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 Pines Nursing And Rehab during CMS and state inspections, most recent first.
Staff failed to maintain resident dignity by not ensuring appropriate clothing and linens, not covering Foley catheter drainage bags with required dignity bags, and restricting resident access to the dining room for dinner and weekend meals. One resident was found unclothed in bed with stained bedding and later complained of being cold and improperly dressed, while laundry backlogs and broken equipment delayed personal clothing availability. Two residents with Foley catheters had visible drainage bags that were not placed in privacy bags, contrary to facility policy acknowledged by the DON. Multiple residents and the resident council president reported that they were not allowed to eat dinner or weekend meals in the dining room and wished to socialize there, and the Administrator and department managers stated that the dining room was closed for those meals due to insufficient staff.
Surveyors found that staff failed to keep call lights within reach for multiple residents on one unit, despite care plans directing that call lights be accessible and used to request assistance for residents with decreased mobility, dementia, encephalopathy, schizophrenia, and poor safety awareness. During observations, several residents in bed or sitting on the bed had call bells on the floor, behind or under the bed, or wrapped around the bed frame; one resident reported staff took the call bell away, and another reported staff turned off the call bell and did not return. A staff member acknowledged the issue with call bells and indicated it was an ongoing problem, and leadership was later informed.
Staff failed to maintain a sanitary, safe, and comfortable environment, particularly on one unit, where a resident was found in bed without clothes, lying on stained linens with a soiled sheet covered in gnats placed on a trashcan, and in a room cluttered with discarded incontinence products and clothing on the floor. Multiple rooms and common areas had stained and cracked ceiling tiles, missing or damaged flooring and laminate surfaces, non-functioning or uncovered lights, rusted exhaust fans, peeling drywall, and dirty, sticky, or discolored floors. One room’s wall A/C unit had visible gaps to the outside, with cold air entering, accumulated dust, cobwebs, and a loose electrical box, while several beds on the unit had no linen. A staff member reported there was no linen available overnight or in the morning, and the maintenance director acknowledged ongoing linen shortages and inoperable laundry equipment, as well as unaddressed structural and cleanliness issues inside and outside the building.
The facility failed to maintain complete and accurate medical records when podiatry visit notes for multiple residents were not uploaded into the EMR, despite staff reporting that podiatry care had been provided. Additionally, care plan meeting documentation for several residents was kept only on paper in a file cabinet by a social worker and was not entered into the medical record, leaving gaps between the dates of documented care plan meetings and the actual meetings held.
Facility staff did not maintain all laundry equipment in working order, contributing to delays in personal laundry and insufficient linen supply for residents. Surveyors observed that only 2 of 3 washers and 2 of 4 dryers were operational, with one of the working dryers being much smaller than the commercial unit. A laundry staff member reported that the broken washer and two dryers had been out of service for some time and that the smaller dryer could not handle the same volume as the larger dryer. The Maintenance and Housekeeping Director confirmed that staff were unable to keep up with residents’ personal laundry needs due to the limited functional equipment.
Facility staff failed to notify a resident’s representative of a scheduled orthopedic appointment, even though the representative typically accompanies the resident to all medical visits. On the day of the appointment, the resident reported being told that morning that there was a doctor’s visit but did not know its purpose, and the representative, present during interview, stated they had not been informed and therefore could not attend. Record review showed the resident went to an orthopedic appointment and received a left shoulder injection, and the DON confirmed that staff did not notify the representative of this appointment.
Staff failed to accurately code MDS assessments for two residents, leading to incorrect documentation of fall history and urinary continence. One resident was admitted after a documented fall that caused a left intertrochanteric femur fracture, yet the admission MDS coded fall history as "unable to determine" despite clear hospital and NP documentation of the fall. Another resident had a physician’s order for a Foley catheter for urinary retention and was observed with a Foley drainage bag at the bedside, but the quarterly MDS coded urinary continence as "always incontinent" instead of reflecting the presence of an indwelling catheter. The MDS Coordinator acknowledged both coding errors during interview.
Facility staff failed to develop and implement a care plan for a resident with an indwelling Foley catheter ordered for urinary retention. The resident’s MDS and Treatment Administration Records documented ongoing catheter use, and the catheter drainage bag with urine was observed hanging at the bedside and visible from the hallway. Despite this, review of the medical record showed no care plan addressing the catheter, even though the MDS Coordinator indicated that the nursing team was responsible for creating and implementing care plans.
Facility staff failed to hold a required quarterly care plan meeting for a resident after completion of a quarterly MDS assessment. The facility’s process requires the IDT to meet after each MDS to review and revise the care plan, which guides individualized care and is reviewed at least quarterly. Record review showed the last care plan meeting occurred months before the most recent quarterly MDS, with no subsequent meeting documented. Social Services, who keeps care plan documentation, reported that a meeting had been scheduled but then postponed and not rescheduled, resulting in the missed quarterly care plan review.
Surveyors found that a resident with a physician’s order for continuous oxygen at 2 L for comfort was not receiving oxygen despite the presence of an oxygen concentrator at the bedside. Across multiple observations, the concentrator remained off and the nasal cannula was coiled on top of the machine rather than in the resident’s nostrils. Review of the MAR showed that six licensed nurses, including RNs and/or LPNs, had documented each shift that the resident was receiving oxygen as ordered, despite the lack of actual oxygen administration. The DON and administrator were informed that the medical record had been falsified, and the DON confirmed the findings.
Staff failed to maintain appropriate shower water temperatures on the Wye Oak Unit, where one of two showers was found to have water at 87°F and a faucet that could not be turned toward the hot setting, while the other shower measured 110°F. The Director of Maintenance and Housekeeping confirmed the low temperature, acknowledged that shower temperatures should be between 100°F and 120°F, and reported being unaware of the problem. No signage was posted to prevent staff from using the malfunctioning shower, and this issue was identified during a complaint survey of one of four nursing units.
The facility failed to maintain an effective pest control program on one nursing unit, where numerous gnats were observed in resident rooms and hallways. In one room, a soiled sheet left on top of a trashcan was covered with multiple gnats, and in another room gnats were seen around the toilet area. A resident was observed in bed with empty plastic juice containers left on the tray table, and gnats were flying around the resident’s chin; a staff member acknowledged that gnats were sometimes present because containers were not removed. Pest management records showed the unit had been treated several weeks earlier, with no documentation of a gnat problem despite staff confirming its presence, and leadership was later informed of these concerns.
Food storage and sanitation practices were not maintained in the kitchen and unit pantries. Surveyors found undated and unlabeled food in refrigerators and freezers, spoiled items, incomplete temperature logs, and inconsistent staff accountability for monitoring the units. A dietary employee was also observed preparing food without a beard covering, and wet nesting was seen on insulated plates and lids, while sanitization buckets were found at improper concentrations.
The facility failed to follow infection control practices when clean linens were left uncovered on a hallway cart, a urine specimen was stored in a med refrigerator with insulin pens, and leftover pudding was kept inside two med carts. The facility also failed to implement EBP for two residents with Stage 3 pressure ulcers, as no EBP order, sign, or PPE supplies were initially in place and staff gave inconsistent responses about when EBP was required.
Pest Control Program Failure in Kitchen: The facility failed to ensure an effective pest control program for the kitchen. The Dietary Manager reported flies as the primary pest concern, and a surveyor later observed five flies above the food prep area while a Dietary staff member was preparing crab cakes for residents. The part-time Dietary Director was informed of the concern and acknowledged it.
Failure to Maintain Resident Dignity: Staff entered a resident’s room without knocking or identifying themselves, delayed urgent toileting assistance, and left a resident waiting while searching for a urine receptacle. Other residents were left watching peers eat while waiting over an hour for meals, one feeder did not receive a tray while others ate, residents reported being barred from lobby restrooms, some staff were not wearing name badges, and a GNA used a personal cell phone in a resident room. A resident receiving G-tube feeding was also observed with drooling oral secretions and poor oral hygiene.
Failure to Offer Advance Directive Information: The facility failed to ensure residents and their representatives were offered the opportunity to develop advance directives. Record reviews showed no advance directive documentation for two residents, including one with a BIMS score indicating cognitive intactness and one with cognitive impairment, and no written advance directive information was provided to two other residents or their representatives. The RSW confirmed that the residents and families were not offered or educated on advance directives during admission.
Dirty flooring and urine odor were observed in resident areas, with carpets throughout the facility showing large stains and white tile floors in multiple rooms and on the Homestead unit having black markings and a sticky substance that caused surveyors' shoes to stick. In one room, a strong urine smell was traced by an RN to the floor and trash can rather than the residents' dry briefs, and housekeeping had not been seen all day.
Resident care plans were not developed for several residents with identified needs. A resident with a vision deficit had no activity care plan and reported no one-on-one activities, another cognitively impaired resident had no activity or bowel incontinence care plan despite being incontinent, a resident with a stage 3 sacral pressure ulcer had no EBP care plan, and a resident with a Foley catheter had no catheter care plan. The Activities Director, MDS Coordinator, and DON confirmed the missing care plans.
Care Plan Meetings and Updates Not Completed as Required: The facility failed to hold required quarterly care plan meetings for a resident, failed to keep several residents’ care plans updated to reflect changes in condition, and failed to develop a comprehensive care plan for a resident with a pressure injury within the required timeframe. Records and staff interviews showed missed quarterly meetings, outdated fall and smoking/vaping care plans, an unaddressed fall, and a delayed pressure injury care plan after an MDS identified unhealed pressure injuries.
Incomplete and inaccurate medical records were identified for three residents. One resident’s MAR required daily weights and provider notification for significant weight gain, but the actual weights were not documented. Another resident had TAR entries showing an occult blood test and specialty air mattress as completed even though progress notes and observations showed the test had not been done and the mattress was not in place. In addition, MRR reports for two residents were missing from the EMR despite being referenced in the pharmacist’s notes.
Failure to Report Alleged Abuse Allegations: Two residents reported that another resident entered their room, exposed themselves, and appeared to seek sexual contact, but the facility did not report the allegation to OHCQ and was not conducting its own investigation at the time. In a separate incident, a resident's representative reported routine verbal abuse and threats from a roommate, but the NHA had not interviewed the resident or reported the allegation when informed by the surveyor.
Failure to Investigate Alleged Abuse: Two residents reported that an individual entered their room, exposed themselves, and appeared to seek sexual contact, but the facility did not conduct its own investigation or report the allegation to OHCQ. In a separate incident, a resident’s representative and a GNA reported that the resident’s roommate routinely threatened and upset the resident, yet the NHA stated the allegation had not been reported as abuse and the resident had not been interviewed.
A facility failed to keep a resident call system working for two roommates, with surveyors observing the corridor light flashing or lit without an audible signal and staff confirming the system was broken for an extended period. Records showed repeated open work orders and delayed vendor contact, while the residents were given manual bells that were not reliably heard. Surveyors also found four residents with call bells placed out of reach, and an LPN, GNA, and DON confirmed the bells were supposed to be within reach.
A resident's representative was not informed when the resident's Foley catheter was discontinued and a voiding trial was initiated. Although the provider was notified and the change was documented, there was no evidence that the representative was contacted, despite facility policy requiring such notification and documentation. Both an LPN and the DON confirmed the expectation for timely communication with representatives regarding changes in resident status.
Failure to Invite Resident to Care Plan Meetings: The facility did not invite a resident to participate in care plan meetings or the development of the person-centered plan of care. The resident stated he/she had never been invited, the record showed severe cognitive impairment with a BIMS score of 5, and the SW later confirmed no attempts had been made to invite the resident because the resident was believed not to be capable. Meeting documentation showed attendance by staff and family, but no evidence that the resident was invited.
A resident was placed on a locked unit without documented justification and without evidence of wandering, exit-seeking, dementia, or other behaviors supporting the placement. The resident stated he/she did not know why he/she was on the unit and had not been given the code to leave independently. Interviews with the DON, Unit Manager, Social Work Director, and Administrator confirmed the placement process was not standardized, residents could not exit freely, and no documentation could be found explaining why the resident was assigned to the locked unit.
Resident Council meetings were held in a public dining area with no privacy, staff walked in and out during the meeting, and residents said they were not allowed to meet without staff present. The facility also left multiple grievances unresolved for months, including repeated laundry and missing-item complaints, and residents reported that no rationale or feedback was provided when concerns were not addressed.
Failure to Notify Residents of All Resident Rights: Residents reported they had not been informed of the full Resident Rights, and an Activities Director only began verbally reviewing a few rights during a Resident Council meeting after the issue was raised. The NHA said rights were in the admission packet and were fully reviewed at an annual Resident Rights fair, but the packet contained only some rights and residents who missed the fair or were admitted later did not receive a complete list or explanation.
Failure to Maintain Resident Privacy During Medication Administration: A resident was observed in bed during medication administration with the blanket below the knee and the gown raised above the abdomen, exposing the thighs and brief while the privacy curtain and door were wide open. The resident’s body parts were visible to visitors and staff, and the CMA acknowledged the privacy curtain should have been pulled during the medication pass.
Failure to Address Missing Clothing Grievance: A resident’s family reported repeated loss of clothing sent to laundry, leaving the resident to wear the same clothes until items were returned and prompting the family to spend nearly $300 replacing missing belongings. The DON and NHA confirmed the concern was discussed with the family and IDT, but no grievance form was completed, grievance forms were not accessible on the units, and the facility did not follow its missing-item grievance process.
The facility failed to provide a bed hold notice to a resident who was transferred to a hospital and returned the same day, with staff stating notices were only given when a resident was out of the facility for more than 24 hours. The facility also failed to timely notify the Ombudsman in writing of resident transfers and discharges, and the Ombudsman reported not receiving the notifications until the lists were emailed months later and only after the surveyor requested them.
Admission MDS Not Completed on Time: A resident’s admission MDS remained in progress beyond the required completion window, with key MDS and CAA sections not signed within the CMS timeframe. The MDS coordinator stated she was uncertain about the timeline and confirmed the resident’s admission assessment should have been signed within 13 days of entry.
Failure to Timely Transmit MDS Assessment: The facility failed to transmit an Entry MDS for a resident within the required 14-day timeframe. The MDS was completed and marked exported, but it was not submitted until after surveyor intervention. The MDS coordinator stated she was unsure of the 14-day submission timeline and confirmed the assessment should have been transmitted on time.
The facility inaccurately coded MDS data for one resident with a Foley catheter by marking urinary continence as always incontinent instead of not rated, despite the catheter being in place during the look-back period. The facility also failed to complete a required discharge assessment for another resident who was transferred to the hospital, and the MDS Coordinator confirmed the omission.
Failure to provide ordered care, hospice orders, and adequate linens. A resident with limited bed mobility was repeatedly observed lying in the same position despite an order for q2h turning and repositioning, while the TAR showed staff had signed the care as completed. Another resident admitted to hospice had no physician orders in the record until after surveyor intervention. Staff also reported ongoing linen shortages, and surveyors observed multiple residents with beds missing sheets, pillowcases, blankets, or other essential linens.
Failure to maintain fall-prevention equipment for a resident at risk for falls. A resident with a history of rolling out of bed had prior falls and a care plan that included a perimeter mattress, but after a room transfer the mattress was left behind. The resident later rolled out of bed and was found on the floor, and staff confirmed the bed still did not have the perimeter mattress during subsequent observations.
Facility staff failed to clarify a resident’s G-tube-related physician orders for medication route, residual parameters, and ordered feedings. The resident was NPO, had orders for oral medications, and had an incomplete tube feeding residual order; during observation, the G-tube feeding bag was connected but the pump was not infusing, and an LPN stated the feeding bottle had not been changed and there was no order to hold the feeding. The DON and MDS Coordinator confirmed the order issues.
Respiratory equipment was not maintained in a sanitary manner for three residents receiving O2 therapy and nebulizer treatment. Surveyors observed unlabeled and undated nasal cannulas and O2 tubing, tubing lying on the floor, and used nebulizers left uncovered or not stored in dated bags. Staff, including an RN, LPNs, and the DON, acknowledged that tubing and nebulizer equipment should be labeled, dated, and bagged when not in use, but these practices were not consistently followed.
Outdated staff assignment boards and a lobby staffing posting were observed during survey. Multiple unit boards and staffing sheets had not been updated, and an LPN, RN, and another LPN confirmed the boards were not current even though the facility expected updates at the start of each shift. An RN also stated one board should have been updated daily and each shift, and the NHA confirmed the lobby posting should have reflected the correct date, staffing assignment, and census.
A facility failed to timely act on a consultant pharmacist’s MRR recommendations for a resident reviewed for unnecessary medications. Surveyors requested the resident’s monthly MRRs, but the July review was not initially provided, and the DON later confirmed the recommendations had not been addressed. The NP’s responses were ultimately signed only after surveyor intervention, 56 days after the recommendations were written.
Unattended medications were found on a med cart with no staff present, including a resident's Rosuvastatin blister pack and a pharmacy bag of meds. Surveyors also found expired oral nutritional supplements in a storage closet and expired Bisacodyl suppositories in a med storage room, and an LPN confirmed the expired medication.
A resident’s dental appointment was requested by the physician, but the facility did not ensure timely dental care after the visit was postponed because of inactive insurance. The resident reported the appointment was cancelled at the last minute and that a tooth was bothering him/her. The DON confirmed the delay was due to insurance issues, and the Administrator acknowledged the on-site dental option was not documented as offered even though the resident later scheduled the appointment independently.
Failure to provide ordered thickened liquids. A resident with dysphagia, aspiration pneumonia, and a high aspiration risk had a physician order for nectar-thickened fluids, but a GNA gave the resident plain water. The resident began drinking and immediately coughed, and the Unit Manager and DON confirmed the resident should have received thickened liquids.
The facility failed to ensure QAPI meetings included the required members. Review of attendance sheets showed the Medical Director missed multiple QAPI meetings and the Infection Preventionist missed two meetings, and the NHA acknowledged the missing attendance during interview.
Failure to document and offer pneumococcal vaccination was cited after staff did not screen an eligible resident for immunization status or record that the vaccine was offered, refused, or discussed with the R/RP. The resident, who had dementia, adult failure to thrive, and muscle wasting/atrophy, had no pneumococcal vaccination status documented in the chart, and the MDS indicated the vaccine was not received because it was not offered. An RN and the DON both confirmed the missing documentation.
Unsafe construction area and dirty laundry room: A resident room beside another resident’s room had been closed for about 2 years due to a roof leak and was being used for storage, with no lock or barrier to prevent entry, standing water, stained and damaged furniture, stored mattresses and bed frames, and ceiling tiles that were missing, broken, or stained. The laundry room was visibly dirty with black marks and brown-like substances on the floor tiles, cracked tiles, a wet towel with black spots under a washer door, and only one working washer; the MDS/EVS Director confirmed the room needed cleaning.
GNA educational files showed no record of the required annual Compliance and Ethics Program for 5 of 5 files reviewed. The NHA said a facility-wide education fair should have included the topic, but the in-service attendance record listed multiple subjects such as abuse, dementia, resident rights, and infection control and did not include Compliance and Ethics training; the NHA acknowledged it was not included.
The facility failed to timely carry out wound care for two residents with pressure injuries. One resident with a Stage III pressure ulcer had repeated wound care recommendations for an air mattress, but the mattress order was delayed and the resident was observed without one. Another resident was admitted with pressure injuries documented by the hospital, yet the wounds were not identified on admission and no wound treatment orders were entered into the EMR until later, despite wound care recommendations for multiple DTIs and Stage 3 wounds.
Failure to maintain operational laundry equipment, telephone access, and dryer lint logs. Surveyors observed only one washer and one dryer working, with wet linen sitting in a bin waiting to be dried because the laundry volume could not be kept up with. A resident representative and another caller reported being unable to leave messages for admin staff because voicemail boxes were full, and the NHA said the phone system was outdated and had been unable to retrieve messages for almost a year. Surveyors also found that lint cleaning logs were not kept as required and observed a large amount of lint being removed from a dryer.
Failure to Maintain Resident Dignity in Clothing, Catheter Privacy, and Dining Access
Penalty
Summary
Facility staff failed to maintain resident dignity in multiple ways, beginning with inadequate clothing and linen management for one resident. On one observation, this resident was found lying in bed with no clothes on, covered only by a blanket that had a dried yellow stain, with a fitted sheet stained with dried food and yellow discoloration, and half of a diaper on the fall mat next to the bed. A hospital gown was observed on the floor near the bathroom alcove. Later, the same resident was observed in the dining/activity room crying, stating that they were cold and that women were supposed to wear long pants, while wearing only a short-sleeved shirt, khaki shorts, and slipper socks. A GNA reported that the resident had no other clothes in the room. In the laundry room, a large backlog of personal laundry was observed, and laundry staff reported that personal laundry had not been done over the weekend, that only one of three commercial dryers and a small non-commercial dryer were functioning, and that it was taking 4–5 days to complete laundry. The Director of Maintenance and Housekeeping confirmed that two dryers and one washer were not working and that staff were unable to keep up with personal laundry. Additional dignity concerns were identified for residents with Foley catheters. One resident was observed lying in bed wearing a hospital gown with a Foley catheter drainage bag hanging on the side of the bed, visible and not placed in a privacy/dignity bag. Another resident was observed lying in bed with a Foley catheter drainage bag visible from the hallway, also not covered by a dignity bag. The DON confirmed that residents with Foley catheters should have dignity bags and provided the facility’s Catheter Care Policy, which states that privacy bags will be available and catheter drainage bags will be covered at all times while in use. These observations showed that the facility did not follow its own policy regarding the use of privacy/dignity bags for catheter drainage bags. Residents also reported restrictions on their ability to dine in the dining room for dinner and on weekends, affecting their right to dignity, self-determination, and socialization. Multiple residents stated that they would like to use the dining room for dinner and to socialize with other residents, but that staff would not allow it, reportedly due to insufficient staffing. Observation of dinner service showed that residents on two units received dinner trays in their rooms, and the dining room was dark and empty during the dinner hour. Resident council notes documented prior concerns from residents about not being able to eat dinner and weekend meals in the dining room, and a council concern form showed that the Administrator had responded that the dining room was only open for breakfast and lunch on weekdays because there was not enough staff to support dinner or weekend meals. The Dietary Manager and Activities Director both stated they understood that dinner and weekend dining room service were not provided due to staffing limitations, and the Administrator confirmed that residents could not use the dining room for dinner and weekends because of lack of staff.
Failure to Keep Call Lights Within Reach as Care Planned
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure residents’ call lights were kept within reach as required by individualized care plans, thereby limiting residents’ ability to summon assistance. During a tour of the Homestead unit, multiple residents were observed in bed or sitting on the edge of the bed with their call bells on the floor, behind the bed, or wrapped around or under the bed frame. One resident’s call bell was found on the floor behind the bed on two separate observations, and the resident stated that staff had taken the call bell away. Another resident’s call bell was repeatedly observed hanging under the bed frame and dragging on the floor. A third resident, who reported using the call button to call the nurse, had the call bell lying on the floor behind the bed. A fourth resident, sitting on the edge of the bed, had the call bell on the floor behind the bed and reported that when the call bell was used, staff came in, turned it off, and did not return. Review of the residents’ care plans showed that several had documented ADL self-care performance deficits related to conditions such as decreased mobility, dementia, encephalopathy, schizophrenia, and poor safety awareness, with specific interventions directing staff to encourage use of the call bell and to ensure the call light was within reach, with prompt response to all requests for assistance. These care plans, initiated on various dates, consistently required that call lights be accessible to residents at risk for falls and with mobility or cognitive impairments. Despite these documented interventions, staff did not maintain the call bells within reach for at least seven residents on the Homestead unit. When a staff member was shown a call bell on the floor, the staff member acknowledged the need for a clip to secure the cord to the sheet and stated that the situation with call bells was a known problem. The DON and Nursing Home Administrator were later informed of these concerns.
Widespread Environmental and Linen Failures Leading to Unsanitary Resident Conditions
Penalty
Summary
Facility staff failed to maintain a safe, clean, sanitary, and comfortable environment in common areas and on one nursing unit, as evidenced by multiple observations during a complaint survey. A complaint alleged that a resident room on the Homestead unit was in deplorable condition, with feces on walls and floors and cold air entering through an air conditioning unit, creating unsanitary conditions. During the tour, surveyors observed multiple stained and cracked ceiling tiles in the conference room, entrance hallway, and Homestead unit hallway, as well as dirty, sticky, and discolored hallway flooring. In the Homestead dining room, drywall was peeling, a section of wall was caved in, several ceiling exhaust fans were rusted, and a piece of ceiling molding was hanging down. In one resident room on the Homestead unit, a resident was in bed without clothes but covered with a blanket, yelling and asking why they had no clothes and where their clothes were. The blanket had a dried yellow stain, and the fitted sheet was yellow and stained with dried food. Half of a diaper was on the fall mat next to the bed, a hospital gown was on the floor near the bathroom alcove, and a soiled sheet covered with gnats was sitting on top of the trashcan by the sink. The laminate on the headboard was missing in a section. In another room, a soiled sheet with a pink stain was on the bed, the overhead light in the toilet area was not working, and the ceiling tile in that toilet area was cracked. In additional rooms, there were missing floor tiles, gnats by the toilet, cracked and stained ceiling tiles, missing light covers, and missing laminate on a closet door. In a room with a wall air conditioner above the radiator, cold air was coming through visible gaps and holes around the unit, with the outside visible through these openings. The bracket around the air conditioner had a black substance, dirt, dust, and cobwebs, and the top of the radiator was full of dust; the electrical box was hanging away from the wall by about an inch, and the bed footboard had peeling laminate and was loose, with a split in the covering of a positioning wedge. Several beds on the unit had no linen, and a staff member reported there had been no linen during the night and that they did not have morning linen to start. The Director of Maintenance and Housekeeping later confirmed that two dryers and a washing machine were down, that they were not able to keep up with laundry, and that there was not enough linen to support the residents. Additional exterior observations included hardy board under the front porch hanging down and a hole in the hardy board, and the Director of Maintenance and Housekeeping stated he had not been aware of the porch ceiling condition until it was pointed out and acknowledged that the air conditioner area had not been cleaned.
Failure to Maintain Complete and Accurate Medical Records and Care Plan Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for multiple residents. For one resident, a complaint alleged that toenails were so long they were growing into the skin. Review of the paper and electronic medical records did not show any podiatry documentation, despite staff stating the resident had been seen by a podiatrist due to thick toenails. The DON was initially unable to locate podiatry notes in the EMR and later produced podiatry visit notes for this resident and 27 other residents, confirming that these office visit records had never been uploaded into the residents’ medical records. The deficiency also includes missing documentation of care plan meetings for three other residents. One resident’s record showed the last documented care plan meeting several months earlier, with only an invitation for a more recent meeting and no record that the meeting occurred until the social worker later produced a paper care plan summary that had not been uploaded. Another resident had a scheduled care plan meeting with no evidence of the meeting in the medical record until the social worker provided paper notes kept in an office file. A third resident’s record showed the last care plan meeting many months prior, and the resident was unsure of the last meeting date; the social worker then produced paper notes of a more recent care plan meeting that were also not in the medical record. The social worker reported keeping care plan documentation on paper in a file cabinet and stated that due to workload, these notes were not consistently uploaded into the EMR and expressed uncertainty about the requirement for them to be in the medical record.
Nonfunctional Laundry Equipment Leading to Inadequate Laundry Capacity
Penalty
Summary
Facility staff failed to maintain essential laundry equipment in working order, resulting in insufficient capacity to meet residents’ laundry and linen needs. During a complaint survey focused on reports of delayed personal laundry and inadequate linen supply, observation of the laundry room showed that 1 of 3 washers and 2 of 4 dryers were not functioning, and one of the two operational dryers was significantly smaller than the other commercial dryer. A laundry staff member reported that the nonfunctioning washer and two dryers had been out of service for an extended period and confirmed that the smaller dryer could not handle the same volume as the larger unit. The Maintenance and Housekeeping Director acknowledged that staff had been unable to keep up with residents’ personal laundry due to this equipment situation, confirming that the facility did not have all washers and dryers in working order to meet residents’ needs. No specific resident medical histories or clinical conditions were described in relation to this deficiency.
Failure to Notify Resident Representative of Physician Appointment
Penalty
Summary
Facility staff failed to notify a resident’s representative of a scheduled physician appointment, resulting in the resident attending the appointment without the representative’s knowledge or presence. During an interview, the resident stated that he/she had a doctor’s appointment that day and indicated that someone had informed him/her of the appointment that morning, but the resident did not know the purpose of the visit. The resident’s representative, who was present during the interview, stated that he/she was unaware of the appointment, typically takes the resident to all medical appointments, and was unable to do so that day due to the lack of prior notice. Medical record review later confirmed that the resident attended an orthopedic appointment and received a left shoulder injection. The DON confirmed that the resident’s representative customarily accompanies the resident to all doctor appointments and that staff failed to notify the representative of this orthopedic appointment.
Inaccurate MDS Coding for Fall History and Urinary Catheter Use
Penalty
Summary
Facility staff failed to ensure accurate completion of MDS assessments for two residents, resulting in incorrect coding of key clinical information. For one resident admitted after a fall that caused a left intertrochanteric femur fracture, hospital records and a nurse practitioner’s initial note documented that the resident had fallen, resulting in hip pain, inability to ambulate, and the fracture. Despite this clear history, the admission MDS with an assessment reference date of 1/20/26 coded Section J1700A (fall history in the last month prior to admission/entry or reentry) as “9 – unable to determine,” rather than capturing the documented fall. For another resident with a physician’s order for a Foley catheter for urinary retention, surveyor observation from the hallway showed a Foley drainage bag with urine hanging at the bedside. The resident’s quarterly MDS with an assessment reference date of 1/6/26 coded Section H0300 (urinary continence) as “always incontinent.” Because the resident had an indwelling urinary catheter in place, urinary continence should have been coded based on catheter use rather than rated as incontinence. In both cases, the MDS Coordinator confirmed the coding errors during interview.
Failure to Develop Care Plan for Resident With Indwelling Foley Catheter
Penalty
Summary
Facility staff failed to develop and implement a care plan addressing a resident’s specific needs related to an indwelling Foley catheter. The resident had a physician’s order for a Foley catheter for urinary retention dated 1/3/26, and the quarterly MDS with an assessment reference date of 1/6/26 documented indwelling catheter use in Section H0100A. The Treatment Administration Records for January, February, and March 2026 also documented ongoing use of an indwelling Foley catheter. Despite these documented orders and assessments, review of the care plan section of the resident’s medical record did not reveal any care plan related to the Foley catheter. On 3/11/26 at 12:55 PM, surveyors observed the resident lying in bed with a Foley catheter drainage bag containing urine hanging on the left side of the bed and visible from the hallway. During an interview at 1:37 PM, the MDS Coordinator stated that the nursing team was responsible for creating and implementing care plans. Later that afternoon, the DON and the Nursing Home Administrator were informed of the finding that no care plan had been developed for the resident’s indwelling Foley catheter, despite its documented use and the facility’s responsibility to ensure care is planned based on identified needs.
Missed Quarterly Care Plan Meeting Following MDS Assessment
Penalty
Summary
Facility staff failed to conduct a required quarterly care plan meeting for Resident #13 following completion of a quarterly MDS assessment. The facility’s process is that once an in-depth assessment (MDS) is completed, the interdisciplinary team meets to develop and review care plans, which are to be reviewed and revised at each assessment time and at least quarterly. Care plans are intended to provide direction for individualized care, organized by the resident’s specific needs, and to communicate and organize actions to ensure needs are attended to. For Resident #13, who was admitted in 2022, the medical record review on 3/9/26 showed the last quarterly care plan meeting occurred on 10/29/25. Further review revealed that a quarterly MDS assessment for Resident #13 was completed on 12/21/25, but there was no documentation of a subsequent quarterly care plan meeting after the 10/29/25 meeting and the 12/21/25 MDS assessment. Social Services, who maintains care plan meeting documentation in her office, was unable to provide any record of a care plan meeting during that period. In interview, Social Services stated that a care plan meeting for Resident #13 had been scheduled for 12/23/25 but had to be rescheduled, and she did not realize it had not been rescheduled. On 3/10/26, the Surveyor informed the DON that Resident #13 did not have a quarterly care plan meeting following the 12/21/25 MDS assessment.
Failure to Provide Ordered Continuous Oxygen and Falsification of MAR Documentation
Penalty
Summary
Surveyors determined that the facility failed to provide respiratory services in accordance with professional standards of practice for one resident who had a physician’s order for continuous oxygen. The resident had an order written on 2/24/26 for oxygen at 2 liters continuous for comfort every shift. During multiple observations over three consecutive days, surveyors repeatedly observed the resident lying in bed with an oxygen concentrator present in the room but turned off, and the nasal cannula coiled and resting on top of the concentrator under the handle, not in use. At no time during these observations was the resident seen receiving oxygen. Review of the resident’s March 2026 MAR showed that nurses had initialed each shift on the dates in question, documenting that the resident was receiving oxygen around the clock as ordered. The initials belonged to six different licensed nurses, indicating that each had recorded that oxygen was being administered when, based on surveyor observations, it was not. On 3/11/26, the DON and Nursing Home Administrator were informed that these six licensed nurses had falsified the medical record by documenting that the resident was receiving oxygen each shift when the oxygen concentrator was off and the nasal cannula was not applied. The DON later confirmed these findings.
Failure to Maintain Safe and Adequate Shower Water Temperature
Penalty
Summary
Facility staff failed to maintain safe and appropriate shower water temperatures on the Wye Oak Unit, resulting in one of two showers in that unit not providing hot water. During a complaint survey regarding lack of hot showers, a Surveyor measured the water temperature in the Wye Oak shower room and found the left shower at 87°F and the right shower at 110°F. The left shower faucet could not be turned toward the "H" (hot) setting, preventing adjustment to the appropriate temperature range. When the Surveyor returned with the Director of Maintenance and Housekeeping (Staff #11), Staff #11 confirmed the left shower temperature was 87°F, acknowledged that shower water temperatures should be between 100°F and 120°F, and stated he was unaware of any issue with the left shower faucet. Observation also showed there were no signs posted to direct staff not to use the malfunctioning left shower. This deficiency was identified on one of two showers in the Wye Oak Unit and one of four nursing units observed during the complaint survey, and the findings were shared with the Administrator the same day.
Failure to Maintain Effective Pest Control Resulting in Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program on one nursing unit, as evidenced by numerous gnats observed in resident rooms and common areas. On 3/9/26 at 9:06 AM, a gnat was seen flying in a resident room, and a soiled sheet sitting on top of the trashcan by the sink was covered with at least nine gnats. In another room, gnats were observed flying around the toilet area. Frequent gnats were also seen flying in the hallway on the Homestead unit. On 3/10/26 at 8:35 AM, a resident was observed lying in bed with empty plastic juice containers on the bed tray table, and gnats were flying around the resident’s chin; a staff member confirmed that gnats were sometimes present because staff did not remove the juice containers. Review of the pest management documentation on 3/10/26 at 10:11 AM showed the pest control company last treated the Homestead unit on 2/17/26, with no documentation of a gnat problem on the unit despite staff acknowledgment of the issue. On 3/11/26 at 2:50 PM, the Nursing Home Administrator and Director of Nursing were informed of the concerns regarding the presence of gnats and the lack of effective pest control measures and documentation on the affected unit.
Food Storage, Labeling, and Sanitation Failures
Penalty
Summary
Food was not stored and prepared in a sanitary manner in the facility kitchen and unit pantries. During the kitchen tour, the Dietary Manager confirmed responsibility for overseeing the kitchen. The surveyor observed multiple food items in the kitchen refrigerator and freezer that were undated, unlabeled, or both, including baked zucchini dated 08/13/25, an opened package of meatballs that was unlabeled and undated, sour cream dated 08/13/25, cheese dated 08/13/25, cream corn dated 08/14, and several sandwiches that were either dated 08/13 or were undated and unlabeled. The Dietary Manager acknowledged that the dated items should have been thrown out and that the undated and unlabeled sandwiches were a concern. The surveyor also observed kitchen staff preparing food without proper protective gear when a dietary employee was seen not wearing a beard covering while handling food. The employee later put on the beard covering and confirmed that it was required during food preparation. The Dietary Manager was informed of the observation and acknowledged the concern. Multiple unit pantry refrigerators and freezers contained undated, unlabeled, or spoiled food items, and temperature monitoring was inconsistent or absent. On one unit, the refrigerator and freezer contained undated and unlabeled ice cream, food containers, condiment containers, and no temperature log was posted. On other units, temperature logs were incomplete or only present for prior months, freezer temperatures were not being logged, and thermometers were positioned so they were difficult to read. Surveyors also found spoiled fruit, moldy grapes and bananas, brown residue on refrigerator surfaces, and several opened bottles and containers without dates or labels. Interviews with nursing staff, unit managers, the part-time Dietary Director, and the Administrator produced inconsistent responses about who was responsible for cleaning the refrigerators, monitoring temperatures, and labeling food items, and the Administrator stated this reflected an education issue and a breakdown in the system.
Infection Control Failures With Linen Storage, Specimen Handling, Food Storage, and EBP
Penalty
Summary
The facility failed to use appropriate infection control practices when clean linens were stored on a hallway linen cart with the cover flipped back and left uncovered after staff were notified. The surveyor observed the cart during an initial tour, informed an RN, and then found on follow-up that the linen cart remained uncovered. The DON and NHA were later informed of the concern. The facility also failed to store a urine specimen properly when a sample for one resident was found in the medication refrigerator in the Homestead unit storage room with insulin pens. An LPN removed the specimen, and another LPN confirmed that the urine sample should have been placed in the soiled utility refrigerator. In addition, leftover pudding was found inside two medication carts on separate units, each in a maroon plastic bowl with a lid and dated for the prior shift. The CMA staff members who witnessed the findings removed the bowls from the carts. The facility further failed to implement Enhanced Barrier Precautions for two residents with pressure ulcers. One resident had a documented Stage 3 sacral pressure ulcer, but no EBP sign, PPE cart, or EBP order was present in the record or outside the room at the time of observation. Another resident was being treated for a Stage 3 pressure ulcer and initially had no EBP order, no sign, and no EBP supplies at the doorway. Interviews with nursing staff and the DON showed differing understandings of when EBP was indicated for residents with wounds, and the facility policy stated that EBP orders were to be obtained for residents with wounds such as pressure ulcers.
Pest Control Program Failure in Kitchen
Penalty
Summary
The facility failed to ensure an effective pest control program for the kitchen. During an interview on 08/19/2025, the Dietary Manager reported that the primary pest concern observed in the kitchen was flies. Later, on 08/29/2025, a surveyor observed five flies flying above the food preparation area while Dietary #44 was preparing crab cakes for residents. The surveyor then informed the part-time Dietary Director of the concern regarding the flies, and he confirmed his understanding of the issue.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure residents were provided a dignified existence in multiple situations involving privacy, timely assistance, meal service, restroom access, staff identification, and personal care. During an interview in a resident’s room, a GNA entered after a rapid knock, opened the door immediately, and yelled that it was her before going to the roommate’s side of the room. The resident reported not remembering the GNA’s name. The GNA stated she should have identified herself when entering the room, and the DON stated staff are expected to provide privacy, introduce themselves when entering a resident’s room, and ask permission to come in. The facility also failed to provide timely and respectful assistance to a resident who urgently needed to urinate. The resident asked a GNA to take him/her to the room because he/she had to pee badly, but the GNA did not respond, walked away, and later told the resident to hold on. The resident continued yelling for help, was pushed back to the room without explanation, and then waited while staff searched for a urine receptacle. The resident remained anxious, yelled for help, and was told the unit was out of urine receptacles. The GNA stated she was not looking for the receptacle and said she had to check on her residents, adding that the resident was not her resident. The unit manager stated it was unacceptable to say it was not my resident and that all staff are there to help all residents. Meal service and feeding assistance were also delayed for multiple residents. One resident who required feeding assistance was seated at a table while other residents were actively eating, but did not have a meal tray in front of him/her. The GNA stated the resident was a feeder and that she had been instructed to distribute all trays to other residents before beginning to serve and assist residents who required help with feeding. In another observation, several residents sat in the dining room watching others eat while waiting over an hour for the second meal cart to arrive. The RN confirmed there was a delay between meal carts, and the NHA acknowledged the delay when informed. Additional dignity concerns included a resident being entered without knocking, residents stating they were restricted from using the public restrooms off the lobby, staff not wearing name badges, a GNA using a personal cell phone inside a resident room, and a resident receiving G-tube feeding while oral secretions drooled onto the gown and dry yellowish mucous was observed in the mouth and on the gown. These observations were documented during survey interviews and direct observations.
Failure to Offer Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents and their representatives were offered the opportunity to develop advance directives. A review of records found no evidence that an advance directive was documented for Resident #12, whose BIMS score was 14 and indicated cognitive intactness, and the resident’s Peak Social Services Assessment Tool did not show that the resident was offered the opportunity to formulate an advance directive. Resident #8 also had no advance directive on file, and the resident’s BIMS score was 5, indicating cognitive impairment. The Regional Social Worker confirmed that Residents #8 and #12, along with their families, were not offered the opportunity to formulate an advance directive. A separate record review found that written information regarding advance directives had not been provided to Residents #3 and #40 or their representatives, and the information was not present at the time of review. The Regional Social Worker stated that during admission residents are asked whether they have an advance directive, a copy is requested if one exists, and if not, they are offered the opportunity to complete one; however, she confirmed that the families of Residents #3 and #40 were not offered or educated on advance directives during the admission process. The surveyor informed the Regional Social Worker that federal regulation requires facilities to offer written information on advance directives to all residents at admission.
Dirty Flooring and Urine Odor in Resident Areas
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment as evidenced by multiple observations of dirty and sticky flooring throughout the building. During the initial tour, carpets throughout the facility had multiple large stains, and in Resident rooms #117 and #205 there were large black markings and a sticky substance on the white tile floors that caused surveyors' shoes to stick to the floor. On the Homestead Nursing unit, the white tiled flooring had a sticky substance and black markings throughout, and in one resident room the black markings and sticky substance extended from the hallway into the room and caused a surveyor's shoes to stick to the floor. During a later tour of the Homestead nursing unit, a strong urine odor was observed coming from a resident room. An RN checked two residents in that room and found both disposable diapers were dry, and stated the odor was coming from the floor and trash can. The RN also stated she had not seen housekeeping all day and would contact housekeeping to clean the floors and remove the trash. The room later no longer had a strong urine smell after housekeeping exited the room. The NHA later stated she would contact corporate for an update on the facility's flooring, and corporate emails showed follow-up about the status of the carpet cleaner and floor cleaning.
Failure to Develop Required Resident Care Plans
Penalty
Summary
Resident care plans were not developed for multiple residents identified during the survey. Resident #92 reported that he/she did not participate in activities because of a vision deficit and stated that one-on-one activities were not provided. Review of the resident’s care plan did not reveal a care plan for activities. Resident #107’s representative reported that the resident was cognitively impaired, did not participate in activities, had not been offered one-to-one visits or other services by the Activities department, and was incontinent of bowel and bladder with concern that routine incontinent care was not being received. Review of the resident’s MDS showed the resident was always incontinent of urine and frequently incontinent of bowel, but the care plan did not reveal a care plan for activities or bowel incontinence. Resident #12 had a stage 3 pressure ulcer of the sacrum that was acquired on 1/1/25, but review of the care plan did not show evidence that an EBP care plan had been initiated for the wound. Resident #8 had a Foley catheter from 6/4/25 to 8/4/25, and review of the care plan showed no evidence that a Foley catheter care plan had been initiated during that period. The Activities Director confirmed that activity care plans had not been developed for Residents #92 and #107, and the MDS Coordinator acknowledged that a bowel incontinence care plan had not been developed for Resident #107. The DON confirmed there was no Foley catheter care plan for Resident #8 and no EBP care plan for Resident #12.
Care Plan Meetings and Updates Not Completed as Required
Penalty
Summary
The facility failed to hold quarterly care plan meetings with the interdisciplinary team for Resident #116. The resident reported having care plan meetings on occasion but could not recall the last one. Review of the medical record showed care plan meetings in 2024 on 4/25/24 and 10/11/24, and in 2025 on 5/07/25; a later review identified an additional meeting on 8/05/25 that had not yet been uploaded into the electronic record. The Regional Social Worker confirmed that Social Work, Nursing, dietary, and a GNA were expected to attend these meetings and that they were to be completed quarterly, but no other quarterly meetings were documented for the resident in 2024 or 2025. The facility also failed to review and revise care plans to reflect residents’ changing needs for Resident #8, Resident #12, and Resident #107. Resident #8’s care plan, initiated on 5/08/25, addressed smoking/vaping non-compliance, but the DON confirmed the care plan should have been resolved after the resident was found with a vape in the room and that care plans are updated quarterly and with changes in condition. Resident #12’s fall care plan, initiated on 9/10/22, had a most recent revision dated 2/23/24, and the MDS Coordinator confirmed it should have been updated quarterly. The DON was notified that the fall care plan had not been updated for 16 months. Resident #107 had multiple falls, including falls on 05/22/24, 09/04/24, 03/08/25, 03/11/25, 03/31/25, and 05/09/25, with reported hip and arm fractures. Review of the care plan did not show revision to include the actual fall on 05/09/25, and the MDS Coordinator confirmed this omission. The facility also failed to develop a comprehensive care plan within the required timeframe for Resident #11, who was readmitted after surgical treatment for a pressure injury. The admission MDS completed on 7/26/25 indicated unhealed pressure injuries, but the comprehensive care plan contained no interventions or approaches for the pressure injury until 8/27/25, 32 days after the MDS completion date. The DON confirmed the pressure injury care plan was not initiated until 8/27/25.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure medical records were accurate, complete, and readily accessible for three residents reviewed. For one resident, the MAR included an order to weigh the resident every morning after voiding and before breakfast and to call the provider for a weight gain of more than 3 pounds in 24 hours, but the MAR did not provide a place to document the actual daily weight. The resident’s record contained only two weights in the vital signs section, and the Nursing Home Administrator acknowledged that the weights should have been recorded. The surveyor noted that staff would not be able to determine whether the resident had gained 3 pounds in 24 hours because the prior day’s weight would not be known. For another resident, the medical record contained multiple NP progress notes stating that stool for occult blood had been ordered but had not been completed, with repeated references that the test was still pending or had never been performed. However, the TAR showed the occult blood order was checked off as completed on numerous dates in May, June, and July 2024. The DON stated she did not know why the specimen was not obtained and acknowledged that the order should not have been signed off in the TAR if it was not completed. The same resident also had an order for a specialty air mattress in place at all times, but observations showed the resident was not on an air mattress on multiple occasions, while the TAR was signed off as completed for the air mattress order during that same period. For two residents, the pharmacist completed Medication Regimen Reviews and the documents referenced separate reports with recommendations, but those reports were not found in the EMR at the time of review. The DON stated the MRR reports are scanned into the EMR and expected prior months’ reports to be present, while the MDS Coordinator stated she was unsure why the reports had not been loaded and later provided the reports, confirming they had not yet been downloaded into the EMR for those residents.
Failure to Report Alleged Abuse Allegations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately. Resident #6 and Resident #91 each told the surveyor that about one week earlier an individual entered their room, pulled up the individual's gown, and exposed themselves in a manner that appeared to seek sexual contact. Both residents gave descriptive information about the individual and believed the person was another resident on the unit. Resident #6 also reported that the same individual had previously urinated in the hallway. When the surveyor informed the Administrator and CNO of these statements, the facility later provided statements from the two residents, an interview statement from the alleged individual, Resident #108, a form signed by GNA #2 and GNA #28 stating employees in the incident area had no knowledge of the incident, and a witness statement from the Unit Manager discussing the incident with Resident #6. The Administrator confirmed that these were all records related to the sexual abuse allegation and stated the facility was not conducting its own investigation at that time, explaining the documentation was only being provided to assist the surveyor. On later interview, the Administrator acknowledged that no report had been made to OHCQ regarding the sexual abuse allegations reported by Resident #6 and Resident #91. In a separate concern, Resident #107's representative reported that the resident's roommate routinely verbally abused the resident with threats and that the concern had been raised in care plan meetings without action. The resident was observed to be visibly upset and stated, "roommate mean, I don't know why." The NHA later stated she found no documentation of threats in the care plan notes and had only learned of an incident in which Resident #115 pushed Resident #107 in a wheelchair; she had not interviewed the resident about the reported verbal abuse and had not reported the allegation to OHCQ at that time.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that alleged abuse incidents were investigated for three residents. Two residents reported that an individual entered their room, pulled up the gown, exposed themselves, and appeared to seek sexual contact. Both residents provided a description of the individual and believed the person was another resident on the unit. One of the residents also reported that the same individual had previously urinated in the hallway. When the surveyor informed the Administrator and CNO of these statements, the facility provided statements from the residents, an interview with the alleged individual, and a note from staff indicating employees in the incident area had no knowledge of the incident, but the Administrator confirmed the facility was not conducting its own investigation and had not submitted a report to OHCQ. A third resident’s representative reported that the resident’s roommate routinely threatened the resident and that the threats had been brought up during care plan meetings without action being taken. The resident appeared upset when speaking about the roommate, and a GNA stated that the roommate continuously threatened and upset the resident and that staff had asked for the roommate to be moved, but nothing had been done. The NHA later stated there was no documentation of threats in the care plan meeting notes and identified only one incident in which the roommate pushed the resident in a wheelchair. When asked whether the verbal abuse allegation had been reported to OHCQ or investigated, the NHA responded that it had not been reported as abuse and that the resident had not been interviewed.
Broken Call System and Unreachable Call Bells
Penalty
Summary
The facility failed to maintain a working nurse call system for two residents sharing a room, Resident #19 and Resident #11. During an initial tour, surveyors observed the call light outside the room flashing with an audible beeping sound at the nurses station, and later observed the same light flashing in the corridor without an audible sound. An LPN confirmed the call light was broken, and both residents and a family member stated the system had not been working for a long time. The family member reported that a manual bell had been provided, but it could not be heard from the nurses station. Record review showed multiple work orders in the facility’s TELS system for the broken call light between 7/28/25 and 8/20/25, all listed as open or in progress with no evidence of completed repair. The Administrator stated she became aware of the broken call light on 8/18/25 and submitted a maintenance request that day. The Maintenance Director confirmed the facility knew about the broken call light and stated he had tried calling the outside vendor a few times in the weeks before, but had no documentation of those calls. An email to the vendor requesting service was not sent until 8/27/25. When the outside vendor completed the service call, the report showed the patient station on the wall in Resident #11’s bed space was broken and needed replacement, and the technician temporarily disconnected it to stop the corridor light from flashing. On 9/3/25, the surveyor again observed the corridor light on but not flashing, with no audible sound, confirming the call system for both residents was still not working. The report also documented that four residents, including Resident #54, Resident #5, Resident #63, and Resident #40, did not have call bells within reach during observations, and staff confirmed the call bells were supposed to be within residents’ reach.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition, specifically the discontinuation of a Foley catheter and initiation of a voiding trial. During a telephone interview, the resident's representative expressed surprise and concern about not being informed of the catheter removal, stating that notification had not occurred. Review of the resident's progress notes confirmed that while the provider was notified and a voiding trial was ordered, there was no documentation indicating that the resident's representative had been informed. Interviews with an LPN and the DON confirmed that facility policy requires notification of both the physician and the resident's representative for any change in condition or order, and that such notifications should be documented in the medical record.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to invite Resident #8 to participate in the development and implementation of the person-centered care plan. During interview, the resident stated he/she had never been invited to any care plan meetings. The resident’s record showed a BIMS score of 5, indicating severe impairment. The facility’s Social Worker Assistant stated that care plan meeting invitations were typically made verbally, sent by email, or hand-delivered, and the Regional SW stated that a care plan meeting form was used to document concerns and attendance by the IDT, family, and resident at quarterly meetings. A paper copy of the Care Plan Conference summary dated 4/1/25 showed attendance by the SW Assistant, nursing staff, and the resident’s family member by phone, but there was no evidence that Resident #8 was invited. The Regional SW later confirmed that she had not attempted to invite the resident to any care plan meetings because she believed the resident was not capable. The resident’s family member stated that the sibling should be invited and confirmed the facility had never invited the resident to any care plan meetings. A later review of care plan meeting notes from 8/27/25 also showed the resident was still not invited, and the DON acknowledged the concern.
Resident Placed on Locked Unit Without Documented Justification
Penalty
Summary
The facility failed to provide the resident's right to self-determination when Resident #121 was placed on the locked Homestead Unit without documented justification. During interview, the resident stated being unsure why he/she had been placed on the secluded unit, and later reported being excited about an anticipated move to another unit. The resident also confirmed that he/she had not been given the code to leave the unit independently and could only exit when accompanied by staff. Record review and staff interviews showed that Resident #121 did not have a dementia diagnosis, had a high BIMS score, and had no documented behaviors of wandering or elopement. The chart contained no wandering or elopement assessment or evaluation. The Unit Manager stated the resident had no behaviors and was unsure why the resident had been placed on the Homestead Unit, initially suggesting diagnoses that were not confirmed by chart review. The Administrator later confirmed there was no documentation explaining why the resident was originally placed on the Homestead Unit. Interviews with the Administrator and Regional Social Work Director showed that placement on the Homestead Unit was described as based on resident behaviors, wandering, exit-seeking, dementia, or family request, but the process was not standardized and there was no formal protocol or official criteria. The Administrator also confirmed that residents on the locked unit could not leave freely and that it was not regular practice to reassess whether placement remained appropriate. Despite these statements, no documentation was found to support why Resident #121 had been placed on the locked unit.
Resident Council Privacy and Grievance Handling Deficiencies
Penalty
Summary
The facility failed to provide a private meeting for the Resident Council. During the Resident Council Meeting observed by the surveyor, the meeting was held in the Main Dining Room, which was open to the public, located off the lobby, and had no privacy from staff, visitors, or residents passing through the area. Staff were observed walking in and out during the meeting, and residents stated that the Main Dining Room had been the only location allowed for Resident Council meetings. The residents also stated they were not allowed to meet without staff present, and the Nursing Home Administrator acknowledged that staff attendance was required because a staff member had to take meeting minutes. The facility also failed to address grievances in a timely manner and failed to provide grievance feedback for multiple residents. Meeting minutes showed laundry concerns had been discussed since December 2024, but the facility did not address them until the surveyor attended the Resident Council Meeting. During that meeting, several residents reported missing clothing and personal items, including jeans, sweaters, a pillowcase, shorts, sweatpants, coats, socks, a blanket, T-shirts, and a sweatshirt, and the Activities Director documented the missing items. Residents stated their grievances discussed in meetings remained unresolved and that the facility did not provide a rationale when concerns could not be resolved. Review of meeting minutes showed grievances discussed from 09/24 through 7/25 were not fully addressed or resolved to the Resident Council.
Failure to Notify Residents of All Resident Rights
Penalty
Summary
The facility failed to ensure residents were notified of all Resident Rights. During a Resident Council meeting on 8/28/25 at 3:37 PM, residents were asked whether they had been informed of the Resident Rights, and the group unanimously replied no. The Activities Director, who was present at the meeting, stated she would begin verbally informing residents of 3 Resident Rights during each meeting going forward, starting with the meeting then in progress. The surveyor observed the Activities Director informing the Resident Council members/residents of the Resident Rights at 3:55 PM that same day. During an interview on 09/02/25 at approximately 9:00 AM, the Nursing Home Administrator stated she believed residents were provided the Resident Rights in the admission packet. A review of the admission packet at 9:12 AM showed that it stated only some of those rights were listed. When asked whether residents received a complete list and description of the Resident Rights, the NHA stated she held an annual Resident Rights fair in September and provided a list and verbal explanation of each right during that fair. When asked how residents who did not attend the fair received the Resident Rights, the NHA replied she believed they were included in the admission packet. The surveyor noted that the admission packet only provided some of the Resident Rights and that the complete list was only provided during the annual fair, leaving residents who were not present at the facility at that time or who were admitted after the fair without a complete list or verbal explanation of all Resident Rights.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to provide adequate privacy to Resident #42 during medication administration. On 8/21/2025 at 8:28 AM, the resident was observed in bed with the blanket pulled below the knee and the gown raised above the abdomen, exposing the thighs and brief while the privacy curtain and door were wide open, making the resident’s body parts visible to visitors and staff. At 8:31 AM, the surveyor informed CMA #10 of the concern, and CMA #10 acknowledged that the privacy curtain should have been pulled during the medication administration. The DON was informed of the concern on 8/26/2025 at 7:43 AM.
Failure to Address Missing Clothing Grievance
Penalty
Summary
The facility failed to ensure grievances were addressed in a timely manner for Resident #122, who was the only resident reviewed for grievances during the recertification survey. The resident’s family member reported that clothing sent to the facility laundry was repeatedly not returned, forcing the resident to wear the same clothes until some items were returned. The family member stated this had been an ongoing problem and that staff responses included explanations that the facility was short-handed or that a washer had broken down. The family also reported spending close to $300 to replace missing clothes and hangers, and that name tags had been placed on every clothing item. During interviews, the DON stated that when items are reported missing, staff notify the laundry department and residents or family members are expected to complete an inventory sheet, but the resident’s inventory list did not include clothing. The DON further stated that families often bring in additional clothing after admission without updating the inventory sheet and that missing-item concerns are supposed to be handled through a grievance form. The NHA confirmed that grievance forms were not accessible on the Wye Oak and Mill Landing nursing units, stated that missing clothing concerns should be handled by laundry search and grievance submission, and acknowledged that a meeting with the IDT and family on 07/22/2025 discussed missing items, but no grievance form was completed. The NHA stated she was not aware of the missing clothing concern and confirmed the process was not followed.
Failure to Provide Bed Hold Notice and Timely Ombudsman Notification
Penalty
Summary
The facility failed to ensure that Resident #107 received a bed hold notice after being transferred to a local hospital and returning to the facility the same day. During a telephone interview, the resident’s representative stated that the resident had recently been hospitalized. Record review showed the resident was transferred to the hospital and returned the same day. When the Nursing Home Administrator was asked for bed hold notifications for the past 6 months, the facility’s Regional Social Worker stated that bed hold notification was provided only when residents had been transferred out of the facility for more than 24 hours. In Resident #107’s case, the resident or representative was not provided a bed hold notice because the resident returned the same day. The facility also failed to notify the Ombudsman in writing of resident transfers and discharges. The Ombudsman stated that she had not been notified in writing of transfers and discharges. When the Nursing Home Administrator was asked for the Ombudsman notification list for May and June 2025, the facility later provided the lists, which showed they were emailed to the Ombudsman after the surveyor requested them and approximately 3 months after those months had passed. During interview, the Nursing Home Administrator acknowledged the concern when informed that the lists were sent late and after the surveyor’s request.
Admission MDS Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to complete an admission MDS assessment within the required timeframe for Resident #102. The resident had an admission/entry date of 8/1/25, and the CMS RAI manual requires the admission MDS completion date and CAA completion date to be no later than 13 days after the entry date. On 8/25/25, record review showed the resident’s admission MDS with an ARD of 8/7/25 was still labeled as in progress, and sections Z0500B and V0200B2 had not been signed within the required timeframe. During interview, the MDS coordinator stated she was uncertain about the 14-day timeline for completing and submitting MDS assessments. She confirmed completing and signing section Z0400 and said the Corporate MDS reviewed her work, signed sections V0200C2 and Z0500B, and transmitted the completed assessments to the national database. On follow-up, the MDS coordinator confirmed she completed section Z0400 on 8/11/25 and acknowledged that the resident’s admission MDS should have been signed within 13 days of 8/1/25. The DON was informed of the concern.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to transmit an MDS assessment within the required 14-day timeframe for one resident. Resident #102 was admitted on 8/1/25, and an Entry MDS with an ARD of 8/1/25 was documented as exported, indicating it had been prepared for transmission to the CMS iQIES system, but it was not submitted within the required timeframe. The assessment was transmitted only after surveyor intervention. During interviews, the MDS coordinator stated she was uncertain about the 14-day timeline for completing and submitting MDS assessments. She confirmed that she completed the Entry MDS and said the Corporate MDS reviewed her work and transmitted completed assessments. In a follow-up interview, she confirmed completing section Z0400 on 8/5/25 and acknowledged that Resident #102's Entry MDS should have been transmitted within 14 days. The DON was informed of the concern.
Inaccurate MDS Coding and Missing Discharge Assessment
Penalty
Summary
The facility failed to accurately code and assess MDS assessments for 2 residents reviewed during the recertification survey. For Resident #8, physician orders showed a Foley catheter was in place from 6/4/25 to 8/4/25. The Quarterly MDS with an ARD of 7/26/25 coded H0100 Appliances as indwelling catheter, but H0300 Urinary Continence was coded as 3, always incontinent. The MDS RAI manual states that when a resident has an indwelling bladder catheter for the entire 7-day look-back period, urinary continence should be coded as 9, not rated. During interview, the MDS nurse confirmed the item was inaccurately coded and should have been coded as not rated. For Resident #13, the record showed the resident was discharged from the facility to the hospital, but the MDS record did not contain a discharge assessment. A nurse's note documented the discharge, and the MDS Coordinator confirmed the discharge assessment had not been completed. After surveyor intervention, an MDS assessment for discharge return anticipation was initiated, but the deficiency was based on the absence of the required discharge assessment at the time of review.
Failure to Provide Ordered Care, Hospice Orders, and Adequate Linens
Penalty
Summary
The facility failed to follow physician orders for turning and repositioning for a resident with limited bed mobility. Resident #40 was observed multiple times lying on the left side in bed without evidence of repositioning during surveyor rounds on the Chesapeake Unit. The resident had a physician order for turning and repositioning every two hours and as needed, and the Treatment Administration Record showed staff signatures indicating the treatment was completed, despite the surveyor’s observations and the DON’s confirmation of the resident’s position. The facility also failed to ensure physician orders were obtained for hospice care. Resident #3 was admitted to hospice care on 07/01/2025, but during medical record review on 08/21/2025, no physician orders were found. A physician order for hospice services was not present until 08/25/2025, after the surveyor’s intervention. The DON stated that the expectation is for the physician to write orders as soon as the resident is admitted. The facility further failed to ensure sufficient linens were available for residents. Staff on the Homestead Unit reported ongoing linen shortages, including only 10 towels available for approximately 44 residents on one day shift and persistent difficulty obtaining enough linen to make beds or provide towels. Surveyor observations found multiple residents’ beds without sheets, pillowcases, blankets, or cover sheets, and one resident was lying on a bare mattress and requested a fitted sheet. The Maintenance Director stated the facility was operating past its linen needs and that insufficient linen availability was a consistent issue.
Failure to Maintain Ordered Fall-Prevention Equipment
Penalty
Summary
The facility failed to implement a fall-prevention intervention that had been identified as necessary for a resident who was at risk for falls. Resident #84 had a history of rolling out of bed and had prior falls on 3/18/25, 4/02/25, and 5/11/25, including being found on the floor beside the bed. After the 5/11/25 fall, the care plan was updated to include a perimeter mattress as a fall-prevention intervention. After the resident was transferred to a different room on 8/15/25, the perimeter mattress was not moved with the resident. On 8/19/25, the resident rolled out of bed and was found near the bed lying on the stomach wrapped in blankets; no injuries were noted and the family was notified. During observations on 8/20/25 and 8/21/25, the resident’s bed did not have a perimeter mattress, and RN #13 confirmed it was missing. The Unit Manager stated the mattress had been left in the previous room, and the DON agreed the resident should have had the perimeter mattress on the bed.
Failure to Clarify G-Tube Orders and Residual Parameters
Penalty
Summary
Facility staff failed to consult the resident’s physician to clarify orders related to a G-tube-fed resident’s medication route, residual parameters, and delivery of ordered feedings. Resident #40 had physician orders for Thiamine HCl 100 mg by mouth daily and Melatonin 3 mg by mouth at bedtime, while also having a separate order indicating the resident was NPO and that medications were to be administered via the G-tube. The record also contained a tube feeding order with residual instructions that were incomplete, stating to hold feeding for one hour if residual was greater than an unspecified amount and to recheck every shift. During survey observation, the resident’s G-tube feeding bag was hanging on the pump and connected to the resident, but the pump was not infusing. The feeding bag was dated two days earlier. An LPN stated the feeding bottle had not been changed and that the 11-7 AM shift did not report that the pump was not working, and also stated there was no physician order to hold the feeding. The DON confirmed the resident was NPO and that all medications had to be given via the G-tube, and the MDS Coordinator later confirmed the residual order did not include parameters for holding the feeding. A revised physician order was then obtained stating to check residual and call the provider to hold if residual was greater than 30 cc.
Respiratory Equipment Not Maintained in a Sanitary Manner
Penalty
Summary
Failure to maintain respiratory equipment in a sanitary manner was identified for three residents receiving oxygen therapy and nebulizer treatment. For one resident, surveyors observed oxygen in use without a sign at the doorway, a nasal cannula that was not dated or labeled, portable oxygen tubing that was also not dated or labeled, and tubing with the nasal prongs lying on the floor of the resident's room. A used nebulizer was also left uncovered on the bedside table. The resident stated the nasal cannula did not appear to have been changed since admission. The RN stated the cannula should not have been on the floor, the nebulizer should have been in a zippered bag, and oxygen tubing should be changed weekly, but there was no oxygen sign because the facility did not have one. The DON stated oxygen tubing should be changed and labeled weekly and nebulizers should be bagged and dated. At the time of review, no orders were found for changing or maintaining the oxygen supplies until an order was later added to the chart. For a second resident, surveyors observed a used nebulizer attached to a mask and tubing sitting on the bedside stand without a label or bag, and the resident was not in the room. The medical record showed an order to change the nebulizer mask and tubing weekly and to date and place it in a dated plastic bag. An LPN stated the nebulizer should be dated and stored in a bag, but the bag placed on the bedside table was unlabeled and undated, and the nebulizer remained uncovered in its holder. For a third resident, surveyors observed portable oxygen via nasal cannula with tubing that was unlabeled. An LPN acknowledged the need for labeling, and another LPN and the DON stated nurses were expected to label oxygen tubing and store it in bags when not in use, with tubing changed weekly.
Outdated Staff Assignment Boards and Lobby Posting
Penalty
Summary
The facility failed to ensure staff postings were updated, as evidenced by 4 of 4 staff assignment boards and 1 facility staff posting being out of date during the recertification survey. During an initial tour of the nursing units, the assignment boards for Mill Landing, Wye Oak, and Chesapeake were observed dated 08/18/25 for the 7-3 shift, and the staffing sheets for each nursing unit had not been completed since 08/17/25. During interviews, LPN #21, RN #20, and LPN #23 confirmed the assignment boards had not been updated and stated the facility expected the boards to be updated at the beginning of each shift. On a continued tour, the Homestead assignment board was observed dated 08/17/22 for the 7 am-3 pm shift with staff assignment by room number, ratio, unit manager, and census. RN #22 stated the board should have been updated for each day and each shift from 08/17/25. Later, a staff posting at the front entrance lobby was observed dated 08/22/25, and the NHA confirmed it should have been updated to reflect the correct date, staffing assignment, and census.
Delayed Response to Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to act on the consultant pharmacist’s medication regimen review recommendations in a timely manner for Resident #7, who was reviewed for unnecessary medications during the annual survey. Surveyors requested the resident’s June, July, and August 2025 medication regimen reviews, but the July 2025 review was not initially provided. The DON later confirmed that the consultant pharmacist completed the July 9, 2025 review, but the recommendations were not addressed and were still being worked on by the NP. When the facility finally provided the July review documentation, the provider responses were signed and dated by the NP on 9/3/25 after surveyor intervention, showing that the pharmacy recommendations were not reviewed or acted on until 56 days after they were written.
Unattended medications and expired supplements found in storage areas
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when a medication cart on the Mill Landing nursing unit was found unattended with Resident #102's Rosuvastatin 40 mg blister pack and a large blue pharmacy bag of medications left on top of the cart. During the initial tour, the resident was sitting in a chair near the cart, and no staff were present at the time of the observation. When interviewed, RN #20 stated he had been distracted by another surveyor and left the medications unattended, and he acknowledged the facility's expectation that medications be stored in a locked room or cart when not being administered. The facility also had expired oral nutritional supplements and medication stored inappropriately. In a storage closet, the surveyor observed 16 cartons of Glucerna with Carbsteady 1.5 calories and 4 bottles of HI-CAL 1 liter, all expired. During inspection of medication storage rooms, a box of expired Bisacodyl suppositories was found in the Chesapeake medication storage room, and LPN #14 confirmed the finding and removed the box. The DON was informed of these findings and stated that staff education would be conducted.
Delayed Dental Care Due to Insurance Issues
Penalty
Summary
The facility failed to provide timely routine dental care for a resident whose physician requested a dental appointment on 07/14/2025. The resident told the surveyor that the facility cancelled the dentist appointment at the last minute in July 2025 and that a tooth was bothering him/her. Record review showed that on 07/30/2025 nursing notes documented the dental appointment needed to be postponed due to insurance, and the Director of Nursing confirmed the facility was unable to schedule the appointment because of insurance issues. Interviews with facility staff showed the resident’s insurance was inactive and that the facility discovered this after admission and during the process of scheduling the dental visit. The Regional Assistant BOM stated the facility reviews eligibility prior to admission and notifies DHS, and confirmed the resident’s insurance was inactive. The Administrator stated that if dental conditions are urgent, the facility uses an on-site provider, but also acknowledged that the resident preferred an outside provider and that the on-site option was not documented as offered. The resident later reported that the facility did not offer on-site dental services and that he/she called and scheduled the appointment independently. The DON then reported that the resident had a dental appointment scheduled for 10/16/2025 and that it was on the facility transportation calendar.
Failure to Provide Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide liquids consistent with a resident’s needs for one resident reviewed for hydration. The resident had a history of dysphagia and aspiration pneumonia and had a current physician order for nectar-thickened fluids. A dietician progress note also documented that the resident was at high aspiration risk. During observation, a GNA gave the resident a cup of water, and the resident began drinking and immediately started coughing. The Unit Manager stated the resident was supposed to be on thickened liquids and removed the water. The GNA stated she was not aware the resident required thickened liquids and confirmed the water was not thickened to nectar consistency. The DON confirmed the resident should have received thickened liquids and stated that diet and drink orders are expected to be followed as prescribed.
QAPI Committee Lacked Required Members at Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) meetings included the required committee members. Review of two quarterly committee attendance sheets showed that the Medical Director did not attend the QAPI meetings for January 2025, March 2025, April 2025, and May 2025, and the Infection Preventionist did not attend the QAPI meetings for January 2025 and May 2025. During interview, the Nursing Home Administrator acknowledged that the Medical Director and Infection Preventionist had not attended the required QAPI meetings and stated that a Google Meet would be used going forward for required members who could not attend in person.
Failure to Document and Offer Pneumococcal Vaccination
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after staff failed to screen and offer pneumococcal vaccination to an eligible resident. Resident #114 was admitted in May 2025 with diagnoses including dementia, adult failure to thrive, and muscle wasting and atrophy. Review of the clinical record did not show the resident’s pneumococcal vaccination status, and there was no documentation that the resident or responsible representative was offered the vaccine or educated on its risks and benefits. The MDS assessment indicated the pneumococcal vaccine had not been received because it was not offered. During interview, an RN stated that pneumococcal vaccines are offered on admission, consent is obtained, a physician order is initiated, and a declination form is kept if refused; however, after reviewing the record, the RN confirmed there was no documentation of vaccination status, offer, or refusal. The DON also reviewed the record and confirmed there was no documentation of the resident’s pneumococcal vaccination status.
Unsafe Construction Area and Dirty Laundry Room
Penalty
Summary
A resident reported that the room beside their room had been closed and under construction for about 2 years because of a roof leak. During observation, the room was not labeled but had a sign stating it was under construction and for authorized personnel only, with no lock or other barrier to prevent entry. The room contained a puddle of water on the floor and on top of a bedside stand near the doorway, a reddish-brown stain beside the puddle, a bedside stand with staining and peeling, splitting wood, and stored items including chairs, replacement lights, mattresses, and bed frames. The ceiling also had a missing tile, a broken and degrading tile, and several tiles with reddish-brownish spots. The Regional Maintenance Director confirmed the room had been closed for over two years due to a roof leak and was being used as storage, and the Administrator agreed the room was a safety concern if residents entered it. The laundry room was observed to be visibly dirty throughout, with large scattered black marks on the white floor tiles and several cracked tiles in the room housing the washing machines. One washing machine was operating, and the Maintenance/EVS Director stated there was only one working machine in the laundry room. A wet towel with black spots was on the floor under the door of the washing machine, and in the clean area near the folding table and door corners there were several patches of brown-like substances on the white floor tiles. The Maintenance/EVS Director confirmed the laundry room needed cleaning and stated that, as an old building, not much could be done with the floor tiles. The Administrator was informed of the laundry room concerns and took notes.
Missing Annual Compliance and Ethics Training for GNAs
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants completed the required annual Compliance and Ethics Program education. Review of the educational files for GNA #17, #35, #39, #40, and #41 showed no training record for this annual course. This was identified during the recertification survey when the surveyor reviewed staff educational files and found that all 5 of the 5 GNA files reviewed lacked documentation of the required annual Compliance and Ethics Program. During interviews, the Nursing Home Administrator provided a 2025 monthly education calendar that listed courses issued by the corporate office and stated that a facility-wide education fair in May 2025 should have included the Compliance and Ethics Program. The Human Resource Director later provided the in-service attendance record for the May 2025 education fair, which listed multiple topics provided to the GNAs, including abuse, dementia, resident rights, infection control, and other subjects, but did not include the Compliance and Ethics Program. The Nursing Home Administrator acknowledged that the Compliance and Ethics Program was not included in the May 2025 educational in-service fair.
Delayed Pressure Ulcer Care and Missing Admission Wound Orders
Penalty
Summary
The facility failed to implement wound care recommendations for a resident with a Stage III pressure ulcer. A wound care provider documented on multiple occasions that the resident needed an air mattress for pressure redistribution, but the order was not entered into the EMR until weeks later. During survey observations, the resident did not have an air mattress, and staff confirmed that the resident should have had one. Maintenance later reported that the request for an air mattress had not been made until after the recommendation had already been documented several times. The facility also failed to initiate wound care upon admission for another resident who was admitted with pressure injuries. The hospital discharge summary identified a coccyx pressure injury present on admission and included wound care instructions such as keeping the area clean and dry, turning and repositioning every 2 hours, and applying zinc paste. However, the resident’s pressure injury was not identified on admission in the facility record, and no treatment orders were entered into the EMR until later. A subsequent wound assessment documented multiple pressure ulcers/injuries, including deep tissue injuries and Stage 3 wounds to the buttocks and gluteal folds, all listed as present on admission. The wound care provider’s recommendations for this resident included specific treatments for each wound and an alternating air/low air loss mattress for pressure redistribution. The DON and MDS Coordinator acknowledged that there was a delay in wound care and in placing wound care orders into the EMR. The facility policies reviewed during the survey stated that licensed nurses conduct a full body skin assessment upon admission and that wound assessments and treatments are to be documented upon admission and as needed, but the record showed these actions were not completed in a timely manner for this resident.
Failure to Maintain Operational Laundry Equipment, Telephone Access, and Dryer Lint Logs
Penalty
Summary
The facility failed to ensure essential equipment was operational in the laundry room. During observation, only one washer and one dryer were in use, and a large grey bin was seen holding wet white linen that had already been washed and was waiting to be dried. The Maintenance/EVS Director stated that the facility had only one operational washer and one operational dryer, and that the laundry staff were washing ahead even though the volume of soiled laundry could not be kept up with using the available equipment. The Maintenance/EVS Director reported that the facility had previously had three washer machines and four dryer machines, but the machines had broken one by one over the last couple of years and had not been replaced except for one recently delivered washer. He stated that the facility was running a second shift to try to address the laundry volume, but that housekeeping mop heads, slings, and other cleaning cloths were also being washed and dried during that time. The Nursing Home Administrator stated she had recently learned that one washer was not operational and acknowledged that a service call had been requested. The facility also had an ongoing problem with its telephone system. A complaint from a resident representative described being unable to leave voicemail messages for the DON and social worker because their voicemail boxes were full. Another resident representative reported being unable to reach the NHA by telephone to discuss concerns about missing clothing, missed medication administration, and a missed meal, and stated that the NHA's voicemail was full. The NHA stated that the phone system was outdated and unable to retrieve messages, that front desk staff were instructed to screen calls and take messages, and that the problem had been ongoing for almost a year. In addition, the surveyor found that dryer lint logs were not maintained according to the stated routine, and immediately after the interview a large amount of lint was observed being removed from the dryer.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 132 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Easton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase | 0.3 mi | ★★★★★ | 0 | 0 |
| Mallard Bay Nursing And Rehab | 12.9 mi | ★★★★★ | 44 | 0 |
| Autumn Lake Healthcare At Chesapeake Woods | 12.9 mi | ★★★★★ | 26 | 1 |
| Caroline Nursing And Rehab | 15.2 mi | ★★★★★ | 5 | 0 |
| Denton Nursing And Rehab | 16.5 mi | ★★★★★ | 36 | 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.