Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Resorts At Chester River Manor Corp during CMS and state inspections, most recent first.
A resident admitted with urinary retention and a Foley catheter was ordered to have a urology follow-up within two weeks, but facility staff cancelled and rescheduled appointments, transported the resident to the wrong office, declined earlier available dates, and ultimately set a later appointment beyond the ordered timeframe. During this period, multiple GNAs and LPNs observed persistent Foley leakage, frequent wetness, and resident manipulation of the catheter, yet staff documented minimal urinary output and did not perform or document thorough catheter reassessments. Providers, including NPs and the Medical Director, were aware of the Foley and some leakage but did not document catheter-focused assessments or plans, and one pain management note recorded the resident’s penile pain and request for catheter removal without evidence of follow-up by nursing or the primary team. When the resident was eventually sent to the hospital due to pain and not feeling well, ER staff documented that the Foley had been problematic since admission, found it overinflated and draining around the catheter with no urine in the bag, replaced it, and obtained large urine volumes, and the resident was admitted with UTI and acute kidney injury.
The facility failed to maintain complete and timely medical records for two residents. For one resident with a lower limb abscess and post-surgical wound care needs, a daily dressing change ordered by the provider was not documented on the TAR for a specific date, and there were no nursing notes to confirm completion, although the RN later recalled performing the treatment. For another resident, multiple provider documents—including a history and physical and NP progress notes—were either missing from the paper chart or uploaded late into the EMR, with some notes not entered until after the resident had been discharged, and an additional MD progress note remained unfiled at the time of surveyor review.
MDS assessments were coded inaccurately for several residents. A resident’s discharge MDS was coded as an unplanned discharge to home/community even though the record showed discharge home with home health services. Another resident’s MDS did not reflect ordered antiplatelet and anticoagulant meds, while other MDSs incorrectly coded pneumonia and weight loss despite record review and staff statements showing those findings were not supported.
A resident who was dependent on staff for bathing received only one documented shower during their stay, despite requiring substantial assistance with ADLs. Documentation and interviews confirmed that showers were not consistently provided or recorded according to scheduled shower days, resulting in inadequate personal hygiene care.
A resident experienced five days without a documented bowel movement following changes to their bowel regimen and administration of an antidiarrheal. Despite facility policy requiring intervention after 72 hours without a bowel movement, there was no evidence that the bowel protocol was initiated or that the provider was notified, and no as-needed suppository was administered during this period.
A resident with pressure ulcers did not receive prescribed Tramadol doses as ordered, with records showing discrepancies between the MAR and the Narcotics Record. Staff signed off on medication administration in error and failed to document any resident refusal in the progress notes, contrary to facility expectations.
Surveyors identified multiple failures in maintaining accurate and complete medical records, including inaccurate assessments of a resident's dental status, missing and untimely provider notes for a resident's care, incomplete documentation of therapy sessions, and an active monitoring order for anticoagulant medication without a corresponding medication order or documentation. These deficiencies were found through record reviews and staff interviews.
Unsafe and Poorly Maintained Resident Areas: The surveyor observed chipped and marred doors in several resident rooms, a missing call light string in a shared bathroom, and doors that did not shut properly because door stoppers were attached. The DON and Regional Administrator observed the conditions with the surveyor and acknowledged the issues.
The facility failed to develop and implement complete care plans for multiple residents. One resident receiving Eliquis for PE had no care plan for the anticoagulant or diagnosis, another resident had an anticoagulant care plan despite no current order or MDS evidence of use, and a third resident’s TAR lacked documentation for evaluating pain medication effectiveness and side effects even though those interventions were listed in the care plan.
Failure to update a resident’s care plan was identified when surveyors found an anticoagulant care plan remained active even though the resident had no current MD order for an anticoagulant and the MDS assessments did not show use of that medication. The RN MDS Coordinator acknowledged the mismatch between the care plan, MD orders, and MDS documentation.
Medication administration standards were not followed when an LPN left medications unattended at a resident’s bedside and another resident was given sulfa/trim ds 800/160 mg without an order on the MAR. The DON confirmed medications should not be left in a resident’s room, and facility policy required medications to be given only as ordered and verified for the right resident, medication, dose, time, and route.
A resident repeatedly complained of left ear wax buildup and difficulty hearing, and an LPN documented that the NP ordered Debrox and an ENT consult because it was a recurring problem. A consult provider recommended irrigating the left ear to remove wax, but the record showed multiple Debrox orders and no ENT consult order. The UM stated she was unaware the resident needed an ENT consult.
Respiratory Care Deficiencies: A resident receiving oxygen and CPAP therapy and another resident receiving oxygen were found without oxygen-in-use signage posted outside their rooms, and the resident using CPAP had no order for cleaning and maintenance of the device despite facility policy requiring one. The DON and Administrator acknowledged the signage concern, and staff identified the missing CPAP maintenance order during record review.
Posted nurse staffing information was missing required details. Survey review of staffing documents and observation of the current posting found that the facility name and resident census were not included, and the HRD/Staffing Coordinator acknowledged the omission during interview.
Failure to Perform Hand Hygiene Before Medication Administration: Two LPNs prepared meds from a shared med cart and administered them to two residents without performing hand hygiene before entering the rooms or giving the medications. Both LPNs confirmed that hand hygiene is expected before medication administration.
A resident’s bathroom toilet was observed leaking, with urine in the bowl and water on the floor around it. The resident said the toilet had been leaking for some time and showed that it continued to leak when flushed. The Maintenance Director said he knew about the issue and had ordered parts, while the DON said she was unaware of the concern and that the bathroom should not have been used while it was not functioning correctly.
The facility failed to maintain accurate medical records for several residents, including improper documentation of wheelchair assessments, incomplete PASSAR assessments, unsigned transportation request forms, discrepancies in controlled drug receipt records, incorrect electronic SOAP notes, and incorrect diagnoses for medication administration.
The facility failed to maintain the dignity and privacy of a resident by leaving their nephrostomy bags uncovered during a social coffee time, making the resident's urine visible. An LPN and the Administrator confirmed that the bags should have been covered.
The facility staff failed to ensure that residents' call bells were within reach to request assistance. During observation rounds, one resident's call bell was found draped over the bedside table, and another's was on the floor. These findings were confirmed by a social worker and acknowledged by the DON, who stated that managers and GNAs are expected to ensure call bells are accessible.
A facility failed to ensure scheduled pain medications were not misappropriated, as evidenced by a discrepancy in the narcotic drawer for a resident's Tramadol 50 mg tablets. The controlled drug receipt record and medication administration audit report did not match, and the nurse involved admitted to failing to sign the controlled drug receipt record for another resident's medication.
The facility staff failed to include necessary dental care assistance in a resident's ADL care plan, despite recommendations and the resident's expressed need. The resident had not seen a dentist in almost a year and experienced pain while brushing, which was known to the nursing staff but not reflected in the care plan.
The facility staff failed to conduct quarterly care plan meetings for a resident, as evidenced by a review of the resident's EMR, which revealed that the last care plan meeting was held several months ago. The social worker indicated that care plan meetings are supposed to be held quarterly and as needed, but the required meeting was not conducted within the expected timeframe.
The facility staff failed to document medication administration in a timely manner for a resident. An LPN admitted to documenting the medication late, although it was given on time. The facility's policy requires immediate documentation after administering medication, which was not followed. The DON confirmed the standard practice, and the deficiency was identified during a survey.
The facility failed to ensure proper medication administration and documentation, including discrepancies in controlled drug counts and late administration of scheduled medications. These issues were identified during a survey and confirmed through interviews and medical record reviews.
A physician failed to timely evaluate a resident's sore throat despite the resident's repeated complaints and a Nurse Practitioner being informed. The NP intended to see the resident but became busy and did not follow through until the next day, when medication orders were finally written.
The facility staff failed to maintain a medication error rate below 5%, with errors including late administration, failure to instruct a resident to rinse their mouth after inhaler use, and improper handling of medications. The DON acknowledged the issues, indicating previous training had been conducted.
Facility staff failed to adhere to infection control practices during medication administration. An LPN did not clean a tablet crusher after use, and another LPN picked up a dropped tablet with an ungloved hand, both actions violating facility policies.
The facility staff failed to offer and administer the pneumococcal vaccine to a resident with a history of Diabetes Mellitus, alcohol abuse, and Viral Chronic Hepatitis C. Despite the facility's policy and CDC guidelines, the resident was not offered the vaccine, and no consent or declination form was completed.
Failure to Ensure Timely Urology Follow-Up and Adequate Foley Catheter Management
Penalty
Summary
Facility staff failed to ensure a resident with urinary retention and an indwelling Foley catheter received a timely urology follow-up as ordered and failed to reassess and intervene appropriately for ongoing catheter problems. The resident was admitted from the hospital with a Foley catheter and discharge instructions specifying a urology follow-up within two weeks. A urology appointment was initially scheduled by the hospital for early April, then cancelled by facility staff due to transportation issues and rescheduled for another date in early April at a different office location. On the day of the rescheduled appointment, the resident was transported to the wrong office location, which was closed that day, and returned to the facility without being seen. The urology office scheduler reported that earlier alternative dates were offered but declined by facility staff, who chose a later date in May. Facility staff, including the unit manager and Medical Director, were aware that the resident had not been seen as originally scheduled and that the next appointment was set for May, beyond the two-week follow-up timeframe. The resident experienced ongoing issues with the Foley catheter, including leakage and manipulation of the catheter by the resident. Multiple GNAs and LPNs reported that the catheter was leaking and that the resident was often found wet, requiring pad or diaper changes. Staff also reported that the resident frequently pushed the catheter inward up to the Y-connection, and nurses stated they would educate the resident not to do this and adjust the catheter position. Nursing staff and the unit manager stated they had been instructed not to remove or change the catheter because it had been inserted by a urologist and was to be changed only by urology. Despite these reports of leakage and resident discomfort, there was minimal documentation of urinary output, with only two notes documenting output amounts and no ongoing output records on the MAR as claimed by the unit manager. Provider assessments and documentation did not address the catheter problems despite staff awareness of leakage and resident complaints. A nurse practitioner documented being consulted on the resident and noted that the Foley was leaking but draining, with an order not to touch the Foley and to schedule a urology follow-up, but did not document an assessment or plan related to the catheter. The Medical Director documented a visit without any catheter assessment or plan and later stated she believed the leakage was mild and not daily, and was unaware of the resident’s manipulation of the catheter or of a pain management note documenting penile pain at the catheter insertion site and the resident’s request for catheter removal. Another NP saw the resident later for blood sugar concerns, documented no genitourinary issues other than no hematuria, and was unaware of catheter problems. On the day the resident was sent to the hospital at the family’s insistence due to pain and not feeling well, facility nursing documentation did not reflect catheter concerns. At the hospital, ER staff documented that facility staff reported the Foley had been a problem since the first day of admission, found the catheter draining around the tubing with no urine in the bag, removed an overinflated balloon, and after catheter replacement obtained large volumes of urine. The resident was admitted with diagnoses including urinary tract infection and acute kidney injury, and surveyors concluded that the facility’s failure to ensure timely urology follow-up and to reassess and intervene for catheter problems caused harm to the resident.
Incomplete and Delayed Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident admitted with diagnoses including a cutaneous abscess of the left lower limb, orthopedic aftercare, a pathological fracture of the left femur, and disruption of an external surgical wound, the March 2026 Treatment Administration Record contained a physician’s order to cleanse the left knee area with a prescribed solution and apply a dry dressing daily beginning on 3/14/26. The Treatment Administration Record for 3/14/26 was left blank, with no nurse’s initials to indicate the treatment was completed and no corresponding nursing notes. During interview, the RN assigned to the resident stated she remembered performing the dressing change on that date and was able to describe the wound and dressing, but acknowledged she had failed to sign off that the treatment was completed. The facility also failed to ensure that provider notes were included in another resident’s medical record in a timely manner. This resident was admitted in March 2026 and discharged on 4/12/26. Review of the paper medical record showed no provider notes, while the electronic record revealed that the Medical Director’s history and physical dated 3/26/26 was not uploaded until 4/10/26, and progress notes from two nurse practitioners dated 3/29/26 and 4/12/26 were not uploaded until 4/20/26, after the resident’s discharge. When asked if there were any additional provider notes not in the record, the DON produced a paper progress note from the Medical Director dated 4/2/26 that had also not yet been included in the resident’s medical record.
Inaccurate MDS Coding for Discharge Status, Medications, Pneumonia, and Weight Loss
Penalty
Summary
The facility failed to ensure that MDS assessments were coded accurately for multiple residents reviewed during the survey. For Resident #103, the discharge MDS dated 9/22/2025 was coded as discharged to home/community with an unplanned discharge, even though the medical record showed the resident was discharged home with home health services through Amedisys and had discharge planning documented by social services. The RN MDS Coordinator stated she coded the discharge MDS that way when residents discharged home. For Resident #33, the medical record showed physician orders for Aspirin 81 mg daily and Clopidogrel 75 mg daily, as well as a temporary order for Lovenox 40 mg twice daily from 10/31/2025 through 11/14/2025. However, the MDS assessments dated 8/28/2025 and 11/6/2025 did not indicate antiplatelet medication use, and the 11/6/2025 MDS also did not code anticoagulant use. For Resident #1, the MDS Quarterly dated 9/1/2025 coded pneumonia as yes even though Unit Manager #4 stated the resident did not have pneumonia, and the MDS Coordinator said she entered pneumonia by accident. For Resident #9, the MDS Quarterly dated 11/19/2025 coded weight loss, but the surveyor did not identify significant weight loss in the record and the Registered Dietician stated the coding was inaccurate and not reflected in the note or care plan.
Failure to Provide Adequate Bathing Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a dependent resident who required assistance with activities of daily living (ADLs), specifically bathing. Documentation review revealed that during the resident's stay from mid-March to mid-April, there was only one recorded instance of the resident being assisted with a shower. Intake records and Point of Care (POC) documentation indicated that the resident was dependent or needed substantial to maximal assistance with showering and bathing, but only one date was documented for a shower transfer. Interviews with the unit manager confirmed that there was limited documentation to support that multiple showers were provided, and skin check sheets did not indicate that showers were given on the assigned days. The unit manager acknowledged that, at the time, showers and transfers were prompted on an as-needed basis rather than on scheduled shower days, and there was no additional documentation to demonstrate that the resident received more than one shower during the reviewed period.
Failure to Provide Timely Bowel Management Interventions
Penalty
Summary
The facility failed to identify and provide appropriate interventions for a resident experiencing constipation and diarrhea. Record review showed that the resident had orders for Miralax and Senna for constipation, which were both reduced or discontinued on 3/19/25, and Imodium was started for diarrhea. Despite these medication changes, the resident had no documented bowel movement for five days (3/25/25-3/29/25). During this period, the bowel regimen had been decreased and an antidiarrheal was administered. The Bisacodyl suppository, ordered as needed, was not documented as given during March 2025. Nursing notes during this time indicated active bowel sounds and noted constipation, but no further interventions were documented. Facility policy required daily monitoring of bowel movements and initiation of a bowel protocol if no bowel activity was noted in 72 hours, with results to be documented in the electronic health record. The surveyor's review found that the resident's lack of bowel movement was not addressed according to protocol, and there was no evidence that the provider was notified or that the bowel protocol was initiated after five days without a bowel movement. The deficiency was confirmed through record review, interviews, and policy review, with no additional information provided by the facility at the time of exit.
Failure to Administer Prescribed Pain Medication and Document Refusals
Penalty
Summary
The facility failed to provide pain management as prescribed for a resident with large pressure ulcers who required pain medication during wound treatment. Medical record review and staff interviews revealed that the resident was not administered Tramadol every 8 hours as ordered, specifically missing the 2 pm dose on several consecutive days. The Medication Administration Record (MAR) indicated that the medication had been given, but a comparison with the Narcotics Record showed it had not actually been administered. Staff involved reported signing the MAR in error and believed the resident had refused the medication, but there was no documentation in the progress notes to support a refusal. The facility's expectation was that any refusal should be documented in the progress notes, which was not done in this case.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards, as evidenced by multiple deficiencies identified during a recertification and complaint survey. In one instance, a resident who reported having no teeth for years was inaccurately assessed in both the nursing admission assessment and the Minimum Data Set (MDS) assessment, with documentation failing to indicate the resident was edentulous. The MDS coordinator relied on documentation from other disciplines rather than direct assessment, resulting in incorrect coding of the resident's oral status. Another deficiency involved a resident whose medical record lacked timely and complete provider notes. Progress notes indicated that a nurse practitioner had seen the resident and ordered medication, but the corresponding provider notes were missing from the electronic medical record. When the surveyor requested these notes, they were subsequently uploaded with creation dates much later than the effective dates, confirming that the documentation was not completed in a timely manner and was not part of the resident's record at the time of care. Additional findings included incomplete documentation of therapy services and inaccurate physician orders. One resident had a physician order for physical therapy 3-5 times per week, but therapy was only provided twice in one week without documentation explaining the missed sessions, despite the resident being available for other therapies. Another resident had an active physician order for monitoring anticoagulant medication, but there was no corresponding order for the medication itself, and the medication was not listed on the MAR, care plan, or MDS assessments. These deficiencies demonstrate failures in maintaining accurate, complete, and timely medical records for residents.
Unsafe and Poorly Maintained Resident Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in multiple rooms and the conference room. During the initial tour, the surveyor observed chipped and marred doors in room [ROOM NUMBER], room 109, room 111, room 112, and room 113, along with a missing call light string for the bathroom call light device in the shared bathroom used by rooms [ROOM NUMBERS]. The surveyor also observed that the resident room door for room [ROOM NUMBER] and the facility conference room door did not shut properly because a door stopper was attached to each door. During an interview, the Regional Administrator and DON were shown the resident room door that did not shut properly and the missing call light string in the shared bathroom. They observed these conditions with the surveyor and acknowledged them, stating they would follow up with maintenance. The report also notes that on the following day the DON stated the bathroom call light string had been found on the counter in the resident room, the stopper on the resident room door had been removed by maintenance, and maintenance was going to remove the stopper from the conference room door.
Incomplete and Unfollowed Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans and follow care plan interventions for 3 of 16 residents reviewed. For one resident, the medical record showed a physician order for Eliquis 5 mg twice daily and a diagnosis of pulmonary embolism, but the comprehensive care plan did not include a care plan for anticoagulant medication or for pulmonary embolism. The resident’s MDS assessments indicated that the resident was receiving an anticoagulant medication and had a diagnosis of pulmonary embolism, and the DON and Unit Manager acknowledged that these items were not on the care plan. For another resident, the medical record showed a comprehensive care plan for anticoagulant medication even though the active physician orders showed the resident was not receiving an anticoagulant medication, and the MDS assessments also showed the resident had not received an anticoagulant. For a third resident, the TAR did not contain documentation for evaluating the effectiveness or side effects of pain medicine, even though those were listed as care plan interventions. The DON stated that staff should have documented the care plan interventions on the TAR.
Failure to Update Anticoagulant Care Plan
Penalty
Summary
The facility failed to update and revise a resident’s care plan for anticoagulant medication. During the recertification/complaint survey, the surveyor reviewed the medical record of Resident #29 and found a care plan for an anticoagulant medication that had been initiated on 9/17/2024 and revised on 8/26/2025 with a target date of 2/12/2026. However, the resident did not have a current physician order for an anticoagulant medication. Further review of the resident’s MDS assessments dated 5/19/2024, 9/23/2024, 8/14/2025, and 11/12/2025 showed that none of the assessments indicated the resident was receiving an anticoagulant medication. In an interview, the RN MDS Coordinator acknowledged that the resident had a current care plan for an anticoagulant medication even though the resident was not receiving that medication, and stated that she would resolve the care plan.
Medication Administration Errors
Penalty
Summary
The nursing facility failed to use professional standards during medication administration. During an interview and observation, four medication cups were found left on a resident’s over-the-bed table, including two cups with liquid and two cups containing what appeared to be medications, one with a crushed substance and another with 12 pills. The resident stated the medications had been left for him/her to take and identified the orange substance as potassium. The DON confirmed that medications should not be left at the bedside and that nurses are responsible for ensuring medications are taken. Facility policy titled "Administering Medications" stated that a medication must never be left unattended in a resident’s room. The facility also administered a medication to another resident without an order. An LPN prepared and gave 15 different medications, gathered from a pharmacy prepackaged pouch, bubble packs, and floor stock bottles, to the resident. During reconciliation of the MAR with the medications observed, it was found that sulfa/trim ds 800/160 mg was administered even though there was no order for it on the resident’s MAR. The LPN stated he did not realize it was not on the MAR and thought it may have been recently discontinued, while the DON stated she would follow up on why the medication was given without an order. The facility policy stated medications must be administered in accordance with orders and that the person administering the medication must verify the right resident, medication, dosage, time, and route before giving it.
Failure to Obtain ENT Consult for Recurrent Ear Wax Buildup
Penalty
Summary
The facility failed to provide treatment/services to maintain hearing for one resident who repeatedly complained of left ear wax buildup and difficulty hearing. A Licensed Practical Nurse documented that the Nurse Practitioner was contacted and ordered Debrox ear drops and an ENT consult because this was a recurring problem. A consult note from the provider recommended that the left ear be irrigated to remove wax, and subsequent nursing notes continued to document left ear fullness and wax buildup despite repeated Debrox courses and an ear flush with minimal to no results. Review of the resident’s orders showed multiple Debrox orders over several months, but no ENT consult was listed in the orders. During interview, the Unit Manager stated she was unaware the resident needed an ENT consult. The surveyor later relayed concern that the ENT consult had never been ordered despite the recurring problem, and an ENT consult order was then placed for left ear pain/wax buildup.
Respiratory Care Deficiencies
Penalty
Summary
Failure to provide safe and appropriate respiratory care was identified for a resident receiving oxygen and CPAP therapy and for another resident receiving oxygen. On 12/8/2025, Resident #1 was observed receiving oxygen and had a CPAP machine that the resident stated was used at night, but no oxygen-in-use signage was found outside the room. On 12/9/2025, Resident #58 was observed using oxygen and no oxygen-in-use signage was posted outside the room. During record review for Resident #1, no order was found for cleaning and maintenance of the CPAP device, although the facility policy required an order for CPAP cleaning and maintenance. During interviews, the DON and Administrator stated they had been told by the Fire Marshall that oxygen signage needed to be posted outside the building rather than at each door, and they acknowledged the concern. The Maintenance Director later placed oxygen signage outside resident rooms. The Unit Manager stated there was no order to clean and maintain the CPAP and that she would review the policy and obtain physician orders, and the DON acknowledged the concern regarding the missing CPAP cleaning and maintenance order.
Posted Nurse Staffing Information Missing Required Details
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information document displayed the required information. During the recertification/complaint survey, the surveyor reviewed the facility’s staffing data documents for 11/17/2025 through 11/30/2025 and found that the facility name and resident census were not included on those documents. The report states that the staffing data document was required to display the facility name, current date, total number and actual hours worked per shift for RN, LPN, and nurse aide staff directly responsible for resident care, and resident census, and that it must be posted daily at the beginning of each shift in a prominent, readily accessible location. The surveyor also observed the current posted nurse staffing information document at the time clock in the facility on 12/9/2025 at 11:45 AM and found that it likewise did not include the facility name or resident census. In an interview on 12/16/2025, the HRD/Staffing Coordinator reviewed the posted staffing documents and acknowledged that the documents for the reviewed period and the current posting were missing the facility name and resident census.
Failure to Perform Hand Hygiene Before Medication Administration
Penalty
Summary
The facility failed to maintain practices to help prevent the transmission of infections during medication administration for two residents. On 12/9/25 at 8:34 AM, an LPN prepared medications for Resident #6 from a shared medication cart, gathering medications from multiple drawers and bottles, then entered the resident’s room, moved a wheelchair and table, and administered the medications without performing hand hygiene. When asked afterward, the LPN confirmed that hand hygiene should be performed before giving medications. On 12/9/25 at 9:20 AM, another LPN prepared medications for Resident #70 from a shared medication cart, gathered medications from multiple drawers and bottles, entered the resident’s room, and administered the medications without performing hand hygiene. When asked afterward, that LPN also confirmed hand hygiene should be performed before giving medications.
Leaking Toilet Left Resident Bathroom Wet and Unusable
Penalty
Summary
The facility failed to provide a safe, functional, sanitary environment for Resident #59 in the resident’s bathroom. During observation, the toilet bowl contained what appeared to be urine and the bathroom floor around the toilet was wet. The resident stated the toilet had been leaking for some time and that the facility was aware of the problem, and the resident asked the surveyor to flush the toilet to show that it continued to leak. When the toilet was flushed, additional water leaked onto the bathroom floor. The Maintenance Director stated he was aware the toilet was leaking, had ordered parts to repair it, and planned to fix it that day after the parts arrived. The DON later confirmed she was unaware of the toilet concern and stated the bathroom should not have been used while it was not functioning correctly.
Deficiencies in Medical Record-Keeping and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents. For Resident #37, the wheelchair and cushion were reported to be inappropriate, and the facility could not provide documentation that the wheelchair was assessed for proper fit. Resident #42's PASSAR assessment was incomplete as it lacked a signature, and Resident #58's transportation request form was not signed or dated by the staff. Additionally, discrepancies were found in the controlled drug receipt records for Resident #5 and Resident #10, where medications were either not administered as recorded or not signed off correctly by the nurse responsible. During a review of Resident #77's medical record, it was found that the electronic SOAP note incorrectly stated that the resident was on no known medications, despite the resident being on medications at the time of the visit. The nurse practitioner acknowledged the error and indicated that the electronic system needs correction. Furthermore, Resident #24's MAR indicated an incorrect diagnosis for the administration of Seroquel, which was being given for psychosis with behavioral disturbances but was recorded as being for depression. These deficiencies highlight significant lapses in documentation and record-keeping practices within the facility, affecting the accuracy and reliability of resident medical records. The issues were identified through medical record reviews, staff interviews, and observations during the survey, and were discussed with the administration team at the time of exit.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident as evidenced by the resident's nephrostomy bags being left uncovered while outside of their room. This was observed during a social coffee time in the Terrace Lounge, where the resident's urine was visible through the clear bags. An LPN confirmed that the nephrostomy bags should have been covered when the resident was outside their room and took the resident back to their room to cover the bags. The Administrator was also made aware of the situation and confirmed that the bags should have been covered.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility staff failed to ensure that residents' call bells were within reach to request assistance. This deficiency was observed in two residents. During observation rounds, one resident was found sitting on the side of the bed with the call bell draped over the bedside table, out of reach. Another resident's call bell was found on the floor near the left side of the bed. These findings were confirmed by a social worker. The Director of Nursing stated that managers are expected to make rounds twice in the morning and twice in the evening, and Geriatric Nursing Assistants are expected to check on residents periodically throughout the day to ensure call bells are accessible.
Medication Misappropriation and Documentation Discrepancy
Penalty
Summary
The facility failed to ensure that scheduled pain medications for a resident were not misappropriated. During a review of a medication cart on the Osprey Unit, a discrepancy was found in the narcotic drawer for a resident's Tramadol 50 mg tablets. The controlled drug receipt record indicated that one tablet was given at 0900 with six tablets remaining, but the blister pack contained seven pills. The medication administration audit report showed the medication was documented as administered at 08:39 AM. The nurse involved could not explain the discrepancy and admitted to failing to sign the controlled drug receipt record for another resident's medication. An interview with the resident revealed no complaints of pain, and the Director of Nursing confirmed that a medication error form was completed for the omission of the scheduled dose. The facility provided documentation of staff education on the issue. The deficiency was discussed with the Director of Nursing during the exit meeting with the survey team.
Failure to Include Dental Care in Resident's ADL Care Plan
Penalty
Summary
The facility staff failed to generate a person-centered care plan for a resident who required assistance with dental care. During an interview, the resident expressed the need to see a dentist. The last dental visit was recorded almost a year prior, and a dental summary from several months earlier recommended assistance with teeth brushing. However, this assistance was not included in the resident's Activities of Daily Living (ADL) care plan. The Director of Nursing confirmed that the care plan did not include teeth brushing, despite the resident sometimes experiencing pain while brushing and requiring assistance. The Geriatric Nursing Assistant also noted that the resident had been struggling with this issue for about a year, and the nursing staff was aware of it but had not updated the care plan accordingly.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility staff failed to conduct quarterly care plan meetings for Resident #73, as evidenced by a review of the resident's electronic medical record (EMR) on 03/05/24, which revealed that the last care plan meeting was held on 09/02/23. During an interview with Social Worker #7, it was revealed that care plan meetings are supposed to be held quarterly and as needed. The social worker receives a monthly list of residents whose care plan meetings are due and usually schedules these meetings on Tuesdays. Invitations are sent a week beforehand to the responsible party (RP) and the resident, and the meetings typically include Therapy, Activities, Social Services, and the resident's RP, with Nursing attending if available. Despite this process, the required quarterly care plan meeting for Resident #73 was not conducted within the expected timeframe.
Failure to Document Medication Administration Timely
Penalty
Summary
The facility staff failed to document medication administration in a timely manner for Resident #32. Upon review of the medication administration audit record (MAAR) for the period of 3/1/24 to 3/6/24, it was found that medications were documented as administered late. Specifically, on 3/4/24, the medication omeprazole, scheduled for 8:00 AM, was documented as administered at 11:44 AM. Licensed Practical Nurse (LPN #23) admitted to documenting the medication administration late, although she claimed the medication was given on time. The facility's policy requires that medication administration be documented immediately after administering the medication to each resident, which was not followed in this instance. The Director of Nursing (DON) confirmed that the standard practice is to document medication administration immediately after it is given. This deficiency was identified during a survey, and the DON, Regional DON, and Administrator were made aware of the concerns at the time of the survey exit. The failure to document medication administration promptly is a violation of the facility's policy and professional standards of quality care.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that a resident received a scheduled dose of medication as ordered by the physician. During a review of a medication cart, it was found that a resident's Tramadol 50 mg blister pack had a discrepancy in the count, with 7 pills observed instead of the expected 6. The controlled drug receipt record indicated that 1 tablet was given at 0900, but the medication administration audit report showed the medication was documented as administered at 08:39 AM. The nurse admitted to thinking she had given the medication but failed to sign the controlled drug receipt record properly. Another resident's Pregabalin 100 mg capsule was also found to have a discrepancy, with the controlled drug receipt record indicating 1 tablet was given, but the blister pack still contained 29 pills instead of 30. The nurse acknowledged the error and stated that she failed to sign the controlled drug receipt record after administering the medication. The Director of Nursing confirmed that a medication error form was completed for the omission of the scheduled dose and that staff would be re-educated on the proper procedures for medication administration and documentation. The facility also failed to administer scheduled medications to residents at the physician-ordered times. During a medication administration observation, it was noted that a resident's Omeprazole 20 mg capsule, scheduled for 8:00 AM, was administered at 10:38 AM. Another resident's Seroquel 50 mg tablet, also scheduled for 8:00 AM, was administered at 10:43 AM. Additionally, a third resident's Seroquel 50 mg and Celexa 10 mg tablets, scheduled for 8:00 AM, were administered at 10:48 AM. The nurse was observed crushing the medications together and mixing them with pudding to ensure the resident would not spit them out. These discrepancies in medication administration times were confirmed through a review of the residents' medical records. The Director of Nursing, Regional Director of Nursing, and Administrator were made aware of these concerns during the survey exit. The facility's failure to administer medications as ordered and to properly document controlled drug administration led to these deficiencies being identified during the survey.
Physician's Delay in Evaluating Resident's Change in Condition
Penalty
Summary
The physician failed to evaluate a resident with a change in condition in a timely manner. During observation rounds, a resident complained of a sore throat and stated they had informed the nurse. The following day, the resident reiterated the complaint and requested to see the doctor. The Nurse Practitioner (NP) was informed of the complaint but did not see the resident until the next day. The Unit Manager claimed the resident did not inform the nurse of the sore throat initially. The NP admitted she intended to see the resident but became busy and did not follow through. The medical record confirmed the resident was seen by the NP the day after the initial complaint, and medication orders were written at that time.
Medication Administration Errors
Penalty
Summary
The facility staff failed to ensure a medication error rate of less than 5% during a medication administration observation, resulting in an error rate of 18.52%. This was evident in several instances, including an LPN administering Omeprazole and Fluticasone-Salmeterol to a resident without instructing them to rinse their mouth afterward, and administering the medications late. Another resident received Seroquel late, and a third resident was given Seroquel and Celexa crushed together, despite Seroquel being on the Do Not Crush List. Additionally, an LPN was observed picking up a dropped Potassium Chloride tablet with an ungloved hand and placing it into a medication cup, contrary to facility policy. The medical records reviewed confirmed that the medications were administered at incorrect times and inappropriately crushed. The facility's policy on medication administration was not followed, as evidenced by the actions of the LPNs. The Director of Nursing acknowledged the issues and indicated that previous in-service training had been conducted to address timely medication administration. However, the observed practices during the survey indicated non-compliance with the established guidelines.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility staff failed to adhere to infection control practices during medication administration, as observed by surveyors. In the first instance, an LPN was observed dispensing medications for a resident by crushing two tablets together and mixing them with pudding without cleaning the tablet crusher after use. This action was contrary to the facility's policy, which requires the tablet crusher to be cleaned after each use. The LPN stated that the medications were mixed with pudding to prevent the resident from spitting them out, but the failure to clean the tablet crusher posed a risk of cross-contamination and infection transmission. In a second instance, another LPN was observed preparing medications for a different resident and dropped a Potassium Chloride tablet onto the top of the medication cart. The LPN then picked up the tablet with an ungloved hand and placed it into the medication cup, which violated the facility's policy that prohibits touching medications with fingers. The Director of Nursing (DON) confirmed that touching medications with fingers or hands, even if sanitized, is not allowed. These observations indicate a lack of adherence to infection control practices as outlined in the facility's medication administration guidelines.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility staff failed to offer and administer the pneumococcal vaccine to a resident, as evidenced by the review of Resident #40's medical records. The resident, who had a history of Diabetes Mellitus, alcohol abuse, and Viral Chronic Hepatitis C, did not receive another pneumococcal vaccine after receiving the Pneumococcal Conjugate 13 vaccine in 2012. The facility's policy indicated that the pneumonia vaccine should be offered to all residents, with a consent or declination form completed and maintained in the medical record. However, Resident #40 did not have a consent or declination form in either the paper medical record or the electronic medical record (EMR). The Assistant Director of Nursing/Infection Preventionist confirmed that the resident was not offered the vaccine because they were not 65 or older, despite CDC guidelines indicating that the resident's medical history made them a candidate for the vaccine. During the survey, it was revealed that the facility's immunization report and the resident's EMR did not align with the facility's policy for resident immunizations. The Assistant Director of Nursing/Infection Preventionist stated that immunizations are reviewed upon admission and that a report is kept to track who needs a vaccine. However, the resident was not offered the vaccine, and no declination form was completed. This discrepancy highlights a failure in the facility's adherence to its own immunization policy and CDC guidelines, resulting in the resident not receiving the necessary pneumococcal vaccine.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 208 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chestertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chestertown Nursing And Rehab | 0.2 mi | ★★★★★ | 9 | 0 |
| Willow Brooke Ct Skilled Care Ctr At Heron Point | 0.6 mi | ★★★★★ | 5 | 0 |
| Complete Care At Corsica Hills Llc | 12 mi | ★★★★★ | 21 | 0 |
| Sterling Care Riverside | 19.5 mi | ★★★★★ | 0 | 0 |
| Oakwood Snf Llc | 21.8 mi | ★★★★★ | 59 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.