Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Largo Nursing And Rehabiliation Center during CMS and state inspections, most recent first.
A resident identified as at risk for skin breakdown was evaluated by a wound NP, who recommended preventive interventions including floating the heels while in bed. This recommendation was not entered as a physician order and was not added to the resident’s care plan, despite the risk status. Later documentation showed the resident had developed multiple wounds, including heel/foot pressure injuries and a Stage 2 sacral pressure ulcer. Although the TAR reflected that weekly skin assessments were completed over several weeks, the skin observation tool in the EHR contained only a single documented assessment. The ADON and DON confirmed the lack of documentation for the weekly assessments and the failure to implement the heel-floating recommendation, and an LPN verified that only one weekly skin assessment was recorded and expressed uncertainty about who was responsible for entering new orders from wound care recommendations.
A resident with severe cognitive impairment and hemiplegia, care-planned for two-person assistance with bed mobility and use of low bed and fall mats, was assisted by a single GNA who released contact during incontinence care, resulting in the resident rolling off the bed and being eased to the floor. Observations showed that this resident’s bed was not kept in the lowest position and fall mats were not in place as ordered. Another resident with hemiplegia, weakness, and lack of coordination had a care plan requiring fall mats at the bedside, but repeated observations found no mats present, and staff acknowledged that these fall interventions, though care-planned, were not implemented.
Surveyors found that the facility did not implement care-planned fall interventions for two residents with cognitive impairment and hemiplegia following cerebral infarction. Both residents had care plans identifying them as at risk for falls, with specific interventions such as placing fall mats at the sides of their beds and keeping beds in the lowest position. On multiple observations, the residents were in bed without fall mats in place, and in one case the bed was not in the lowest position. Staff, including GNAs and the ADON, acknowledged that these interventions were required by the care plans but had not been implemented, despite expectations from the DON and Administrator that fall interventions be followed.
A resident with a seizure history and intact cognition had an active order for Dilantin, with care plan instructions for staff to administer medications as ordered. After lab results showed an elevated Dilantin level, an LPN documented that the physician ordered the Dilantin to be held and the level rechecked. Despite this, the medication administration record showed the LPN administered another dose of Dilantin later that same day. The physician, ADON, DON, and Administrator all confirmed that the dose was given after the hold order, constituting a significant medication error.
Surveyors found that staff did not consistently use required PPE for two residents on contact precautions and enhanced barrier precautions. One resident with an ESBL wound infection had active orders and care plan directives for contact isolation, with signage on the door, yet an LPN entered the room and stood by the bed without donning a gown or gloves, later acknowledging this was contrary to the posted instructions and facility expectations. Another resident with an indwelling urinary catheter and surgical wound had orders for EBP, but during a mechanical lift transfer, a GNA and an LPN wore only gloves and no gowns, despite both later stating that residents with catheters or wounds under EBP require a gown and gloves when care is provided. Leadership, including the ADON, DON, and Administrator, confirmed that staff are expected to follow PPE requirements as indicated on isolation and EBP signage.
Environment Not Kept in Good Repair: Surveyors observed patched walls, peeling paint, stained ceiling tiles, broken or missing bed remotes, broken furniture, a broken clock, and dirt buildup in multiple resident rooms during the recertification survey. The MD stated he was not aware of the broken items and said staff were supposed to enter maintenance repair requests in the records system, but he had not received requests for the items observed.
Improper medication storage was observed on multiple med carts and in the med room refrigerator. An LPN had unopened insulin pens, eye drops, vaccines, and Retacrit stored on carts in pharmacy bags labeled to refrigerate until opened or until administered, and one cart also held two home medications. The refrigerator contained expired insulin pens and Prevnar vaccine vials, and the DON confirmed the expired items were present.
Incomplete Investigation of Alleged Sexual Abuse: A resident alleged inappropriate touching by a housekeeping staff member, but the facility’s investigation only included female residents on one unit. The LPN who conducted the investigation did not interview or observe male residents or residents on other units, even though the staff member had clocked in earlier and worked on other floors. The DON and ADON confirmed the limited scope of the investigation and acknowledged that male residents were also at risk for sexual abuse.
Failure to Notify Cognitively Intact Resident of Care Plan Meeting: A resident with a BIMS of 15 and who was his or her own RP was not directly invited to the care plan meeting. Staff sent the invitation to a family member who was not the RP, and the resident was only told in person on the day of the meeting. The resident stated dissatisfaction with not being notified, and staff confirmed the invitation should have gone to the resident.
A resident’s choice to get out of bed and receive scheduled ADL care was not honored. The resident reported being left in bed for extended periods because staff said there was low staffing, and observations showed the resident in bed in a gown without ADL care. Record review showed missed showers, limited documentation, and conflicting staff statements about whether the resident was up daily or whether showers were completed, including a GNA stating there was not enough time to shower everyone.
A resident did not receive required Medicare beneficiary notices after Medicare Part A billing stopped. Survey review found the ABN and NOMNC were missing from the record, even though the resident had not exhausted all Part A skilled benefit days, and the SS Director confirmed both forms should have been issued when the resident transferred to the skilled unit.
Failure to Monitor Residents Receiving Psychotropic Medications: The facility failed to ensure adequate monitoring for three residents receiving psychotropic medications, including orders for anxiolytic, antidepressant, antipsychotic, and sedative medications. Their records lacked behavior monitoring, side effect monitoring, and non-pharmacological intervention orders, and the ADON confirmed these monitoring measures had not been initiated when documentation was requested.
The facility failed to give a resident and/or RP written notice of the bed-hold policy after the resident was transferred from a nephrology appointment to the ER and later admitted with fluid overload related to CHF. The DON and ADON also confirmed there was no documentation that the Ombudsman was notified of the resident’s hospital transfer.
A resident’s MDS assessment failed to include anxiety in Section I, Active Diagnoses, even though the attending provider documented anxiety and the resident was receiving buspirone for that condition. The MDS Coordinator acknowledged the diagnosis was missed on both the admission and Modification assessments, and the record later showed the MDS was modified after the surveyor raised the concern.
Failure to Provide Scheduled Showers: A resident who required staff assistance with ADLs did not receive scheduled showers as directed in the POC. The resident’s RP stated the resident had only received bed baths since admission, and shower documentation showed missed showers with no documented reason for at least one missed occurrence. Interviews with the UM, GNA, ADON, and DON confirmed that showers were expected twice weekly and that there was no documentation explaining why the resident did not receive them.
A facility failed to provide comprehensive, individualized activities for 3 residents whose care plans and conditions called for more than routine TV watching. A blind resident reported no activities were offered in the room, a resident needing 1:1 engagement had no documented 1:1 interactions or drawing supplies offered, and a bedbound, non-verbal resident had no documented recreation activities. Recreation staff reported understaffing and limited time for 1:1 engagement.
A resident reported pressing the call bell for help with being changed and cleaned and still had not received assistance hours later. The call bell remained lit on the hallway display and at the nurse’s station until a CNA checked the room, then went to the elevator for break without first ensuring another staff member knew the resident still needed help; two staff members entered the room shortly afterward.
Failure to prevent pressure ulcers was identified for a resident admitted with intact skin but a high Braden score, total dependence for transfers/bed mobility/personal care, and bowel/bladder incontinence. The resident developed an in-house acquired sacral pressure injury that progressed from Stage II to Stage III, with wound measurements fluctuating and later increasing in size; survey observations also found the resident lying on the back for extended periods and later on the side while calling for help.
Insufficient pain management occurred for a resident who fell out of bed and reported left shoulder pain. The resident was observed wincing with movement, and an LPN documented pain at 3/10 in a progress note, but the MAR showed 0/10 and no PRN analgesic was ordered. An LPN and the DON stated staff are expected to assess pain, notify the MD when no pain med is ordered, and obtain an order, but no pain medication was obtained at that time.
Medication administration error rate exceeded the allowed threshold after an LPN gave two ordered 10:00 AM medications to a resident with the 8:00 AM med pass. MAR review showed gabapentin and acetaminophen were administered 1 hour and 50 minutes early, contributing to an 8% error rate during survey observation. The DON stated the facility’s procedure is to follow the 5 rights and give meds within one hour before or after the scheduled time.
Food was not stored under sanitary conditions in the kitchen freezer, where a nonworking fan caused icicles to form and drip onto an open box of packaged ice cream. Surveyors also found opened frozen fish packages with loose, exposed pieces. In a nourishment refrigerator, an LPN observed Tupperware containers that were unlabeled or missing dates, despite the expectation that food brought in by families or residents be labeled with a name and date.
Inaccurate pain documentation in resident record: A resident who recently fell out of bed reported left shoulder pain, and an LPN documented pain as 3/10 in a progress note while also recording 0/10 in the MAR for the same day. The DON was informed of the discrepancy, and an LPN stated that pain assessments are documented in the MAR and may also appear in progress notes.
Infection control practices were not maintained when a resident was left on a bare mattress after soiled linens were removed and placed on the floor. In addition, an unvaccinated CNA was observed in common areas without the required mask during flu season, despite the ICP stating that staff without the influenza vaccine were expected to wear one.
A resident reported inappropriate touching by a Geriatric Nurse Assistant to a nurse, but the nurse did not immediately report the allegation to a supervisor as required. Another LPN later learned of the allegation and promptly notified the Social Worker, Administrator, and DON. The facility's protocol for immediate reporting of abuse allegations was not followed by the initial staff members involved.
A resident was discharged without proper documentation or communication regarding their needs, appeal rights, or bed-hold policies. The social worker failed to coordinate discharge planning, resulting in missed RN assessments, lack of home care setup, and no evidence of Medicaid benefit renewal or transfer of responsibility. The resident, who had a wound, left on an approved LOA, did not return, and was discharged without home care, leading to a worsening condition and hospital admission.
The facility failed to securely store medications and hazardous items, and did not investigate the root cause of falls or regularly assess fall risks. Surveyors found unsecured medication rooms and supply rooms, and residents with cognitive impairments were observed near these areas. Additionally, fall incidents involving two residents were not properly documented or investigated.
A resident sustained a laceration requiring 6 sutures after an altercation with a receptionist who tried to stop the resident from calling 911 due to a delayed smoke break. Witnesses confirmed that the resident was struck with a phone handset by the receptionist, leading to the injury.
The facility failed to document, review, and provide written responses to grievances and concerns from the resident council. The resident council president confirmed that concerns such as short staffing, staff using phones, and cold water were not reflected in the meeting minutes. The nursing home administrator acknowledged hearing these complaints but did not ensure proper documentation or follow-up.
The facility failed to employ a full-time clinically qualified nutrition professional to oversee food preparation and daily kitchen operations. The Food Service Manager was not a certified dietary manager, and the registered dietician was not full-time, affecting the quality of food and nutrition services for all residents.
A resident expressed dissatisfaction with the facility's food and relied on family-provided meals. The dietitian's assessments and notes did not document the resident's food preferences or dislikes, and the facility did not make reasonable efforts to provide food the resident would eat. The process for determining food preferences was unclear and inconsistently documented, leading to the resident's reliance on outside food sources.
The facility administration failed to provide effective oversight, resulting in insufficient nursing staff, an unclean and hazardous environment, unqualified kitchen staff, unmet social services needs, and an ineffective QAPI program. Multiple residents reported delays in care, and staff confirmed frequent understaffing. The Administrator was unaware of several regulatory requirements and issues within the facility.
The facility failed to maintain an effective QAPI program, as evidenced by informal tracking, lack of formal audits, and the Administrator's unawareness of missed or late baseline care plans. This deficiency was identified during the recertification survey and had the potential to affect all residents, families, and visitors.
The facility failed to maintain essential equipment in safe operating condition, including a walk-in freezer with significant ice buildup and assistive shower chairs and a sitting chair with safety hazards. Staff acknowledged the issues but did not take timely corrective actions.
The facility staff failed to maintain a clean, neat, attractive, and well-repaired environment, as observed by surveyors across all three nursing units. Numerous issues were noted, including discolored and marked shower room doors, a hanging electric box, scraped paint, holes in bumper moldings, and various other damages in multiple rooms and hallways. Despite an ongoing renovation project, the facility staff failed to maintain a safe, clean, and comfortable environment for the residents.
The facility failed to conduct and document care plan meetings at required intervals, involving residents and their representatives. This deficiency was observed in five residents, with instances of outdated care plans and missed meetings, leading to inaccurate and unreviewed care interventions.
The facility failed to provide sufficient nursing staff to meet resident needs, as evidenced by complaints and interviews. Residents reported long wait times for assistance and lack of care, while staff confirmed experiencing burnout and being unable to adequately care for residents due to low staffing levels. The DON acknowledged these concerns.
The facility failed to act on multiple pharmacy drug problems identified for a resident, including not following recommendations for Fosamax administration and not addressing significant drug therapy problems from a previous review. Interviews revealed a flawed process for handling pharmacy recommendations, with no follow-up actions taken.
The facility failed to ensure a resident was free from unnecessary medications, accurately reconcile and transcribe medication orders, and provide clear physician orders for pain medication, leading to inappropriate administration of medications.
The facility failed to maintain an effective infection control program, including not placing an order for contact precautions for a resident with C-diff, improper hand hygiene by an LPN during wound care, contaminated linens, outdated infection control policies, and inconsistent waterborne infection monitoring.
The facility failed to monitor and track antibiotic usage and resistance data, as evidenced by the lack of documented indications for antibiotic use in two residents' orders and inadequacies in the antibiotic stewardship program. The facility did not include diagnoses in the antibiotic orders and lacked a specific report for antibiotic surveillance. These deficiencies were confirmed during interviews with the ICP and DON.
The facility failed to provide comprehensive behavioral health training for staff, resulting in inadequate care for residents with mental and psychosocial conditions. A staff member allegedly struck a resident during a physical struggle, highlighting the lack of proper training in behavior management.
The facility failed to treat residents with dignity and respect, as evidenced by a staff member continuing to care for a resident despite the resident's request for reassignment, untimely emptying of urinals, and improper transport of a resident in a Geri chair. These incidents were confirmed through resident interviews and surveyor observations.
The facility failed to thoroughly investigate multiple allegations of abuse, neglect, and injuries of unknown sources. Investigations lacked proper documentation, witness statements, and timely actions to prevent further harm. In some cases, alleged perpetrators continued to work during the investigation, and critical records were missing or incomplete.
The facility failed to maintain complete and accurate medical records for multiple residents, including missing documentation for a court-ordered transfer, incomplete wound treatment orders, lack of hospital visit records, and inability to access previous records for a resident with an injury.
The facility failed to accurately code a resident's significant weight loss on the MDS assessment. Despite documented weight loss and the use of appetite-stimulating medication, the MDS coordinator marked the weight loss section as no/unknown. The coordinator could not explain the discrepancy and mentioned the resident's refusal to be weighed.
The facility failed to provide residents and their representatives with a summary of the baseline care plan within 48 hours of admission. This deficiency was identified for three residents, with staff confirming the absence or delay of the required documentation in each case.
The facility staff failed to develop and initiate comprehensive person-centered care plans for residents, including those with behavioral-emotional health needs, suprapubic catheter care, hospice care, and C. diff infection. The care plans lacked measurable objectives, specific interventions, and did not address all relevant diagnoses.
A facility failed to meet professional standards by not ensuring staff followed physician orders for medication administration and documentation. An LPN administered Acetaminophen to a resident outside the scheduled time and signed off on it before administration. The Unit Manager confirmed the need to follow the five rights of medication administration, and the DON expressed a preference for minimal errors. The facility's policy requires timely administration and proper documentation.
The facility failed to provide adequate activity services to meet a resident's needs. The resident reported insufficient staff for transportation to activities, lack of adaptive equipment, and not being taken to the patio for four years. The care plan was outdated, and the Director of Activities was unaware of the need for thorough documentation.
A resident readmitted with a Foley catheter did not receive appropriate catheter care from the time of readmission until four days later, despite having a urine culture indicating infection. This lapse was confirmed through medical record review and staff interviews, highlighting a significant deficiency in catheter care protocols.
Failure to Implement Pressure Ulcer Prevention Orders and Document Weekly Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to implement provider-recommended pressure ulcer prevention interventions and to complete and document weekly skin assessments for a resident identified as at risk for skin breakdown. A Skin and Wound Progress Note dated 01/22/2026 documented that the resident had no wounds but was at risk for skin breakdown, and the wound NP recommended preventative interventions, including floating the resident’s heels while in bed. This recommendation was not translated into physician orders, and the resident’s care plan, although identifying the resident as at risk for pressure ulcers, did not include an intervention to float heels while in bed. The DON and ADON later confirmed that the 01/22/2026 provider recommendation to float heels was not implemented through orders or the care plan. The clinical record further showed that by 02/20/2026 the resident had developed multiple wounds, including pressure injuries to the heels/feet and a Stage 2 pressure ulcer to the sacrum, as documented in a Skin and Wound Progress Note. The Treatment Administration Records indicated that weekly skin assessments were marked as completed on multiple dates in January and February 2026, but review of the skin observation tool documentation revealed no corresponding entries for those dates, with only one skin observation tool completed on 02/20/2026 since admission. The ADON stated that the wound care provider’s recommendations are communicated to the assigned nurse and unit manager, who are responsible for entering orders and updating the care plan, and that weekly skin assessments are to be documented using the skin observation tool. An LPN confirmed, upon review of the record with the surveyor, that no additional weekly skin assessments were documented aside from the 02/20/2026 entry and was unsure who was responsible for entering new orders based on the wound provider’s recommendations.
Failure to Provide Required Assistance and Implement Care-Planned Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate assistance with bed mobility and to implement care-planned fall interventions for residents at risk for falls. Resident #6, admitted with a history of cerebral infarction and resulting hemiplegia/hemiparesis, had a Minimum Data Set (MDS) showing severe cognitive impairment (BIMS score of 0) and dependence on staff for toileting hygiene and rolling in bed. The resident’s care plan, initiated shortly after admission, directed staff to provide two-person assistance with bed mobility and to keep the bed in the lowest position while the resident was in bed. Despite this, a progress note documented that the resident fell during activities of daily living care. An LPN reported that a GNA pulled the resident to turn them in bed and the resident rolled off the bed; the GNA stated she believed the resident was a one-person assist and described releasing contact with the resident to retrieve an incontinence brief, after which the resident began to roll and she eased the resident to the floor. The ADON, another LPN, the DON, and the Administrator all stated that Resident #6 required two-person assistance for bed mobility and that two staff should have been present during such care. The facility also failed to implement fall interventions that were included in Resident #6’s care plan. The care plan for Resident #6, updated after a recent hospitalization and fall risk identification, included interventions to place fall mats on both sides of the bed and to maintain the bed in the lowest position while the resident was in bed. Multiple observations of the resident’s room on different days showed that fall mats were not present on either side of the bed and that the bed was not in the lowest position, despite these interventions being listed on the care plan. During interviews conducted concurrently with these observations, a GNA and the ADON acknowledged that fall mats were not in place and that the bed was not in the lowest position, even though the care plan required these measures. Resident #4, admitted with hemiplegia, muscle weakness, cerebral infarction, and lack of coordination, was also care-planned as being at risk for falls related to weakness, hemiplegia, and a recent hospitalization. The resident’s care plan included an intervention to place fall mats at the sides of the bed. However, during observations on multiple occasions, Resident #4 was seen in bed without fall mats present. In concurrent interviews, a GNA and the ADON confirmed that fall mats should have been in place according to the care plan but were not. The DON and the Administrator both stated they expected fall interventions to be implemented, yet the observations showed that the planned fall-prevention measures for Resident #4 were not carried out.
Failure to Implement Care-Planned Fall Interventions for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall interventions for two residents identified as being at risk for falls. Facility policy required licensed nursing staff, with the interdisciplinary team, to develop and implement individualized care plans to provide necessary services for each resident’s highest practicable well-being. Resident #6, admitted with a history of cerebral infarction and resulting hemiplegia/hemiparesis, had a Minimum Data Set (MDS) showing a BIMS score of 0, indicating severe cognitive impairment. The resident’s care plan, initiated after a recent hospitalization and fall, included interventions to place fall mats on both sides of the bed and to keep the bed in the lowest position while the resident was in bed. On multiple observations in February, surveyors and staff noted that fall mats were not present and the bed was not in the lowest position, despite these interventions being listed on the care plan. Resident #4, admitted with hemiplegia and hemiparesis following cerebral infarction, muscle weakness, cerebral infarction, and lack of coordination, had an admission MDS with a BIMS score of 12, indicating moderate cognitive impairment. This resident’s care plan, also initiated after a recent hospitalization and fall, identified risk for falls related to weakness and hemiplegia and directed staff to place fall mats at the sides of the bed. On repeated observations, the resident was in bed without fall mats present. Staff, including a Geriatric Nursing Assistant and the Assistant Director of Nursing, acknowledged during interviews that fall mats should have been in place according to the care plan but were not. The Director of Nursing and the Administrator both stated they expected fall interventions to be implemented, confirming that the planned interventions were not carried out as required.
Dilantin Administered After Order to Hold Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when staff administered Dilantin despite an active order to hold the medication. Facility policy required medications to be administered in accordance with written prescriber orders. The resident, admitted with a history of seizures and care planned as being at risk for complications related to seizures, had an active order for Dilantin 50 mg chewable tablets, three tablets by mouth twice daily. A quarterly MDS showed the resident had intact cognition and was receiving an anticonvulsant during the assessment period. On the day of the incident, a lab result showed the resident’s Dilantin level was greater than 40 mcg/mL. LPN #5 documented that the physician was notified and ordered the Dilantin to be held and the level repeated on a later date. Despite this order to hold the medication, the Medication Administration Audit Report showed that LPN #5 administered a dose of Dilantin to the resident later that same evening. The physician later stated concern that the resident received more Dilantin after he ordered it held, though he reported no lasting effect from the extra dose. The ADON, DON, and Administrator each confirmed through review of the electronic medical record that the nurse administered Dilantin after the order to hold the medication had been received, contrary to the physician’s order and facility policy.
Failure to Use Required PPE for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff consistently used required personal protective equipment (PPE) for residents on contact precautions and enhanced barrier precautions (EBP). Resident #10, admitted with a history including a local skin and subcutaneous tissue infection and extended spectrum beta lactamase (ESBL) resistance, had active orders and a care plan for contact precautions related to an ESBL wound infection, directing staff to use appropriate PPE and maintain isolation precautions. A contact isolation sign was posted on the resident’s door. During observation, an LPN entered the resident’s room without a gown or gloves, stood next to the resident’s bed, and stated she believed PPE was only required if she was providing care. After reviewing the posted contact isolation information, the LPN acknowledged she should have donned a gown and gloves before entering. The ADON, DON, and Administrator each stated that staff were required to wear a gown and gloves whenever entering the room of a resident on contact isolation, even if only asking a question. The facility also did not ensure proper PPE use for Resident #12, who had an indwelling urinary catheter and a surgical wound, with active orders for EBP every shift and a care plan indicating the need for EBP. During observation, a GNA and an LPN transferred the resident from bed to wheelchair using a mechanical lift while wearing gloves but no gowns. The LPN later stated that EBP should be used, including PPE, when caring for residents with urinary catheters and acknowledged she should have stopped the transfer to put on a gown upon seeing the catheter. The GNA stated that residents with wounds, infections, feeding tubes, or catheters required EBP and that a gown and gloves were to be worn when providing care. The ADON, DON, and Administrator each confirmed that EBP, including both gown and gloves, was required when providing care, such as transfers, to residents with devices like indwelling urinary catheters or wounds, and that staff were expected to follow the PPE requirements listed on signage.
Environment Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure that the environment was in good repair in 6 of 6 resident rooms observed on the [NAME] Wing during the recertification survey. Surveyors observed patched walls, stained ceiling tiles, wall damage, peeling paint, missing or broken bed remotes, broken furniture, a broken clock, and dirt buildup on the floor in front of wardrobe cabinets in resident rooms #239, #240, #237, #245, #235, and #242. During the later tour, the Surveyors and Maintenance Director observed wall damage, peeling paint, and walls patched but not painted in several rooms, a missing bed remote in one room, a broken nightstand drawer front in another, a bed remote that did not work, a clock that was not holding time, stained ceiling tiles above the bed, and a large amount of black substance that appeared to be dirt in front of wardrobe cabinets in rooms #235 and #242. The Maintenance Director stated he was not aware of the broken items and explained that staff were supposed to enter maintenance repair requests in a system called records, but he had not received repair requests for the broken items.
Improper Storage of Refrigerated and Expired Medications
Penalty
Summary
Drugs and biologicals were not properly stored in accordance with accepted professional principles. During observation of three medication carts, unopened eye drops and multiple unopened insulin pens for several residents were found stored on carts in pharmacy bags labeled to refrigerate until opened. One cart also contained an unopened respiratory syncytial virus vaccine labeled to refrigerate until administered, three unopened Retacrit vials labeled to refrigerate until administered, and two medication bottles brought from home that were being stored on the cart. Staff confirmed the medications were unused and that the home medications should not have been kept on the cart. The medication storage room and refrigerator also contained expired medications. Two expired insulin pens and two expired Prevnar pneumonia vaccine vials were observed in the medication refrigerator for residents whose medications had expired on the dates listed in the report. The DON confirmed the expired items were in the refrigerator. A record review further showed that three residents associated with the expired medications had been discharged before the survey findings were reviewed.
Incomplete Investigation of Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident and housekeeping staff member #19. The resident reported that the staff member had touched him/her inappropriately, and the facility-reported incident investigation was reviewed during the annual survey. The investigation documentation showed that only residents on the Arcadia Unit were interviewed, and only female residents were included. There was no documentation that male residents or residents on other units were interviewed or observed for potential signs of abuse. During interview, the DON and ADON confirmed that the LPN who conducted the investigation interviewed only female residents because the alleged employee was on the female side of the unit at the time of the alleged incident. It was also discussed that the employee had clocked in earlier that morning and could have had access to male residents before the alleged incident time, and that the employee was not permanently assigned to the Arcadia Unit and worked on other floors. The DON and ADON acknowledged that male residents were also at risk for sexual abuse and recognized the concern raised by the surveyor.
Failure to Notify Cognitively Intact Resident of Care Plan Meeting
Penalty
Summary
The facility failed to ensure a resident’s right to participate in the development and implementation of his or her person-centered plan of care. Resident #5 stated that he or she did not receive an invitation to the care plan meeting and was only informed by staff when they came to the room on the day of the meeting. The resident reported that the Social Worker said the invitation had been sent to a family member who was not the resident’s responsible party, and that the family member received it after the meeting had already occurred. The resident, who stated being alert and oriented, expressed dissatisfaction with not being notified directly. Review of the medical record showed the resident had a BIMS score of 15, indicating cognitive intactness, and was his or her own responsible party for medical decisions. The Social Services Coordinator stated that invitations are sent to the resident and/or responsible party if the resident is capable, with a follow-up call one week before the meeting; however, for Resident #5, the invitation was sent to a family member who was not the responsible party. The Social Services Coordinator and Regional Social Worker confirmed that the facility’s expectation is to notify the resident unless the resident lacks capacity, and both acknowledged that the invitation should have been sent to the resident rather than to a non-responsible family member.
Resident Choice and ADL Care Not Honored
Penalty
Summary
The facility failed to ensure a resident’s choices were honored. Resident #61 told surveyors that he/she could not get up, had not been out of bed in 2 weeks, and wanted to get up every day, but was told by staff that there was low staffing and no one was available to assist with getting out of bed. The resident reported being dependent on staff to transfer him/her from bed to a chair using a hoyer lift. During observations on 11/18/2025 and 11/19/2025, the resident was seen in bed wearing a gown and had not received ADL care. Record review showed the resident received only 2 showers in a 30-day look-back period, and the shower binder contained only one shower sheet for the resident in the last 30 days, with no documentation showing whether the shower was completed. The care plan did not address bed baths only or getting out of bed on certain days. Staff interviews reflected that the facility expected bedbound residents to be gotten out of bed daily as part of routine care, unless the resident requested otherwise, and that missed showers due to hot water being off would be made up. However, an LPN stated the resident was up out of bed every day, while a GNA stated she did not shower the resident on two scheduled days and would not be showering the resident that day because there was not enough time and a bed bath was just as clean. On review of the 90-day shower record, the resident received 11 of 28 scheduled showers, with only one documented refusal.
Missing Medicare Beneficiary Notifications
Penalty
Summary
The facility failed to ensure that a resident received beneficiary notifications related to Medicare coverage and potential liability for non-covered services. Record review showed that Medicare Part A billing for Resident #16 stopped on 05/27/2025, but the facility was unable to locate the Advance Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) forms when they were requested during the survey. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review form confirmed that both the ABN and NOMNC were missing, and the resident had not exhausted all Medicare Part A skilled benefit days. The Social Services Director confirmed that both notices should have been issued when the resident transferred to the skilled nursing unit and that the facility had no record of either form for the resident.
Failure to Monitor Residents Receiving Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring for residents receiving psychotropic medications. During record review, Resident #14 had an order for busPIRone HCl 5 mg once daily for anxiety, Resident #5 had an order for bupropion HCl ER (XL) 300 mg once daily for depression, and Resident #1 had orders for ARIPiprazole 10 mg via PEG-tube once daily for bipolar disorder and traZODone HCl 100 mg via PEG-tube at bedtime for depression. For these residents, the records did not contain orders for behavior monitoring, side effect monitoring, or non-pharmacological interventions. During interview, the ADON stated that residents receiving psychiatric medications were monitored through non-pharmacological interventions, behavior monitoring, side-effect monitoring documented on flow sheets, AIMS assessments, and physician verification of medication indications. However, when documentation was requested for Residents #14, #5, and #1, the ADON reported that behavior monitoring, non-pharmacological interventions, and side-effect monitoring had not been initiated for them. The surveyor later found that orders for non-pharmacological interventions, behavior monitoring, and side effect monitoring had been added to the medical records after the surveyor's intervention.
Failure to Provide Bed-Hold Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to the resident and/or resident representative after Resident #120 was transferred from a nephrology appointment to the emergency room due to a change in condition and later admitted to the hospital with fluid overload related to CHF. Review of the medical record found no documentation in either the paper or electronic record showing that the bed-hold notice had been provided. The facility also failed to notify the Ombudsman of the resident’s transfer to the hospital. During interviews, the DON stated she was unsure whether a bed-hold notice had been provided and was not sure about the Ombudsman notification process. Later, the DON and ADON reported that the facility had not provided the bed-hold policy notice after the hospital admission was confirmed and that there was no documentation verifying that the Ombudsman had been notified of the transfer.
Inaccurate MDS Diagnosis Coding
Penalty
Summary
Facility staff failed to ensure the accuracy of the MDS assessment for a resident reviewed for unnecessary medications. The resident was admitted with diagnoses including anxiety, and the attending provider documented anxiety in a note dated 10/24/2025. The resident’s MAR for 11/1/2025 through 11/20/2025 showed an order for buspirone HCl 5 mg by mouth once daily for anxiety, indicating the condition was being actively treated. Review of the MDS assessment completed on 10/27/2025 showed that anxiety was not included in Section I, Active Diagnoses. During interview, the MDS Coordinator stated that diagnoses must be active and documented by the physician within the past 60 days and acknowledged that anxiety should have been coded because the resident was prescribed buspirone for anxiety. She confirmed the diagnosis was missed on both the admission and Modification assessments. The record later showed the MDS was modified after the surveyor raised the concern.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident who required assistance with ADLs received scheduled showers. Resident #6 had been in the facility since 8/4/25, and the plan of care directed staff to provide showers on Mondays and Thursdays, with staff assistance required. The resident’s Responsible Party stated that the resident had not received a shower since admission and had only received bed baths, despite the availability of a chair that could be used to transport the resident to the shower room. Record review showed that GNA shower documentation for Resident #6 from 11/1/25 to 11/19/25 did not show showers on 11/3, 11/6, and 11/13. On 11/17, the resident was marked as not available, but the medical record did not indicate the reason or whether the resident was out of the facility. Interviews with the Unit Manager, GNA #18, ADON, and DON confirmed that residents were scheduled for showers twice weekly, refusals were to be reported and documented, and there was no documentation explaining why Resident #6 did not receive showers on the identified dates.
Failure to Provide Individualized Resident Activities
Penalty
Summary
The facility failed to offer comprehensive activities in accordance with residents’ interests and physical, mental, and psychosocial well-being for 3 of 24 residents reviewed. Resident #61, who was blind, stated there were no activities for blind people other than bingo and reported that staff had never offered or brought activities to the room. The resident was observed lying in bed with the TV on and no activity supplies in the room. The activity care plan called for assistance with planning leisure-time activities, encouragement of group participation, provision of supplies and materials as needed, and respect for limited or no participation, but the 30-day activity record documented watching TV in the room every day. Resident #9’s care plan identified a preference or need for 1:1 activities because the resident was unable or unwilling to participate in other activities, yet the 30-day activity record also documented only watching TV in the room each day. Recreation staff confirmed they had not offered drawing supplies and that no documented 1:1 interactions were found for the last 90 days. Resident #10 was observed bedbound, non-verbal, and receiving enteral feeding, and recreation staff and the Recreational Director could not identify the resident or document any 1:1 activities. Staff stated they were understaffed for about a year and reported that for bedbound or cognitively impaired residents they would play music or put lotion on their hands, but Resident #10 had no documented 1:1 activities with recreation staff.
Delayed Assistance After Call Bell Request
Penalty
Summary
The facility failed to provide quality of care when a resident who reported needing assistance with being changed and cleaned did not receive timely help after pressing the call bell. On 11/17/2025 at approximately 11:30 AM, Resident #56 stated that he/she pressed the call bell for assistance with being changed and cleaned and had not yet received help when interviewed later that afternoon. While the surveyor was present in the room, the resident pressed the call bell again, indicating the request for assistance was still unresolved. During observation, the resident’s call bell light remained illuminated outside the room and on the nurse’s station display at 2:33 PM. At 2:34 PM, CNA #6 was observed walking down the hallway, and the call bell light for Resident #56 was then turned off. CNA #6 stated she had checked on the resident but was going on break. When asked whether another staff member had been informed that the resident still needed assistance, CNA #6 exited the elevator and notified two staff members at the nurse’s station that she was going on break and requested they assist Resident #56. Two healthcare staff were then observed entering the resident’s room at 2:36 PM.
Failure to Prevent Worsening Sacral Pressure Ulcer
Penalty
Summary
Failure to implement measures to prevent pressure ulcers was identified for one resident who was admitted with intact skin and no wounds, but who had a Braden Scale score of 11, indicating high risk for pressure ulcer development. The resident was totally dependent on staff for transfers, bed mobility, and personal care, and was incontinent of both bladder and bowel, requiring full assistance with all ADLs. An at-risk assessment later noted excoriation to the left buttock, and the resident subsequently developed an in-house acquired Stage II pressure ulcer on the sacrum/buttock area. The resident’s sacral wound later worsened to a Stage III pressure ulcer, with record reviews showing fluctuating measurements over time and a significant increase in size on one weekly skin observation sheet. Physician wound notes documented the progression from intact skin on admission to a new Stage II sacral pressure injury, then worsening to Stage III with slough present. During survey observations, the resident was seen lying on the back for extended periods and later lying on the left side while calling for help, and the DON and ADON acknowledged that the wound had worsened.
Insufficient Pain Management After Resident Fall
Penalty
Summary
The facility failed to provide sufficient pain management for Resident #75 after the resident fell out of bed on 11/16/2025 at 5:00 PM and reported left shoulder pain from landing on the floor. During an interview on 11/18/2025, the resident stated there was pain in the left shoulder, and the resident was observed wincing when attempting to move the shoulder. A progress note dated 11/17/2025 documented that the resident verbalized shoulder pain rated 3/10 and was able to move and elevate both arms with assistance. Record review showed the November 2025 MAR included a 0-10 pain scale section, but on 11/17/2025 LPN #20 documented the resident’s pain level as 0/10. The MAR also showed the resident did not have any PRN pain medication ordered. During interviews, LPN #12 stated that when a resident reports pain without PRN pain medication ordered, staff are expected to obtain an order from the physician, and the DON stated staff are expected to assess pain using a 0-10 scale, notify the physician if no pain medication is ordered, and ensure pain medication is prescribed. The DON was informed that the resident’s pain was documented as 3/10 in the progress note, yet no pain medication was obtained at that time.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, with 2 medication administration errors out of 25 observed opportunities for an 8% error rate during the recertification survey. During a medication administration observation, an LPN prepared and administered Resident #29’s morning medications, including Breo, cholecalciferol 1000 units, losartan potassium 100 mg, mirabegron 25 mg, acetaminophen 500 mg, aspirin 81 mg, gabapentin 200 mg, and ipratropium bromide/albuterol sulfate 0.5 mg/1 mg. A later review of the MAR showed that gabapentin and acetaminophen were ordered for 10:00 AM but were administered at 8:10 AM with the resident’s 8:00 AM medications, which was 1 hour and 50 minutes before the scheduled time. The DON stated the facility’s medication administration procedure is to follow the 5 rights of medication administration and administer medications within one hour before and one hour after the scheduled time.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store food under sanitary conditions in the kitchen freezer. During the annual survey kitchen review, a surveyor observed two fans in the freezer, with the right fan not operating and icicle formation beneath it. The icicles had formed to the point of dripping onto an open box of packaged ice creams. The surveyor also observed an opened package of frozen breaded fish with loose pieces of fish outside the box and exposed, as well as another box of frozen fish containing loose, exposed pieces. The facility also failed to ensure food items in the nourishment refrigerator were properly labeled and dated. In the nourishment refrigerator for the Congressional Unit, a container of food in Tupperware was observed without a label or date, and another Tupperware container was labeled but did not include a date. An LPN stated that when families or residents bring food in, items are expected to be labeled with a name, date, and sometimes a room number, and that nurses and GNAs are responsible for ensuring this is done.
Inaccurate pain documentation in resident record
Penalty
Summary
The facility failed to accurately document resident records for one resident reviewed for pain management. After the resident reported a recent fall out of bed and left shoulder pain from landing on the floor, the record showed the fall occurred on 11/16/2025 at 5:00 PM. A progress note by an LPN on 11/17/2025 documented that the resident verbalized shoulder pain rated 3/10 and was able to move and elevate both arms with assistance. However, review of the November 2025 MAR showed a pain assessment section using the 0-10 scale, and the same LPN documented the resident's pain level as 0/10 for 11/17/2025. During interview, an LPN stated that pain assessments are documented in the MAR and may also be included in progress notes. The DON stated that staff are expected to assess and document pain using the 0-10 scale, and was informed that the resident's pain was documented as 3/10 in the progress note but 0/10 in the MAR for the same date, creating a discrepancy in the medical record.
Infection Control Lapses With Soiled Linens and Unmasked Unvaccinated CNA
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices by allowing visibly soiled linens to be placed on the floor in a resident’s room and leaving the resident lying on a bare mattress without clean sheets. On 11/21/2025 at 8:33 AM, a surveyor observed soiled linens on the floor of Resident #15’s room and observed Resident #15 lying on the bed without sheets, directly on a bare mattress. At approximately 8:34 AM, the resident stated that a staff member had cleaned him/her, removed the soiled linens, placed them on the floor, and left the resident on the uncovered mattress. The facility also failed to ensure required PPE use by staff who had not received the seasonal influenza vaccine. On 11/21/2025, the Infection Control Preventionist stated that employees who had not yet received the influenza vaccine were expected to wear a mask during flu season. Record review showed CNA #7 had not yet received the influenza vaccine, and on 11/20/2025 a surveyor observed CNA #7 in the hallway on the second floor and at the nurse’s station on the Arcadia Unit without wearing a mask. The Infection Control Preventionist later confirmed that CNA #7 had not been vaccinated for influenza.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse were immediately reported as required. A resident reported to a nurse that a Geriatric Nurse Assistant had touched them inappropriately during care. The resident stated that the night nurse was informed of the incident on the same day it occurred, but the nurse did not report the allegation to a supervisor in a timely manner. Further review showed that another LPN became aware of the allegation during a meeting with the resident and immediately notified the Social Worker, Administrator, and Director of Nursing. The administrative record and staff interviews confirmed that the initial staff members who received the resident's report did not follow the facility's expectation to report abuse allegations immediately to administration. The deficiency was identified during a complaint survey, and the facility's investigation found that the required immediate reporting protocol was not followed by the night shift nurse and the LPN who first received the allegation.
Failure to Ensure Proper Discharge Process and Documentation
Penalty
Summary
The facility failed to ensure the proper process of discharge for a resident, as evidenced by a lack of required documentation and communication regarding the resident's needs, appeal rights, and bed-hold policies. The assigned Social Services Coordinator was repeatedly unresponsive to the family's attempts to communicate and did not follow through on discharge planning. During the Social Services Coordinator's leave of absence, the resident was unable to obtain a necessary RN assessment for home care setup. Upon the coordinator's return, the RN assessment was completed, but the family was then informed of difficulties obtaining insurance clearance for home care. There was no documentation provided regarding the expiration and renewal of the resident's Medicaid benefits, nor was there evidence of communication or transfer of responsibility to another social worker during the coordinator's absence. The resident, who had developed a wound during their stay, left the facility on an approved leave of absence with family and subsequently declined to return. The facility discharged the resident due to failure to return, but no home care was arranged, and the required discharge documentation was not provided. The wound worsened and became infected, resulting in the resident's hospital admission. Record reviews and interviews confirmed the absence of documentation related to discharge readiness, home care approval, and communication with the family, indicating a failure to follow the required discharge process.
Failure to Secure Medications and Investigate Falls
Penalty
Summary
The facility failed to ensure medications and hazardous items were safely and securely stored, which was evident in two of the three units observed. Surveyors found that the central supply room on the second floor and the first-floor medication room were both accessible without the use of a keypad, allowing unauthorized access to various medications and supplies. This included aspirin, acetaminophen, insulin, and other hazardous items. Additionally, the maintenance log revealed that the keypad to the second-floor central supply room had been reported as not working since June, but no action had been taken to repair it. Residents with cognitive impairments were observed near these unsecured areas, posing a significant risk to their safety. As a result, a state of immediate jeopardy was declared, and multiple plans to remove the immediacy were initially rejected before one was finally accepted by the state agency. The facility also failed to investigate the root cause of falls and initiate nursing interventions to prevent further incidents. For instance, Resident #38 experienced a fall from bed, resulting in swelling and an open area near the left upper cheek and knee. However, there was no documentation to indicate the cause of these injuries or any investigation into the fall. The Director of Nursing (DON) confirmed that the night shift nurse did not report the fall, and no fall assessment or documentation was completed to address the incident. Additionally, the facility did not regularly assess residents' fall risks before actual fall incidents. Resident #323 was found lying face down with injuries, but the most recent fall assessment prior to this incident was conducted more than three months earlier. The assessment form used did not indicate the level of fall risk or the resident's health condition, which could affect the fall risk. The DON acknowledged that the fall assessment form had changed, but no additional documentation was provided to support the assessment of Resident #323's fall risk.
Removal Plan
- A 100% audit of all medication rooms and supply rooms have been conducted by the Administrator, Maintenance Director and DON to ensure medications and hazardous items were safely and securely stored.
- The lock to the central supply room on the 2nd floor located on Independence unit has been replaced with a new code by maintenance staff and is currently secured. Only authorized staff will be allowed access to this room.
- The nurse managers immediately removed all the over-the-counter medications from the central supply room on Independence unit and secured them in the 2nd floor medication room nearest to the nurses' station.
- All insulin needles, hypodermic needles, tuberculin syringes, twin blade shaving razors, and bandage scissors are all currently safely secured in the 2nd floor central supply room on the Independence unit.
- The door to the 1st floor medication room has been repaired and is secured. Education with all licensed nurses has been initiated and will be completed. Training is being conducted by the Staff development nurse, ADON, and DON to ensure the refrigerator is kept locked when not in use.
- The door to the 1st floor supply room across from rehab gym is repaired, locked, and code changed. Education with all licensed nurses has been initiated and will be completed. Training is being conducted by the Staff development nurse, ADON, and DON to ensure the supply room is kept locked when not in use.
- A Staff member was immediately stationed outside each door that did not lock appropriately until the repairs were completed by maintenance.
- Training with licensed nurses, housekeeping staff, and Maintenance staff was initiated by the Staff Development nurse to make certain that the staff pulls the door shut when exiting to ensure all medications and hazardous items are kept safe and secure, and to notify the Administrator and Maintenance director immediately if any door is identified as in need of repair. This will be completed.
- The Administrator and Maintenance director will validate all supply rooms and medication room doors are repaired and secured.
- The Unit managers and nursing supervisors will inspect all supply rooms and medication rooms to ensure all medications and hazardous materials are properly secured and in compliance every shift, then daily.
- Results of the audits will be submitted to the QAPI committee for further review and recommendations as needed.
Resident Injured in Altercation with Receptionist
Penalty
Summary
The facility staff failed to ensure all residents were free from abuse and mistreatment, resulting in actual harm to a resident. Resident #18 experienced a laceration requiring 6 sutures to the forehead after an altercation with a receptionist. The incident occurred when Resident #18 attempted to call 911 due to a delay in the scheduled smoke break. The receptionist, Staff #29, tried to stop the resident from making the call, leading to a physical confrontation where both parties struck each other. Witnesses and staff confirmed that the resident sustained the injury from being hit with the phone handset by Staff #29. The medical record indicated that the resident was found with a bloody face and was sent to the hospital for evaluation and care. The facility's investigation included statements from witnesses and staff, revealing that the receptionist attempted to unplug the phone, leading to the altercation. Staff #30, who witnessed the event, confirmed that the resident was injured as a result of being struck by the receptionist. The incident highlights a failure in the facility's duty to protect residents from abuse and mistreatment.
Failure to Document and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that grievances and concerns from the resident group were documented, reviewed, and responses provided to the group in writing. This was evident in the review of seven resident council meeting minutes, which showed minimal documentation and only one concern noted. The resident council president confirmed that the minutes did not reflect the concerns expressed by residents, such as short staffing on weekends, staff using phones while in residents' rooms, and issues with cold water. The water temperature in the resident council president's bathroom was checked and remained cold without heating up, corroborating one of the concerns raised by the residents. Interviews with the Director of Activities and the nursing home administrator revealed that there was a lack of proper documentation and follow-up on the residents' concerns. The administrator acknowledged hearing the complaints but did not ensure they were addressed in the meeting minutes or followed up in writing. Additionally, the facility failed to hold resident council meetings for December 2023 and January 2024, further neglecting the residents' right to organize and participate in resident/family groups effectively.
Lack of Qualified Nutrition Professional
Penalty
Summary
The facility failed to ensure a full-time clinically qualified nutrition professional for the oversight of food preparation and daily kitchen operations. During an interview, the Food Service Manager revealed that she was not a certified dietary manager (CDM) despite being in the role since March 2021. Documentation provided confirmed that she had completed a Nutrition and Foodservice Professional Training Program but did not have the necessary dietary manager certification. Additionally, the Nursing Home Administrator confirmed that the registered dietician was not full-time at the facility. This deficiency affects all residents as it compromises the quality and oversight of food and nutrition services.
Failure to Address Resident's Food Preferences
Penalty
Summary
The facility failed to assess a resident's needs and preferences and respond to a resident who expressed dissatisfaction with the food provided by the facility. Resident #109, who was at risk for weight loss due to chronic diagnoses, indicated that they did not eat the facility's food and relied on food brought by family members. The dietitian's initial nutrition assessment and subsequent notes did not document the resident's food preferences or dislikes, and there was no evidence that the resident had met with the dietitian to discuss these preferences. Despite the resident's dissatisfaction being documented by a psychogeriatric certified registered nurse practitioner, the facility did not make reasonable efforts to provide food that the resident would eat, as evidenced by the lack of documentation and follow-up in the resident's medical record. The dietitian's notes and interviews revealed that the facility's process for determining food preferences for newly admitted residents or any other resident was unclear and inconsistently documented. The dietitian admitted to not knowing whether the food service manager documented in resident medical records. The surveyor's review of the medical record and interviews with the dietitian highlighted the facility's failure to address the resident's expressed concerns about the food, leading to the resident's reliance on outside food sources. The resident was eventually transferred to the hospital, and the dietitian's late entry progress notes did not reflect timely or adequate efforts to address the resident's nutritional needs and preferences.
Facility Administration Fails to Provide Effective Oversight
Penalty
Summary
The facility administration failed to provide effective oversight to ensure that resident needs were met. This included insufficient nursing staff, as evidenced by multiple residents reporting delays in receiving care, such as bathing, changing, and medication administration. Staff interviews confirmed that the facility often operated with fewer GNAs than required, leading to burnout and inadequate resident care. The Regional Director of Operations indicated that staffing levels were determined by a combination of budget, census, and special needs, but the facility itself could not independently adjust staffing levels without corporate approval. The Administrator was unaware of the federal staffing posting regulation, further highlighting the lack of oversight in staffing management. The facility's physical environment was also found to be in disrepair, with multiple resident care areas needing attention. The Administrator acknowledged these issues but attributed them to the building's age. Additionally, unsecured storage room doors posed potential hazards, which the Administrator was unaware of until the survey team brought it to his attention. The facility also employed unqualified kitchen staff, with the Food Service Manager not being a Certified Dietary Manager, a fact unknown to the Administrator until the survey. Social services were inadequately managed, with the Regional Licensed Clinical Social Worker admitting to insufficient oversight and being unaware of multiple missed care plan meetings. The facility's QAPI program was ineffective, as the Administrator, who chaired the QAPI Committee, could not describe any formal QAPI process and admitted to recurring issues due to a lack of accountability. No QAPI projects had been undertaken to address the identified concerns in staffing, environment, kitchen/dietitian, or social services.
Failure to Maintain Effective QAPI Program
Penalty
Summary
The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced during the QAPI facility task investigation conducted during the recertification survey. The Administrator, who was responsible for the QAPI program, provided a 3-ring binder containing QAPI information and sign-in sheets for the 2023 monthly QAPI meetings. However, the process described by the Administrator revealed that each department head was responsible for identifying and bringing issues to the monthly QAPI meetings, with informal tracking and no formal audits to ensure sustained changes over time. The Administrator mentioned a Performance Improvement Project (PIP) on baseline care plans conducted in May 2023, but there was no evidence of sustained improvement or formal audits to support this claim. During the interview, the Administrator was unaware of any missed or late baseline care plans, despite the survey team's findings indicating such deficiencies. The Administrator could not provide additional evidence of tracking or auditing for the QAPI program. This lack of formal tracking, auditing, and awareness of ongoing issues demonstrates the facility's failure to maintain an effective QAPI program, potentially affecting all residents, families, and visitors.
Failure to Maintain Safe Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as evidenced by multiple observations and staff interviews. During an initial tour of the kitchen, the walk-in freezer was found to have poor visibility due to cloudiness, and subsequent visits revealed significant ice buildup on the ceiling, fan units, and food boxes. Despite the food service manager's acknowledgment and intention to call maintenance, the issue remained unresolved over multiple inspections, indicating a lack of timely corrective action. Additionally, the facility did not ensure the safety of assistive equipment in resident areas. A seated bath chair in the [NAME] Wing shower room was found with a detached and ripped back support, and another shower chair exhibited significant wear and fraying. Furthermore, a sitting chair in a resident's room had an exposed sharp metal piece and loose arms, posing a safety hazard. Staff confirmed the unsafe conditions of these items upon inspection but did not take immediate action to rectify the issues, leading to continued use of compromised equipment.
Facility Staff Failed to Maintain Clean and Well-Repaired Environment
Penalty
Summary
The facility staff failed to maintain a clean, neat, attractive, and well-repaired environment, as observed by surveyors across all three nursing units on both floors of the facility. The maintenance director, who had been in his position for three months, acknowledged the ongoing renovation project but admitted that several areas still required attention. During the tour, surveyors noted numerous issues, including discolored and marked shower room doors, a hanging electric box, scraped paint, holes in bumper moldings, and various other damages in multiple rooms and hallways. These observations were confirmed by the maintenance director, who indicated that contractors were handling more complex issues while his crew addressed other areas. Specific rooms exhibited significant deficiencies, such as warped window blinds, exposed wallboard, unpainted spackled areas, stained ceiling tiles, and damaged door frames. Additionally, there were issues with loose outlet plates, rust-colored stains, and chipped paint. The maintenance director acknowledged these problems and indicated that systemic issues, such as door frames and unpainted repairs, were prevalent throughout the building. He also mentioned that contractors were being brought in to address more complex issues, while his team worked on other areas. Further observations included dirty air vent grates, dark stains on floors below hand sanitizer units, and damaged ceiling tiles in the newly remodeled lounge area. The environmental services director admitted responsibility for the dirty vent grate and indicated plans to address it. The maintenance director also noted that some rooms on the first floor had not yet received renovations and exhibited similar systemic concerns. Despite the ongoing renovation project, the facility staff failed to maintain a safe, clean, and comfortable environment for the residents, as evidenced by the numerous deficiencies observed by the surveyors.
Failure to Conduct and Document Care Plan Meetings
Penalty
Summary
The facility failed to ensure that an interdisciplinary team, including the resident and/or the resident's representatives, contributed to the resident's comprehensive care plan. This was evidenced by the failure to conduct care plan meetings for residents at quarterly intervals and the lack of documentation and evaluation of each care plan to ensure the interventions continued to be appropriate for the resident's condition. This deficiency was observed in five residents reviewed for care planning, including instances where care plan meetings had not been held for extended periods, and care plans were not updated to reflect current conditions or interventions accurately. Resident #5 reported not having a care plan meeting for over three months, and a medical record review confirmed that the last documented care plan meeting was held in May 2023. Similarly, Resident #75's care plan inaccurately indicated the presence of a midline venous access site, which the resident did not have, and the care plan was only updated after the surveyor's intervention. Resident #17's medical records showed no documentation of care plan meetings for several MDS ARD dates, and the social worker could not provide an explanation for the missed meetings. Resident #39 indicated that care plan meetings were infrequent and could not recall the last meeting. A review of the resident's electronic health record confirmed that the last documented care plan meeting was in November 2022. Resident #96's medical records revealed that care plan meetings were not held within the required seven-day window after MDS assessments, and there was a lack of documentation for care plan meetings between June 2023 and September 2023. The Director of Nursing acknowledged these deficiencies when reviewed by the surveyor.
Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to have sufficient nursing staff to meet the needs of the residents, as evidenced by multiple complaints and interviews with residents and staff. Three complaints submitted to the Office of Health Care Quality (OHCQ) highlighted issues such as residents being left wet with urine for over two hours, not receiving timely medication, and being found heavily soiled. Resident interviews further corroborated these issues, with several residents reporting long wait times for assistance, lack of bathing or changing, and insufficient staff presence during night and weekend shifts. For instance, one resident mentioned not seeing staff from 11 PM to 5:30 AM, while another reported a two-hour wait for a response to a call bell. Additionally, residents expressed concerns about short staffing on weekends, leading to some residents remaining in bed all weekend due to a lack of available staff to assist them out of bed. Staff interviews also confirmed the issue of insufficient staffing. An LPN reported having to extend their work hours to complete tasks, including medication administration, due to short staffing. GNAs described experiencing burnout and being assigned to more residents than they could adequately care for, which affected their ability to change, feed, and respond to call bells for residents. The Director of Nursing (DON) validated these concerns during an interview with the surveyor, acknowledging the issues related to insufficient staffing in the facility.
Failure to Act on Pharmacy Drug Problems
Penalty
Summary
The facility failed to act upon multiple pharmacy drug problems identified for a resident reviewed for unnecessary medications. The surveyor's review of the medical record revealed that pharmacy medication regimen reviews on two occasions noted irregularities and recommendations that were not acted upon. Despite requests for documentation, the surveyor was only provided with incomplete records, and it was found that recommendations regarding the administration of Fosamax were not followed. The medication administration record did not reflect the necessary instructions for Fosamax, such as not sucking, chewing, or crushing the medication, and ensuring it was taken with water in the morning before any other food or drink. Interviews with the DON and other staff revealed a flawed process for handling pharmacy recommendations, where the recommendations were placed in the physician's box but not consistently acted upon. The surveyor found that significant drug therapy problems identified in a May 2023 review were not addressed, and there was no documentation of responses to these recommendations. The DON acknowledged the concerns, and it was confirmed that no follow-up actions were taken to address the pharmacy recommendations as of the surveyor's exit from the facility.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary medications. Resident #1 had an active medical order for Levothyroxine Sodium tablet 112mcg, but the last lab result for monitoring the TSH level was almost a year old, indicating elevated levels. The Director of Nursing (DON) acknowledged the lapse in monitoring and ordered the lab test only after surveyor intervention, revealing a significant delay in addressing the resident's elevated TSH levels. The facility also failed to reconcile and transcribe medication orders accurately, leading to Resident #12 receiving a duplicate medication. The Medication Administration Record (MAR) showed two different orders for Dorzolamide HCL-Timolol Maleate Solution (Cosopt) eye drops, resulting in the resident receiving more medication than necessary. The Unit Manager (UM) confirmed the error and took steps to discontinue the duplicate order only after the surveyor's observation. Additionally, the facility did not ensure clear physician orders for pain medication for Resident #18, leading to the administration of as-needed pain medications without clear parameters. The MAR revealed that staff administered Oxycodone and Acetaminophen for varying pain levels, including instances where the resident reported no pain. The LPN involved could not provide a rationale for choosing one medication over the other, highlighting a lack of clear guidelines for pain management in the resident's care plan.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program in several key areas. Firstly, a resident who tested positive for Clostridium difficile colitis did not have an order for contact precautions, which is necessary to prevent the transmission of this infectious agent. The Infection Control Preventionist confirmed that an order should have been placed but was not. Additionally, during wound treatment observations, an LPN failed to perform proper hand hygiene before and after applying gloves, which is a critical step in preventing infection. The LPN incorrectly believed that hand hygiene was not required because gloves were used, contrary to the facility's policy that mandates handwashing after removing gloves or aprons. The facility also failed to keep linens from contamination. In the Arcadia unit, the bottom portion of the linen closet was stained and soiled with dust, and some linens and a fabric shopping bag were found on the floor. In the laundry room, soiled linen bags were observed untied in a linen bin, contrary to the procedure that requires them to be tied before being sent to the laundry chute. These issues were validated by staff during interviews. Furthermore, the facility's infection control policies and procedures were not reviewed annually, with some policies having effective dates as far back as 2020. Lastly, the facility did not ensure consistent infection prevention monitoring of waterborne infections. The water temperature monitoring logs were incomplete, with gaps in data and inconsistencies in documentation. The logs did not indicate who performed the checks or the specific locations, and some entries were made on days when the responsible maintenance tech was not working. These deficiencies were confirmed through interviews with the Maintenance Director and a review of the maintenance tech's timecards.
Failure to Monitor and Track Antibiotic Usage
Penalty
Summary
The facility failed to monitor and track antibiotic usage and resistance data, as evidenced by the lack of documented indications for antibiotic use in residents' orders and the inadequacies in the facility's antibiotic stewardship program. Specifically, for two residents, the facility did not include the diagnoses in the antibiotic orders. One resident had an order for Clindamycin without a diagnosis listed, and another had an order for Ceftriaxone without specifying the type of infection being treated. These deficiencies were confirmed during interviews with the Infection Control Preventionist (ICP) and the Director of Nursing (DON), who acknowledged the absence of appropriate indications in the antibiotic orders during daily clinical meetings and upon review by the surveyor. Additionally, the facility's antibiotic stewardship program failed to document essential elements for antibiotic use, such as the duration of antibiotic use and resistance data. The ICP provided a generic Infection Surveillance Monthly Report that did not include a specific report for antibiotic surveillance. This deficiency was confirmed during interviews with the ICP and the DON, who validated the concerns about the inadequacies in the antibiotic surveillance program. The facility did not have a specific report to monitor and track residents' antibiotic use effectively.
Inadequate Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide a comprehensive behavioral health training program for all staff, which included care for residents diagnosed with mental, psychosocial, or other behavioral health conditions and individualized non-pharmacological approaches to care. This deficiency was evident in the case of a resident who was allegedly struck by a staff member during a physical struggle. The staff member involved had only received minimal training on managing aggressive behaviors and no specific behavioral health training. The facility's staff development nurse was unable to describe any specialized training for staff related to caring for residents with psychiatric disorders. The facility's most recent assessment indicated a significant number of residents with behavioral health needs, including schizophrenia, depression, anxiety disorder, psychosis, and bipolar disorder. Despite this, there was no evidence that staff received adequate training on behavior management, including handling aggressive behavior, hallucinations, or delusions. The facility's records and training programs did not meet the required standards for providing care to residents with behavioral health conditions.
Failure to Ensure Resident Dignity and Proper Care Practices
Penalty
Summary
The facility failed to treat residents with dignity and respect in several instances. Resident #72 reported not getting along with Staff #49, a Geriatric Nursing Assistant (GNA), and stated that Staff #49 was unhelpful and rude during activities of daily living (ADL). Despite the resident's request to the Director of Nursing (DON) to have Staff #49 removed from their care, the staff member continued to be assigned to the resident. The DON acknowledged the complaint but only provided verbal counseling to Staff #49 without removing her from the resident's assignment. Additionally, Resident #11 reported that staff were not timely in emptying their urinals, which was confirmed by surveyor observations of filled urinals in the resident's room on multiple occasions. The resident expressed distress over the situation, and a Licensed Practical Nurse (LPN) confirmed the surveyor's concerns. Another deficiency was observed when GNA #56 was seen pulling Resident #114's Geri chair backward while also pushing an IV/tube feeding pole. This improper transport method was noted by the Unit Manager, who then corrected the GNA by demonstrating the proper way to push the resident facing forward. These incidents highlight the facility's failure to ensure residents' dignity and proper care practices, as evidenced by the staff's actions and inactions in handling resident care and transport.
Inadequate Investigations into Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse, neglect, misappropriation of resident property, and injuries of unknown sources. For Resident #87, the investigation lacked a written statement from the resident, did not identify the alleged perpetrator, and failed to document specific dates or times of the incident. Additionally, the alleged perpetrator continued to work and was assigned to the resident during the investigation. The investigation also lacked proper documentation of interviews and notifications to relevant authorities, including the police department. Furthermore, one of the residents documented as having been interviewed had expired prior to the date of the interview, indicating a significant lapse in the investigation process. For Resident #319, the investigation into an allegation of physical abuse by a Nursing Assistant was incomplete. While statements were taken from the GNA and other staff, there was no evidence of interviews with other residents. The Director of Nursing and Social Worker were unable to provide the missing documentation, indicating a failure to maintain thorough records. Similarly, for Resident #369, the investigation into an injury of unknown origin was inadequate. Although staff interviews were conducted, there were no statements from other residents, and the facility failed to document the cognitive levels of other residents in the dementia unit. The facility also failed to maintain evidence of a thorough investigation into an allegation of inappropriate sexual behavior involving Resident #39. The investigation summary lacked actual statements or witness accounts. In another case, the facility did not investigate a physical assault witnessed by a staff member involving Resident #470 and Resident #18. The investigation focused solely on the sexual assault allegation and did not include statements from the alleged victim, perpetrator, or other residents. Additionally, the facility's investigation into a verbal abuse allegation involving Resident #418 was incomplete, lacking witness statements and documentation of staff training. Lastly, the investigation into an injury of unknown origin for Resident #419 was not thorough, with missing medical records and incomplete documentation of the incident and subsequent assessments.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. For Resident #18, there was no documentation related to the circumstances of a court order for emergency evaluation, including any changes in the resident's condition leading up to the transfer or the basis for the transfer. Additionally, there was no evidence that pertinent medical information was provided to the receiving hospital or a physician's order to send the resident to the hospital. The Director of Nursing confirmed the lack of documentation regarding the resident's behaviors and the rationale for the transfer. For Resident #30, the medical order for wound treatment did not include the location for the application of skin prep and foam dressing. This omission was confirmed by the wound nurse and later corrected after the surveyor's observation. For Resident #323, there was no documentation from the hospital visit in the resident's electronic medical records. The Director of Nursing confirmed that the facility expected to receive and scan hospital visit records into the residents' charts, but this was not done for Resident #323. Regarding Facility Reported Incident MD00145026, the facility was unable to provide complete medical records for Resident #419, who had discoloration to the left eye. The facility staff could not access the resident's records from the previous owner, and the provided login information did not yield any records. The Director of Nursing acknowledged the incomplete records and the facility's responsibility to maintain them. Despite efforts to retrieve the records, the surveyor was unable to find documentation of the resident's condition at the time of the incident.
Failure to Accurately Code Significant Weight Loss on MDS Assessment
Penalty
Summary
The facility failed to accurately code significant weight loss for a resident on the Minimum Data Set (MDS) assessment. The medical record review revealed that the resident experienced a weight loss from 191.6 lbs to 168.6 lbs in July 2023, which is greater than 10%. Despite this significant weight loss, the MDS assessment coded by the MDS coordinator did not reflect this change, marking the section for weight loss as no/unknown. The resident's medical record also indicated the use of an appetite-stimulating medication and a dietician's note confirming the significant weight loss. During an interview, the MDS coordinator was unable to explain why the significant weight loss was not captured in the MDS assessment. The coordinator mentioned that the resident was eating and had refused to be weighed, and they had struck out the weight entry, which they believed was permissible. However, there was no recollection of obtaining a re-weight. This discrepancy in documentation and coding led to the deficiency noted by the surveyor.
Failure to Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to provide residents and their representatives with a summary of the baseline care plan within 48 hours of admission. This deficiency was identified for three residents during the survey. Resident #173 was admitted in January 2024, and although a baseline care plan was developed on 1/6/24, there was no evidence that the resident or their representative received a summary of the plan within the required timeframe. The Unit Manager confirmed that the baseline care plan was missing from the resident's record. Similarly, Resident #96, admitted in November 2022, did not have any documentation of a baseline care plan in their medical records, and the Director of Nursing confirmed the absence of such documentation. Resident #50, admitted in December 2023, received a baseline care plan later than the required 48 hours, as evidenced by a form signed by the resident on 12/14/23. Interviews with staff, including the Unit Manager and the Director of Nursing, revealed that the facility's process for providing baseline care plans was not consistently followed. The Unit Manager acknowledged that the baseline care plan for Resident #173 was not uploaded into the electronic medical record system. The Director of Nursing confirmed the lack of documentation for Resident #96 and could not provide further information regarding the delay in providing the baseline care plan to Resident #50. These findings indicate a systemic issue in the facility's process for ensuring that residents and their representatives receive timely summaries of baseline care plans upon admission.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility staff failed to develop and initiate comprehensive person-centered care plans for residents residing in the facility. This was evident for one resident with behavioral-emotional health needs and two residents reviewed for comprehensive care plans. For Resident #18, the care plan did not include measurable objectives or specific interventions for the resident's behaviors, depression, and antipsychotic use. Additionally, the care plan did not address the resident's diagnoses of Anxiety Disorder or Schizophrenia. The Regional Corporate Social Worker indicated that the MDS nurse and the Social Worker were responsible for overseeing the development of behavioral care plans, but the interdisciplinary team failed to incorporate psychogeriatric services progress notes into the plan of care. Resident #75 had a suprapubic catheter and was re-admitted to hospice care, but the care plan did not include measurable goals and nursing interventions for both the suprapubic catheter and hospice care. The Director of Nursing confirmed that the care plans were missing these elements due to a failure to carry forward all aspects of the care plan when the current care plan was created. The DON acknowledged that the staff failed to ensure that all aspects of the care plan were included after the resident's transfer to the hospital. Resident #23 had an order for antibiotics to treat C. diff, but the care plan did not include a comprehensive plan for C. diff. The Licensed Practical Nurse verified that the C. diff care plan should have been developed when the provider ordered a new medication or added a new diagnosis. The Infection Control Preventionist validated that no care plan had been developed for the C. diff infection and resulting antibiotic usage for Resident #23.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to meet professional standards of practice by not ensuring staff followed physician orders for medication administration and documentation. During a recertification survey, an LPN was observed administering Acetaminophen to a resident at 10:05 AM, despite the medication being scheduled for 6:00 AM, 12:00 noon, and 8:00 PM. The LPN signed off on the medication before giving it to the resident, contrary to the facility's policy, which requires medications to be administered within a 60-minute window of the scheduled time and documented immediately after administration. The LPN justified the early administration by stating that the resident preferred to take the medication early to avoid missing it during lunch in the dining room. The Unit Manager confirmed that nurses are expected to follow the five rights of medication administration and that any deviation from the scheduled time should be addressed by obtaining a PRN order. The Director of Nursing expressed a preference for minimal medication pass errors. A review of the facility's medication administration policy corroborated the requirement for timely administration and proper documentation. The surveyor shared these concerns with the facility's administration and corporate staff during the survey exit.
Failure to Provide Adequate Activity Services
Penalty
Summary
The facility failed to provide adequate activity services to meet the needs of a resident, specifically Resident #39. The resident reported that there were not enough staff to transport him/her to and from activities. The last activity note in the resident's medical record was dated 11/2/2022, and it indicated that the resident preferred independent activities such as listening to music and audio books. However, the resident later indicated that he/she did not have a device to listen to books and that the staff did not read the daily activity flyer to him/her. The resident also mentioned that he/she had not been taken to the patio for four years and described an incident where he/she was left outside without a way to get back into the building. The resident expressed a need for adaptive equipment, such as a document reader, to participate in activities due to blindness. The care plan for the resident had not been updated to reflect these needs and preferences adequately. The Director of Activities was interviewed and revealed that she was unaware of the need to document all aspects of the resident's activity routine. She stated that the resident was very independent and would communicate his/her needs, but this was not reflected in the care plan. The director also mentioned that the resident had contacted the Lighthouse for the Blind for assistance, but there was no documentation to support this. Additionally, the director could not provide recent documentation of progress notes or evaluations related to the resident's activity program. This lack of documentation and failure to update the care plan contributed to the deficiency in meeting the resident's activity needs.
Failure to Provide Timely Foley Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services upon admission for the care of a resident with an indwelling catheter. Resident #169 was readmitted to the facility from an acute care facility with a Foley catheter. The resident's discharge summary from the hospital indicated that the urine culture grew Proteus Mirabilis, a common pathogen responsible for complicated urinary tract infections. Despite this, there was no documentation that the facility staff provided the necessary Foley catheter care for Resident #169 from the time of readmission on 1/05/24 until 1/08/24, when an order for Foley catheter care every shift was finally placed on 1/09/24. This gap in care was confirmed through medical record review and staff interviews, including an interview with an LPN who stated that orders were required for Foley catheter care and that nurses were responsible for the care, while nurse assistants emptied the bag. The Director of Nursing validated the concerns raised by the surveyor regarding the lack of Foley catheter care for Resident #169 during this period. The deficiency was identified through a combination of medical record review, staff interviews, and observations. The failure to provide timely and appropriate Foley catheter care upon the resident's readmission to the facility highlights a significant lapse in the facility's adherence to proper catheter care protocols. This lapse potentially exposed the resident to an increased risk of infection and other complications associated with improper catheter management. The deficiency was evident for one of the four residents reviewed for Foley catheter care during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,226 citations issued within 25 miles in the last 12 months — including the 12 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 Glenarden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Future Care Capital Region | 2.5 mi | ★★★★★ | 31 | 0 |
| Villa Rosa Nursing And Rehabilitation, Llc | 4.1 mi | ★★★★★ | 37 | 0 |
| Forestville Rehabilitation And Wellness Center | 4.3 mi | ★★★★★ | 44 | 0 |
| Larkin Chase Center | 5.9 mi | ★★★★★ | 9 | 2 |
| Deanwood Rehabilitation And Wellness Center | 6.3 mi | ★★★★★ | 13 | 1 |
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.