Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Lions Rehab Center during CMS and state inspections, most recent first.
A facility failed to maintain a safe, clean, comfortable, and homelike environment when surveyors found a cracked call light panel and a cracked ceiling light cover in shared resident bathrooms. Surveyors also found no washcloths in the supply closet or emergency linen supply, and staff confirmed the LTC facility had an ongoing washcloth shortage for resident bathing.
Oxygen signage and labeling were missing for multiple residents receiving continuous O2. A resident was observed with an oxygen concentrator in use, but the room door had no oxygen-in-use sign and the tubing and humidifier bottle were not labeled and dated. Another resident had no oxygen sign on the door and unlabeled tubing, and two additional residents were also observed with oxygen in use without required signage. The DON acknowledged the findings, and the facility policy required No Smoking / Oxygen in Use signs on the room entrance door and over the bed.
A resident with an ADL self-care deficit and a care plan requiring assistance to the toilet/commode with maximum assistance of one staff was placed in a room where the bathroom was out of order due to renovation. During an incident involving alleged abuse/neglect, a GNA reported attempting to assist the resident to the bathroom, discovering it was under construction, and instead providing a bedpan. The DON later confirmed that the bathroom was nonfunctional at admission because the floor was setting and acknowledged that a commode should have been available, indicating the resident’s toileting needs and preferences for toilet/commode use were not reasonably accommodated.
A resident who had been determined unable to make medical treatment decisions and had a designated healthcare power of attorney developed a new genital wound that was evaluated by a wound provider and documented by an RN as a change in condition. The RN recorded that the resident, described as alert and oriented, refused to allow family notification, and no notification of the responsible party occurred. In an interview, the DON acknowledged that the responsible party should have been notified of the new skin condition and required treatment.
A resident urgently requested assistance to use the toilet, stating they had been asking for help for a long time and feared wetting themselves, but the assigned GNA told the resident to go ahead and wet the bed because they were serving breakfast trays and would clean the resident later, then left without providing the requested care. When another GNA later returned to collect breakfast trays, the resident again reported needing to use the bathroom and believed they had started to wet themselves. Other residents reported that the same GNA frequently delayed or failed to return to provide promised baths and incontinence care, stated they did not have time to change residents, expressed hating their job when asked for help, and made residents feel afraid to request assistance, including during painful bathing. The coworker GNA confirmed their account, and the facility’s investigation verified the allegation of verbal abuse and neglect.
Surveyors found that the facility failed to timely revise care plans after changes in condition for two residents. One resident had new physician orders for PRN and then continuous O2 via nasal cannula, was observed on O2, yet had no care plan addressing oxygen use; the DON acknowledged the care plan should have been updated. Another resident, admitted earlier in the month, sustained a fall from bed, with an RN note indicating fall protocol was initiated; although a fall-risk care plan existed and was revised to add monitoring for medication side effects, it did not capture the actual fall or fully reflect existing risk factors. Only after a second fall was a more detailed fall-risk care plan created, documenting history of falls and multiple contributing conditions that were already present after the first fall, which the DON agreed were not captured in the earlier revision.
A resident’s coccyx wound care was not consistently ordered or documented after a change in treatment orders. An initial order directed application of skin guard ointment to both the genital area and coccyx each day and evening, but when the order was changed, it specified only the genital area and omitted the coccyx. No coccyx wound treatment was ordered or documented for several days until a new order was written to cleanse the wound, apply medi-honey, and cover with a border foam dressing. During an interview, the DON acknowledged the concern and was unable to provide additional documentation of coccyx wound care for the gap period.
A resident with increased behaviors had lorazepam changed from PRN to scheduled BID and was also started on Depakote BID for behaviors and agitation. Over several days, lorazepam doses were left blank on the MAR, indicating they were not given, while Depakote was documented as administered after an initial "not available" entry. Progress notes alternately stated that lorazepam was not given due to pharmacy and unsigned-provider-order issues and, on other entries, that it was given as ordered, yet these administrations were not reflected on the MAR. In an interview, the DON stated that the pharmacy would not release medication without a signed order and acknowledged that the medication should have been administered as ordered and properly documented.
A resident with a urinary catheter was observed with the urinary drainage bag visible while in bed and later while on a stretcher in the hall. The resident had an order for catheter drainage below bladder level and a care plan intervention for a privacy bag, but the DON acknowledged the bag was not covered with the expected blue privacy bag.
Psychotropic Medication Ordered Without Qualifying Diagnosis: A resident was given Seroquel for agitation, restlessness, yelling, and delusional behaviors even though the facility had not yet obtained a qualifying diagnosis. The DON said the resident was a new admission and records were still being gathered, the pharmacist identified antipsychotic use without a qualifying diagnosis, and the PNP said it was too soon to diagnose delusional disorder. The Medical Director stated the prescriber should have had a diagnosis attestation before ordering the medication.
The facility failed to accurately code MDS assessments for two residents. One resident’s MDS was coded incorrectly for ostomy and bowel continence, and another resident’s MDS did not reflect a central line chest port used for dialysis. The DON confirmed the inaccuracies during survey review.
Failure to document and provide baseline care plan summary. The facility did not have documentation showing that a resident’s baseline care plan was signed or that a copy was provided to the resident or the representative. The DON stated the social worker gave the resident a copy, but this was not documented.
Failure to Develop Comprehensive Care Plans: The facility did not develop comprehensive care plans for three residents. One resident receiving hemodialysis had a physician order for dialysis, but no dialysis care plan was in place. Another resident had a fall with a forehead laceration, but the care plan only addressed fall risk and not the actual injury. A third resident on COVID-19 isolation had no care plan for isolation precautions or the COVID-19 diagnosis.
An LPN administered a resident’s insulin glargine without sanitizing the insulin pen before attaching the needle and without priming the needle before giving the dose. The DON confirmed that the expectation was to sanitize the pen and prime the needle to ensure accurate dosing.
Failure to monitor a resident’s hemodialysis access site. A resident receiving HD three times weekly through a right chest port had no physician order for access-site monitoring and no comprehensive care plan for HD and emergency management at the time of review. The DON confirmed the resident’s outside HD schedule and access type, and facility policy required the care plan to reflect ESRD/dialysis needs and shift documentation for central dialysis catheters.
Incomplete behavior monitoring documentation was identified for a resident with major depressive disorder and anxiety. The resident was ordered Mirtazapine and had a care plan and TAR that included monitoring and documenting adverse behaviors for anti-anxiety/antipsychotic medication use, but the behavior monitoring and interventions task was left blank on multiple day and evening shifts. The DON stated the task was incomplete due to either an EHR technical issue or staff not completing it.
Improper Food Storage in Refrigerator: During an initial kitchen tour, a surveyor observed multiple containers of food covered with punctured foil in the refrigerator. The Dietary Manager stated it was an error when interviewed about food storage requirements, and the administrator later acknowledged the concern.
Infection prevention and control deficiencies were identified when multiple hand sanitizer dispensers in resident rooms and hallways were not functioning or empty, airborne precautions signage was posted outside a semi-private room with the door open, and an staff member did not perform hand hygiene after handling a dirty linen bag before direct resident contact. The DON and Administrator acknowledged the concerns, and the staff member stated many sanitizer dispensers in the 400's hallway were not working and/or empty.
Broken Resident Call Lights: The facility failed to ensure working call systems were available for two residents’ bathroom and bathing areas. A resident reported that the call light was not working, and staff confirmed that both that resident’s and another resident’s call lights were not functioning. The DON was notified, and the Administrator later acknowledged the broken call light concern.
Damaged doors and a loose ceiling screen cover were observed in the Rehab Dept and on the 300 hall. A surveyor found a ceiling speaker screen hanging loose at the Rehab entrance and resident room doors with marred, chipped, and splintered wood, including rooms 300 and 304. The DOR and Regional Maintenance Director both observed the conditions during the survey.
A resident on comfort care for pain management did not receive the correct dose of morphine as ordered, with nursing staff administering only 0.25 ml instead of the prescribed 5 ml per dose over multiple administrations. Additionally, an agency LPN failed to document five administrations of the medication, as confirmed by the DON after review of records.
A resident on comfort care received incorrect doses of morphine for pain management after nursing staff administered a discontinued morphine solution multiple times, rather than the newly ordered concentration. The DON confirmed that the wrong medication was used and that the error was not prevented.
A resident's physician was not notified when doses of metoprolol were withheld due to low blood pressure or heart rate, as documented in the MAR. Review by the DON and Regional Nurse confirmed the absence of physician notification for these missed doses.
The facility did not complete a thorough investigation into an allegation of verbal abuse involving a resident. Interview statements from residents lacked interviewer names and dates, staff interviews were incomplete, and there was no list of staff present during the incident or evidence of abuse education provided to staff. The DON confirmed the investigation's deficiencies.
A resident who suffered an unwitnessed fall and fractured their left wrist had conflicting medical records filed, with duplicate documents indicating both the right and left wrist as affected. The DON and orthopedic PA could not confirm who altered the documentation, and the facility accepted the amended record without proper verification, resulting in a deficiency for failing to maintain accurate medical records.
Surveyors found that several residents did not receive prescribed medications and treatments, including pain management, diabetes care, thyroid medication, and port monitoring. The DON confirmed that these omissions occurred and that there was no documentation to show the care was provided.
A resident with a Foley catheter was found with their urine collection bag resting on the floor, contrary to the care plan instructions to keep the bag above the floor and below bladder level. The assigned GNA confirmed the situation during surveyor observation and acknowledged the bag's improper placement.
Staff failed to document complete pain assessments—including pain location, description, and use of non-pharmacological interventions—when administering PRN pain medications to two residents. Pain intensity was sometimes recorded, but other required assessment elements and interventions were missing, as confirmed by the DON.
A resident continued to receive both a 40 mg and a 20 mg daily dose of an antiulcer medication after a provider ordered a reduction to 20 mg daily, resulting in a medication error confirmed by the DON.
Staff failed to implement Enhanced Barrier Precautions (EBP) for two residents with pressure ulcers, as required by infection prevention protocols. During wound care, staff did not wear protective gowns, and there was no documentation, care plan indication, or physician order for EBP. The DON confirmed EBP should have been used for these residents.
The facility failed to monitor and document temperatures for the dishwasher and certain food items, compromising sanitation and food safety. During a GI outbreak, the dish machine log was not updated for several days, and food temperature logs lacked documentation for pureed and mechanical soft diets on three occasions.
The facility failed to ensure accurate MDS assessments for several residents, leading to discrepancies in documentation. One resident was incorrectly recorded as having natural teeth, while another's insulin use was inaccurately documented. Additionally, a resident's pressure ulcer documentation was inconsistent with available records. The DON confirmed these inaccuracies during interviews.
The facility failed to update a resident's care plan to reflect a decline in functional abilities and did not include another resident in their care plan meeting despite being off isolation. The RN responsible for care plan meetings was not informed of changes in the resident's condition, and the resident capable of making decisions was not followed up with after the meeting.
The facility failed to provide adequate assistance to residents during meals and incontinence care, as evidenced by missing documentation and interviews with the DON. Several residents requiring extensive assistance with eating had missing documentation for meal assistance on multiple days. Additionally, residents needing incontinence care were found in soiled briefs or reported being left soiled, with documentation confirming a lack of care on specific days. These deficiencies were confirmed through interviews and documentation reviews.
The facility failed to document and manage pain effectively for residents, including a resident with chronic pain and another with a crushing injury. PRN pain medications were administered without proper documentation of pain assessments or non-pharmacological interventions (NPIs) as required by the facility's policy. The DON acknowledged the lack of documentation and confirmed that NPIs should precede medication.
The facility failed to ensure the dignity of two residents with urinary catheters by not using privacy bags for their urine collection bags. Observations showed the bags were visible from the hallway, and staff acknowledged the issue.
A facility failed to provide a resident with quarterly statements of their personal funds account, despite the resident being capable of making their own decisions. The BOM admitted to only providing copies upon request, leading to the deficiency as the resident had not received a written statement for a year.
A facility failed to inform a resident of their right to formulate an advance directive. The resident, capable of making decisions, had no documentation of being informed about this right. The nurse manager, acting as the social services designee, only asked if residents had existing directives and did not discuss creating one if they did not. This occurred after the facility lost their social worker, and the nurse manager assumed additional duties.
A facility failed to notify a physician when a resident's Metoprolol was held multiple times due to low systolic blood pressure (SBP) and heart rate, as per the medication order for cardiomyopathy. Despite the order to hold the medication if the pulse was below 60 or SBP was below 100, the physician was not informed of these instances, as confirmed by the primary care physician. The deficiency was identified during a surveyor's review of the April 2024 MAR and discussed with the DON.
A facility failed to include catheter care in a resident's comprehensive care plan, despite physician orders and completed care documented in the Treatment Administration Record. The DON acknowledged the omission after reviewing the care plan.
A facility failed to adhere to a physician's orders for a resident with CHF, who required daily weights to manage fluid volume imbalance. The resident refused daily weights, and the physician agreed to change the order to weekly weights. However, the facility did not document this change, and the medical record incorrectly showed an order for monthly weights. The ADON confirmed the lack of documentation, and the physician later stated the order should have been for weekly weights.
A resident identified as a fall risk was repeatedly observed without the fall mat properly placed as per their care plan. Despite being at risk for falls, the fall mat was found folded and not in use on multiple occasions. A GNA acknowledged the oversight and corrected the placement after being prompted. The DON was informed of the issue.
Two residents in the facility were found to have inadequate catheter care. One resident's urine collection bag was observed on the floor, and their medical record lacked complete documentation of catheter size and balloon fluid amount. Another resident's Foley bag was repeatedly observed on the floor, despite staff acknowledging it should not be there. The DON was informed of these issues, which could lead to infection risks.
A resident's care was not properly overseen, as necessary A1C and TSH blood work were not completed in 2024 despite the attending provider's notes indicating the need for these tests. The facility lacked documentation of these tests being ordered or completed, and interviews revealed a lack of awareness and oversight regarding the resident's blood work orders.
The facility failed to ensure complete, accurate, and timely physician documentation for two residents. One resident's attending provider's notes were not part of the medical record and inaccurately reported stable blood sugar levels without testing. Another resident's medical record lacked documentation from the primary care provider for 2024, with no goal range for PT/INR results noted. Both cases involved late signing of notes, highlighting deficiencies in maintaining accurate medical records.
The facility failed to ensure nursing staff competency, as two RNs lacked competency evaluations. RN #19, hired in August 2024, and RN #3, an agency staff member since May 2023, had no records of evaluations. This was identified during a recertification survey, and the DON acknowledged the deficiency.
The facility was found deficient for not having a full-time Director of Nursing (DON) during a survey. The DON was also serving as the only Infection Preventionist (IP) nurse, which prevented her from fulfilling the full-time DON role. This dual role was acknowledged by the facility's administration as a concern, potentially impacting all residents, staff, and visitors.
A facility failed to ensure timely review and action on a pharmacist's medication regimen recommendation for a resident. The pharmacist suggested changing an antifungal cream to a barrier cream in May, but the attending physician did not sign off until September, and the change was not implemented until December. The facility's policy lacked a clear timeframe for addressing such recommendations.
Two residents received medications outside of prescribed parameters. One resident was given Morphine without documented pain levels, and another received Metoprolol and Spironolactone despite low blood pressure readings. The DON confirmed these findings.
The facility failed to properly document narcotic reconciliation, store medications according to standards, and ensure medications were not left unattended. A narcotic record book was incorrectly signed, expired medications were found in two medication carts, and an inhaler was not dated when opened. Additionally, a resident's medications were left at the bedside without a process to ensure they were taken. The DON acknowledged these issues.
Unsafe Room Conditions and Linen Shortage
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in two resident rooms and in its linen supply. Surveyors observed a cracked call light panel in a shared bathroom in one resident room and a large crack in the cover to the ceiling light in another shared bathroom. During an interview, the Regional Maintenance Director toured the 300 hall with the surveyor and observed both cracked items in the resident shared bathrooms. The facility also did not have an adequate supply of linen. GNA #13 and GNA #18 stated that the facility never had enough washcloths to bathe residents, and the surveyor observed that the supply closet contained no washcloths. Staff #30 confirmed a shortage of washcloths and stated the facility ordered 600 per month, which was never enough. The surveyor also observed that the emergency linen supply did not have any washcloths, and the LNH Administrator stated the facility was aware of the linen shortage and was increasing the supply for daily use and emergency linen.
Oxygen signage and tubing labeling were missing for residents receiving continuous oxygen
Penalty
Summary
The facility failed to provide appropriate respiratory care for residents using oxygen. During observations on 03/23/2026, Resident #8 was seen in bed with an oxygen concentrator in use, but the oxygen tubing was not labeled and dated and there was no oxygen-in-use signage on the room door. At 1:02 PM, Resident #2 was observed in the room with an oxygen concentrator in use, and there was no oxygen signage on the room door; the oxygen tubing was also not labeled and dated. Staff nurse #9 stated that oxygen signs should be on resident room doors when oxygen is being used. Later that day, Resident #11 was observed in bed with an oxygen concentrator in use, with no oxygen sign posted on the room door or door frame and the oxygen tubing and humidifier bottle not labeled and dated. Resident #3 was also observed in the room with an oxygen concentrator in use, and there was no oxygen signage posted on the room door. The DON acknowledged the surveyor’s findings. Review of the facility’s Oxygen Administration policy dated February 2026 showed that a No Smoking / Oxygen in Use sign should be placed on the outside of the room entrance door and in a designated place on or over the resident’s bed. Physician orders reviewed for Residents #2, #3, #8, and #11 showed continuous oxygen by nasal cannula tubing and orders to change tubing, mask, and/or nasal cannula weekly, or sooner as needed.
Failure to Provide Commode When Bathroom Was Out of Order
Penalty
Summary
Failure to reasonably accommodate a resident’s toileting needs occurred when a resident with an ADL self-care deficit and a care plan intervention requiring assistance to the toilet/commode with maximum assistance of one staff was admitted to a room whose bathroom was out of order due to recent floor renovation. During review of a facility-reported incident alleging abuse/neglect, a GNA documented that while attempting to assist this resident to the bathroom, it was discovered that the resident’s bathroom was under construction, and a bedpan was provided instead. The care plan, initiated two days after admission, specified assistance to the toilet/commode, but no commode had been made available in the resident’s room while the bathroom was nonfunctional. In an interview, the DON stated that at the time of the resident’s admission the bathroom was out of order because the floor needed time to set after renovation, and acknowledged that a commode should have been available for the resident’s use while the bathroom was out of commission. These findings, based on record review and staff interview, show that the resident’s identified need for assisted toileting to a toilet/commode was not reasonably accommodated when only a bedpan was provided in the absence of an accessible bathroom or commode.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident’s Responsible Party (RP) of a change in condition when a new wound was identified. Record review showed that the attending physician had determined on 12/5/25 that Resident #96 was unable to comprehend and make medical treatment decisions, and the resident had an advance directive naming a healthcare power of attorney. On 12/10/25, a wound provider documented a new wound on the resident’s genitalia, and RN #34 also entered a change of condition note for this new wound. In the section of the note addressing notification of the resident representative, RN #34 documented that the resident, described as alert and oriented, refused to have family notified, stating that it was their genitalia and they did not want to tell them. During an interview, the DON confirmed that the RP should have been notified when the new skin condition was found and treatment was needed. These findings, based on record review of the complaint and facility-reported incident and interviews, showed that the facility did not ensure the RP was informed of the resident’s new wound and related treatment needs, despite the resident’s documented inability to make medical treatment decisions and the presence of a designated healthcare power of attorney.
Failure to Protect Residents From Verbal Abuse and Neglect by a GNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse and neglect by a Geriatric Nursing Assistant (GNA). According to the facility’s own investigation, an allegation that a GNA verbally abused and refused to provide care to a resident was substantiated. On the morning in question, a GNA asked a coworker to assist in repositioning the resident. As they entered the room, the resident stated that they had been asking for help to use the toilet for a long time and urgently needed to urinate to avoid wetting themselves and the bed. The assigned GNA responded that they were serving breakfast trays and told the resident to go ahead and urinate in the bed, stating they would clean the resident up later. The coworker then left to return to their own assignment and, upon returning later to pick up breakfast trays, the resident again reported needing help to use the bathroom, stating they badly needed to urinate and believed they had started to wet themselves. Additional statements in the investigation file from other residents described broader concerns with how the same GNA provided care and spoke to them. One resident reported that when they asked this GNA for anything and the GNA was in a bad mood, the GNA would become upset, say they hated their job, and the resident felt scared to ask for help. Another resident stated that the GNA would offer a bath, say they would return, and then not come back until the afternoon, and also told the resident they did not have time to change them and would do it later, causing the resident to be afraid to ask for things because they would be told no. A third resident reported that the GNA would say they would be right back in the morning but would not return until after lunch even though the resident was wet and dependent on staff for help, and also reported hearing another resident yell in pain during a bath while the GNA told that resident they did not have to bathe them and could be taken off the assignment. The coworker GNA confirmed the accuracy of their statement during an interview, and the facility’s investigation concluded that the allegation of verbal abuse and neglect was verified.
Failure to Timely Revise Care Plans After Changes in Condition and Falls
Penalty
Summary
The deficiency involves the facility’s failure to review, update, and revise residents’ care plans after changes in condition. For one resident, surveyors observed the resident in bed using oxygen and later confirmed through record review that the resident had a physician’s order for PRN oxygen at 2 L/min via nasal cannula and a subsequent order for continuous oxygen every shift. Despite these orders, oxygen use was not reflected anywhere in the resident’s care plan. In an interview, the DON acknowledged that the resident was new to oxygen use and agreed that the care plan should have been updated to address oxygen usage. For another resident, the deficiency centered on incomplete and delayed care plan revisions following falls. The resident was admitted in early February and experienced a fall from bed on 2/9, documented by an RN note stating that fall protocol was initiated. A fall-risk care plan had been initiated earlier in the month, and after the 2/9 fall, an intervention was added to monitor side effects of medication; however, the actual fall event and existing risk factors were not fully captured in that revision. A later care plan, initiated after a second fall, documented that the resident was at risk for falls related to history of falls, gait and transfer dysfunctions, fatigue or weakness, new environment, impaired safety awareness/cognition loss, and unsteady gait—conditions that were already present after the first fall. In an interview, the DON confirmed that the fall care plan revised on 2/10 did not capture the actual fall and that care plans are expected to be updated as needed after such events.
Failure to Maintain Continuous Ordered Treatment for Coccyx Wound
Penalty
Summary
The facility failed to provide treatment according to a resident’s wound care orders and plan of care for a coccyx wound. Record review showed that on 12/10/25 an order was written to apply skin guard ointment to the genital area and coccyx every day and evening shift for skin healing, and this was documented as completed on the evening of 12/10/25 and the morning and afternoon of 12/11/25 before being discontinued on 12/11/25. A new order effective 12/12/25 directed staff to apply skin guard to the genital area every day and evening shift for wound healing, but this order did not include treatment to the coccyx. No other coccyx wound treatment was ordered or documented from 12/12/25 through 12/16/25. A new coccyx wound order was not written until 12/17/25, directing staff to cleanse with wound cleaner, apply medi-honey to the wound bed, and cover with a border foam dressing as needed. During an interview on 3/24/26, the DON was informed of the gap in coccyx wound care orders and documentation between 12/12/25 and 12/17/25 and stated she would look for wound care documentation; no additional documentation was provided by the time of survey exit. The deficiency involved one resident reviewed for wound care whose coccyx wound lacked ordered and documented treatment for several days following a change in the treatment orders.
Failure to Administer and Document Psychotropic Medication as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered for one resident. Record review showed that this resident had a lorazepam order changed on 3/14/25 from every hour as needed to a scheduled twice-daily dose due to an increase in behaviors. On the same day, Depakote was ordered twice daily for behaviors and agitation. Review of the March 2026 MAR revealed that lorazepam doses were left blank, indicating they were not given, from the afternoon dose on 3/14/26 through the morning dose on 3/19/26, when the medication was discontinued in the afternoon. In contrast, Depakote was marked as not available only for the afternoon dose on 3/14/26 and then documented as administered as ordered on subsequent days. Progress notes documented multiple reasons for lorazepam not being given, including waiting for medication delivery on 3/16/26 and the prescription not being signed by the provider on 3/17/26 and 3/19/26. Additional progress notes on 3/17/26 at 11:36 AM and on 3/18/26 at 11:53 AM and 7:40 PM stated that lorazepam was given as ordered, but these administrations were not recorded on the MAR. During an interview, the DON explained that if a provider had not signed the medication order, the pharmacy would not release the medication, and acknowledged that the medication should have been given as ordered and that staff should have obtained the provider’s signature. No additional documentation was provided to reconcile the discrepancies between the progress notes and the MAR entries.
Failure to Maintain Privacy for Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure the personal privacy of a resident with a urinary catheter. Survey observations found the resident in bed with a yellow substance in the urinary drainage bag hanging on the bedframe, and later the resident was observed on a stretcher in the hall outside the room with the urinary drainage bag in view. The resident had a physician order for the catheter bag to drain by gravity below bladder level and for catheter care every shift. The resident’s care plan included an intervention to position the catheter bag and tubing below the level of the bladder with a privacy bag. During interview, the DON stated the urinary drainage bag should be in a blue privacy bag that covered the bag, but the surveyor observed the resident in bed with the urinary drainage bag hanging on the bedframe without a privacy bag. The DON acknowledged that the urinary drainage bag was not covered with the blue privacy bag.
Psychotropic Medication Ordered Without Qualifying Diagnosis
Penalty
Summary
The facility failed to obtain a qualifying diagnosis before prescribing SEROquel 25 mg by mouth every morning and at bedtime for agitation for Resident #97. During record review, the surveyor found that the antipsychotic was ordered on 03/19/2026, and the DON stated the resident was a new admission and the facility was still trying to obtain records and learn a diagnosis for the medication. The clinical pharmacist’s unnecessary medication review, dated 03/23/26, stated the facility was administering antipsychotic pharmacotherapy to the resident without a qualifying diagnosis. On 03/26/2026, the PNP stated he started SEROquel because the resident had restlessness, yelling, and delusional behaviors, and that he was trying the medication to see if it would help because the behaviors were disturbing other residents. The PNP also stated it was too soon to give the resident a diagnosis of delusional disorder because the resident had just been admitted. The Medical Director stated they were familiar with the resident from before admission and that the resident had been having behavior issues, hallucinations, and psychotic behaviors, but also stated the prescriber should have had a diagnosis attestation before ordering SEROquel.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to code Minimum Data Set (MDS) assessments accurately for 2 of 8 residents reviewed. For one resident, the 1/27/2026 Admission/Medicare-5 Day MDS was coded No for ostomy and Not rated for bowel continence, although the Director of Nursing stated the resident did not have an ostomy. The surveyor later reviewed a modification of that MDS and found the bowel continence item had been corrected to Always continent. For another resident, the 2/18/2026 Admission/Medicare-5 Day MDS was not coded for IV Access, Central, even though the Director of Nursing stated the resident had a central line chest port for dialysis. The surveyor later reviewed a modification of that MDS and found the item had been corrected to Yes for IV Access, Central. The report states that the MDS assessments were inaccurately coded for these residents.
Failure to Document and Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to ensure that Resident #99 was provided with a summary of the baseline care plan and that documentation showed the baseline care plan was signed or a copy was given to the resident or the resident’s representative. During record review, the surveyor found no documentation that the facility obtained a baseline care plan signature or provided a copy to Resident #99 or the representative. When interviewed, the DON stated the facility lacked documentation showing that a copy of the baseline care plan was signed by and provided to Resident #99, and that the social worker gave Resident #99 a copy but did not document it.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for 3 of 8 residents reviewed. Resident #2 had a physician order for hemodialysis on Tuesdays, Thursdays, and Saturdays, and the medical record showed dialysis treatments were performed at UPMC - Regional Dialysis Center, but the comprehensive care plan did not include hemodialysis. The facility policy for care of a resident with ESRD stated that the comprehensive care plan would reflect the resident’s needs related to ESRD/dialysis care. During interview, the DON confirmed that Resident #2 did not have a hemodialysis care plan, and a hemodialysis care plan was later provided after surveyor intervention. Resident #11 was observed in bed with two steri-strips to the right side of the forehead and stated that he/she recently fell out of bed. Record review showed a fall on 3/17/2026 with a laceration to the right side of the forehead, but the care plan only addressed risk for falls and did not include a comprehensive care plan for the actual fall with injury. Resident #5 had room signage indicating isolation, and the record showed a physician order for COVID-19 isolation for 10 days, but the comprehensive care plan did not include a problem, goal, or interventions for isolation or COVID-19. The DON confirmed that there was no care plan for active COVID-19 and isolation precautions.
Insulin Pen Not Sanitized or Primed Before Administration
Penalty
Summary
The facility failed to administer medications according to professional standards of quality for one resident who received insulin glargine. During observation on 3/24/26 at 8:24 AM, an LPN prepared the resident’s insulin by placing a needle onto the insulin pen and dialing the pen to 20 units. The surveyor observed the LPN administer the insulin to the resident and then asked about the preparation process. The LPN stated that she disinfects multi-dose vials but not insulin pens before applying the needle, and she confirmed that she did not prime the insulin needle before administration. The report states that standard priming dose is 2 units of insulin. During an interview on 3/24/26 at 11:05 AM, the DON reviewed the observation with the surveyor and confirmed that the expectation was to sanitize the insulin pen before applying the needle and to prime the needle to ensure accurate dosing. The deficiency involved one of five residents reviewed for medication administration.
Failure to Monitor Hemodialysis Access Site
Penalty
Summary
The facility failed to monitor a resident’s hemodialysis access site. Resident #2 had a physician order for dialysis treatment every Tuesday, Thursday, and Saturday, and the medical record showed the resident received hemodialysis at an outside dialysis center three days a week through a right chest port. However, the record review found no physician order for monitoring the hemodialysis access site. The resident also did not have a comprehensive care plan for hemodialysis and emergency management at the time of the survey review. The DON confirmed that the resident received outside hemodialysis and had a right chest port, and the surveyor informed the DON that the resident lacked both an access-site monitoring order and a comprehensive care plan for hemodialysis. The facility policy stated that the comprehensive care plan should reflect the resident’s ESRD/dialysis needs, and the policy for central dialysis catheters called for documentation each shift of the catheter location, dressing condition, needed interventions, dialysis status, post-dialysis report information, and post-dialysis observations.
Incomplete Behavior Monitoring Documentation
Penalty
Summary
Failure to complete a resident's behavior management documentation was identified for a resident with diagnoses of major depressive disorder and anxiety. The resident's medication administration record showed scheduled Mirtazapine 7.5 mg and Magnesium Oxide 400 mg, and the care plan and treatment administration record included monitoring and documenting adverse behaviors for anti-anxiety/antipsychotic medication use. During record review, the behavior monitoring and interventions task was found blank for multiple dates and shifts in March 2026, including day and evening shifts on several days and evening shifts on others. When interviewed, the DON stated that the task was incomplete either because of a technical issue in the electronic health record or because staff did not complete it, and stated that she had reminded staff to complete the task every shift.
Improper Food Storage in Refrigerator
Penalty
Summary
The facility failed to properly store food in the refrigerator, as multiple containers of food were observed covered with punctured foil during the initial kitchen tour. The surveyor identified this storage issue on 03/23/26 at 8:51 AM. At 8:52 AM, the Dietary Manager was interviewed about food storage requirements and stated that the condition was an error. The administrator acknowledged the concern later that day at 3:01 PM.
Infection Prevention Deficiencies: Nonworking Sanitizers, Incorrect Precaution Signage, and Missed Hand Hygiene
Penalty
Summary
The facility failed to provide functioning hand sanitizers in multiple resident rooms and hallway locations. On 03/23/2026, the surveyor observed hand sanitizer not working in room [ROOM NUMBER], room [ROOM NUMBER], and in the hall outside rooms 101, 111, and 112. On 03/24/2026, the surveyor also found non-working hand sanitizer in rooms [ROOM NUMBER]. When Staff #7 was asked about replacing empty hand sanitizer, Staff #7 stated the facility did not yet possess the bags for the new sanitizer bottles. The Maintenance Assistant confirmed that the facility ordered the hand sanitizer, and the Administrator and DON acknowledged the concern and stated they would investigate it. The facility also failed to correctly identify a resident requiring transmission-based precautions and failed to perform hand hygiene before direct contact with a resident. The surveyor observed airborne precautions signage outside room [ROOM NUMBER], a semi-private room with the door open, and the DON acknowledged the incorrect signage and stated it had already been corrected. In a separate observation, Staff #18 was seen transferring a dirty linen bag to a hamper and then immediately wheeling a resident to the activities room, followed shortly by pouring a beverage from the beverage cart. During interview, Staff #18 acknowledged not performing hand hygiene after handling the dirty linen bag and stated that most hand sanitizer dispensers in the 400's hallway were not functioning and/or empty. The DON acknowledged these concerns.
Broken Resident Call Lights
Penalty
Summary
The facility failed to ensure that resident call systems functioned properly in the bathroom and bathing area for 2 residents, #32 and #100, out of 11 residents evaluated for call light access during the recertification survey. During observation and interview on 03/23/2026, Resident #100 stated, “My call light is not working.” A GNA investigated and confirmed that Resident #100’s call light and Resident #32’s call light were not working, and the concern was brought to the DON while she was in the hall. On 03/24/2026, staff reported that maintenance had fixed Resident #100’s call light, and the Maintenance Assistant stated the call cords were not functioning and that changing the cords corrected the issue. The Administrator later acknowledged the broken call light concern during interview and stated it had been repaired.
Damaged Doors and Loose Ceiling Screen Cover
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff. During a tour of the Rehabilitation Department, the surveyor observed a screen cover to a speaker in the ceiling at the entrance of the department that was hanging loose and not intact to the ceiling. The Director of Rehabilitation observed the condition and stated she would notify maintenance. The surveyor also observed resident room doors on the 300 hall, including rooms 300 and 304, that were marred, chipped, and had spots of splintered wood. The Regional Maintenance Director later toured the area with the surveyor and observed the same damaged doors.
Failure to Accurately Dispense and Document Pain Medication Administration
Penalty
Summary
The facility failed to ensure accurate dispensing and administration of medications for a resident receiving comfort care for pain management. A physician's verbal order was given to administer 5 ml of Morphine every 3 hours and to discontinue all other medications. However, review of the narcotic count sheet revealed that nursing staff were administering only 0.25 ml per dose from the morphine solution, rather than the ordered 5 ml. This incorrect dosing occurred 22 times over a period of several days, involving multiple nurses. Additionally, documentation discrepancies were identified, as there was no evidence in the electronic medication administration record (eMAR) that the medication was administered on 5 out of the 22 occasions when it was pulled from the stock solution. All five undocumented administrations were recorded by an agency LPN. The Director of Nursing confirmed the lack of documentation for these administrations after reviewing the records and acknowledged the concern regarding the facility's failure to ensure accurate medication dispensing and administration.
Failure to Prevent Significant Medication Error in Pain Management
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to pain management. The resident, who was on comfort care, was prescribed morphine for pain relief. Initially, a verbal order was given for morphine 10mg/5ml, to be administered 5ml by mouth every 3 hours. This order was later discontinued the same day, and a new order for morphine 100mg/ml, to be administered at 0.25ml every 3 hours as needed, was entered. Despite the change, both morphine solutions were delivered to the facility, and nursing staff continued to use the discontinued 10mg/5ml solution, administering 0.25ml doses from it over a period of several days. A review of narcotic count sheets confirmed that the discontinued morphine solution was used 22 times by different nurses, instead of the newly ordered concentration. The Director of Nursing acknowledged that the discontinued medication should not have been delivered and that the nursing staff should have used the correct morphine solution as per the updated order. As a result, the resident received incorrect doses of morphine for pain management, and the facility did not prevent a significant medication error.
Failure to Notify Physician When Medication Held
Penalty
Summary
The facility failed to notify a resident's physician when doses of metoprolol, a blood pressure-lowering medication, were held due to low systolic blood pressure or low heart rate. Record review showed that the medication was withheld on multiple occasions in May 2025, as documented in the Medication Administration Record (MAR), but there was no evidence that the physician was informed of these occurrences. Both the Director of Nursing and the Regional Nurse confirmed, upon review of the MAR and nursing documentation, that there was no documentation of physician notification for the held doses.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of verbal abuse involving a resident. The investigation file included several resident interview statements, but none of these statements identified the interviewer or the date the interviews were conducted. Staff interview statements were also incomplete; one Geriatric Nursing Assistant (GNA) stated she was not assigned to the resident at the time, while the other did not clarify if she worked with the resident during the incident. Additionally, the investigation file did not include a list of staff who were working on the resident's unit on the day of the alleged incident, nor was there any documentation showing that abuse education was provided to staff following the event. The Director of Nursing confirmed that the investigation was not thorough.
Failure to Maintain Accurate Medical Records Following Resident Fall
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards of quality for one of seven facility-reported incidents reviewed during a complaint survey. Specifically, after a resident experienced an unwitnessed fall resulting in a left wrist fracture, the facility's investigation file contained two duplicate handwritten documents from the consultant orthopedic Physician Assistant. One document indicated the right wrist was affected, while the other indicated the left wrist, with both otherwise being identical. The presence of these conflicting documents created confusion regarding the accurate medical record for the resident's injury. Interviews with the DON and the Physician Assistant revealed uncertainty about who altered the documentation to correct the affected wrist from right to left. The DON acknowledged that the facility accepted and filed the document with the correction, despite not knowing who made the change. The Physician Assistant stated he did not amend the document or write an addendum in this case. The DON confirmed that the document was incorrectly amended and that this constituted a deficiency in maintaining accurate medical records.
Failure to Administer Ordered Medications and Treatments
Penalty
Summary
Surveyors identified that the facility failed to administer physician-ordered medications and treatments to three residents, as evidenced by a review of Medication Administration Records (MAR) and Treatment Administration Records (TAR). Specific missed medications included acetaminophen for chronic pain, levothyroxine for hypothyroidism, megestrol acetate for benign endometrial hyperplasia, and multiple scheduled doses of insulin and blood sugar checks for diabetes management. Additionally, a physician's order to maintain and monitor a chest port for signs of infection every shift was not followed for one resident. These omissions were confirmed by the Director of Nursing (DON) after a review of the records, with no documentation found to indicate the medications or treatments had been provided. The missed administrations occurred on multiple dates and shifts, affecting residents with chronic pain, diabetes, hypothyroidism, and a need for port maintenance. The surveyor discussed the findings with the DON, who acknowledged the lapses, and later with the Regional Director and Consultant RN, who were also made aware of the deficiencies. The report documents that the required medications and treatments were not given as ordered, and the necessary monitoring was not performed, as confirmed by facility leadership.
Urine Collection Bag Not Secured Off Floor for Catheterized Resident
Penalty
Summary
A deficiency was identified when a resident with a Foley catheter was observed with their urine collection bag resting on the floor while sleeping in bed. The observation was made by surveyors, and the assigned Geriatric Nursing Assistant (GNA) confirmed the resident's identity and later acknowledged that the urine collection bag was on the floor. The GNA stated she was preparing to clean the resident at the time of the observation. A review of the resident's care plan indicated specific interventions for catheter care, including maintaining the catheter tubing and bag above the floor and below the level of the bladder, ensuring the tubing was free of kinks or occlusions, and securing the catheter with a leg strap if needed. Despite these documented interventions, the urine collection bag was not properly secured, resulting in noncompliance with the care plan and facility policy.
Failure to Document Comprehensive Pain Assessments and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide safe and appropriate pain management for residents requiring such services. Specifically, staff did not document the reasons for administering as-needed (PRN) pain medications, nor did they record comprehensive pain assessments that included the intensity, location, and description of pain. Additionally, non-pharmacological interventions (NPI) were not implemented or documented prior to administering pain medications, as required by facility policy and physician orders. For two residents reviewed, one received acetaminophen on multiple occasions with only the pain intensity recorded, lacking documentation of pain location, description, and use of NPI. Another resident was administered oxycodone and acetaminophen regularly, but the records did not consistently include pain assessments or documentation of pain characteristics and NPI. The DON confirmed that pain management should include assessment of location, intensity, description, and effectiveness, as well as the use of NPI, and acknowledged the documentation deficiencies upon review.
Failure to Discontinue Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident continued to receive an antiulcer medication at a total daily dosage of 60 mg, despite the attending provider's order to reduce the dose to 20 mg daily. The pharmacist had recommended a dose reduction after reviewing the resident's medication regimen, and the provider issued a new order to decrease the medication. However, review of the Medication Administration Record (MAR) showed that the resident was administered both the original 40 mg dose and the new 20 mg dose daily, rather than discontinuing the higher dose as ordered. The DON confirmed during interview that the staff failed to discontinue the 40 mg dose, resulting in a medication error.
Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as part of its infection prevention and control program for residents with pressure ulcers. Specifically, during a wound care observation for a resident with an active wound and a history of pressure ulcers, staff did not adhere to EBP requirements by failing to wear protective gowns in addition to gloves. The medical record review for this resident did not show any physician order for EBP, nor was there documentation or care plan indication that EBP was being used or considered. Another resident requiring wound care also did not have documentation of EBP implementation or assessment in their record, and there was no signage at the resident's doorway indicating the need for EBP. The Director of Nursing confirmed that EBP should be implemented for residents with pressure ulcers and was made aware of the staff's failure to wear gowns during wound care and the lack of physician orders for EBP for both residents.
Failure to Monitor Dishwasher and Food Temperatures
Penalty
Summary
The facility failed to adequately monitor and document temperatures for both the dishwasher machine and certain food items, leading to deficiencies in sanitation and food safety. During a gastrointestinal outbreak, it was observed that the dish machine log had not been updated since January 3, 2025, indicating a lack of temperature checks for several days. This was confirmed during a kitchen tour on January 8, 2025, and discussed with the Nursing Home Administrator and the Director of Nursing. A follow-up on January 14, 2025, confirmed that the dishwasher eventually reached the required temperature of 180 degrees after several runs. Additionally, a review of food temperature logs for January 2024 revealed missing documentation for the temperatures of pureed and mechanical soft diets during dinner meals on three specific days. This was confirmed by the Regional Manager, highlighting a failure to ensure food safety standards were consistently met.
Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented and reflected the residents' status. This was evident in four residents out of 35 reviewed during the survey. For Resident #60, the MDS assessment inaccurately recorded the resident as having natural teeth, despite observations and dental assessments indicating the resident was edentulous and wore dentures. Similarly, Resident #24's MDS assessment incorrectly documented the presence of natural teeth, contrary to the resident's statement and dental records showing edentulism. Resident #64's MDS assessments inaccurately recorded insulin use, while the resident was actually receiving Ozempic injections for diabetes, which is not insulin. The Director of Nursing (DON) confirmed these inaccuracies during interviews. Additionally, the facility failed to accurately document the presence of pressure ulcers for Resident #75. The Admission MDS assessment indicated two unstageable pressure ulcers were present upon admission, based on a wound specialist's note dated four days after admission. However, there was no documentation in the hospital discharge summary, facility nursing documentation, or primary care physician notes to support the presence of a heel wound upon admission. The MDS nurse acknowledged the discrepancy during a phone interview, but no additional documentation was provided to confirm the heel ulcer was present at the time of admission.
Deficiencies in Care Planning and Resident Participation
Penalty
Summary
The facility failed to ensure that a resident participated in the care plan process and failed to revise a resident's care plan. For one resident, the comprehensive assessment indicated a decline in functional abilities, including eating, mobility, and transfers, which was not reflected in the care plan. The resident required more assistance than previously documented, but the care plan was not updated to reflect these changes. The RN responsible for scheduling care plan meetings was not informed of the changes in the resident's condition, and the care plan meeting did not address the decline in the resident's abilities. Another resident did not participate in their care plan meeting due to a gastrointestinal outbreak in the facility. Although the resident's symptoms had resolved, and they were off contact isolation, they were not included in the meeting. The nurse manager confirmed that the resident and their representative were not part of the meeting, and the resident was not followed up with afterward, despite being capable of making their own decisions. The Director of Nursing acknowledged that the resident should have been part of the meeting once they were off isolation. The facility's process for updating care plans and involving residents in their care planning was inadequate, leading to deficiencies in the care planning process for these residents.
Deficiencies in Meal Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance to residents during meals and incontinence care, as evidenced by the lack of documentation and interviews with the Director of Nursing (DON). Resident #469, who required extensive assistance with eating, had missing documentation for meal percentages and fluid consumption for several days in May 2023. Similarly, Resident #74, who also needed extensive assistance with eating, had missing documentation for meal assistance on multiple days. Resident #270, with moderately impaired cognition, also lacked documentation for meal assistance on several days. The DON confirmed that the absence of documentation indicated a lack of care provided on those days. In addition to meal assistance deficiencies, the facility failed to provide incontinence care to residents who required it. Resident #60 was found in a soiled brief upon transfer to the emergency room, with documentation showing a lack of toileting hygiene care on specific days before the transfer. The DON confirmed that Resident #60 did not receive care the night and morning prior to the transfer. Resident #22 also reported being left soiled on certain days, and a review of complaints and documentation revealed multiple instances where toilet care was not provided. The deficiencies in providing assistance with activities of daily living (ADLs) were confirmed through interviews with the DON and reviews of documentation. The lack of documentation for meal assistance and incontinence care indicated that the necessary care was not provided to the residents, leading to the deficiencies identified during the recertification survey.
Deficiencies in Pain Management Documentation and Practices
Penalty
Summary
The facility failed to adequately document and manage pain for several residents, leading to deficiencies in pain management practices. Resident #24, who has been residing in the facility since 2015 with chronic pain conditions such as arthritis and neuropathy, received PRN pain medications without proper documentation of the reasons for administration, pain assessment details, or implementation of non-pharmacological interventions (NPIs) prior to medication. The resident's care plan required NPIs before administering PRN pain medication, but this was not followed, and the staff only provided NPIs if explicitly ordered by the attending provider. Resident #59, admitted in early 2024, was identified as having constant pain. Despite having routine and PRN orders for pain medications, there was no documentation of NPIs being attempted before administering PRN medications. The facility's policy required evaluation and documentation of NPIs before administering pain medication, but this step was not followed. The Director of Nursing acknowledged the lack of documentation and confirmed that NPIs should be the first step in pain management. Similarly, Resident #64, who suffered a crushing injury with paralysis, received PRN pain medication without documentation of NPIs being attempted beforehand. The facility's policy was again not adhered to, as the required steps for evaluating and documenting NPIs were not followed. The Director of Nursing confirmed the absence of documentation for NPIs and recognized the concern, indicating that a non-medicated approach should always precede medication administration.
Failure to Maintain Privacy for Residents with Urinary Catheters
Penalty
Summary
The facility failed to maintain the dignity of residents with urinary catheters by not ensuring that urine collection bags were kept in privacy bags. This deficiency was observed in two residents. For Resident #419, multiple observations were made over several days where the foley bag was seen without a privacy cover, either on the floor or attached to the bed rail, visible from the hallway. Staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), acknowledged the absence of a privacy cover during these observations. Similarly, Resident #64's urine collection bag was observed without a privacy cover during an initial tour of the facility, visible from the hallway. The Registered Nurse (RN) assigned to the unit confirmed the observation and subsequently applied a privacy bag. A review of Resident #64's medical record indicated a care plan for catheter care, which included positioning the catheter bag and tubing below the bladder level and away from the entrance room door. The Director of Nursing acknowledged the concern regarding the visibility of the urine collection bag from the hallway.
Failure to Provide Quarterly Financial Statements to Resident
Penalty
Summary
The facility failed to provide residents with quarterly statements in writing of their personal funds account managed by the facility. This deficiency was identified during a survey when a resident confirmed that they had not received a written quarterly statement of their account for a year, despite keeping money in the facility. The resident's medical record indicated that they were capable of making their own decisions, which should have ensured they received these statements. The Business Office Manager (BOM) admitted to hand-delivering quarterly statements to residents who could make their own decisions and discussing the statements with them. However, the BOM only made copies for residents who specifically requested them. During the survey, the BOM presented a quarterly statement for the resident, which was signed but did not confirm that a copy was provided to the resident. This oversight led to the deficiency, as the facility did not ensure that residents received their quarterly financial statements in writing as required.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to inform a resident of their right to formulate an advance directive, as evidenced during a survey. The medical record review for a resident admitted in December 2024 showed that the resident was capable of making their own decisions. However, there was no documentation indicating that the resident had been informed of their right to create an advance directive or that they had one in place. The nurse manager, who was also acting as the social services designee, admitted during an interview that she only inquired if residents already had advance directives and did not discuss the option to create one if they did not. This oversight occurred after the facility lost their social worker, and the nurse manager took on additional responsibilities. The nursing home administrator expected staff to assist residents in establishing advance directives if needed, but this expectation was not met in this instance.
Failure to Notify Physician of Medication Holds
Penalty
Summary
The facility failed to notify the physician when a medication was held several times for low systolic blood pressure (SBP) in the case of Resident #44, who was being treated for cardiomyopathy with Metoprolol. The medication order specified that Metoprolol 50 mg should be administered twice daily unless the resident's pulse was less than 60 or the SBP was less than 100. Despite these parameters, the medication was held on multiple occasions in April 2024 due to low SBP or heart rate, but there was no documentation indicating that the physician was informed of these instances. The surveyor's review of the April 2024 Medication Administration Record (MAR) revealed several dates when the medication was withheld due to low SBP or heart rate, including instances on April 3, 6, 9, 10, 12, 13, 14, 16, 17, and 18. During an interview, the primary care physician confirmed that she expected to be notified via fax or phone call if medications were held due to vital signs outside of the prescribed parameters. The lack of communication with the physician regarding these medication holds was discussed with the Director of Nursing (DON) and highlighted as a deficiency in the facility's processes.
Failure to Include Catheter Care in Resident's Care Plan
Penalty
Summary
The facility failed to provide a person-centered comprehensive care plan for a resident with an indwelling Foley catheter. The deficiency was identified during a survey when it was found that the resident's comprehensive care plan did not include catheter care, despite physician orders indicating the need for maintaining a 16 French indwelling Foley catheter and providing catheter care every shift. The Treatment Administration Record showed that catheter care was being completed, but this was not reflected in the care plan. The Director of Nursing acknowledged the omission upon review of the care plan, confirming that it did not address the resident's catheter care needs.
Failure to Follow Physician's Orders for Resident Weights
Penalty
Summary
The facility failed to follow the physician's orders for monitoring the weight of a resident diagnosed with congestive heart failure (CHF). The care plan for the resident included an intervention of daily weights to manage potential fluid volume imbalance related to CHF. However, the resident refused daily weights, and the facility communicated with the physician, who agreed to change the order to weekly weights. Despite this agreement, there was no documentation in the medical record to indicate that the order was officially changed to weekly weights. Instead, the medical record showed an order for monthly weights, which was not consistent with the physician's response. The Assistant Director of Nursing confirmed the lack of documentation for the change to weekly weights, and the primary care physician later reiterated that the order should have been for weekly weights.
Failure to Properly Place Fall Mat for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure that fall mats were properly placed for a resident identified as a fall risk. Resident #10, who has been residing in the facility since 2018, was observed multiple times with the fall mat folded and not in the designated position on the left side of the bed as per the care plan. On several occasions, the resident was found in bed without the fall mat in place, despite being identified as a fall risk in the most recent evaluation dated 12/30/24. During an observation, the resident was noted to be in a precarious position with their head hanging over the side of the bed, and the fall mat was still not in place. A Geriatric Nursing Assistant (GNA #4) acknowledged the oversight and repositioned the fall mat after being prompted. The Director of Nursing was informed of the repeated failure to utilize the fall mat correctly, and they acknowledged the concern.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents with indwelling catheters, as evidenced by observations and interviews. Resident #64 was observed with a urine collection bag lying directly on the floor, which was confirmed by RN #3. The resident's medical record lacked complete documentation regarding the catheter size and balloon fluid amount, which was only corrected after the surveyor's inquiry. LPN #5 confirmed the incomplete order and attempted to rectify it, but there was no documentation to verify the catheter size. The Assistant Director of Nursing confirmed the absence of documentation, and a statement was provided indicating an attempt to clarify the catheter size with Urology. Resident #419 was repeatedly observed with a Foley bag on the floor, despite being in bed or using a bedside table. The bag was observed on the floor multiple times over several days, and staff confirmed that it should not be on the floor. The Director of Nursing was informed of the frequent observations of the Foley bag on the floor, acknowledging that it could be a source of infection. These observations indicate a failure to maintain proper catheter care and documentation, potentially compromising resident safety.
Failure to Oversee Resident's Medical Care
Penalty
Summary
The facility failed to ensure that a resident's care was properly overseen by a physician, specifically in the management of their antidiabetic and thyroid medications. The resident, who had been living in the facility since 2015, did not have necessary A1C and TSH blood work completed in 2024, despite the attending provider's notes indicating the need for these tests. The provider's notes from June, July, and August 2024 mentioned the requirement for A1C blood work, but there was no documentation of these tests being ordered or completed. Interviews with the Director of Nursing and the medical director revealed a lack of awareness and oversight regarding the resident's blood work orders. The attending provider admitted to missing the orders for the resident's blood work and acknowledged the oversight in managing the resident's care. This deficiency was evident in the lack of documentation and follow-through on necessary medical tests for the resident, which were crucial for monitoring their health condition.
Incomplete and Inaccurate Physician Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that physician's notes were complete, accurate, signed, and dated at each visit for two residents. For Resident #24, the attending provider's visit notes from January to December 2024 were not part of the medical record at the time of the survey. Although the resident received regular visits from the attending provider, the progress notes were not signed at each visit and were only completed on January 12, 2025. Additionally, the notes inaccurately stated that the resident's blood sugar levels were stable, despite no orders or tests being conducted to verify this information. The attending provider admitted to documenting based on staff reports without reviewing the resident's blood sugar logs. For Resident #44, the medical record lacked documentation from the primary care provider for the entire year of 2024. The resident, who had a diagnosis of atrial fibrillation and was on Coumadin, required regular PT/INR tests, but there was no documentation of the goal range for these results in the provider's notes. The primary care physician's notes, faxed to the facility on January 14, 2025, contained lab values from before 2024 and were signed off on January 13, 2025, indicating a lack of timely and accurate documentation in the resident's medical record.
Lack of Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were competent in their skill set, as evidenced by the lack of competency evaluations for two registered nurses. RN #19, who was hired in August 2024, and RN #3, an agency staff member hired in May 2023, both had no records of competency evaluations. This deficiency was identified during a recertification survey when the Director of Nursing (DON) was asked to provide competency evaluations for two randomly selected nurses. Upon review of staff documents, it was confirmed that there were no competency evaluations for these two RNs. The DON acknowledged the absence of these evaluations as a deficiency.
Deficiency in Full-Time Director of Nursing
Penalty
Summary
The facility was found to be deficient in having a Director of Nursing (DON) who worked on a full-time basis during a recertification survey. The deficiency was identified through interviews and record reviews. The DON confirmed that she was also serving as the only Infection Preventionist (IP) nurse, which resulted in her not being able to fulfill the role of a full-time DON. The dual role of the DON was acknowledged by the facility's administration as a concern, indicating awareness of the deficiency. This situation had the potential to impact all residents, staff, and visitors at the facility.
Delayed Response to Pharmacist's Medication Review
Penalty
Summary
The facility failed to ensure that irregularities identified by the pharmacist during the monthly Medication Regimen Review (MRR) were reviewed and acted upon in a timely manner by the attending physician. This deficiency was observed in the case of a resident who had been residing in the facility since 2015 and was receiving multiple medications, including an antifungal cream for moisture-associated skin damage. The pharmacist recommended on 5/21/2024 that the antifungal cream be reviewed for possible change to a barrier cream, in line with the antibiotic stewardship program. However, the attending physician did not sign off on this recommendation until 9/25/2024, and the change in medication was not implemented until 12/11/2024. The facility's policy and procedure for MRR were found to be inadequate as they did not specify a timeframe for the attending physician to address the MRR recommendations. Although the Director of Nursing (DON) reported that the regional office advised that MRRs should be addressed within 30 days, the delay in addressing the pharmacist's recommendation for the resident's medication change exceeded this timeframe. The DON confirmed that the facility did not receive the signed report from the attending provider's office until 12/11/2024, which contributed to the delay in implementing the new order.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications, as evidenced by the administration of medications outside of prescribed parameters. Resident #59, who had been residing in the facility since early 2024, was observed to be in discomfort and declined an interview due to not feeling well. The resident had orders for Morphine Sulfate to be administered as needed for severe pain, with specific instructions for administration prior to dressing changes. However, the resident received Morphine on several occasions without documentation of the pain level, including an instance where it was administered for a pain level of 3, which was outside the prescribed parameters. The Director of Nursing (DON) confirmed these findings upon review. Additionally, Resident #44 had an order for Metoprolol to be held if the pulse was less than 60 or systolic blood pressure was less than 100. Despite this, the medication was administered when the resident's blood pressure was below the specified threshold on two occasions. Furthermore, Spironolactone was also administered when the resident's blood pressure was below the ordered parameter. The surveyor discussed these concerns with the DON, who was unable to provide additional documentation or information before the survey exit.
Medication Management Deficiencies
Penalty
Summary
The facility failed to accurately document the reconciliation of controlled medications and store medications according to professional standards. During an observation, a narcotic record book was found on a medication cart with a nurse's signature in the space designated for a later shift, indicating an incorrect documentation of the narcotic count. The Director of Nursing confirmed that the signature was incorrect as it was placed before the actual transfer of narcotics to another nurse. The facility's policy requires that both the oncoming and outgoing nurses count the narcotics together and document the count, which was not adhered to in this instance. Additionally, expired medications were found in two medication carts during inspections. The medications included Allergy Relief, [NAME]-Tussin DM, Oyster shell, Fish oil, Mucus relief, Vitamin C, Dulcolax, and Aspirin, all of which were past their expiration dates. Furthermore, an inhaler for a resident was not dated when opened, contrary to the instructions that require it to be discarded six weeks after opening or when the counter reads zero. The LPNs responsible for the carts confirmed the presence of expired medications and the lack of proper documentation for the inhaler. Another issue was observed with a resident's medications being left unattended at the bedside. A plastic medicine cup with pills was found on the resident's bedside table, and the medications were documented as given in the Medication Administration Record. The LPN stated that the resident takes the medications at their discretion, and the facility lacked a process to ensure the resident takes their medications. The Director of Nursing acknowledged the need for procedures to secure the resident's medications until they are ready to take them.
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 260 citations issued within 25 miles in the last 12 months — including the 3 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 Cumberland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Devlin Manor Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 29 | 0 |
| Allegany Health Nursing And Rehab | 2 mi | ★★★★★ | 19 | 0 |
| Cumberland Healthcare Center | 2.9 mi | ★★★★★ | 27 | 1 |
| Frostburg Rehab Center | 5.9 mi | ★★★★★ | 54 | 0 |
| Mountain City Rehab Center | 7 mi | ★★★★★ | 33 | 0 |
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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.