Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Julia Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Unsafe bed and mechanical lift transfers led to avoidable accidents for two residents. One resident with cognitive impairment, severe vision loss, and total care needs rolled out of bed while staff briefly left the room with the bed not fully lowered and the fall mat not in place, resulting in a scalp laceration, clavicle fracture, and rib fracture. Another resident with CVA-related hemiplegia fell during a Hoyer lift transfer when a sling hook was not secured and staff did not complete the required safety check before starting the lift.
Medication administration errors involved two residents. One resident with DM received insulin from a pen labeled for another resident after the nurse assumed the pen was correct based on where it was stored. Another resident with dysphagia and a mechanically altered diet received doxycycline by having a capsule labeled "Do Not Crush" opened and mixed with pudding, despite staff disagreement about whether the medication could be altered.
A resident who was cognitively intact and needed extensive assistance reported that a GNA moved the resident’s bedpan away and told the resident the resident made a mess when using it. Another staff member later observed the bedpan on a nightstand out of reach, and the DON confirmed the resident had reported the incident.
Failure to Prevent Verbal Abuse by Staff: Two cognitively intact residents were verbally abused by staff during care and activities. One resident recovering from joint replacement surgery reported a GNA responded in a demeaning, aggressive way during incontinent care, while another resident said an Activities Director yelled and was mean after a request for a word search; a witness confirmed the resident was in tears.
A facility failed to ensure proper medication labeling and Do Not Crush handling for two residents. One nurse administered insulin from a pen labeled for another resident after assuming it belonged to the correct resident because it was stored in that resident’s bag. In another case, a nurse opened a doxycycline capsule marked Do Not Crush and mixed the contents with pudding for a resident with dysphagia, despite staff having inconsistent understanding of Do Not Crush instructions and the facility’s reference list identifying the medication as a time-release formulation.
Medication Error Rate Exceeded Allowable Threshold: Surveyors observed 2 medication errors in 29 opportunities, resulting in a 6.89% error rate. One RN administered insulin from a pen labeled for another resident after assuming it belonged to the correct resident because it was stored in a bag with that resident’s name. Another nurse opened a doxycycline capsule from a Do Not Crush package, mixed the contents with pudding, and gave it to a resident with dysphagia and a puree diet.
Meals were not consistently served according to the predetermined menu or the residents’ meal tickets. A resident received the wrong sandwich, several residents were served corn instead of peas when peas were listed on the tickets, other trays were missing items such as Ensure Plus, seasoned peas, and fruit yogurt, and one test tray showed an underportioned serving of baked beans. The Dietary Director stated staff had run out of peas and that portions were not always filled to the full level.
Food was not stored in accordance with professional standards, and clean dishes were not maintained to prevent contamination. A large sugar container under a meal prep area had a cracked lid, debris on the outside, and an open bag of sugar with a scoop inside. During tray line service, a dome drying rack used for resident lunch covers was observed with significant debris on it, and a Cook said it had not been cleaned that week.
Laundry staff folded clean linens on the clean side of the laundry room while the door to the soiled side was left open and two uncovered carts of dirty linens were present nearby. Staff later confirmed the process, and the Housekeeping Director stated disposable aprons had been used for dirty linen handling for over 2 years; the IPN questioned the apron use because the arms were still exposed.
Failure to Individualize Care Plans for Diabetes and Activities Needs: A resident with DM, CKD, heart disease, and a recent amputation had severe hypoglycemia requiring glucagon and EMS, yet the care plan only listed a carb-controlled diet and lacked resident-specific DM interventions. Two other residents also had generic activities care plans that did not reflect documented preferences such as Bingo, baking, Resident Council, dining room socialization, parties/socials, or puzzle books, despite AD notes and resident interviews showing individualized interests.
Activities care plans were not reassessed and revised to reflect resident-specific preferences for three residents. Progress notes documented interests such as Bingo, Resident Council, baking, dining room meals, socials, puzzle books, pet visits, TV preferences, snacks, animals, and devotionals, but the care plans remained generic or outdated and did not include these details. One resident was paraplegic with anxiety and depression, another had depression, anxiety, and significant mobility impairment, and a third preferred to stay in her room and reported no 1:1 activity visits.
Meals were not consistently served at proper temperatures. A grievance noted food was still cold, and residents reported that foods meant to be hot were often cold and foods meant to be cold were often warm. During tray line observation, the Dietary Director measured hot items below the facility standard and a cold fruit item above the cold-food standard.
Failure to maintain resident dignity during meals: staff fed a resident while standing at the bedside even though the resident was in bed and there was no documentation directing that approach, another staff member placed a clothing protector on an alert, oriented resident without asking, and two residents in the dining room waited while others finished eating before their trays arrived. The DON stated staff were expected to sit at residents’ level when assisting with meals and to ask before placing clothing protectors.
Unsanitary room conditions and damaged surfaces were observed in multiple resident areas. A resident's privacy curtain had dark red splotches reported by the resident as blood and present for months, and two residents' bathrooms had cracked sinks, loose or missing laminate, and duct tape on a bathroom board. Cracked hallway tile repairs were also observed to be deteriorated or missing in unit entrances.
A resident with Type 2 DM, heart disease, and CKD had repeated hypoglycemic episodes, including a blood sugar of 37 with mumbling and confusion, requiring glucagon and EMS transfer, followed by another low blood sugar of 39 the next day. Review of the baseline and comprehensive care plans found only a carbohydrate-controlled diet and no resident-specific diabetes interventions such as blood sugar monitoring, HBgA1c, skin checks, medications, or glucagon parameters. The DON confirmed the care plan lacked diabetes management interventions.
A resident who required 2 staff for mechanical lift transfers was transferred by a GNA alone, despite the facility policy also requiring 2 staff for Hoyer lift use. The resident said the lift transfers were frightening and that staff may not have used the lift correctly. The GNA confirmed she completed the transfer by herself because she wanted to help quickly, and the unit manager, DON, and NHA confirmed the deficient practice.
Pharmacist Recommendation Not Reviewed by MD A resident's monthly pharmacy review documented a pharmacist recommendation to adjust the timing of Omeprazole 20 mg BID for GERD so it would be given 1 hour before or 2 hours after other meds and food. The DON reported that pharmacy recommendations were supposed to be received as hard copies, routed through the nurse manager, and then reviewed and signed by the MD, but the December recommendation was not received and was not reviewed by the MD. A Consult Pharmacist Summary Report for the month did not include the recommendation noted in the chart, and the DON confirmed the MD never received or reviewed it.
A resident with HTN had orders for Carvedilol and Losartan with hold parameters for low SBP or HR, but the eMAR showed both medications were administered on multiple occasions when the resident’s SBP was below the ordered threshold. The DON reviewed the record and confirmed the doses were given and should have been held.
Medication Error Rate Exceeded 5 Percent: During med pass observations, two residents received Clear Lax doses that were less than ordered because the powder was not measured to the full marked line on the cap, and one resident’s scheduled multivitamin was omitted when the LPN documented it as not given due to unavailability. These three errors resulted in a medication error rate above 5 percent.
Failure to document COVID-19 vaccine education for a resident who declined the vaccine. The resident had intact cognition and the record showed the vaccine was refused, but the section indicating whether education was provided to the resident, family, or POA was left blank. The IP Nurse later confirmed she could not find documentation that the resident was informed about the benefits and risks of the vaccine.
Failure to provide and document ADL care for dependent residents. A resident dependent on staff for bathing had repeated missed showers, and concerns about personal hygiene and shower care were raised but not documented as addressed; staff confirmed a scheduled shower was given as a bed bath instead, with no refusal documented. Two other residents who required assistance with toileting, hygiene, bathing, and dressing had multiple missed ADL documentation entries, and staff reported both were incontinent, used briefs, and needed at least one-person assistance.
Unsafe Bed and Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure residents were free from avoidable accidents for 2 of 3 sampled residents. For Resident #10, the annual MDS indicated cognitive impairment, severe vision impairment, and dependence for eating, hygiene, toileting, bathing, dressing, and bed mobility. The care plan identified a self-care performance deficit related to mild cognitive impairment, impaired visual acuity/blindness of the right eye, pain/neuropathy, and left foot fractures, with interventions including Hoyer lift transfers with two-person assistance, bed bath only, toileting/incontinent care with one-person assistance, and bed mobility with one-person assistance. On 3/21/26, Resident #10 was receiving incontinence care in bed when staff raised the bed, moved the floor mat, and left the room to get linen from a cart immediately outside the room. The bed was not lowered completely and the fall mat was not properly in place when staff stepped away. Resident #10 rolled out of bed and was found on the floor with a large amount of blood and clots from the scalp, later diagnosed in the ED with a closed displaced right clavicle fracture, a scalp laceration requiring staples, and a probable minimally displaced right mid-rib fracture. Staff interviews and the DON’s statement confirmed that the resident was very restless, required close supervision, and could turn independently in bed, and that the fall interventions were not in place when the resident was left unattended. For Resident #14, the care plan identified a self-care performance deficit related to a history of CVA with hemiplegia, cognitive impairment, and arthritis, with transfers to be completed via Hoyer lift and 2-person assist. During a transfer from a wheelchair to bed, staff did not perform the required safety check to ensure all sling hooks and straps were secured before initiating the lift. One hook under the resident’s left shoulder was not attached, the resident began slipping from the sling, the wheelchair tilted backward, and staff lowered the resident to the floor. The resident reported pain after the fall and was sent to the hospital for evaluation. Interviews with staff and the DON confirmed that the sling was not fully secured and that the required pre-lift safety check was not completed.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of nursing practice for 2 of 5 residents reviewed. For one resident with diabetes who was cognitively intact and ordered Lantus Solostar U-100 insulin 37 units subcutaneously every day at 8:30 a.m., a medication administration observation showed a nurse retrieved an insulin pen from a zip-lock bag labeled for that resident, prepared the medication, and administered 37 units. After the injection, the insulin pen was observed to be labeled for a different resident, and the nurse stated the label had not been checked before administration and that the pen was assumed to belong to the resident based on its placement in the bag. For another resident who was cognitively impaired, on a mechanically altered diet, and had an order for doxycycline hyclate 100 mg by mouth twice daily for urinary tract infection, a nurse administered the medication by opening a capsule labeled "Do Not Crush," mixing the contents with pudding, and giving it to the resident. The nurse stated the resident was on a puree diet and would have difficulty swallowing the capsule whole. During interviews, one nurse stated that "Do Not Crush" meant the capsule should not be crushed but could be opened, while another nurse stated that "Do Not Crush" means the medication should not be altered, including crushing or opening, particularly for time-release medications, and identified doxycycline capsule as a time-release formulation.
Resident’s Bedpan Was Moved Out of Reach and Resident Was Spoken to Disrespectfully
Penalty
Summary
The facility failed to provide dignity and respect to one cognitively intact resident who required extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. The resident stated that a GNA placed the resident’s bedpan out of reach and told the resident that the resident made a mess when using it, which upset the resident. The resident preferred to keep the bedpan near the bed rail and was able to use it independently, but instead it was moved to a nightstand away from reach. Other staff members reported that the resident complained the GNA had taken the bedpan away and placed it far from the resident. A housekeeping assistant later observed the bedpan sitting on a nightstand away from the resident after the resident requested it. The DON confirmed that the resident had reported the night GNA removed the bedpan and placed it out of reach.
Failure to Prevent Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse by staff for 2 sampled residents. One resident was admitted after joint replacement surgery with chronic pain and was cognitively intact, requiring extensive assistance with bed mobility, transfers, and incontinent care. During incontinent care, the resident reported asking a GNA not to be rough because of recent surgery, but the GNA responded in a verbally aggressive and demeaning manner, including telling the resident to "hell" with what the resident was saying about surgery and pain. The resident stated the interaction was hurtful and upsetting and occurred for no reason. A second resident, who was cognitively intact and needed minimal assistance with ADLs, reported asking the Activities Director for a word search and said the staff member began yelling and being mean. A housekeeping assistant witnessed the interaction and stated the Activities Director yelled loudly, refused to provide any more word searches, and was screaming at the resident, who was in tears. The unit manager and DON also documented that the resident was upset and crying, and the investigation record reflected that the allegation was substantiated. For both incidents, the facility investigation records showed the allegations were reported and investigated, and the involved staff members denied or disputed parts of the allegations. The reports also documented that the staff members had prior concerns noted in the investigation process, including rude or mean behavior toward others in one case and a refusal to provide the requested activity item in the other. The deficiency was based on the staff conduct toward the residents during these encounters and the facility's failure to prevent the verbal abuse from occurring.
Medication Labeling and Do Not Crush Errors
Penalty
Summary
The facility failed to ensure proper medication labeling, storage, handling, and administration for two residents. One resident had an order for Lantus insulin glargine 37 units daily for diabetes and was cognitively intact. During a medication pass observation, a nurse retrieved an insulin pen from a zip-lock bag labeled with that resident’s name, administered the dose, and then the surveyor inspected the pen and found it was labeled for a different resident. The nurse acknowledged assuming the pen belonged to the resident because it was stored in that resident’s bag and stated the label should have been verified before administration. Another nurse and the nurse who removed the pen from the refrigerator confirmed the pen had been labeled for the other resident and placed in that resident’s medication storage bag, although it had been used on the first resident. The facility also failed to follow Do Not Crush instructions for another resident with cognitive impairment and dysphagia who had an order for doxycycline hyclate 100 mg twice daily for urinary tract infection. The medication was supplied in a bubble pack labeled Do Not Crush, and the physician’s order indicated a tablet. During observation, a nurse removed the medication, opened the capsule, poured the contents into a medicine cup, mixed it with pudding, and administered it orally. The nurse stated the resident was on a puree diet and would have difficulty swallowing the capsule whole, and explained that Do Not Crush meant the capsule should not be crushed but could be opened. Staff interviews showed inconsistent understanding of medication handling requirements. One nurse stated capsules are opened for administration, while another stated Do Not Crush means the capsule or contents should not be crushed and noted the facility’s reference list identified doxycycline capsule as a time-release formulation. The DON stated staff are not allowed to open or crush medications because it changes the release rate, and also stated the medication may have been thought to be labeled as extended release.
Medication Error Rate Exceeded Allowable Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5% during medication pass observations, with 2 errors identified in 29 opportunities observed for a rate of 6.89%. One error involved Resident #1, who was cognitively intact, had diabetes, and was ordered Lantus Solostar U-100 insulin 37 units subcutaneously each morning. During the medication pass, Staff Nurse #9 retrieved an insulin pen from a zip-lock bag labeled with Resident #1’s name, administered the insulin, and only afterward was it discovered that the pen was labeled for Resident #14. Staff Nurse #9 confirmed the pen label was for Resident #14 and stated the pen had been assumed to belong to Resident #1 because it was in a bag labeled for that resident. The second error involved Resident #15, who was cognitively impaired, on a mechanically altered diet, and had an order for doxycycline hyclate 100 mg by mouth twice daily for urinary tract infection. During observation, Staff Nurse #15 removed the medication from a bubble pack labeled Do Not Crush and opened the capsule before administration. The nurse stated the resident was on a puree diet and would have difficulty swallowing the capsule whole, then poured the contents into a medicine cup, mixed it with pudding, and administered it by mouth.
Meals Not Served According to Menu and Meal Tickets
Penalty
Summary
The facility failed to ensure that residents were served meals according to the predetermined menu and the residents’ meal tickets. During a lunch observation on the 2S Wing, Resident #100 was eating a roast beef sandwich, ice cream, Jell-O, cranberry juice, iced tea, and seasoned peas, but the meal ticket listed a chicken sandwich, no-sugar-added ice cream, two cranberry juices, Jell-O, and seasoned peas. The resident stated that the kitchen frequently did not read what was on the ticket and that the wrong sandwich was sent. Additional meal observations showed multiple discrepancies between meal tickets and what was served. On the 2W Wing, Residents #53, #54, #92, and #121 were supposed to receive seasoned peas, but they were served corn instead, and the Dietary Director stated the facility had run out of peas and staff decided to serve corn. Resident #126’s tray was missing Ensure Plus and seasoned peas listed on the ticket, and Resident #85’s tray was missing fruit yogurt listed on the ticket. During dinner tray line observation, Resident #35’s tray was supposed to include 4 oz of baked beans, but the portion served was less than 4 oz, and the Dietary Director confirmed the portion was not filled to the full level.
Food Storage and Clean Dish Storage Deficiencies
Penalty
Summary
Food was not stored in accordance with professional standards, and clean dishes were not stored and maintained in a manner to prevent contamination. During the initial kitchen tour, a large white container stored underneath a meal prep area was observed with a cracked clear lid, debris on the outside, and a large open bag of sugar with a serving scoop inside. The Dietary Director was present and stated she had another lid and would replace it after the surveyor's intervention. During a later observation of lunch tray line service, a dome drying rack filled with covers used for residents' lunch was observed with a significant amount of brownish-yellowish debris and substances on it. A Cook stated the rack was usually cleaned three times a week but had not been cleaned that week, and the Dietary Director said, "It looks dirty," and stated she would take care of it.
Laundry Room Cross-Contamination During Linen Processing
Penalty
Summary
The facility failed to ensure linens were processed appropriately to prevent cross contamination. During an observation of the laundry room, Housekeeping staff was folding clean linens on the clean side while the door separating the clean and soiled sides was wide open. At the same time, two rolling carts full of dirty linens without covers were present on the soiled side of the room. When interviewed, the Housekeeping staff confirmed that the dirty linen carts were waiting to be loaded into the washer while she was folding on the clean side and that the door between the two sides had been left open. Later, the Housekeeping Director confirmed that staff had been using disposable aprons when processing dirty linens for over two years, and the Infection Preventionist Nurse stated she did not know why aprons were being used because the arms were still exposed.
Failure to Individualize Care Plans for Diabetes and Activities Needs
Penalty
Summary
The facility failed to develop person-centered, resident-specific care plans for residents with identified needs. For a resident with a long history of Type 2 diabetes, heart disease, and chronic kidney disease who was receiving care after a surgical amputation, the record showed a severe hypoglycemic episode with blood glucose of 37 mg/dL that required glucagon and a 911 call, followed by another low blood sugar episode with a blood glucose of 39 mg/dL the next day. The resident reported that the facility had initially had difficulty getting the blood sugar under control and that the resident had been transferred to the hospital after a low blood sugar incident. Review of that resident’s current care plan showed only a carbohydrate-controlled diet and no diabetes-related interventions. The surveyor reviewed the care plan and could not find interventions for blood sugar checks, lab work, skin checks, vital signs, medications, or standing orders for glucagon, even though the DON stated those were the kinds of interventions that should be included. The DON also acknowledged that the diabetes-related interventions should have been included in the care plan and that the oversight should have been caught after the hospital transfer. The facility also failed to individualize activities care plans for two residents. One resident stated that they usually preferred to stay in the room and said the facility did not provide 1:1 visits or in-room activities, and the surveyor observed no entertainment items other than a television. Although activities progress notes documented interests such as Bingo, Resident Council, baking, and group activities, the current care plan contained only generic template interventions and did not reflect those preferences. Another resident denied participating in activities, yet progress notes documented enjoyment of dining in the dining room, socializing with peers, attending parties or socials, and using puzzle books; the current care plan again contained generic interventions and did not include those resident-specific interests.
Activities Care Plans Not Updated With Resident-Specific Preferences
Penalty
Summary
The facility failed to reassess the effectiveness of resident activity care plans and revise them to reflect resident-specific needs for 3 residents reviewed. For Resident #4, the activities progress notes documented that the resident was alert, communicated needs, spent much of the day watching TV, enjoyed Bingo, Resident Council, baking activities, and was becoming more involved in group activities, but the current activities care plan did not include those preferences and had not been meaningfully updated since 2021 except for a behavior-related change in 2022. The resident also stated that they usually preferred to stay in their room and reported that no 1:1 visits or in-room activities were provided. For Resident #13, the resident denied participating in activities when interviewed and had diagnoses of depression and anxiety, lower body impairment, wheelchair use, and maximum assistance needed to get out of bed. The activities progress notes stated that the resident enjoyed eating meals in the dining room, socializing with peers, attending parties or socials, and reading puzzle books, but the current activities care plan contained only generic interventions and had not been updated since 7/5/24. The resident-specific interests documented in the quarterly notes were not reflected in the care plan. For Resident #60, who is paraplegic and has anxiety and depression, the resident stated that she did not attend activities and that no 1:1 activity was provided in her room. The activities progress notes documented that she spent most of her day watching TV, socializing with staff, participating in room visits, enjoying pet visits, and reading the Daily Chronicle, but these preferences were not included in the current care plan. An evaluation note also documented that she preferred to stay in her room due to pain and enjoyed her soap opera, the Hallmark Channel, snacks, animals, reading the Daily Chronicle and devotionals, and independent activities, yet the care plan was not updated to include these details.
Meals Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure that residents received meals at an appropriate and palatable temperature. A grievance summary report showed that a concern was reported to the Social Services Director stating the facility's food was still cold, and the concern was later reviewed by the Nursing Home Administrator. During a facility tour, residents reported that food was often cold when it should have been warm and warm when it should have been cold. During observation of the dinner tray line service, a test tray was requested and the Dietary Director measured temperatures of 127 degrees for pulled pork, 129 degrees for baked beans, and 59 degrees for peaches/pears, which were below the facility's stated standards of 135 degrees for hot foods and 40 degrees for cold foods. The Dietary Director acknowledged the acceptable temperatures and stated that a 2-lid plate cover had been found to keep meals warm after the surveyor's intervention.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to treat residents with respect and dignity during mealtime in 3 of 5 meal observations. Resident #71 required physical assistance with eating. During a breakfast observation in the resident’s room, staff #15, an occupational therapy assistant, fed the resident while standing at the bedside as the resident lay in bed. Staff #15 stated she knew standing to feed a resident was undignified, but she stood because it was comfortable for the resident. The resident’s record did not show documentation directing staff to stand while feeding. On a later breakfast observation, staff #16, a GNA, fed the same resident while sitting at the bedside, and stated that sitting at the resident’s level was comfortable for residents. The DON stated it was her expectation that staff sit at residents’ level when assisting with meals, but earlier observations showed otherwise. During breakfast in the dining room, staff #17 placed a clothing protector on Resident #69 without asking, even though the resident was talkative, alert, oriented, and able to verbalize needs. Staff #18 stated that staff had to ask residents before placing clothing protectors on them to respect dignity, and the DON later stated that staff were expected to ask before placing them. In another dining room observation, Residents #69 and #98 finished breakfast while Residents #70 and #31 continued waiting for their trays. One resident stated, “I just gotta wait for my tray while others are eating, there's nothing else I can do about it.” The residents waited about 30 minutes for breakfast, and one resident wanted to return to the room because he/she felt cold in the dining area.
Unsanitary room conditions and damaged bathroom and flooring surfaces
Penalty
Summary
The facility failed to ensure a sanitary and homelike environment in Resident #97's room when a privacy curtain between Bed A and Bed B was observed with several dark red splotches about 2 inches long near the top of the curtain. The resident, who had lived at the facility for more than one year and was cognitively intact with a BIMS score of 15 out of 15, reported that the stain was blood and that it had been there for months. The unit nurse manager acknowledged the stain when shown the curtain, and the Director of Nursing was later informed that the stain had been observed earlier in the survey and reported by the resident as longstanding. The facility also failed to maintain bathroom fixtures and unit flooring in a sanitary condition. In Resident #97's bathroom, the sink had at least 7 cracks branching from the drain and the laminate board below the sink was loose with duct tape present. In Resident #67's bathroom, the sink had more than 10 cracks branching from the drain with additional cracks in the basin, and a bathroom drawer had two areas of missing laminate exposing wood underneath. In addition, the facility had previously been cited for cracked floor tiles on the second and third floor hallways, and surveyors again observed cracked tile areas with clear epoxy repairs that were not intact in some locations, including a missing section at the entrance to the 3 East unit and a rough area at the entrance to the 3 South unit.
Diabetes Care Plan Missing Resident-Specific Interventions
Penalty
Summary
The facility failed to ensure Resident #92 received treatment and care in accordance with professional standards by not including diabetes-related interventions in the resident’s care plan. Resident #92 was admitted for physical therapy and nursing care after a surgical amputation of one leg and had a long history of Type 2 diabetes, along with heart disease and chronic kidney disease. The resident reported that the facility had difficulty getting blood sugar under control after admission and that the resident was later transferred to the hospital following a low blood sugar event. Progress notes showed that on 7/1/25 the resident became mumbling and not making sense, with a blood sugar of 37, and was given glucagon 1 mg injection before 911 was called. The resident returned from the hospital later that day with a diagnosis of hypoglycemia. A physician note documented that the resident had an insulin-dependent diabetes mellitus diagnosis and had experienced a hypoglycemic episode, with insulin being decreased. On 7/2/25, the resident again had a blood sugar of 39 and was treated with food and milk with sugar, then the physician was notified and orders were received to decrease glargine and give a bedtime PBJ sandwich. Review of the baseline care plan dated 6/26/25 and the current care plan dated 8/22/25 found only a carbohydrate-controlled diet and no other diabetes management interventions. The DON stated that care plans should include resident-specific interventions and identified diabetes-related interventions such as HBgA1c monitoring, skin checks, blood sugar checks, vital signs, medications, and standing glucagon orders, but confirmed that none of these were included in the resident’s care plan. The DON agreed that these interventions should have been included in both the initial and comprehensive care plans and after the resident’s change in condition.
Mechanical Lift Transfer Completed Without Required Two-Staff Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and staff assistance during a resident’s mechanical lift transfer. Resident #90’s care plan stated that the resident required assistance from two staff members to transfer out of bed with a mechanical lift, and the facility’s mechanical lift policy also required two staff for Hoyer lift transfers. During the initial screening, the resident stated being afraid of Hoyer lift transfers and said the resident was not sure staff used it correctly. During observation, a GNA was seen leaving the resident’s room with a mechanical lift, and the resident and a family member later stated that the GNA had transferred the resident from the wheelchair back to bed alone. The GNA confirmed that no second staff member assisted with the transfer, explaining that she had tried to get help but other staff were busy and that she proceeded alone because she wanted to help the resident quickly. The unit manager confirmed that this was unacceptable and acknowledged that the facility had enough staff available at the time, and the DON and NHA later reviewed and confirmed the deficiency.
Pharmacist Recommendation Not Routed for Physician Review
Penalty
Summary
The facility failed to have an effective process to ensure that medication recommendations made by the pharmacist were delivered to the physician for review. For Resident #10, a monthly pharmacy review note dated 12/11/24 documented Omeprazole 20 mg BID for GERD, administered at 0800 and 2000, and the pharmacist recommended reviewing and considering a time change so the medication would be given either 1 hour before or 2 hours after other medications and food. No other recommendations were noted in that review. During interviews, the DON stated that pharmacy recommendations were normally sent to the facility as a hard copy with the next pharmacy delivery, received first by the DON, then given to the appropriate nurse manager for physician review and signature before being returned to the DON. The DON later reported not receiving the December pharmacy recommendations referenced in the progress note, and the recommendation was therefore not reviewed by the physician. A Consult Pharmacist Summary Report for 12/01/24 through 12/31/24 did not include the recommendation documented in the progress note. The DON confirmed that Omeprazole was discontinued when the resident was hospitalized on 1/11/25 and acknowledged that the physician did not receive or review the pharmacist's recommendation.
Medication Given Outside Ordered Hold Parameters
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications. Resident #8 was admitted in early 2025 with a diagnosis of hypertension. The resident had medication orders for Carvedilol twice daily and Losartan at bedtime, both with instructions to hold if systolic blood pressure was below 120 or heart rate was below 60. A review of the September 2025 eMAR showed that Carvedilol was administered on multiple occasions when the resident’s systolic blood pressure was below the ordered hold parameter, including readings of 118, 107, 110, 112, and 109. Losartan was also administered when the resident’s systolic blood pressure was 118 and 109. The DON reviewed the eMAR with surveyors and confirmed that the medications were given on those dates and should have been held.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, with 3 errors identified out of 29 opportunities during medication administration observations. Two errors involved incorrect dosing of Clear Lax (polyethylene glycol 3350) for two residents. For one resident, a nurse prepared the powder using the lid of the medication container and filled it to approximately 3/4 of the way up the white section of the cap, then mixed it with water in a disposable cup; the resident’s order was for 17 grams mixed with 8 ounces of water or juice, and the nurse later acknowledged the dose given was a little under what was ordered. For another resident, a nurse also prepared Clear Lax using the lid measuring cup, but the powder did not appear to fully cover the white section of the cup, and the nurse later confirmed the dose administered was less than ordered. The third error involved omission of a multivitamin for one resident. During observation, the nurse documented the vitamin as not administered because it was unavailable on the medication cart. Review of the MAR showed the vitamin was scheduled for administration at 9:00 AM, and later the nurse stated she had obtained the multivitamin but did not administer it because she had already charted it as not given. The surveyor informed the DON and NHA that the medication error rate was above 5 percent based on the two wrong-dose errors and one omission.
Failure to Document COVID-19 Vaccine Education
Penalty
Summary
The facility failed to ensure education was provided to residents and/or responsible parties regarding the benefits and potential risks associated with the COVID-19 vaccine for 1 resident reviewed for immunizations. Resident #31 had been in the facility since 2023 and was documented as having intact cognitive function. The resident's immunization record showed that the COVID-19 vaccine had been declined, but the preventive healthcare documentation left unanswered the section indicating whether education was provided to the resident, family, or power of attorney. During record review and interview, the Infection Preventionist Nurse stated that Resident #31 had been refusing the COVID-19 vaccine but she could not find documentation showing that the resident had been informed about the benefits and risks of the vaccine.
Failure to Provide and Document ADL Care
Penalty
Summary
The facility failed to ensure that dependent residents received and had documented assistance with activities of daily living, including bathing, toileting, hygiene, dressing, and incontinence care. For Resident #20, a long-term resident dependent on staff for showering and bathing, the record showed concerns about personal hygiene and shower care were raised with the Social Services Director, but no grievance form or other documentation was available showing the concerns were addressed. The resident reported being scheduled for a shower but receiving a bed bath instead, and staff confirmed the resident was scheduled for two showers per week and was assigned a shower on the evening of 9/11/25, yet no refusal documentation or progress note supported that the shower was declined. Task documentation also showed multiple missed showers across June, July, August, and early September 2025. For Residents #58 and #60, review of ADL documentation showed repeated missed entries for bladder and bowel control, toileting dependence, and hygiene needs over multiple dates in July and from mid-August through mid-September 2025. Both residents were observed in bed with staff assigned to care for them, and staff reported that both residents were incontinent, wore incontinence briefs, and required at least one-person assistance with bathing and dressing. Staff also stated that neither resident was known to refuse care. The Nursing Home Administrator and DON acknowledged the deficiency related to failing to provide and document consistent ADL care that resulted in residents not receiving the care and assistance they were care planned for.
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What surveyors actually found near you
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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.
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Nursing homes near Hagerstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hagerstown Healthcare Center | 0.6 mi | ★★★★★ | 28 | 0 |
| Creekside Center For Rehabilitation And Nursing | 1.1 mi | ★★★★★ | 34 | 1 |
| Coffman Nursing Home | 2.1 mi | ★★★★★ | 16 | 0 |
| Western Md Hospital Center | 2.4 mi | ★★★★★ | 20 | 0 |
| Homewood Living Williamsport | 4.6 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.