
Failure to Maintain Safety and Follow-Up on Appointments
Penalty
Summary
The facility failed to maintain safety by allowing the bed of a resident at risk for falls to be in the up position when care was not being provided. This was observed when Resident #51 was found asleep in bed elevated about 3 feet high without any care being rendered. The resident's care plan indicated that the bed should be kept in the low position except when care was being provided. Staff members, including an agency Geriatric Nursing Assistant and a Registered Nurse, confirmed that the bed should be lowered to prevent potential injury from falls. The unit manager also acknowledged that the bed should be at the lowest position to maintain safety, especially for residents at risk of falls. The facility also failed to assess a resident's fall risk after a fall incident occurred. Resident #98 had a fall resulting in a large hematoma and laceration to the face and was transferred to the hospital. Upon readmission, the resident's fall risk was not reassessed, despite the facility's policy to assess fall risk after an actual fall. Additionally, the facility did not ensure follow-up for a resident's outside consult appointments. Resident #292, admitted for amputation rehabilitation, had follow-up appointments scheduled with the Vascular Surgery Center and the Wound Healing Center, but there was no documentation of these appointments in the resident's medical records. The Director of Nursing confirmed that the appointments were missed and that the family had canceled appointments without notifying the facility.
Failure to Perform Wound Treatments and Timely Consultations
Penalty
Summary
The facility failed to ensure physician-ordered wound treatments were performed and to provide timely wound consultations for two residents. Resident #295 was admitted with a pressure injury on the buttock, and although the attending physician ordered a specific treatment, it was not transcribed to the treatment administration record (TAR), resulting in no documentation of the treatment being performed. Additionally, the initial wound evaluation by the consultant wound care physicians was conducted 17 days after the wound was identified, by which time the wound had deteriorated. The Director of Nursing confirmed the treatment was not transcribed to the TAR, indicating a lapse in care documentation and execution. Resident #293 was admitted with a new in-house acquired wound identified as Moisture Associated Skin Damage (MASD). The wound was initially assessed and treated, but subsequent evaluations were incomplete and lacked proper measurements. The wound deteriorated over time, developing into two separate wounds, one on the buttock and one on the sacrum. The attending physician and nurse practitioner failed to document or assess the wounds adequately, and the consultant wound physicians' evaluation occurred 20 days after the initial assessment, revealing a stage 4 sacrum pressure wound. The corporate nurse confirmed the lack of weekly wound assessments and the potential inaccuracies in the initial wound assessments.
Failure to Provide Required PEG Site Care
Penalty
Summary
The facility staff failed to provide required care to a resident's percutaneous endoscopic gastrostomy (PEG) site. This was evident for one resident who was admitted with diagnoses including cerebral infarction, dysphagia with PEG tube placement, and dementia. A review of the Treatment Administration Record (TAR) revealed that PEG site care was not included in the TAR form, and there was no evidence that the PEG site care had been completed for the resident from the time of admission. The Director of Nursing confirmed that the TAR should include PEG site care to ensure consistent monitoring and cleaning by the nursing staff.
Failure to Obtain Physician's Order for Leave of Absence
Penalty
Summary
The facility failed to ensure that a resident's care was directed by a physician. This was evident when a resident went on a leave of absence (LOA) and returned the same day without a physician's order for the LOA. The resident had an order for an LOA on the previous day, but did not go on that day. The Director of Nursing (DON) confirmed that a new order should have been obtained for the LOA on the day the resident actually left, but this was not done, resulting in a deficiency.
Failure to Follow Physician Orders for PRN Pain Medication
Penalty
Summary
The facility staff failed to follow physician orders by administering PRN pain medication outside the prescribed parameters, resulting in the administration of unnecessary medication. This deficiency was identified for two residents during a recertification/complaint survey. Resident #116, who was admitted with multiple medical diagnoses including chronic ulcer, pain, diabetes, and atrial fibrillation, received Oxycodone 15 mg for pain scores below the prescribed range of 5-10 on multiple occasions in February 2024. Additionally, in September 2023, Resident #116 was given Oxycodone 20 mg for pain scores below the prescribed range of 7-10. Both the LPN and the Unit Manager confirmed the inappropriate administration of Oxycodone, acknowledging that alternative pain management options should have been considered or the physician should have been contacted for further orders. Similarly, Resident #57 had an active order for Oxycodone 5 mg to be given for pain scores of 7-10. However, the medication was administered for pain scores below the prescribed range on several occasions in January and February 2024. The Director of Nursing confirmed these findings and acknowledged that the staff did not follow the physician's orders, resulting in the administration of unnecessary medication. The DON indicated that staff education on pain management and PRN medication administration would be conducted to address these issues.
Deficiency in Call System Accessibility
Penalty
Summary
The facility staff failed to ensure that the call system in the 3A central bathing room was fully functional. Specifically, 2 of the 3 shower stalls and the call switch wall panel for the toilet did not have cords attached to the call system. This deficiency was observed on 3/5/24 at 2:26 PM. The maintenance director confirmed the findings on 03/08/24 at 10:39 AM. The nursing home administrator was informed of these observations on 03/11/24 at 1:30 PM. Without the cords, residents would not be able to access the call system if they were lying on the floor, potentially compromising their ability to call for help in an emergency situation.
Failure to Document and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that grievances and concerns from the resident council were documented, reviewed, and responses provided to the group in writing. This was evident in a review of 9 resident council meeting minutes, which did not reveal the actual concerns or if previous concerns were reviewed. The resident council president and other members indicated that there was no real follow-up or review of previous concerns, and multiple residents expressed ongoing issues with laundry, linens, and the condition of shower rooms. The facility's process for addressing these concerns was found to be incomplete and lacking proper documentation and follow-up with the residents. Interviews with the resident council president and a group of residents revealed dissatisfaction with the facility's handling of their concerns. Issues such as missing or untimely returned personal laundry, poor quality and insufficient linens, and unclean shower rooms were repeatedly brought up in meetings but not adequately addressed. The residents also reported that staff were sometimes disrespectful when asked for basic necessities like towels and washcloths. The facility's concern forms often lacked complete information, such as the staff person receiving the concern, the results of the investigation, and whether the resident council was satisfied with the resolution. The nursing home administrator and activities staff acknowledged the deficiencies in the documentation and follow-up process. The activities director admitted that previous concerns were not properly reviewed, leading to residents having to restart the complaint process. The nursing home administrator confirmed that the appropriate department is supposed to respond to concern forms and review them at the next meeting, but several forms were found to be incomplete or lacking signatures and dates. This failure to properly document, review, and resolve resident council concerns led to ongoing dissatisfaction and unresolved issues among the residents.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify the resident or the resident's representative in writing of the bed-hold policy upon transfer to an acute care facility. This deficiency was identified for two residents during the recertification/complaint survey. Resident #118 was sent to the hospital in November 2023, but there was no documentation that the bed-hold notification form was signed by the resident or staff, nor was there any indication that the resident received a copy. The Director of Nursing (DON) confirmed that the bed-hold notification form was not signed and that there was no proof the resident received it. Similarly, Resident #12 was hospitalized on two occasions, but there was no documentation in the resident's physical chart or electronic medical records indicating that the bed-hold policy was provided. Staff indicated that the bed-hold policy should be given prior to transfer, but the DON was unable to provide proof that the policy was given to Resident #12. The emergency room checklist form did not show that the bed-hold agreement was provided on either transfer date. The DON acknowledged the concern and mentioned that the bed-hold notification process was being revamped.
Deficiencies in Documentation and Dialysis Care Competency
Penalty
Summary
The facility failed to meet professional standards of practice by not ensuring proper documentation and competency in two critical areas. Firstly, the nursing staff did not consistently document opioid use on the Medication Administration Record (MAR) and Controlled Drug Administration Record. This was evident for two residents, where multiple instances of opioid administration were not recorded in the MAR, leading to discrepancies in the narcotic count sheets. Specifically, one resident had nine instances of Oxycodone administration not documented, and another had nine instances of Tramadol administration not recorded in the MAR, despite being pulled from the medication cart multiple times within the review period. Secondly, the facility failed to ensure that a licensed nurse had the necessary competencies and skill sets to care for a dialysis resident. An incident occurred where a resident returned from dialysis with an arterial needle and clamp left in their access point, which was not discovered until over two hours later when the resident was found bleeding. The nurse responsible for the resident did not recognize the issue or take appropriate action, as she was not trained in dialysis care. The Director of Nursing admitted that there was an assumption that agency nurses were competent to care for dialysis patients, which was proven incorrect in this case. The deficiency in documentation and lack of proper training for dialysis care led to significant risks for the residents involved. The failure to document opioid administration accurately could result in medication errors and potential abuse, while the lack of competency in dialysis care led to a serious incident of bleeding that required emergency intervention. These findings highlight critical gaps in the facility's adherence to professional standards of practice and the need for improved training and documentation protocols.
Failure to Provide Appropriate Urostomy Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a urostomy upon admission. Resident #88, who had a urostomy due to bladder cancer diagnosed in 2022, reported that the facility nurses did not empty, monitor, or assess the urostomy. A review of the resident's medical record revealed an order to change the urostomy per physician order within 24 hours as needed, but there was no specific order or documentation for urostomy care, including monitoring and assessment. Additionally, the resident's care plan did not include resident-centered and measurable interventions for urostomy care. Interviews with an LPN and the DON confirmed that there should have been an order for urostomy care and that the care plan should have detailed its specifics.
Failure to Develop Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to place a physician's order for the indication of Oxygen administration and did not develop and implement a person-centered comprehensive care plan for a resident's respiratory care, including oxygen therapy. This deficiency was observed for one resident who had an Oxygen nasal cannula prepared at the bedside but was not using it initially. Later, the resident was observed using 2 liters of Oxygen via nasal cannula. A review of the resident's medical record revealed an order for Oxygen therapy that lacked an indication for its use, and no care plan was developed for the resident's Oxygen therapy. The Director of Nursing confirmed the need for an Oxygen order with an indication and a corresponding care plan.
Failure to Perform Timely Post-Dialysis Assessment
Penalty
Summary
The nurse failed to perform a timely assessment on a resident post dialysis. On 02/22/24, a complaint was reviewed alleging that Resident #82 was not assessed immediately upon return from dialysis, with an hour delay before the assessment was completed. The nurse's note documented that the resident returned from dialysis at 12 PM on 11/29/23, but the blood pressure was not obtained until 12:48 PM, and medication was administered at 12:49 PM. The resident was then assisted back to bed at 12:51 PM. Later, at 2:30 PM, the nurse found the resident's Arteriovenous Fistula (AVF) bleeding, with a needle and a white clamp on the resident's lap in bed. The bleeding was controlled, and the physician was notified for follow-up interventions. Staff interviews revealed that the post-dialysis process requires immediate vital signs and dialysis port checks upon the resident's return. Both Staff #18, an LPN, and the unit manager, Staff #12, confirmed that post-dialysis assessments should be done immediately. The Director of Nursing (DON) stated that the expectation is for the resident to be assessed within 10-15 minutes of return if there are no emergent issues. The DON was made aware of the concern for Resident #82.
Failure to Ensure Competency in Dialysis Care
Penalty
Summary
The facility failed to ensure that a licensed nurse was competent to care for a dialysis resident, leading to a serious incident. On 11/30/23, a resident returned from a dialysis session with an arterial needle and clamp left in their dialysis access point. This was not discovered until more than two hours later when the resident was found bleeding from the access site with the needle and clamp pulled out. The nurse's notes indicated that the resident returned to the unit at 12 PM, and the issue was discovered at 2:30 PM during rounds. The nurse controlled the bleeding, notified the physician, and implemented follow-up interventions. However, the dialysis communication form had already noted that the dressing was not clean, dry, and intact, and that the needle and clamp were still attached to the patient upon return from dialysis. An interview with the Registered Nurse (RN) revealed that the expectation was to assess the resident's vital signs and the AV fistula site immediately upon return from dialysis. However, the Agency Licensed Practical Nurse (LPN) who was caring for the resident at the time of the incident admitted to not having received any training in caring for dialysis patients and did not think there was anything wrong with the needle and clamp being left in place. The Director of Nursing (DON) acknowledged that she had assumed agency nurses were competent to care for dialysis residents and was unaware that this was a concern. This lack of proper training and assessment led to the resident's bleeding incident, highlighting a significant deficiency in staff competency and oversight.
Failure to Monitor and Document Resident's Inappropriate Behavior
Penalty
Summary
The facility staff failed to monitor and document a resident's inappropriate behavior related to mental health. This was evident for one resident who exhibited behaviors such as entering other residents' rooms, taking their food, and hitting them. Despite the Psychologist's orders to monitor and document the resident's mood, sleep, appetite, and behavior, the medical records lacked the necessary documentation. The Licensed Practical Nurse (LPN) confirmed that behavior should be documented in the electronic medical record system every shift, but a review of the records showed no checklist or progress notes regarding the resident's behavior monitoring. During an interview, the Director of Nursing (DON) stated that behavior issues would only be documented if an incident was identified. When asked about the lack of documentation, the DON acknowledged the concern but did not provide a method to validate that behavior monitoring was being conducted. This failure to document and monitor the resident's behavior as ordered by the Psychologist led to the identified deficiency.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility staff failed to ensure that narcotics removed from the resident's supply were administered to the resident, as evidenced by the lack of documentation of the need for the narcotic or its administration. This was evident for three residents reviewed for controlled drug administration. Specifically, the count sheets for two residents showed multiple instances where narcotics were removed, but the corresponding Medication Administration Records (MAR) did not document the administration of these medications. Interviews with the LPN and DON confirmed that the facility's protocol requires documentation in both the count sheet and MAR, which was not followed in these cases. Additionally, the facility failed to timely provide medication to meet the needs of a resident who had recently undergone spinal surgery and required both IV and oral antibiotics. The resident reported not receiving the prescribed antibiotics on time. A review of the resident's physician orders and MAR revealed that the IV antibiotic Cefepime was not administered at all on the day it was ordered to start, and the first dose of oral Metronidazole was delayed. The DON confirmed that the orders for the antibiotics were not entered promptly due to oversight by the evening shift supervisor and the unit manager. The deficiencies highlight significant lapses in medication administration and documentation protocols within the facility. The failure to document narcotic administration and the delay in providing critical antibiotics to a resident post-surgery were confirmed by staff interviews and record reviews. These lapses were acknowledged by the DON, who identified specific staff members responsible for the oversights.
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What surveyors actually found near you
We read the 1,593 citations issued within 25 miles in the last 12 months — including the 5 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 Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Nursing Home Operator, Llc | 1.3 mi | ★★★★★ | 4 | 0 |
| Autumn Lake Healthcare Post-acute Care Center | 1.8 mi | ★★★★★ | 27 | 0 |
| Autumn Lake Healthcare At Overlea | 1.8 mi | ★★★★★ | 5 | 0 |
| The Nursing And Rehab Center At Stadium Place | 2 mi | ★★★★★ | 8 | 0 |
| Autumn Lake Healthcare At Perring Parkway | 2.3 mi | ★★★★★ | 17 | 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.