Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Hartley Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to develop and implement care plans for a resident's O2 therapy and another resident's cardiac medications. Three residents were observed receiving O2, and the records showed O2 orders or change-in-condition documentation, but care plans were missing or created only after surveyor intervention. Another resident had a change in condition with abnormal VS and decreased responsiveness, and the record showed multiple cardiac-related meds for AFib, HTN, stroke prevention, HLD, and HF, but no care plan addressing those medications was initiated.
Unlabeled O2 equipment was observed for 4 of 4 residents reviewed for respiratory care. A resident on NC had unlabeled tubing and an unlabeled humidifier bottle, another resident had unlabeled tubing and humidifier, a third resident had unlabeled tubing connected to a cylinder tank, and another resident's O2 concentrator was found turned off. The UM verified that O2 tubing and humidifier bottles were expected to be labeled with the date of use and replacement information.
RN coverage was not maintained for the required daily hours. Staffing sheets showed no RN on duty for two shifts on one day and no RN on duty for another evening shift, and the DON confirmed she could not fulfill her on-call duties due to personal reasons while the ADON confirmed she did not report when on call.
Food Storage and Dishwasher Temperature Deficiencies: The Surveyor and FSD observed multiple opened food items in dry storage, the walk-in refrigerator, and the walk-in freezer that were undated, exposed to air, or had illegible labeling, including noodles, cereal, meat, potatoes, and frozen entrées. The high-temp dishwasher was also observed with wash cycle temperatures below the required 150 degrees F, while the rinse cycle reached the expected range and the gauge did not reset to zero.
Failure to Notify Physician and RP of Change in Condition: Two residents had documented changes in condition that led to hospital transfer or ER evaluation, but the record lacked evidence that the physician or RP was notified. One resident had mental status changes and abdominal pain before transfer to the hospital, and another had SOB with SpO2 88% and was sent to the ER after PCP feedback.
A resident was found with a bathroom door locked for weeks, with staff stating it was locked because the resident was a fall risk, usually incontinent, and dependent on staff for toileting; the fall care plan did not list the locked bathroom as an intervention. In another room, an LPN and the DON confirmed that food, toiletries, and personal items were left on the floor, and follow-up observation showed most of the items were still there.
A facility failed to update care plans when residents’ conditions changed. One resident developed a right heel arterial ulcer, but the care plan still only addressed potential pressure ulcer risk and did not include interventions for the actual wound. Another resident with atrial fibrillation was receiving Eliquis, but no care plan with anticoagulant interventions was in place; an LPN and the DON reviewed the record and confirmed the omission.
Failure to Treat Rash on Breast Area: A resident with intact cognition had a rash present on admission, but the initial skin order only addressed abdominal folds and did not include the chest/breast area. Nursing notes documented rash on both breasts as present on admission, yet the skin issue was later noted as not evaluated, and the ADON/IP was unsure whether the MD had been notified.
Missing Nursing Staff Competency Evaluations: Surveyors found that nursing staff competency evaluations were not completed upon hire and annually for several staff members. Record review showed that a GNA, an RN, and an LPN had no competency checklists in their files, and another GNA stated he/she had not received any competency training since hire. The DON and ADON/IP Nurse/Staff Educator confirmed that only two competency checklists were available and that several staff files had none.
A resident receiving PEG for constipation had a consulting pharmacist recommendation to add mixing instructions with water or a non-carbonated beverage, and the physician agreed and signed the recommendation. However, the MAR did not document the pharmacist’s recommendation while the medication was being given daily, and staff stated the instructions were not updated after the resident returned from hospitalization.
Infection control practices were not followed for a resident’s oxygen equipment when the O2 concentrator was off and the nasal cannula was found on the floor under the bed. In the laundry area, personal items were stored on a table used for clean linens, and infection surveillance logs were incomplete, missing key data, IP Nurse signatures, and QAA reporting dates.
Incomplete antibiotic stewardship monitoring was identified when review of antibiotic surveillance logs showed missing onset dates, room numbers, antibiotic orders, diagnoses, ordering practitioner information, and documentation supporting necessity across 9 of 9 months reviewed. One month’s log also lacked the IP Nurse signature and QAA report dates, and the ADON/IP confirmed daily antibiotic surveillance for January was not available because the log was still being created.
The facility failed to consistently screen, offer, and document education for flu and pneumococcal vaccines for 4 of 5 residents reviewed. Records for several residents lacked evidence that vaccines were offered on admission or afterward, and one resident’s consents were only signed after surveyor intervention. The DON stated consents were with the family for one resident, but there was no documentation of refusal, and the ADON/IP and UM confirmed immunizations were not routinely checked or completed consistently during admission.
The facility failed to consistently offer COVID-19 vaccine education and document vaccination status for residents and staff. Record review found missing immunization records for several staff members and no evidence that the vaccine had been offered or that education on benefits, risks, and side effects had been provided. For multiple residents, the chart lacked documentation of vaccine offer or education, and consents or declinations were only signed after surveyor intervention.
The facility failed to provide evidence that nursing staff received required abuse prevention, neglect, and exploitation training upon hire and annually. A review of employee records showed that several staff members had abuse quiz documentation without completion dates, and one GNA had no evidence of the required training on file. The ADON/IP Nurse/Staff Educator stated that training was done through face-to-face in-services or classroom sessions, with records kept in individual employee folders.
Missing QAPI training documentation was identified for all five randomly selected nursing staff reviewed. The ADON/IP Nurse said staff education was provided through face-to-face in-services or classroom sessions and that records were kept in individual employee folders, but no evidence of QAPI training was found for the GNA, RN, and LPN staff reviewed.
The facility failed to provide required infection prevention and control training to staff upon hire and routinely thereafter. Record review found no training evidence for two GNAs, and incomplete documentation for a GNA, RN, and LPN, with hand hygiene and targeted catheter-care training lacking recorded completion dates. The ADON/IP Nurse stated that training was conducted through face-to-face in-services or classroom sessions and stored in employee folders.
The facility failed to provide compliance and ethics training for five of five randomly selected nursing staff reviewed. The ADON/IP Nurse/staff educator said training was done through face-to-face in-services or classroom sessions and kept in employee folders, but record review found no evidence of the required training for multiple GNAs, an RN, and an LPN.
Missing Annual In-Service Training for Nurse Aides: The facility failed to provide the required 12 hours of annual in-service training for three GNAs. Record review found no training evidence for GNA #8, GNA #11, and GNA #10. Staff stated the ADON/IP Nurse served as the staff educator and that training was done through face-to-face in-services or classroom sessions, with records kept in employee folders.
The facility failed to provide required behavioral health training for all staff upon hire and annually. Record review found missing or incomplete training documentation for 5 of 5 sampled nursing staff, including no evidence of training for one GNA, no hire or annual training for another GNA, and undated dementia-related quizzes or records for a GNA, an RN, and an LPN. Staff stated training was handled through face-to-face in-services or classroom sessions, with records kept in individual employee folders.
A resident was discharged to an independent living apartment without home health services or community referrals in place. The responsible staff member was unfamiliar with the discharge process for independent living and did not arrange for home health or meals on wheels until several days after discharge, resulting in a delay in services.
A facility failed to notify a resident with intact cognitive function that their Medicare services were ending, as evidenced by the absence of the resident's signature on the Notice of Medicare Non-Coverage form. The resident confirmed they were not informed about the termination of services and did not receive the notice to sign.
The facility was found deficient in maintaining a clean and homelike environment. Observations revealed damaged walls, cracked tiles, and dirty floors in several residents' rooms. The Administrator acknowledged the issues and mentioned ongoing renovations, but the deficiencies were evident during the survey.
A facility failed to provide written notification to a resident and/or their representative about a hospital transfer, including the reason for the transfer. The deficiency was identified during a medical record review, which showed no documentation of notification. Interviews with the DON and Administrator confirmed the lack of documentation, and the Ombudsman noted inconsistencies in receiving transfer/discharge forms.
A facility failed to notify a resident and/or their representative in writing about the bed hold policy during a transfer to an acute care facility. Medical record review and staff interviews confirmed the absence of written evidence of such notification.
The facility did not create person-centered care plans for two residents. One resident was prescribed Paxil for off-label use to manage sexually inappropriate behavior, but no care plan was in place. Another resident received pain management treatments, including Tylenol, Tramadol, and a steroid injection, yet lacked a care plan for pain management. These deficiencies were confirmed by the DON.
A facility failed to complete a smoking assessment for a resident identified as a smoker in their care plan. Despite the Administrator's claim of a smoke-free environment, the resident was observed smoking outside unattended. The resident's medical record noted their smoking habit, but no assessment was completed. The Administrator confirmed the resident was signed out daily to smoke.
A discrepancy was found in the documentation of a resident's medication. The resident, with anxiety and depressive disorders, was noted by a physician and NP to be on Lexapro for panic attacks, despite the medication being discontinued earlier. This inconsistency was confirmed by the ADON.
The facility was found to improperly store medications and biologicals at incorrect temperatures. During a survey, the North Hall medication storage room's refrigerator and freezer were observed to be above the required temperature limits. The Maintenance Director acknowledged the issue and planned to investigate.
During a survey, a facility was found to have failed in storing food according to professional standards. Items in the kitchen's refrigerators and freezer lacked date labels, including pudding, sandwiches, salsa, peaches, and meat products. The Kitchen Supervisor, new to the facility, acknowledged the issues and noted that temperature logs were incomplete or missing. These concerns were discussed with the Administration team.
Failure to Develop Care Plans for Oxygen Therapy and Cardiac Medications
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for oxygen therapy for Residents #45, #62, and #53. Resident #45 was observed with an O2 concentrator turned off and tubing on the floor under the bed, while the medical record showed an order for O2 at 2 L/min via nasal cannula continuously related to low saturations and progress notes confirming ongoing O2 therapy. The record did not show evidence that an O2 therapy care plan was in place until one was created after surveyor intervention. Resident #62 was observed using O2 via nasal cannula connected to a cylinder tank, and the record showed an order for O2 at 3 L/min for shortness of breath/low oxygen saturation, but the care plan for O2 use was also created only after surveyor intervention. Resident #53 was observed receiving O2 via nasal cannula, and a change in condition note confirmed O2 at 3 L/min via nasal cannula, but the record did not show that an O2 order was placed or that a care plan was initiated and implemented. The facility also failed to initiate a care plan for cardiac-related medications for Resident #2. The resident had an admission date of 11/18/25 and later had a change in condition with abnormal vital signs, including a pulse of 123, respirations of 36, blood pressure of 60/39, and difficulty being aroused with general weakness, which was confirmed by a physician discharge note. The medication list included amiodarone, amlodipine, apixaban, aspirin, atorvastatin, furosemide, metoprolol succinate, and sacubitril-valsartan for conditions including chronic atrial fibrillation, hypertension, cerebral infarction, hyperlipidemia, and heart failure. The medical record did not show that a care plan addressing these medications had been initiated.
Unlabeled Oxygen Equipment
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when oxygen administration equipment was found unlabeled for 4 of 4 residents reviewed for respiratory care. During the initial tour, Resident #57 was observed in bed receiving O2 therapy via nasal cannula, and both the tubing and humidifier bottle were unlabeled. Resident #53 was also observed using unlabeled tubing and an unlabeled humidifier, and Resident #62 was observed using unlabeled tubing connected to a cylinder tank. Resident #45's O2 concentrator was found turned off. The report states that neither the tubing nor the humidifier bottles were labeled with the date of use or the scheduled replacement date. The Unit Manager verified the observations and stated that O2 tubing was changed every Tuesday night and the humidifier was changed as needed, and that it was expected that O2 tubing and humidifier bottles be labeled accordingly. The DON and NHA were later notified of these concerns.
RN Coverage Not Maintained for Required Daily Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours, 7 days a week. A review of staffing sheets showed that no RN worked during the 7-3 and 3-11 shifts on Sunday, January 4, 2026, or during the 3-11 shift on Saturday, January 10, 2026. During interview, the Director of Nursing confirmed that although she was the on-call RN on January 4, she was unable to fulfill her duties due to personal reasons. The Assistant Director of Nursing also confirmed that she was the on-call RN on January 10 but did not report to the facility.
Food Storage and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to store and prepare food in a manner that maintained professional standards of food service safety. During the initial kitchen tour on 01/14/2026, the Surveyor and Food Service Director observed multiple dry storage items that were opened and either undated or had illegible labeling, including packs of ziti noodles, elbow noodles, egg noodles, spaghetti noodles, toasted oats cereal, and crisp rice cereal. In the walk-in refrigerator, they also observed opened and undated items including ground beef, natural smoked bacon, red potatoes, and French toast. During the continued kitchen tour, the Surveyor and Food Service Director observed additional opened, exposed, and undated items in the walk-in freezer, including corn, cultivated blueberries, pizza dough, sugar cookie dough, philly beef sandwich slices, breakfast turkey sausage patties, bulk beef hamburger patties, and hot dogs. In the dishwashing area, the facility's high-temperature dishwasher was observed in operation with a wash cycle temperature of approximately 140 degrees F on 01/14/2026 and approximately 144 degrees F on 01/21/2026, both below the required wash temperature of 150 degrees F. The rinse cycle temperatures reached approximately 186 degrees F and 190 degrees F, respectively, and the temperature gauge remained fixed and did not reset to zero during or after the cycles.
Failure to Notify Physician and Resident Representative of Changes in Condition
Penalty
Summary
The facility failed to notify the physician and resident representative of residents’ changes in condition for 2 of 4 residents reviewed for hospitalizations. For Resident #5, the clinical record showed the resident was transferred to the hospital on 1/6/26 after a change in condition and returned on 1/14/26, but there was no documentation that the physician was notified. A late entry nursing progress note entered into PCC on 1/15/26 described a change in mental status and abdominal pain and stated the resident was sent to the ER for evaluation and treatment, but it did not document physician notification. The ADON stated that nursing staff are expected to notify the physician when a resident has a change in condition and that this is documented in a CIC note, but no CIC note was completed for Resident #5. For Resident #57, a change in condition report dated 12/7/25 at 5:29 PM documented shortness of breath, SpO2 of 88% on O2 via nasal cannula, and a PCP recommendation to send the resident to the ER for evaluation and treatment. Despite these findings, the report contained no evidence that the RP was notified of the change in condition. The DON provided the report and confirmed that the RP had not been notified.
Unsafe Room Conditions and Restricted Bathroom Access
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for two residents. One resident was observed lying in bed with a wheelchair at the bedside, and the resident stated that the bathroom door had been locked for weeks and could only be used when a staff member was present. The bathroom door was found locked during the observation, and staff confirmed it had been locked to prevent falls because the resident was a fall risk, usually incontinent, and dependent on staff for toileting. The resident’s fall care plan did not identify the locked bathroom as an intervention. In another room, a resident was observed with a box of crackers, a case of bottled water, two bottles of shampoo, and personal items in gift bags placed on the floor under the window. Staff confirmed the items should not have been on the floor, and the DON also confirmed the findings and stated that food items were not allowed on the floor and that food should be stored in containers with lids. During follow-up observation, the bottled water, shampoo, and other personal items were still on the floor, with only the box of crackers removed.
Care plans not updated for wound care and anticoagulant therapy
Penalty
Summary
The facility failed to review and revise interdisciplinary care plans when residents’ conditions changed. For Resident #3, the medical record showed an admission care plan dated 11/20/25 that identified only a potential for pressure ulcer development, but after the resident acquired an arterial ulcer to the right heel on 12/23/25, the care plan was not updated to reflect the actual wound or include interventions for it. The current treatment order for the ulcer was to cleanse the right heel arterial ulcer with wound cleanser/normal saline, apply calcium alginate and Medi honey to the wound base, and secure with ABD and rolled gauze daily on the evening shift, with a start date of 01/15/26. For Resident #7, the record showed diagnoses including atrial fibrillation and hypertension, and the resident was receiving Eliquis 5 mg by mouth twice daily for atrial fibrillation with an order start date of 11/12/25. The medical record did not contain a care plan with interventions for anticoagulant therapy. During interviews, the Unit Manager reviewed the records and confirmed that the care plan had not been initiated, and the DON also reviewed the record and acknowledged that a care plan should have been in place but was missed.
Failure to Treat Rash on Breast Area
Penalty
Summary
The facility failed to ensure that Resident #9 received treatment for a rash that had been present since admission. On 1/15/2026, the resident was observed with redness on the chest, and the condition was confirmed to have existed since admission. The resident was admitted on 12/3/25 and had a BIMS score of 15, indicating intact cognitive function. The admission skin treatment order written on 12/3/25 directed Nystatin External Powder 100000 UNIT/GM to be applied to abdominal folds four times a day for a yeast rash, but no treatment was ordered for the chest/breast area. Progress notes documented new skin issues on 12/4/2025 for both the left breast and right breast, each identified as a rash and noted as present on admission. On 1/22/2026, the skin issue for both breasts was documented as not having been evaluated. During interview, the ADON/IP stated she was unsure whether the physician had been notified and later confirmed that the initial admission order failed to address the correct sites. RN #6 stated that the admitting nurse documents skin issues in the medical record and wound book for the wound nurse to review.
Missing Nursing Staff Competency Evaluations
Penalty
Summary
The facility failed to ensure that nursing staff received competency evaluations upon hire and annually thereafter. During the recertification survey, record review showed that GNA #8, hired on 2/23/24, had no competency evaluation found; RN #9, hired on 10/10/23, had no competency evaluation found; and LPN #12, hired on 1/29/24, had no competency evaluation found. These three staff members were among five randomly selected nursing staff reviewed for staff competency. During interviews, Staff #1 stated that the ADON/IP Nurse served as the facility's official Staff Educator and that staff training upon hire and annually was a collective effort involving the DON, NHA, and ADON/IP Nurse/Staff Educator. GNA #16 stated that he/she had not received any competency training since hire. The DON and the ADON/IP Nurse/Staff Educator explained that competency training involved return demonstrations of skills listed on a competency checklist, and they acknowledged that only two competency checklists were found among the reviewed files, with several staff members having no checklist at all.
Pharmacist Recommendation Not Documented on MAR
Penalty
Summary
The facility failed to ensure that a consulting pharmacist’s recommendation was followed and documented in the resident’s record for Resident #11, who was receiving Polyethylene Glycol Powder 17 gram by mouth daily for constipation. The medical record showed that the pharmacist recommended adding instructions to mix the medication with 4 to 8 ounces of water or a non-carbonated beverage of choice, and the resident’s physician reviewed and signed the recommendation with a note stating, “AGREE: Please write orders.” However, the resident’s MAR did not contain documentation of the pharmacist’s recommendation while the medication was administered daily, and staff stated that the medication instructions were not updated on the MAR after the resident returned from hospitalization.
Infection Control Deficiencies in Oxygen Care, Linen Storage, and Surveillance
Penalty
Summary
The facility failed to use appropriate infection control practices related to oxygen administration equipment for Resident #45. During initial rounds, the resident’s oxygen concentrator was found turned off, and the nasal cannula was resting on the floor under the bed. The Unit Manager later verified the observation and stated that nasal cannulas not in use should be stored in a clean plastic bag. The Director of Nursing was notified of the concern and acknowledged the finding. The facility also failed to maintain proper infection control practices in the laundry area and to complete adequate infection surveillance. In the laundry room, personal items including a can of soda, facial tissue, lotion, and a cellphone were observed on top of a table used for clean, folded linens. Review of infection tracking logs from May 2025 through January 2026 showed missing critical information such as unit and room numbers, onset dates, specific organisms, symptoms, and whether infections were hospital or community acquired. Logs for May and September also lacked the Infection Preventionist Nurse’s signatures and the dates of report to the QAA Committee, and daily infection surveillance for January was not available because the log was still being created.
Incomplete Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to collect all information required for monitoring antibiotic stewardship for 9 of 9 months of antibiotic logs reviewed during the recertification survey. A review of the antibiotic surveillance logs from May 2025 to January 2026 found significant inconsistencies, including missing onset dates, room numbers, antibiotic orders, diagnoses, ordering practitioners, and documentation supporting necessity. The September log also lacked the Infection Preventionist Nurse’s signature and the dates the report was presented to the QAA Committee. On 1/21/2026, the ADON/Infection Preventionist Nurse confirmed that daily antibiotic surveillance for January was not available because the log was still being created, and on 1/23/2026 the NHA was notified of the systemic tracking failures and acknowledged the findings.
Failure to Consistently Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to screen, offer, and educate residents or their Responsible Parties about the risks and benefits of pneumococcal and flu vaccines. This was identified for 4 of 5 residents reviewed for immunizations: Resident #62, Resident #57, Resident #45, and Resident #9. The record for Resident #62 lacked evidence that the pneumococcal vaccine was offered upon admission or afterward. Resident #57, who had an original admission and a recent readmission, also had no documentation that pneumococcal or flu vaccines were offered, and although the DON stated consents were with the family, there was no documentation of vaccine refusal in the medical record. Resident #45’s record likewise lacked evidence that the pneumococcal vaccine was offered upon admission or thereafter. Resident #9’s record lacked evidence that flu and pneumococcal vaccines were offered until 1/21/26, when consents were signed following surveyor intervention. The facility’s General Immunization/Vaccination policy stated that residents would be offered immunizations and screened prior to receiving them, but on 1/22/2026 the ADON/Infection Preventionist confirmed that pneumonia, flu, and COVID-19 vaccines were not routinely checked upon admission. The Unit Manager also confirmed that immunizations are part of the admission process but had not been completed consistently.
Failure to Document and Offer COVID-19 Vaccine Education
Penalty
Summary
The facility failed to offer and provide required education regarding the benefits, risks, and potential side effects of the COVID-19 vaccine to residents and staff, and failed to properly document vaccination status. During record review and interviews, the surveyor found that RN #10, GNA #10, and GNA #11 had no immunization record in their employee files at the time of review, and the ADON/IP Nurse stated that immunization was not required for staff and that whatever was in the employee file was all that was available. The DON was present during this discussion. Later, the NHA provided a list of employees with immunization records on file, and the staff members reviewed were not on that list except for one previously recorded staff member. For residents, record review showed a lack of documentation that COVID-19 vaccine offers or education had been provided to Resident #57, Resident #45, and Resident #9. Resident #57 had no evidence of vaccine offer or education in the record, and a declination was signed only after surveyor intervention. Resident #45’s record lacked evidence of both vaccine offer and education. Resident #9 had no documented evidence of vaccine offer or education until consents were signed after surveyor intervention. The facility’s General Immunization/Vaccination policy stated that residents, staff, and volunteer workers would be offered immunizations, screened for eligibility, and have documentation of education regarding benefits and potential side effects filed in the record, but the ADON/IP Nurse confirmed that pneumonia, flu, and COVID-19 vaccines were not routinely checked upon admission and that immunizations had not been completed consistently.
Missing Documentation for Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide evidence that nursing staff received required training on abuse prevention, neglect, and exploitation upon hire and annually. During the survey, the Assistant DON/Infection Preventionist, who served as the facility’s staff educator, stated that staff training upon hire and annually was a collective effort involving the DON, NHA, and ADON/IP Nurse/Staff Educator. A review of nursing employee records on 1/21/2026 showed that 5 of 5 randomly selected nursing staff reviewed for annual training requirements did not have complete documentation of the required training. The record review found that GNA #8, GNA #10, RN #9, and LPN #12 each had a 7-item abuse quiz on file, but the completion date was not recorded. GNA #11 had no evidence on file of abuse prevention, neglect, and exploitation training upon hire or annually. The ADON/IP Nurse/Staff Educator stated that the facility did not use an online learning platform and that all training was conducted through face-to-face in-services or classroom sessions, with training documents stored in individual employee folders and not available elsewhere in the facility.
Missing QAPI Training Documentation
Penalty
Summary
The facility failed to provide QAPI training to staff, as shown by record review and interview during the recertification survey. Staff #1 stated that the ADON/IP Nurse served as the facility’s official staff educator and that staff training upon hire and annually was a collective effort involving the DON, NHA, and ADON/IP Nurse/staff educator. However, a review of nursing employee records found no evidence of QAPI training for five of five randomly selected nursing staff: GNA #8, GNA #11, GNA #10, RN #9, and LPN #12. The ADON/IP Nurse/staff educator confirmed that the facility did not use an online learning platform and that training was conducted through face-to-face in-services or classroom sessions, with training documents kept in individual employee folders and not available elsewhere in the facility.
Missing Infection Prevention Training Documentation
Penalty
Summary
The facility failed to provide mandatory infection prevention and control training to staff upon hire and routinely thereafter as required by its infection prevention and control program. During record review and interview, the Assistant Director of Nursing/Infection Preventionist stated that staff training upon hire and annually was a collective effort involving the DON, NHA, and ADON/IP Nurse/Staff Educator, and that the ADON/IP Nurse served as the facility’s official Staff Educator. Review of nursing employee records showed no evidence of required training for GNA #8 and GNA #11. GNA #10, RN #9, and LPN #12 each had documentation of a hand hygiene quiz and a targeted infection prevention program on indwelling urinary catheter care, but the completion dates were not recorded, and no further evidence of training was found. The facility’s Infection Prevention and Control Program policy stated that all staff shall receive training relevant to their roles and responsibilities, demonstrate competence in infection control practices, and direct care staff shall demonstrate competence in resident care procedures established by the facility.
Missing Compliance and Ethics Training for Nursing Staff
Penalty
Summary
The facility failed to provide compliance and ethics training to staff. During interview, Staff #1 stated that the ADON/IP Nurse served as the facility’s official staff educator and that staff training upon hire and annually was a collective effort involving the DON, NHA, and ADON/IP Nurse/staff educator. However, review of nursing employee records showed no evidence of compliance and ethics training for five of five randomly selected nursing staff reviewed during the recertification survey: GNA #8, GNA #11, GNA #10, RN #9, and LPN #12. The records identified each staff member’s hire date, and the DON and ADON/IP Nurse/staff educator were notified of the findings and acknowledged them. The ADON/IP Nurse/staff educator stated that the facility did not use an online learning platform and that training was conducted through face-to-face in-services or classroom sessions, with training documents stored in individual employee folders.
Missing Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to provide the required 12 hours of annual in-service training for nurse aides. During record review, no evidence of training was found for three Geriatric Nurse Assistants: GNA #8, hired 2/23/24; GNA #11, hired 11/1/22; and GNA #10, hired 3/19/25. During interview, Staff #1 stated that the ADON/IP Nurse served as the facility’s official Staff Educator and that staff training upon hire and annually was a collective effort involving the DON, NHA, and ADON/IP Nurse/Staff Educator. The DON and the ADON/IP Nurse/Staff Educator were notified of the findings and acknowledged them. The ADON/IP Nurse/Staff Educator also stated that the facility did not use an online learning platform and that all training was conducted through face-to-face in-services or classroom sessions, with training documents stored in individual employee folders.
Missing Behavioral Health Training Documentation for Nursing Staff
Penalty
Summary
The facility failed to provide the mandatory behavioral health training program for all staff members upon hire and annually. During interview, Staff #1 stated that the ADON/IP Nurse served as the facility’s official staff educator and that staff training upon hire and annually was a collective effort involving the DON, NHA, and the ADON/IP Nurse/staff educator. A review of nursing employee records showed missing or incomplete behavioral health training documentation for 5 of 5 randomly selected nursing staff. GNA #8 had no evidence of training on file. GNA #11 had a Dementia Overview completed, but there was no evidence of training upon hire or annually. GNA #10, RN #9, and LPN #12 had dementia-related quizzes or topic records in their files, but completion dates were not recorded. The DON and the ADON/IP Nurse/staff educator were notified of these findings and acknowledged them.
Failure to Arrange Home Health and Community Referrals at Discharge
Penalty
Summary
Facility staff failed to ensure that home health services and community referrals were in place at the time of discharge for a resident who was transitioning to an independent living apartment. The resident, who had been admitted for rehabilitation following hospitalization and was later determined not to require skilled nursing services or meet the criteria for nursing facility level of care, was discharged without the necessary referrals for home health and meals on wheels. The referrals were not made until three days after discharge. Interviews revealed that the staff member responsible for the discharge was inexperienced with independent living discharges and was unaware of the resources needed for the resident. The regional social worker became involved after the fact and directed the necessary referrals, which resulted in a delay in the resident receiving home health services. The Director of Nursing confirmed that the facility did not have the required services and referrals in place at the time of discharge.
Failure to Notify Resident of Medicare Service Termination
Penalty
Summary
The facility failed to notify a resident that their Medicare services were ending, along with the right to appeal this decision. This deficiency was identified during a review of the medical records and interviews conducted with the resident and staff. Specifically, the Notice of Medicare Non-Coverage form, which indicated that the resident's Medicare-covered services would end on January 10, 2024, lacked the resident's signature, confirming receipt of the notice. Staff #10 confirmed that the form was not signed by the resident. The resident, who had a BIMS score of 15 out of 15, indicating intact cognitive function, was able to accurately state the current date and confirmed during an interview that they were not notified about the termination of Medicare services and did not receive the notice to sign.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as observed during a survey. In one room, the upper part of the wall above the headboard had ripped drywall with large holes, visible immediately upon entering. The floor had several cracked tiles, was black throughout, and had a broken and peeling baseboard near the sink. Additionally, the shower on the back hall had cracked and yellow-stained glass tiles. These issues were noted during an initial tour and remained unresolved by the time of the survey exit. Further observations revealed that the rooms of three residents were not maintained in a clean state. Two residents' rooms had floors that were dirty with streaks of a black-colored substance, piles of gray dust-like matter, and brown-colored stains under the beds. The Administrator acknowledged the condition of these rooms and mentioned ongoing renovations, but the deficiencies were evident during the survey period.
Failure to Notify Resident of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and/or their representative regarding a transfer to the hospital, including the reason for the transfer. This deficiency was identified during a review of the medical record of a resident who was hospitalized due to a change in their medical condition. The review revealed that there was no documentation indicating that the resident or their representative was informed in writing about the transfer. Interviews with the Director of Nursing and the Administrator confirmed the absence of such documentation, and it was noted that the facility previously used The Maryland Notice of Involuntary Transfer and Discharge Forms for hospital transfers. Additionally, the Ombudsman reported inconsistencies in receiving transfer/discharge forms for residents.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify a resident and/or the resident's representative in writing of the bed hold policy when the resident was transferred to an acute care facility. This deficiency was identified during a review of the medical record for a resident who was sent to an acute care facility due to a change in medical condition. The review revealed that there was no written evidence provided to the resident or their representative regarding the bed hold policy. Interviews with two social workers confirmed that they were unable to produce or locate any written notice of the bed hold policy given to the resident or their representative.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans for two residents, leading to deficiencies in their care. For Resident #11, the electronic medical record indicated the prescription of Paxil for off-label use to manage sexually inappropriate behavior. However, there was no care plan addressing the use of Paxil or the resident's behavior. The Director of Nursing confirmed the absence of a care plan and noted that the Unit Manager should have completed it. For Resident #21, the medical record showed physician orders for Tylenol and Tramadol to manage right knee pain, and a steroid injection was administered in June 2024 at a pain management clinic. Despite these interventions, there was no care plan developed for pain management. This oversight was identified during the survey, highlighting a gap in the facility's care planning process.
Failure to Complete Smoking Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking assessment for Resident #56, who was identified as a smoker in their care plan. During the entrance conference, the Administrator stated that the facility was smoke-free and had no smoking residents. However, during observation rounds, Resident #56 was found smoking outside unattended on the facility property. The resident's medical record indicated they were admitted on Hospice and had a care plan noting they were a smoker, but no smoking assessment was completed. The Administrator acknowledged that Resident #56 was a smoker and was signed out daily for a leave of absence to smoke outside.
Discrepancy in Resident Medication Documentation
Penalty
Summary
A deficiency was identified in the documentation of a resident's medical record at the facility. The resident, who was admitted with diagnoses including anxiety disorder and depressive disorder, was seen by a physician and a nurse practitioner on separate occasions. During these visits, both healthcare providers documented that the resident was receiving Lexapro for panic attacks. However, a review of the Medication Administration Record and the Physician Order revealed that Lexapro had been discontinued by the physician prior to these visits. This discrepancy in documentation was confirmed during an interview with the Assistant Director of Nursing.
Improper Medication Storage Temperatures
Penalty
Summary
The facility failed to properly store medications and biologicals under appropriate temperature controls, as observed during a survey. In the North Hall medication storage room, the refrigerator thermometer displayed a temperature of 44 degrees Fahrenheit, and the freezer thermometer showed 30 degrees Fahrenheit. These temperatures exceeded the facility's policy requirements, which mandate that refrigerator storage must be maintained at or below 41 degrees Fahrenheit and freezer storage at or below -4 degrees Fahrenheit. This deficiency was identified during observation rounds conducted with the Maintenance Director, who acknowledged the temperature discrepancies and indicated an intention to investigate further.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety, as observed during a recertification survey. During an initial tour of the facility's kitchen, several items inside the Reach In Refrigerator and the main Refrigerator were found without date labels, including nine containers of pudding, one sandwich, a 69-ounce container of chunky salsa, a half-full bucket of peaches, a half-full bucket of bar-b-que sauce, a quarter-full bucket of vanilla pudding, a quarter-full bucket of chocolate pudding, and a half-full bucket of pears. Additionally, inside the Freezer, a large bag containing approximately 15-16 hamburgers and two large bags of meatloaf patties were also found without date labels. The Kitchen Supervisor, who had recently started at the facility, acknowledged these issues during an interview. She mentioned that the hamburgers and meatloaf patties were placed in the freezer by the activities department and expressed her intention to discuss the supervision of these items with the administration. Furthermore, the temperature logs for June 2024 were incomplete, and the July 2024 temperature log was missing entirely. The supervisor stated that temperature logs are supposed to be completed during both morning and evening shifts but was unable to identify who was responsible for the missing July log. These concerns were communicated to the Administration team at the time of the survey exit.
What surveyors are citing around you — mapped
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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 130 citations issued within 25 miles in the last 12 months — including the 4 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 Pocomoke City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Snow Hill Rehabilitation & Healthcare Center | 11.4 mi | ★★★★★ | 6 | 0 |
| Manokin Nursing And Rehab | 12.5 mi | ★★★★★ | 44 | 2 |
| Alice Byrd Tawes Nursing Home | 16.8 mi | ★★★★★ | 14 | 0 |
| Anchorage Rehabilitation And Wellness Center | 20.6 mi | ★★★★★ | 28 | 0 |
| Bay Harbor Post Acute Healthcare Center | 21 mi | ★★★★★ | 15 | 2 |
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.