Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manokin Nursing And Rehab during CMS and state inspections, most recent first.
A resident with dementia and PTSD, who had moderate cognitive impairment, was involved in an altercation with the facility Administrator during a smoking break. Witnesses, including staff and cognitively intact residents, reported that the Administrator blocked the door to prevent the resident from re-entering the building due to a cigarette, pushed the resident in the chest multiple times, and used a racial slur. The resident stated the Administrator was hitting them and calling racial slurs while they tried to return inside, leading the resident to choke the Administrator to get past her. These actions constituted physical and verbal abuse by the Administrator, in violation of the facility’s abuse policy and the resident’s right to be free from abuse, and were cited at an Immediate Jeopardy level under 42 CFR 483.12.
A facility failed to report an allegation of abuse to the state survey agency within the required two-hour timeframe after a resident with dementia and moderate cognitive impairment was involved in a physical altercation with the Administrator following a smoking break. The resident reported being pushed and yelled at by the Administrator after refusing to pick up a discarded cigarette and surrender an unlit cigarette, leading the resident to choke the Administrator. Two CNAs stated they saw the Administrator blocking the door, shoving the resident, and slamming the door shut when staff tried to deescalate the situation, which escalated the resident’s behavior. An LPN on duty received reports that the Administrator provoked the resident and that the resident alleged being pushed, and she notified the family, police, DON, and MD, but the required external report to the SSA was not submitted until several days later, contrary to facility policy and regulatory timeframes.
Failure to prevent resident-to-resident physical abuse occurred when a cognitively impaired resident was pulled out of bed by another resident with a documented history of homicidal ideations, verbal aggression, and physical aggression, resulting in a head laceration requiring sutures. The aggressive resident had repeated behavior notes and no care plan in place until after the incident, and a separate resident with a history of hitting other residents was also not actually receiving the documented 1:1 supervision.
Failure to Employ a Qualified Full-Time Social Worker: The facility, licensed for 135 beds, did not have a qualified social worker on a full-time basis. The SWD stated she was not licensed or certified and had previously worked as a certified medicine aide. Surveyors requested documentation of her degree and credentials, but none was provided during the survey. Her file showed a Health certificate program, and the DON confirmed the facility did not have the qualifying degree or credentials for the SWD.
Failure to Provide and Document Mandatory Communication Training: The facility did not ensure mandatory communication training was provided or documented for direct care staff. The HRD said new hires completed onboarding by reading tasks and signing off, but communication was not included in the onboarding materials and there was no evaluation of understanding. Review of staff files for GNAs, an LPN, and an RN found no evidence of communication training, and interviews with the DON, Staff Educator, and other department leaders confirmed there was no online learning platform and no further documentation of staff participation in communication education or in-services.
Failure to Provide Mandatory QAPI Training: The facility did not provide evidence of required QAPI training for 7 of 7 staff records reviewed, including GNAs, an LPN, an RN, a DA, and an HA. The HRD said onboarding consisted of reading and signing tasks, but QAPI was not included in the onboarding packet. Interviews with the Staff Educator, DON, ADON, CNO, and department leaders showed inconsistent information about mandatory training, and the available education binders and folders did not contain attendance sheets or other proof of QAPI training.
Failure to Treat Residents with Dignity: Surveyors observed 13 residents on the memory care unit sitting with no activities, no music, and no meaningful staff interaction while one resident cried and another complained. Staff were also observed asleep at a resident’s bedside during a 1:1 visit and feeding a resident breakfast while talking on a cell phone, with the resident lying in bed. The resident’s care plan called for 1:1 bedside/in-room visits and activities when unable to attend out-of-room events.
Failure to Maintain a Homelike Environment: Surveyors observed extensive damage and disrepair in resident rooms and bathrooms, including scraped doors, missing trim, peeled paint, holes in doors and ceilings, stains, a broken soap dispenser, worn nightstands, and a torn wheelchair armrest with a resident picking at the foam and string. The regional maintenance director stated the prior maintenance director had been terminated and that the maintenance assistant was doing all the work, with issues tracked through TELs and PCC and wheelchair repairs handled through PT orders or monthly inspections.
Facility staff failed to appropriately respond to a resident’s repeated episodes of markedly elevated BP. The resident had a history of HTN and had recently transferred to the hospital for systolic BP over 200 mm Hg, yet the record showed multiple later readings with systolic BP over 190 mm Hg, including a peak of 215/88 mm Hg, with no documentation that the physician was notified or that specific care was provided. An LPN stated high BP should be reported, rechecked, and treated per orders, and the DON and Medical Director confirmed the elevated readings should have been communicated and assessed.
The facility failed to complete required annual performance reviews for two GNAs. Employee file review showed one GNA had no 2025 review and another had no review for 2023 or 2024, and interviews with the DON, ADON, and one GNA confirmed the reviews were not available in the files and had not been received by the GNA.
Controlled medication records were not reconciled with MARs for several residents receiving narcotics and sedatives. A resident on morphine, a resident on alprazolam, a resident on oxycodone, and a resident on zolpidem had mismatches between MAR documentation and count sheets, including extra administrations, missing MAR entries, and a time discrepancy. In addition, shift count sheets on two units were not completed by both on- and off-duty nurses, with missing signatures and unanswered count questions noted by the DON and IP.
Opened medications were found without open dates on multiple med carts, including nasal spray, eye drops, lactulose, magnesium citrate, sodium polystyrene sulphonate, Imodium oral solution, and valproic acid oral solution. An LPN stated open meds should be dated when opened, while a CMA said she was unsure whether to follow the manufacturer’s expiration date or the open date; the DON confirmed that open meds should be dated with open dates.
Food items were found in the freezer without labels, including fish, sliced cheese, and several open jars of dressing and BBQ sauce. The FSD stated the items should have been labeled with receive and use-by dates. The facility also had freezer temperature logs showing repeated out-of-range readings on a unit, with no documented action taken when temperatures were outside the expected range; the IP could not account for the log entries, and the DON was informed of the concern.
Incomplete TB screening was identified when medical record review showed that several newly admitted residents lacked required TB testing documentation, including missing second-step results and missing admission TB tests. The Infection Preventionist and DON confirmed that 2-step TB skin testing should be completed and documented in the resident record, but the records reviewed showed the tests were not completed as required.
Missing Documentation for Flu and Pneumococcal Immunizations: Record review and staff interviews showed that staff failed to assess and document immunization status for flu and pneumococcal vaccines and failed to document education when a resident refused the flu vaccine. Two residents had missing vaccine documentation, and an IP and the DON confirmed that vaccination status, refusals, and education should be documented in the medical record.
The facility failed to maintain COVID-19 vaccination status in resident and staff records. Five residents had no COVID-19 vaccination information documented in their charts, and an employee health file for an LNA/direct care staff member lacked any health records, including COVID-19 vaccination status. The IP and DON confirmed the missing documentation during record review, and no additional documentation was provided before the survey ended.
Freezer Not Maintained in Working Order: Surveyors observed significant ice and frost build-up inside the kitchen freezer, including on the curtain sleeves, door, floor, cart poles, ceiling above the compressor fans, and boxes stored inside. The Dietary Manager and maintenance director acknowledged the freezer had previously been worked on and that the door was not always closed and the unit did not freeze properly.
Failed pest control program with repeated fly, gnat, roach, ant, beetle, and spider activity observed throughout the facility, including the conference room, dining room, hallways, kitchen, offices, and service areas. A resident reported flies in the room, and the Regional Maintenance Director acknowledged flies were the biggest recent concern while pest logs and vendor reports documented ongoing activity near the loading dock, dumpsters, and multiple units.
Failure to Document Compliance and Ethics Training: The facility failed to ensure staff received and documented compliance and ethics training. The HRD said new hires completed printed onboarding tasks by reading and signing off, but compliance and ethics was not included in the onboarding materials. Review of employee files for a GNA, RN, dietary aide, and housekeeping aide showed no evidence of this training, and the facility’s education binders contained only two compliance and ethics attendance sheets with 12 signatures total, including only 2 of the 7 employees reviewed. Interviews with the HRD, DON, CNO, and department leaders showed inconsistent accounts of who provided training and what records were available.
Staff failed to maintain an accurate medical record when a progress note documented a telehealth visit for a resident who was not present in the facility at the time. The entry lacked required annotations for late entry or error, and staff could not explain the discrepancy.
Facility staff failed to honor a guardian’s objection when a resident was transferred to another facility without consent. The record showed discharge paperwork completed with verbal consent documented by staff, but no evidence of a 30-day involuntary discharge notice. The guardian reported they were told the resident would be moved, did not agree to the transfer, and later learned the resident had already been moved.
A resident’s RP was not informed before three new psychotropic medications were started, including Depakote, lumateperone, and trazodone. The resident’s spouse was listed as the RP, but the medical record did not show evidence of notification. The DON stated that the RP should be notified by the doctor or floor nurse before a new medication is started, but no documentation was available to confirm that this occurred.
Failure to notify physician and responsible party of a resident’s significant change in condition. A resident on palliative care with frequent narcotic use was documented with agonal breathing and a RR of 4, then later found without heart or lung sounds and without a pulse. The record lacked detailed documentation of the resident’s decline between those notes, and the DON confirmed no further documentation was present. The Medical Director stated the change should have been documented and the attending physicians notified.
Failure to timely report an abuse allegation to OHCQ. A resident stated that aides yelled at her weekly and that she felt abused when staff pushed and forcefully moved her during in-bed care and bathing. The DON later said she spoke with the resident and considered it a misunderstanding, but acknowledged the allegation was not reported within the required 2-hour timeframe and described the 5-day follow-up process.
Improper Resident Discharge Without Guardian Consent: Facility staff transferred a resident to another facility without the guardian’s consent and despite the guardian’s objection. The record showed discharge paperwork completed with verbal consent documented by staff, but no evidence of a required 30-day involuntary discharge notice. The guardian reported being told the resident had already been moved after they had asked for other placement options and answers to their concerns.
Facility staff failed to give a guardian the required 30-day notice before transferring a resident to another facility. The record showed discharge paperwork with verbal consent documented by staff, but no evidence of an involuntary discharge notice. The guardian reported objecting to the transfer, asking for other placement options, and learning the resident had already been moved without consent.
A facility failed to ensure comprehensive care plans were developed for two residents. One resident was receiving antibiotics and topical medications for a UTI and skin conditions, but no care plan was documented for the medication-related focus, goals, or interventions. Another resident was going out for dialysis three times weekly, but the record contained no dialysis care plan. Staff, including the IP, unit manager, and DON, confirmed the missing care plans.
Failure to hold quarterly interdisciplinary care plan meetings for two residents. One resident had quarterly MDS assessments and an annual assessment, but only one care plan meeting summary was documented, and the DON confirmed meetings were not completed after each assessment. Another resident had one documented care conference, with no evidence of meetings for multiple quarters; a later EHR summary showed a meeting, but there was no sign-in sheet for earlier conferences, and the DON stated they were probably not done.
Failure to provide needed feeding assistance: Three residents were observed eating meals with their hands in the dining area without staff present, despite care plans and meal tickets indicating supervision or feeding assistance. One resident with Alzheimer’s-related ADL deficits, one resident with dementia and gait dysfunction, and one resident with dementia and behaviors were all seen eating without the assistance level documented in their records, while staff stated residents who eat with their hands should receive help or appropriate utensils.
Failure to Provide 1:1 Resident-Centered Activities: A resident dependent on staff for activities because of immobility and physical limitations did not receive documented 1:1 bedside/in-room activities despite a care plan calling for them. The resident stated activities were not being done in the room and was observed in bed with the TV off and no bedside activity occurring. The resident’s preferences included music, news, favorite activities, fresh air, and religious services, but the facility had no daily activity documentation to show activities were provided.
A resident on a locked dementia/psychiatric unit had multiple containers of Greer's goo left at the bedside, including an open bottle and a near-empty container marked past its use date. A GNA said the nurse must have done a treatment earlier, and the unit nurse said it was normal to have medications at bedside. The DON later said bedside meds were not usually allowed, and the chart contained no physician order permitting them.
Oxygen Tubing Not Labeled or Dated: Two residents receiving O2 via nasal cannula were observed with tubing and humidifiers that were not labeled with a date showing when they were last changed. One resident had an order for continuous O2 and a separate weekly tubing-and-sterile-water change order, while the other had an O2 order without a tubing-change order. An LPN confirmed the tubing should be dated, and the DON agreed staff should label it with the last change date.
A physician failed to timely document a resident’s progress note and enter medication orders for a resident with HTN and resistant BP. The DON confirmed there were no provider notes in the chart after the last note on file, even though the physician said he had seen the resident in November. The physician’s note later documented new meds, but the orders were not entered until later, and the DON confirmed the delay.
A resident with schizoaffective disorder, major depressive disorder, and anxiety disorder was receiving medications for mental health symptoms, including verbal or physical aggression, but the chart had no behavior monitoring order. The DON confirmed the resident had aggressive behavior and that nursing staff should document behaviors in the TAR, yet no behavior monitoring documentation was found.
The facility failed to ensure monthly MRR recommendations were reviewed and documented by the physician in the resident record. A resident receiving Depakote and sertraline had pharmacist recommendations for dose evaluation and later for evaluation and monitoring of an elevated NT-proBNP, but the record lacked physician response, rationale, or evidence that the recommendations were addressed. The DON acknowledged the missing documentation.
Failure to Follow PRN Pain Medication Orders: A resident had PRN APAP ordered only for mild pain, but reported pain levels above that range on multiple occasions. There was no evidence the MD was contacted for pain outside the ordered range, no order addressed moderate pain, and a later PRN tramadol order for severe pain was not given even when the resident reported severe pain. The DON stated staff should have called the MD and should have given the tramadol instead of Tylenol.
Failure to Screen Resident for Rehabilitative Services: A resident with Parkinson’s disease, generalized weakness, abnormal posture, and muscle wasting stated therapy was supposed to be provided but was not. The family requested therapy at a care plan meeting, and the DOR said that such a request should trigger a screen or eval within a couple of days. However, the resident was not on caseload, had previously refused OT, and no documentation showed a required LTC rehab screen or eval had been completed.
QA meetings did not include required key personnel. Review of sign-in sheets showed the MD, SW, infection preventionist, and dietitian were absent from certain monthly QA meetings, and the NHA acknowledged that these staff are needed to address issues requiring their expertise.
A resident with impaired vision and intact cognition reported a missing ring, but staff failed to maintain an inventory of the resident's belongings and did not document or investigate the loss according to facility policy. Interviews and record reviews confirmed the absence of an inventory list and grievance documentation related to the missing item.
Two residents experienced physical abuse by staff members, including a cognitively impaired resident who was struck in the face by a GNA and another resident who was hit on the head by an intoxicated maintenance assistant. Both incidents were witnessed or reported by staff and other residents, and the facility's policies prohibiting abuse were not upheld.
A resident with severe cognitive and physical impairments, identified as high risk for falls, experienced multiple unwitnessed falls despite an existing care plan with fall prevention measures. After each fall, incident reports were completed, but no new interventions or care plan updates were documented or implemented to address the repeated incidents, as confirmed by record review and staff interviews.
Administrator Physical and Verbal Abuse of Resident During Smoking Break
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by the Administrator during a smoking break. The facility’s abuse policy prohibited abuse, including physical abuse such as hitting, slapping, and pushing, and verbal abuse such as the use of disparaging and derogatory terms, including when residents are within hearing distance regardless of their cognitive status. Resident #3, who had dementia, post-traumatic stress disorder, generalized anxiety disorder, and moderate cognitive impairment (BIMS score of 10), was participating in a smoke break when an altercation occurred with the Administrator. The resident reported that the Administrator allowed more residents than usual to go out to smoke and then began calling the resident racial slurs while the resident was smoking and attempting to return inside. According to Resident #3, when they tried to re-enter the building, the Administrator repeatedly hit them and blocked their way, leading the resident to choke the Administrator to get her out of the way. Multiple witnesses, including staff and residents, described the Administrator physically blocking the door and preventing Resident #3 from entering the facility because of a cigarette. CNA #1 stated she saw the Administrator standing in front of the door, screaming "no" at the resident, blocking the door, and pushing Resident #3 in the chest twice while the resident tried to get around her. An activity aide reported seeing the Administrator and the resident shoving each other, and that when she attempted to open the door with the keypad, the Administrator yelled "no" and told her not to open it, after which the resident choked the Administrator. Several cognitively intact residents who witnessed the event provided consistent accounts that the Administrator pushed Resident #3 and used a racial slur before the resident placed hands on the Administrator. One resident witness stated the Administrator pushed the resident back from the door twice and then used the N-word, after which the resident grabbed the Administrator by the throat. Another resident reported that the Administrator shoved the resident in the chest multiple times, causing the resident to rock back, and then called the resident a racial slur, which led to the resident becoming angry and choking the Administrator. Additional witnesses described the Administrator blocking the keypad with her body and hand, shoving the resident in the chest with both hands, and engaging in a verbal argument with the resident. Collectively, these accounts show that the Administrator initiated physical contact and used a racial slur toward Resident #3, constituting physical and verbal abuse in violation of the facility’s abuse policy and the resident’s right to be free from abuse. The surveyors determined that this conduct by the Administrator toward Resident #3 constituted non-compliance with 42 CFR 483.12, Freedom from Abuse, Neglect, and Exploitation, at a scope and severity level J, indicating Immediate Jeopardy that began on 02/05/2026 when the Administrator verbally and physically abused the resident.
Failure to Timely Report Allegation of Staff-to-Resident Abuse to SSA
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident abuse to the state survey agency (SSA) within the required two-hour timeframe, as required by its own abuse, neglect, and exploitation policy. The policy specified that all alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the allegation is made, to the Administrator, state agency, adult protective services, and other required agencies. Despite this requirement, the facility did not submit the initial Facility Reported Incident (FRI) for an abuse allegation involving Resident #3 and the Administrator until several days after the incident. Resident #3, who had dementia, post-traumatic stress disorder, generalized anxiety disorder, and moderate cognitive impairment (BIMS score of 10), was involved in a physical altercation with the Administrator following a smoking break. According to the incident report and resident’s account, the resident stated they were outside smoking, discarded a cigarette in the snow, and refused the Administrator’s instruction to pick it up. The resident further reported that the Administrator pushed them and demanded an unlit cigarette the resident wished to keep, and when the resident again refused, the Administrator continued pushing and saying the resident was not listening, leading the resident to choke the Administrator. The incident report categorized this as physical aggression initiated by the resident toward a staff member. Witness statements from two CNAs described the Administrator blocking the door and preventing the resident from reentering the building, with both the Administrator and the resident shoving each other. One CNA reported that when she opened the door to deescalate the situation, the Administrator slammed it shut with her body and yelled "No," which further triggered the resident, after which the Administrator shoved the resident again and the resident choked the Administrator. The nurse on duty stated that staff were required to report any witnessed or alleged abuse immediately, within two hours, and confirmed she was informed that the Administrator had provoked the resident and that the resident alleged the Administrator yelled at and pushed them. Although the nurse notified the resident’s family, local police, DON, and MD, the initial abuse report to the SSA was not submitted until days later, and facility leadership acknowledged that the incident and witness statements constituted an allegation of abuse that should have been reported immediately.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident from physical abuse by another resident with a documented history of homicidal ideations, verbal aggression, and physical aggression toward staff and residents. The aggressive resident had multiple prior notes describing threats to kill others, yelling, derogatory language, punching fists, and repeated episodes of aggression, yet there was no care plan in place from admission until after the physical abuse event to address the resident’s homicidal ideations, abusive behaviors, or aggression toward others. On 08/16/2025, staff found the cognitively impaired resident on the floor in a puddle of blood with a laceration above the right eye after the aggressive resident pulled the resident out of bed. Witness statements and staff interviews confirmed that the aggressive resident demanded that the other resident be removed from the bed and then forcefully yanked the resident out by the shirt and pants before staff could intervene. The injured resident was transferred to the hospital and required 3 sutures to the right eyebrow. The aggressive resident’s record showed a care plan was initiated only after this incident and did not include non-pharmacological interventions or de-escalation techniques for the resident’s ongoing aggressive behavior. The report also identified a separate resident-to-resident physical abuse event involving another resident with a behavior problem related to physical aggression. That resident had prior documented incidents of hitting other residents, including slapping a resident in the face, hitting a resident in the neck, and being observed hitting another resident in the dayroom. Although the care plan listed 1:1 supervision as an intervention, there was no evidence the resident was actually under 1:1 supervision, and the plan was not revised to include additional interventions to prevent further physical aggression toward other residents.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker on a full-time basis in a facility licensed for 135 beds. During the survey, the Social Worker Designee stated she was not licensed or certified and reported that she had worked at the facility for 1 year, had been in the Social Services position for 5 months, and had previously worked as a certified medicine aide. When the surveyor requested documentation of her degree and credentials qualifying her for the Social Worker position, none was provided by the end of the survey team’s exit on 9/23/25. Review of the employee file later showed an application for the Social Work Designee position and education listed as a certificate program in Health. The DON later verified that the facility did not have the qualifying degree or credentials for the Social Worker Designee.
Failure to Provide and Document Mandatory Communication Training
Penalty
Summary
The facility failed to ensure staff received mandatory communication training. During the survey, the Human Resources Director stated that new hires completed onboarding tasks by reading printed materials and signing off that they had finished them, but there was no evaluation criteria or written assessment of staff understanding. She also stated that the onboarding tasks were estimated to take about 5 hours and included topics such as resident rights, abuse prevention, HIPAA, fire safety, infection control, OSHA right to know, dementia care tips, elopement, pain assessment and management, but communication was not listed as an onboarding task. Review of employee files for five direct care staff members, including GNAs, an LPN, and an RN, showed no evidence of communication training. The files reviewed showed hire dates ranging from 2005 through 2024, but none contained documentation of communication training. When the surveyor asked the Staff Educator and DON for evidence of communication, QAPI, dementia, cognitive impairment/mental illness, and infection control training from 10/1/23 through the present, they stated that training was tracked through sign-in sheets and that the facility did not use an online learning platform. The Staff Educator also stated she had only been in the role for about a month and had not seen the sign-in sheets. The Monthly Education Calendar for 2025 showed Effective Communication scheduled for April and October, but review of the binders and manila folders provided by the CNO failed to reveal any attendance sheet or other evidence of Effective Communication training. Interviews with an Activities Aide, an RN, and a GNA also indicated they had not received communication training upon hire or since employment. Additional department leaders, including Activities, Housekeeping/Laundry, and Rehab, stated they did not provide mandatory training for their staff, and the DON and Staff Educator confirmed there was no further documentation of staff participation in education, in-services, or trainings.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to staff. The deficiency was identified during the extended survey investigation portion of the recertification survey and involved 7 of 7 employees reviewed: GNA #3, GNA #18, GNA #22, LPN #33, RN #19, DA #41, and HA #42. The report states this practice had the potential to impact all residents. During an interview, the HRD stated the facility did not use an online learning platform and that new hires completed onboarding tasks by reading printed materials and signing off that they had read them. She confirmed there was no evaluation criteria, written or otherwise, after staff read the tasks. The onboarding packet titled Mandatory Staff Education listed multiple topics, but QAPI was not included as an onboarding task. The HRD also stated that additional training and in-services existed, but nursing would have the sign-in sheets. Review of the employee files for the seven staff members showed no evidence of QAPI training for any of them. Interviews with the Staff Educator, DON, ADON, CNO, and department leaders showed inconsistent information about who provided mandatory training and which staff were required to attend. The Monthly Education Calendar for 2025 showed QAPI scheduled for January and July, but review of the available binders and folders of staff education, training, and in-services did not reveal attendance sheets or other evidence of QAPI training. An Activities Aide also stated no training had been received in 2023, 2024, or 2025, and a GNA stated she did not know what QAPI was.
Failure to Treat Residents with Dignity
Penalty
Summary
Facility staff failed to treat residents with dignity on the memory care unit. On 12/1/25, surveyors observed 13 residents sitting in the dining/activity area with no activities in progress, no music, and a television on with only a still photo and no sound. One resident was crying, another was complaining, and none of the residents had books, coloring books, music, videos, or staff interaction; five nursing staff members were observed standing and sitting around the nurse’s station. A resident told the surveyor that staff would not turn the TV on and that it bothered him/her. Surveyors also observed Staff #10, an Activity Assistant, asleep in a chair at the bedside of Resident #214 while activity materials were on her lap. Resident #214 was lying in bed and stared at the surveyor. The resident’s care plan stated the resident was dependent on staff for activities and needed 1:1 bedside/in-room visits and activities if unable to attend out-of-room events. On 12/2/25, Staff #32 was observed standing in Resident #97’s room feeding the resident breakfast while talking on a cell phone in another language; the resident was lying in bed. Staff #32 stated she was talking to her sister because she needed money. LPN #33 entered the room, stated it was a dignity issue, and left. The DON and NHA were informed of the observations, and the NHA stated the behavior of the staff was unacceptable.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in 2 of 3 units observed during the recertification/complaint survey. During the initial tour, surveyors observed multiple areas of damage and disrepair in resident rooms and bathrooms, including scraped and damaged bedroom doors, missing wall trim, paint scrapings on walls, large holes in bathroom doors, scraped wood on bathroom doors, peeled wall paint, a loose bathroom ceiling vent, holes in bathroom ceilings, brown circular stains on ceilings, and a broken soap dispenser with a missing cover. Surveyors also observed worn nightstands and a wheelchair armrest that was torn, with the resident sitting in it picking at the foam and string. During interview, the regional maintenance director stated that the prior maintenance director had been terminated at the end of August and that the maintenance assistant was doing all the work. He explained that maintenance tasks were tracked in the TELs system and that issues could be reported through PCC, with repairs prioritized by urgency. He also stated that physical therapists were responsible for entering wheelchair repair orders for residents who used therapy, and that maintenance performed monthly inspections for residents who did not go to therapy. During a later walk-through with the nursing home administrator and the regional maintenance director, the surveyor pointed out the observed concerns, and the regional maintenance director stated he would get started on some of the repairs right away.
Failure to Address Repeatedly Elevated Blood Pressure
Penalty
Summary
Facility staff failed to provide appropriate care to a resident with repeatedly elevated blood pressure readings. Resident #6 had transferred to the hospital on 8/13/25 due to elevated BP, with systolic pressure over 200 mm Hg. A review of vital signs from 8/14/25 to 9/23/25 showed 14 instances of systolic BP over 190 mm Hg, including a high of 215/88 mm Hg on 9/12/25. Despite these abnormal readings, there was no documentation that the resident’s condition was reported to the physician or that specific care was provided to manage the symptoms. During interviews, an LPN stated that abnormally elevated BP should be reported to the provider, rechecked, and medication obtained per order if still high, with all communication documented and a change in condition form completed. The DON, Medical Director, and DON later confirmed that the elevated blood pressures should have been notified to the physician and assessed, even though the resident was followed by a cardiologist and had a history of hypertension.
Missing Annual Performance Reviews for GNAs
Penalty
Summary
The facility failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. During review of employee files for GNA #3 and GNA #18, surveyors found that GNA #3 was hired on 1/19/24 but her file did not contain a performance review for 2025, and GNA #18 was hired on 11/7/05 but her file did not contain a performance review for 2023 or 2024. The deficiency was identified during the Sufficient and Competent Nurse Staffing task for the facility's recertification survey. Interviews with the DON and ADON on 9/24/25 confirmed that performance reviews were expected to be completed and stored in employee files, but the DON stated that if HR did not have them in the files, then they did not have them. When asked about the reviews, the DON said the ADON or DON conducted them, while the ADON stated they were done every 12 months. In an interview, GNA #3 stated that she had never had a performance review. The surveyor requested the missing performance reviews for GNA #3 and GNA #18, but none were found in the employee files reviewed.
Controlled Medication Records and Shift Counts Were Not Reconciled
Penalty
Summary
The facility failed to maintain controlled medication records in a manner that allowed reconciliation of dispensed and administered medications for four residents reviewed for narcotic administration. Resident #44 was prescribed Morphine Sulfate 100 mg/5 ml liquid 0.25 ml by mouth every 4 hours as needed for breakthrough pain, but the MAR showed four administrations while the count sheet documented fifteen administrations during the same period. Resident #79 was prescribed Alprazolam 0.5 mg tablet by mouth every 8 hours as needed for anxiety for 14 days starting 8/05/25; the MAR showed doses on 8/11/25, 8/14/25, and 8/18/25, while the count sheet documented thirteen administrations from 8/01/25 to 8/29/25, including ten administrations not documented on the MAR, and the MAR also showed no active order for the medication during portions of that time. Resident #96 was prescribed Oxycodone 10 mg by mouth every 4 hours as needed, with the MAR showing administration on 9/19/25 at 3 PM, but the count sheet documented removal at 6 AM that same day. Resident #35 was prescribed Zolpidem 5 mg by mouth every 24 hours as needed for insomnia, with the count sheet documenting nightly administration from 9/16/25 to 9/22/25, while the MAR lacked documentation for 9/16/25 and 9/18/25. The facility also failed to complete controlled medication shift counts with two nurses. Review of the 100s unit shift count sheets showed missing on-duty or off-duty nurse signatures on multiple shifts, including 9/11/25 day shift and 9/15/25 evening and night shifts, and the form contained incomplete answers for the EDK box sealed and count correct questions on 34 of 49 columns from 8/29/25 to 9/22/25. On the Dementia unit, the shift count sheets showed missing on-duty nurse signatures on 9/18/25 and 9/20/25, and one 9/22/25 day shift line had an off-duty nurse signature without other information. Staff stated that two nurses were required to count narcotic medications and document them with signatures, and the DON and IP confirmed that the shift count sheet should be completed by both on- and off-duty nurses with all questions answered.
Opened medications were left undated on multiple med carts
Penalty
Summary
The facility failed to date and label drugs when opened with an open date. During observation and staff interviews, surveyors found opened medications on 3 of 6 medication carts reviewed on the nursing units during the recertification/complaint survey that did not have open dates. On the short hall med cart, medications were found opened and undated, including Fluticasone Propionate (Flonase) nasal spray 50 mcg and Clopatadine (olopatadine) eye drops (Pataday 0.1%). The report noted manufacturer instructions that Flonase nasal spray should be discarded after 2 months or when the number of sprays indicated on the bottle has been used, whichever comes first, and that olopatadine eye drops should be discarded after 4 weeks (28 days). On the 200 unit long hall med cart, opened medications without open dates included lactulose 10 gm/15 mL, magnesium citrate lemon bottle, and Fluticasone Propionate nasal spray. On the 500s unit chase long hall med cart, opened and undated medications included sodium polystyrene sulphonate liquid, Imodium oral solution house stock bottle, lactulose solution, and valproic acid oral solution. An LPN stated that open medications are supposed to be dated on the day they were opened, and a CMA stated she was confused and not sure whether to go by the manufacturer’s expiration date or the date the bottles were opened. The DON stated that when meds are open, they should be dated with open dates.
Unlabeled Food Items and Improper Freezer Temperature Monitoring
Penalty
Summary
Food items were observed stored in the freezer without labels during a kitchen tour with the food service director. The unlabeled items included a bag of fish, sliced cheese in a container, and 1-gallon open jars of ranch dressing, golden Italian dressing, creamy [NAME] dressing, and BBQ sauce. During interview, the food service director stated that food items are normally labeled with a receive date and a use-by date and acknowledged that the observed items should have been labeled. The facility also failed to maintain proper freezer temperatures on the Chase Unit. The September 2025 temperature log showed freezer readings of 15 F, 20 F, and 18 F on multiple days, with no entries in the log indicating any action taken when temperatures were out of range. The surveyor checked the freezer temperature and found it at -5 F. The Infection Preventionist stated he/she could not account for what was written on the log, and the DON stated concern after being informed of the temperature log findings.
Incomplete TB Screening for Newly Admitted Residents
Penalty
Summary
The facility failed to implement an effective infection control program when staff did not complete tuberculosis (TB) screening for newly admitted residents. Medical record review showed that Resident #17, admitted in October 2024, had a TB skin test completed on 10/22/24 but there was no documentation of a second test. Resident #8, admitted in May 2024, had no documentation of a TB test upon admission. Resident #3, admitted in March 2025, had a 2-step TB skin test completed on 3/05/25 and 3/12/25, but there was no result documented for the second test. Resident #77, admitted in February 2024, also had no documentation of a TB test upon admission. During interview, the Infection Preventionist stated that the 2-step TB skin test should be completed for residents and documented in the medical record. The DON later reviewed the records and verified that the TB test should be completed in 2 steps. The surveyor determined that the TB tests for the above residents were not completed as required.
Missing Documentation for Flu and Pneumococcal Immunizations
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after a record review and staff interviews showed that facility staff failed to assess and document residents’ influenza and pneumococcal vaccination status and failed to provide education about the benefits and risks of the vaccines. The deficiency was identified during review of five residents’ immunization records in the recertification/complaint survey. Resident #17, admitted in October 2024 and identified as a candidate for the pneumococcal vaccine, refused the flu vaccine when it was offered, but there was no evidence that staff documented education about the vaccine. There was also no documentation of the resident’s pneumococcal vaccination status in the electronic record. Resident #3, admitted in March 2025, also had no documentation of flu vaccination status. The Infection Preventionist stated that residents’ immunization status, including COVID-19, flu, and pneumococcal vaccines, should be assessed and documented, and that refusal and education should be documented. The DON reviewed the records and verified that vaccination status and education should be documented for any resident who refused a vaccine.
Missing COVID-19 Vaccination Documentation in Resident and Staff Records
Penalty
Summary
The facility failed to maintain residents’ and staff members’ COVID-19 vaccination status in their medical records. During a surveyor review of five randomly selected resident records, Resident #3, #8, #17, #27, and #77 did not have COVID-19 vaccination status documented in their medical records. The Infection Preventionist stated that facility staff should maintain residents’ COVID-19 vaccination status and update the medical records, and the DON later verified that there was no COVID-19 vaccination information for those five residents. For staff records, a review of five randomly selected employee files showed that Staff #19, a direct resident care staff member hired in December 2024, did not have any health records, including COVID-19 vaccination status, in her file. The Infection Preventionist stated the facility was supposed to obtain employees’ immunization records from Immunet and that she should monitor the data, but she had not yet been involved in monitoring employee immunization status. The DON reviewed Staff #19’s employee health file and said she would search for the documentation, but no further documentation was provided before the survey ended.
Freezer Not Maintained in Working Order
Penalty
Summary
The facility failed to ensure the kitchen freezer was in working order during a revisit survey. During an observation of the kitchen freezer, surveyors found significant ice and frost build-up on the plastic curtain sleeves and ice build-up on the door, with chunks of ice on the floor and on the poles of the storage carts. Small mounds of ice were also observed on the ceiling above the compressor fans, and ice was present on top of boxes stored in the freezer. The Dietary Manager was brought into the freezer to confirm the findings and stated the freezer had been worked on a month or two earlier and that he would call the company to look at it. The maintenance director later stated he had been made aware of the freezer the day before, that there had been no work order before then, and that his assessment was that the door was not always closed, the freezer did not freeze properly, and ice had built up around the door.
Failed Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program. Surveyors observed flies and gnats in the conference room on the first day of the survey and continued to observe gnats and flies in the conference room and hallways throughout the survey. Flies were also observed in the dining room, and on one occasion several flies were seen flying around a resident’s room and landing on Resident #72. When asked about the flies, the resident stated that a wall-mounted device was supposed to catch them but did not work. During interview, the Regional Maintenance Director stated the facility had a preventative insect/pest control program and that Allstate came every other week, but he also stated flies were the biggest recent concern. Review of pest logs showed repeated reports of ants, flies, beetles, spiders, and roaches in multiple units, offices, the kitchen, and service areas. Allstate service reports documented fly activity throughout the facility, heavy activity near the loading dock and front entry doors, trash bins placed against the building near the loading dock, employee use of doors for smoking and traffic, and roach activity in the dish machine electrical box. The DON was informed of the pest concern and confirmed understanding.
Failure to Document Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure staff received compliance and ethics training. During the survey investigation, the Human Resources Director stated that new hires completed onboarding tasks by reading printed materials and signing off that they had read them, and she confirmed there was no evaluation criteria after staff reviewed the tasks. She also stated the onboarding tasks were estimated to take 5 hours and included topics such as resident rights, abuse prevention, HIPAA, fire safety, infection control, OSHA right-to-know, incident/accident prevention, advanced directives, dementia care tips, sexual harassment, elopement, and pain assessment and management, but compliance and ethics was not listed as an onboarding task. Review of employee files for five of seven employees reviewed showed no evidence of compliance and ethics training for a GNA hired in 2005, a GNA hired in 2024, an RN hired in 2024, a dietary aide hired in 2025, and a housekeeping aide hired in 2024. Interviews with the HRD, DON, and other department leaders showed inconsistent descriptions of who provided staff education and which staff were required to attend trainings. The HRD stated she handled onboarding and a 4-hour orientation, while the DON stated a 12-month calendar was used for clinical staff and that department heads would provide any training for nonclinical staff. When surveyors reviewed the facility’s education binders and folders, they found only two attendance sheets with compliance and ethics listed as the in-service topic, with 12 total signatures. Only 2 of the 7 employees reviewed were identified on those attendance sheets. The Staff Educator, DON, CNO, ADON, Activities Director, Director of Housekeeping/Laundry, and Director of Rehab each gave differing statements about staff training records and participation, and the Staff Educator and DON acknowledged there was no further documentation available for staff training from 2024 or 2025.
Inaccurate Medical Record Entry for Absent Resident
Penalty
Summary
Facility staff failed to maintain an accurate medical record for one resident who had been transferred to the hospital for suicidal ideation. During a review of the resident's records, a progress note was found documenting a telehealth visit on a date when the resident was not present in the facility. The unit manager was unable to explain why this note was entered, and the medical record director confirmed that the note did not include any indication of being a late entry or written in error, as required by facility policy. The Director of Nursing also confirmed that the resident was not in the facility on the date the telehealth visit was documented.
Failure to Honor Guardian’s Objection to Resident Transfer
Penalty
Summary
Facility staff failed to honor the wishes of the guardian for Resident #21 when arranging the resident’s transfer/discharge. The clinical record showed a court-consent order naming [NAME] County Department of Social Services as guardian of person for the resident. The record also included a discharge form dated 9/26/25 and a discharge planning instruction sheet completed the same day, both documenting verbal consent with the initials of a staff member; the instruction sheet listed the relationship to the resident as facility staff member. The record contained no evidence that a 30-day involuntary discharge notice was issued. A complaint from the guardian stated that facility staff contacted the guardian on 9/25/25 and said they wanted to transfer the resident to a sister facility in another county, but the guardian did not consent and asked that other placements be considered and concerns be answered. The guardian reported that when they contacted the facility the next day, staff said the resident had already been moved earlier that day. During an interview on 9/30/25, the guardian stated the resident was transferred without consent and despite objection, and that no 30-day discharge notice was issued. An interview with the administrator on 9/30/25 provided no additional information.
Failure to Notify Responsible Party Before New Psychotropic Medications
Penalty
Summary
The facility failed to inform the responsible party when new psychotropic medications were ordered for one resident. Review of the medical record for Resident #72 showed orders for Depakote 500 mg delayed release tablets, lumateperone tosylate 42 mg capsules, and trazodone 50 mg tablets, along with an existing sertraline 50 mg order. The resident’s spouse was listed in the record as the responsible party, accounts receivable guarantor, and emergency contact. The medical record did not show evidence that the responsible party was informed before the resident started Depakote, lumateperone, and trazodone. During interviews, the DON stated that if a resident has a responsible party, they should be notified by a doctor or floor nurse before a new medication is started. When asked for documentation, the DON was unable to provide evidence that the responsible party had been informed prior to the three psychotropic medication orders.
Failure to Notify Physician and Responsible Party of Resident’s Change in Condition
Penalty
Summary
Facility staff failed to timely notify the physician and the responsible party of a resident’s significant change in condition. For Resident #113, a nurse documented agonal breathing with a respiration rate of 4 on 7/16/25 at 11:03 AM and noted that the resident did not appear to be in pain or discomfort, with care continuing. Agonal breathing was described in the report as an abnormal, involuntary reflex indicating a severe medical emergency and imminent death without immediate intervention. The resident’s record also showed palliative care since June 2025 and frequent narcotic use for pain management. A later note on 7/19/25 at 2:55 AM documented that the resident had no heart or lung sounds and no palpable pulse, was DNR per MOLST, and had ceased to breathe. However, there were no detailed notes from 7/16/25 through 7/19/25 documenting the resident’s changing condition. The DON confirmed there was no further documentation during that period, and the Medical Director stated the resident’s decreased condition was expected due to health status and narcotic use, but the change in condition should have been documented and the attending physicians notified.
Failure to Timely Report an Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the State Survey Agency, the Office of Health Care Quality (OHCQ), in a timely manner for one resident reviewed for abuse. During an interview, the resident stated that aides yelled at her at least once a week and that she felt abused when staff pushed and forcefully moved her during in-bed care and bathing. The resident also stated that most aides did not wear name tags or introduce themselves to her. The DON was informed of the allegation by the surveyor and stated she would look into it. Later, the DON stated she spoke with the resident and determined the allegation was not substantiated, describing it as a misunderstanding. When asked about the reporting requirements, the DON stated that allegations of abuse must be reported within 2 hours, but she acknowledged that this allegation was not reported within that timeframe. She also stated that the follow-up report is due within 5 days and described the investigation as complete when all information and statements are obtained and the 5-day follow-up has been submitted.
Improper Resident Discharge Without Guardian Consent
Penalty
Summary
Facility staff failed to appropriately discharge Resident #21. The clinical record showed a court-consent order naming [NAME] County Department of Social Services as guardian of person for the resident, and a discharge form dated 9/26/25 documented the signature line for the patient/representative as verbal consent. A discharge planning instruction sheet completed on 9/26/25 also documented verbal consent under the person receiving instructions, with the initials of a staff member, and listed the relationship to the resident as facility staff member. The record contained no evidence that a 30-day involuntary discharge notice was issued. A complaint from the resident’s guardian stated that facility staff contacted the guardian on 9/25/25 and said they wanted to transfer the resident to a sister facility in another county, but the guardian did not consent and asked that other placements be considered and concerns be addressed. The guardian reported that when they contacted the facility the next day, staff told them the resident had already been moved earlier that day. On 9/30/25, the guardian stated in interview that the resident was transferred without consent and despite objection, and that no 30-day discharge notice was issued. The administrator interview provided no additional information.
Failure to Provide Required Transfer/Discharge Notice
Penalty
Summary
Facility staff failed to provide the guardian of Resident #21 with a 30-day notice of involuntary transfer or discharge before the resident was moved. The clinical record showed a court-consent order naming [NAME] County Department of Social Services as guardian of the person for Resident #21, and a discharge form dated 9/26/25 documented verbal consent for the patient/representative signature. A discharge planning instruction sheet completed on 9/26/25 also documented verbal consent with the initials of a staff member, and the relationship to the resident was recorded as facility staff member. The record contained no evidence that a 30-day involuntary discharge notice was issued. A complaint from the guardian stated that facility staff contacted them on 9/25/25 and said they wanted to transfer the resident to a sister facility in another county, but the guardian did not consent and asked that other placements be considered and concerns be addressed. The guardian reported that when they contacted the facility the next day, they were told the resident had already been moved earlier that day. On interview, the guardian stated the resident was transferred without consent and despite objection, and that no 30-day discharge notice was issued. The administrator interview provided no additional information.
Failure to Develop Care Plans for Antibiotic Use and Dialysis
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for 2 of 6 residents reviewed. One resident was receiving Cephalexin 500 mg twice daily for a UTI for 6 days, and also had orders for Ketoconazole 2% cream for a facial rash and Triamcinolone Acetonide 0.1% cream for a right leg rash. The resident stated he/she was getting antibiotics but did not know for how long. Medical record review and staff interview confirmed there was no care plan documented for the focus, goal, or intervention related to these medications. The Infection Preventionist stated that the Antibiotic Stewardship program included maintaining a line listing of residents on antibiotics and ensuring an updated care plan for antibiotics, and the unit manager confirmed there was no care plan written for antibiotic medications for this resident. A second resident had an order for dialysis scheduled every Monday, Wednesday, and Friday and stated during interview that he/she went out to dialysis on those days. Record review showed there was no care plan for dialysis. The unit manager stated that the resident went off site to dialysis and agreed that the resident should have had a care plan for dialysis. The DON was informed that there was no dialysis care plan for this resident, and the DON agreed that the resident should have had an individualized dialysis care plan.
Failure to Hold Quarterly Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to hold interdisciplinary team care plan meetings for residents concurrent with their quarterly care plan revisions. For Resident #88, the record showed a re-admission to the facility in July 2024 and quarterly MDS assessments completed on 9/24/24, 12/28/24, and 3/30/25, with an annual assessment completed on 6/28/25. However, only one care plan meeting summary was documented on 6/28/25, and the DON confirmed that care plan meetings were not completed after each MDS assessment. For Resident #10, the clinical record showed one care plan meeting on 12/30/24, but no evidence of meetings in March 2025, June 2025, or September 2025. A care plan summary was later added to the EHR showing a meeting held on 9/2/25, but there was no sign-in sheet for care conferences in March or June 2025. The Social Worker stated that care plan meetings are held quarterly and documented in the care plan summary, and the DON later confirmed that if social work had not brought the conferences in, they were probably not done.
Failure to Provide Needed Feeding Assistance
Penalty
Summary
The facility failed to provide the level of feeding assistance needed for dependent residents. During observation, Resident #50 was seen eating breakfast in the dining area with his/her fingers while only a fork and knife were on the tray and no staff member was present. Resident #50’s care plan identified an ADL self-care deficit related to Alzheimer’s with behaviors and included supervised meals as an intervention. Resident #55 was also observed eating breakfast with his/her fingers without staff present, and the medical record showed an ADL care plan for dementia, history of falls, and gait dysfunction, but no intervention addressing the level of assistance needed for eating. Resident #97 was observed eating pureed food with his/her right hand while chewing on a wet white washcloth held in the left hand, with no staff present during the meal. The meal ticket stated feeding assistance instructions, and the medical record showed an ADL care plan for dementia with behaviors and Alzheimer’s with an intervention for eating of supervision and verbal cueing. Staff interviews indicated that residents who eat with their hands should have finger foods or assistance, that food should not be placed in front of a resident unless staff are available to assist, and that supervision in the care plan meant the presence of a staff member during meals. The DON also stated that residents observed eating with their hands should be provided feeding assistance, and meal tickets for the three residents included feeding assistance instructions.
Failure to Provide 1:1 Resident-Centered Activities
Penalty
Summary
The facility failed to provide 1:1 resident-centered activities to support the mental and psychosocial well-being of one resident who was dependent on staff for activities because of immobility and physical limitations. During the survey, the resident stated that activities were not being done in the room and, when observed in bed with the television off, stated that no bedside activity was occurring. The care plan documented a need for 1:1 bedside/in-room visits and activities if the resident was unable to attend out-of-room events, and the resident’s preferences included listening to music, keeping up with the news, doing favorite activities, going outside for fresh air, and participating in religious services or practices. Record review showed an activity progress note stating the resident preferred to remain in the room and would watch TV programs, current events, and receive 1:1 visits. The Activities Director stated that residents who are bedbound or do not want to leave their rooms are provided 1:1 bedside activity, but also stated that the resident would close his/her eyes when activity staff entered the room. When asked for documentation of activities offered, staff provided a quarterly activities assessment and stated there was no documentation of daily activities. The Activities Director and DON were informed that this was a concern, and the Activities Director acknowledged that moving forward staff would document activities provided.
Unattended Medications Left at Bedside on Locked Unit
Penalty
Summary
The facility failed to ensure medications were not left unattended on the locked unit for 1 resident out of 45 sampled. On 9/22/25 at 9:00 AM, the surveyor observed Resident #10’s room on the locked unit, which houses residents with dementia and/or psychiatric diagnoses, and found an open bottle of Greer's goo on the bedside table, a near-empty container of Greer's goo on the nightstand with a “do not use past 9/4/25” date, and another container of Greer's goo on the nightstand. The surveyor showed the items to a GNA, who said the nurse must have done a treatment earlier and stated she would move the creams. The nurse on the unit stated that the resident had received care that morning and that it was normal to have medications at bedside. The DON later stated that medications were not usually allowed at the bedside on the locked unit, but said to take it up with the Medical Director when asked whether an order could allow it. Review of the resident’s clinical record on 09/23/2025 found no physician order for leaving medication at the bedside, and when informed of that finding, the DON said that if it was not in the chart then there probably was not an order.
Oxygen Tubing Not Labeled or Dated
Penalty
Summary
The facility failed to label and date oxygen tubing to show when it was last changed for 2 residents reviewed for respiratory care. During the initial round, two residents were observed in their rooms receiving oxygen via nasal cannula connected to oxygen humidifiers, and both sets of oxygen tubing were not labeled with a date indicating when they had last been changed. A later observation found one resident in the day room with family members and a portable oxygen tank, and the oxygen tubing was still not labeled with a change date. Review of the medical record showed one resident had an order for oxygen at 2 LPM via nasal cannula to maintain saturation above 92% every 12 hours for oxygen saturation monitoring, but no order was found for the oxygen tubing to be changed. The other resident had an order for oxygen at 2 LPM via nasal cannula continuously every 12 hours, along with a separate order directing that oxygen tubing and sterile water be changed weekly and labeled and dated every night shift every Tuesday. In interview, an LPN stated that oxygen tubing is supposed to be changed weekly by night shift and that the humidifier and nasal cannula tubing should have dates on them to show when they were last changed; she confirmed both were not dated. The DON later confirmed that oxygen tubing should have an order to change weekly and that staff should label it with a date to indicate when it was last changed.
Delayed Physician Documentation and Medication Orders
Penalty
Summary
The physician failed to enter progress notes and medication orders in a timely manner for a resident admitted in 2021 with hypertension. The resident’s last physician or nurse practitioner note in the medical record was dated 10/20/25, and the Director of Nursing confirmed on 12/3/25 that there were no physician or nurse practitioner notes since that date. The DON stated the physician reported seeing the resident in November but had not yet entered the progress note into the medical record. After surveyor intervention, the DON provided the physician progress note dated 11/27/25, which documented resistant blood pressure and the decision to start Isosorbide Dinitrate 20 mg twice daily, HCTZ 12.5 mg daily, and Folic Acid 5 mg daily. Review of the physician orders showed these medications were not ordered until 12/3/25. The DON confirmed on 12/4/25 that the physician did not document the 11/27/25 visit in the medical record until 12/3/25 and did not place the medication orders from that visit until 12/3/25.
Failure to Monitor and Document Behavior for Resident With Mental Disorders
Penalty
Summary
The facility failed to monitor and document behavior for a resident with mental disorders. Resident #11 was admitted in April 2025 with diagnoses of schizoaffective disorder, major depressive disorder, and anxiety disorder, and had been given several medications for the mental disorder, including medications addressing symptoms of verbal or physical aggression. During record review, there was no order for behavior monitoring. The Director of Nursing confirmed that the resident had several mental disorders, including aggressive behavior, and stated that nursing staff should monitor behaviors and document them in the Treatment Assessment Records in the electronic medical record. She also verified that there was no documentation for Resident #11's behavior monitoring.
Failure to Document and Respond to Monthly Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen review recommendations were reviewed and documented by the physician in the resident’s medical record, and that the consulting pharmacist’s recommendations were responded to in a timely manner. This was identified for one resident who was receiving psychotropic medications, including Depakote 500 mg twice daily and sertraline 50 mg every morning for bipolar disorder, and whose record contained multiple consultant pharmacist reviews noting irregularities. On review of the resident’s medical record, the 5/24/24 pharmacist review stated that the resident had been taking sertraline and Depakote and asked that the current dose be evaluated and a dose reduction be considered. The form contained response options and space for clinical rationale, but none of the boxes were checked and there was no physician signature or date. The DON acknowledged during interview that there was no signed original in the record and that the medical director’s progress note from 5/29/24 did not reference Depakote or show that the monthly pharmacy recommendation had been reviewed and responded to by the physician. A later pharmacist review on 7/15/25 noted that the resident had a high NT-proBNP reading of 166 and asked that the resident be evaluated and monitored. The provider, NP #34, signed and dated the recommendation form on 8/14/25 and checked the Agree box, but when surveyors requested evidence that the resident was evaluated and monitored after that agreement, the DON stated there was no documentation to provide for the July 2025 pharmacy recommendation. The facility policy required the attending physician to document review of identified irregularities and any action taken, or the rationale for no change, but the record did not contain that documentation for the cited recommendations.
Failure to Follow PRN Pain Medication Orders
Penalty
Summary
The facility failed to ensure a resident received medication as ordered and failed to address pain levels outside the parameters of the existing PRN order. Resident #10’s record showed an order for acetaminophen 325 mg, two tablets every six hours as needed for mild pain rated 1-3. The resident reported pain rated 6, 8, and 10 on separate occasions, but there was no evidence the physician was contacted after the first two pain episodes to obtain instructions for pain above the ordered range. A later order for tramadol 50 mg every 8 hours as needed for severe pain rated 7-10 for 14 days was entered, but the medication was not administered even when the resident reported pain rated 10. There was also no order to address moderate pain rated 4-6. The DON reviewed the MAR and orders and stated staff should have called the doctor for another order and should have administered tramadol instead of Tylenol.
Failure to Screen Resident for Rehabilitative Services
Penalty
Summary
The facility failed to screen or evaluate a resident for rehabilitative services. Resident #72 stated that therapy was supposed to be provided but was not being given. The resident’s medical record showed diagnoses including Parkinson’s disease, generalized muscle weakness, abnormal posture, and muscle wasting and atrophy. A care plan conference summary documented that the family wanted some type of therapy ordered for the resident so the resident could participate more in activities, receive emotional support, and try daily routines. The Director of Rehab stated that residents are usually screened within 72 hours of admission and that LTC residents are screened or evaluated about every 90 days, or sooner with a change in condition. She also stated that if a resident’s responsible party requested therapy, that would be enough to trigger a screen or evaluation, and that the timeline is usually within a couple of days. She reported that Resident #72 was not on caseload and that the resident had last been on PT caseload from 12/20/24 to 2/6/25 and last evaluated by OT on 3/27/25, when services were refused. However, no documentation was provided showing that a screening or evaluation had been completed in June, despite the family’s request for therapy during the care plan meeting. The DON acknowledged the concern at the exit conference and no further documentation was provided.
QA Meetings Lacked Required Key Personnel
Penalty
Summary
The facility failed to have key essential personnel present during its monthly quality assurance (QA) meetings. Review of the QA agenda and meeting sign-in sheets for January through August 2025 showed that in July the medical director, social worker, and infection preventionist did not attend the meeting, and in August the social worker, dietitian, and infection preventionist were absent. During an interview, the nursing home administrator who oversees QA acknowledged that certain key personnel are required to be present at each monthly QA meeting and stated their presence is needed to help address issues that may require their expertise. He was informed of the months when key personnel were absent and stated he would be more consistent going forward.
Failure to Maintain Resident Property Inventory and Investigate Lost Item
Penalty
Summary
The facility failed to protect a resident's property and provide a safe environment by not maintaining an inventory of the resident's belongings and not investigating a reported lost item. A resident with intact cognition and impaired visual function reported a missing ring to both staff and family. The care plan for this resident directed staff to inform the resident where items were placed due to visual impairment. Documentation showed that staff searched the room and contacted laundry, and the resident's family involved the state police. However, there was no evidence that a formal inventory of the resident's belongings was completed at admission, nor was there documentation of a grievance or investigation into the missing ring. Interviews with current staff, including the Social Services Director and the Nursing Home Administrator, confirmed the absence of an inventory list and a lack of documentation regarding the grievance or its resolution. Staff recalled being notified about the missing ring and informing the previous Social Services Director, but could not confirm if any follow-up or formal grievance process occurred. The facility's policy required completion of an inventory list at admission and a documented grievance process for missing items, but these procedures were not followed in this case.
Failure to Prevent Staff-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from staff-to-resident abuse, resulting in two separate incidents involving physical abuse by staff members. In one case, a resident with severe cognitive impairment and diagnoses including Alzheimer's disease and major depressive disorder was involved in an altercation where a Geriatric Nurse Aide (GNA) struck the resident in the face after the resident had first smacked the aide. The incident was reported to the administrator, and the resident was assessed for pain and injury, with no physical harm noted at the time. The resident did not recall the event and denied pain, but the event was corroborated by other staff who heard the altercation. In another incident, a cognitively intact resident with diagnoses including spinal stenosis, bipolar disorder, and chronic heart failure reported being physically assaulted by a Maintenance Assistant (MA) who was intoxicated while on duty. The MA used profane language, hit the resident on the back of the head, and poked the resident on the shoulder. Another resident witnessed the event and noted the smell of alcohol on the MA's breath. The MA was observed by staff to be intoxicated, refused to leave the facility when directed, and was later reported to have struck the resident. The resident expressed fear of the MA following the incident. Both incidents were documented in the facility's records and confirmed through interviews with staff and residents. The facility's abuse prevention policy prohibits such actions and requires immediate reporting of abuse allegations. Despite these policies, the facility did not maintain an environment free from staff-to-resident abuse, as evidenced by these two events involving physical harm to residents by staff members.
Failure to Implement Post-Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement interventions to prevent multiple falls for a resident identified as being at high risk for falls. The resident had severe intellectual disabilities, major depressive disorder, restlessness, agitation, and severely impaired cognitive skills, and was dependent on staff for hygiene and mobility. The care plan identified the resident as at risk for falls and included specific interventions such as placing the bed against the wall, keeping the bed in the lowest position, ensuring proper posture, using floor mats, and applying a perimeter mattress. Despite these measures, the resident experienced multiple unwitnessed falls, each time being found on the floor next to the bed, sometimes with minor injuries. After each fall, incident reports were completed, but no new interventions were documented or implemented to address the repeated falls. Record reviews and staff interviews confirmed that after each fall, there was no evidence of updated interventions or care plan modifications. The Minimum Data Set Coordinator, Nursing Home Administrator, and Director of Nursing—all of whom were not employed at the time of the incidents—were unable to find documentation of any interventions added after the falls. The staff involved in the incidents were no longer employed and did not respond to inquiries. The lack of follow-up interventions after each fall event constituted a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent further accidents.
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 122 citations issued within 25 miles in the last 12 months — including the 2 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 Princess Anne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anchorage Rehabilitation And Wellness Center | 12 mi | ★★★★★ | 28 | 0 |
| Wicomico Nursing Home | 12.5 mi | ★★★★★ | 13 | 0 |
| Hartley Nursing And Rehab | 12.5 mi | ★★★★★ | 32 | 0 |
| Bay Harbor Post Acute Healthcare Center | 13.1 mi | ★★★★★ | 15 | 2 |
| Deer's Head Center | 13.2 mi | ★★★★★ | 10 | 0 |
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