Below 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 Of Augsburg during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple neurologic and psychiatric diagnoses had a documented allergy to acetaminophen in the clinical record. Despite this, a physician later ordered scheduled Tylenol for pain in the same note that listed acetaminophen as an allergy, and the medication was administered. The resident’s MPOA reported that the MD prescribed a drug to which the resident was allergic, and in interviews the MD acknowledged missing the allergy, noting that nursing staff and the pharmacy also did not detect the error. Facility leadership stated that the medication error was not identified or documented at the time and was only recognized after the resident’s daughter reported it months later.
Infection control practices were not consistently followed when a GNA clipped fingernails in a dining room while residents were present, oxygen tubing for a resident was observed touching the floor, infection control policies lacked review or revision dates, and a resident with MRSA under Transmission-Based Precautions had no documented follow-up after a hospital discharge summary directed ID follow-up. The DON, NHA, and other staff confirmed the concerns.
Missing Annual GNA Performance Reviews: The facility failed to complete and properly file annual performance reviews for multiple GNAs. Review of employee files showed no current-year evaluations for most GNAs reviewed, and the DON and HRD gave conflicting statements about where the missing reviews were stored. Staff interviews also showed uncertainty about whether the evaluations had been completed and who was responsible for them.
The facility failed to complete and track monthly MRRs consistently and did not have policies that clearly addressed MRR time frames or urgent irregularity steps. For one resident, multiple pharmacist recommendations were left unanswered, several monthly reviews were missing or late, and a lab follow-up recommendation lacked evidence of completion. For another resident, the pharmacist missed that Seroquel was again documented with the wrong indication even though the resident’s use was for Bipolar disorder.
Unsecured medications were found at a resident’s bedside and on the floor after an RN left doses unattended while intending to return later. Surveyors also found open floor-stock meds without open dates, expired IV fluids, needles stored outside original packaging, and unlabeled or improperly dated medications on carts and in supply rooms; the DON was present during the review and was informed of the concerns.
Kitchen Food Labeling and Dating Deficiency: The surveyor observed multiple nourishment items with expired dates, missing use-by dates, and containers with no labeling or dates, including produce and other food items. The DM acknowledged that proper dating and labeling were everyone's responsibility, stated that not all kitchen staff had been trained on proper labeling, and confirmed the concern when asked whether the lack of training may have contributed to the issue.
The facility failed to ensure required key personnel attended monthly QAPI meetings. Review of QA attendance sheets showed the Medical Director's signature was missing for several months and the Infection Preventionist's signature was missing for one month. The DON stated that monthly QAPI meetings should include the Medical Director, Administrator, DON, Infection Preventionist, and other interdisciplinary staff, and the NHA later validated the missing signatures.
Failure to maintain an effective pest control program. A resident reported mice were a big problem, with traps under a radiator, mice seen running across the floor, and mice heard in the walls. An outside agency staff member also reported an ongoing infestation for over 2 to 3 years. Facility logs and pest service reports documented repeated mouse activity in multiple rooms and common areas, plus prior roach activity, while the NHA stated he was not aware of the issue and that the pest vendor handled it.
A resident sustained a serious injury after an altercation with another resident, resulting in a hospital visit and diagnosis of a foot fracture. While the initial incident was reported to OHCQ as required, the facility failed to submit the follow-up investigation report within the mandated 5 working days. Documentation inconsistencies and lack of submission confirmation were noted during the survey.
A resident’s advance directive status was not documented in the medical record, and no Physician’s Certificate of Incapacity was present despite unclear cognitive status. The resident had a MOLST completed as full code on admission, but the chart lacked an Advance Directive and the required two-physician incapacity evaluation; the SW confirmed the documents were not available.
Failure to document grievance resolution communication: A resident’s grievance form was left incomplete, with blank sections for the resolution communicated to, copy offered, and response to investigation. Although the SSD stated he had communicated the findings to the resident, the record did not show that the resolution was documented as communicated, and the facility’s grievance policy required the resident or responsible party to be notified once the resolution was completed.
Psychotropic medication monitoring and PRN evaluation deficiencies were identified for two residents. One resident receiving duloxetine for depression did not have a behavior monitoring order, despite the DON stating psych meds require behavior monitoring. Another resident with anxiety received scheduled lorazepam plus repeated PRN lorazepam orders, but the record lacked documentation of provider or psychiatry evaluation before the PRN orders, and one nurse-entered PRN order was not verified by a provider until several days later.
Failure to provide written hospital transfer and bed-hold notices for two residents. The facility did not document written notice to the resident and/or representative when a resident was transferred to the hospital after an alleged assault with injury, and another resident’s record showed no written notice of hospitalization to the resident or family. Staff reported sending clinical transfer paperwork and giving verbal notice, while the DON stated the facility did not have a bed-hold policy and was unsure about written copies.
MDS assessments were not accurately coded for two residents. One resident with bipolar disorder had the diagnosis omitted from a later MDS despite being documented since admission, and the DON confirmed it should have been listed as an active dx. Another resident with schizoaffective disorder and a newly diagnosed visually significant cataract also had those diagnoses omitted from Section I of the MDS; the PNP and DON acknowledged the omissions.
Failure to follow PASARR Level II recommendations and timely refer for psych review. A resident admitted with paranoid personality disorder and delusional disorders had a PASARR II recommending outpatient psychiatric care with an individualized treatment plan, but psych consults were delayed and the resident was not seen by psych until well after admission. The record also showed a later during-stay dx of adjustment disorder with mixed anxiety and depressed mood, while the RNH administrator stated there was no PASARR policy and the SSD could not find documentation that the resident’s records were sent to AERS after the new mental health dx was identified.
A facility failed to ensure PASARR screening was completed prior to or upon admission for two residents. One resident had no completed PASARR on file at admission, and the Social Worker confirmed the missing documentation. For another resident, staff searched the electronic record and hard chart but could not locate a PASARR, and the Social Worker was unsure whether one had been completed.
Missing Baseline Care Plan and Medication List: A resident’s BLCP, including a current med list, was not found in the medical record, and there was no evidence it had been provided to the resident and/or RP. The SSD described a process for completing the BLCP within 48 to 72 hours and giving a copy to the resident or RP, but could not produce one for the resident when requested.
The facility failed to develop and implement person-centered care plans for residents with UTI and pneumonia and failed to ensure care plan interventions were carried out for a resident with depression, anxiety, and schizoaffective disorder. One resident had a UTI diagnosis and antibiotic treatment, another had pneumonia and antibiotic treatment, and a third resident’s care plan required monitoring specific behaviors, but the TAR listed different behaviors instead of the care plan items.
Delayed Incontinence Care: A resident who required incontinence assistance was not changed for over 5.5 hours, despite staff stating briefs should be checked and changed every 2 hours or sooner if needed. The resident reported this was typical on the day shift, and an RN confirmed the delay after finding the resident had remained wet since early morning while staff were busy with breakfast and feeding.
A resident missed multiple specialty appointments after the facility failed to properly coordinate transportation and follow through on cancelled visits, including ENT and vascular appointments that were documented as missed or cancelled without the office cancelling them. During a medication pass, an LPN prepared Enulose from a container labeled for another resident and attempted to give it to the resident, despite staff confirming the medication was not floor stock and should not be substituted from another resident’s supply.
Failure to provide ordered vision assistive devices. A resident stated he/she was fitted for glasses but never received them, and no glasses were observed at bedside. Records showed an in-house eye visit for frame measurement, a later note indicating mild to moderate cataract with observation preferred, and a nursing entry stating the resident wore glasses. Staff and the DON could not provide documentation showing the resident refused glasses or that the facility had the ophthalmology recommendations or plan for the resident's vision care.
Failure to Monitor and Change Colostomy Bag as Needed: A resident with a colostomy reported that staff checked the bag no more than once per shift. The resident stated the bag exploded and was not changed for several hours, leaving feces on the resident’s body, pants, and shoes. An PT who saw the resident before noon said she had to put the resident’s pants on and confirmed the resident had a history of an open or overflowing colostomy bag, including times with no bag on at all.
Failure to Timely Address Significant Weight Loss: Two residents had significant, documented weight loss that was not addressed in a timely manner. One resident had major weight loss after hospitalizations, with no documented assessment or intervention after the first loss and no prompt follow-up weight check after the second. Another resident had a 5.5% weight loss in one week, but the MD progress note did not address it and the dietitian note was delayed. The DON and dietitian validated the concerns.
Respiratory Care Deficiency: Oxygen Order, Labeling, and Flow Rate Errors. Staff failed to document the indication for a resident’s continuous O2 order, failed to label the oxygen tubing, and administered O2 at 1.5 L/min instead of the ordered 2 L/min. An LPN confirmed the resident needed O2 for COPD but said that reason was not included in the order, and the DON validated the concerns.
Food was not consistently served at proper temperatures. Several residents reported that meals were often cold and that microwaves were not allowed. During tray observation, hot items such as lasagna and broccoli were below the expected temperature, and milk was above the expected cold temperature. The Dietary Director acknowledged the temperature issues and said returned trays were not reheated but replaced with a new plate of food.
A facility failed to keep resident charts accurate and failed to document medication indications correctly. Another resident’s face sheet and discharge summary were found in a resident’s paper chart, and staff confirmed the records belonged to someone else. In addition, Seroquel orders for residents were indicated for schizophrenia even though the diagnosis was not listed or the resident had bipolar disorder instead; the DON and NP acknowledged the mismatch and referenced prior psych history and discharge paperwork.
Antibiotic stewardship monitoring was incomplete because the facility’s log did not consistently document antibiotic duration or organism identification. In addition, a resident receiving daily Cephalexin prophylaxis for UTI was started on Bactrim for a new UTI before the urine culture results were reported, and the DON confirmed there was no provider documentation justifying the order before the lab report.
The facility failed to document COVID-19 vaccine education for a resident and failed to maintain vaccination status records for four newly hired staff members. A resident admitted in October 2025 had no COVID-19 vaccination record or evidence of vaccine education in the chart, and four staff health files lacked COVID-19 vaccination documentation. The DON validated the missing documentation and stated that resident immunization status is reviewed on admission and staff vaccination status is reviewed at hire.
Inaccessible Call Bell: A resident’s call bell was observed on the floor and behind the bedside table/nightstand during the surveyor’s tour, making it inaccessible and not within reach. An RN confirmed that all residents should have an accessible call bell and agreed this one was not accessible.
Incomplete and Late Posting of Required Staffing Information: Surveyors found that daily staffing schedules lacked required details, including the facility name, resident census, and the total number and actual hours worked by RNs, LPNs/LVNs, and CNAs. The posted staffing information was also not updated by the beginning of the shift, and the DON, NHA, and RA confirmed the missing information and late posting.
The facility failed to report abuse and neglect incidents within the required timeframe. A resident with dementia was found with a fracture, but local law enforcement was not notified promptly. Another resident's incident was reported late to the state agency. Additionally, a resident with severe cognitive impairment eloped, and an abuse allegation was reported late to OHCQ. These issues were discussed with the facility's administrative team.
The facility failed to adhere to professional standards for food safety and sanitation, as observed during a recertification survey. Expired food items were found, and staff were not wearing required hairnets or beard restraints. Additionally, the test strips used for evaluating dishwasher sanitation were expired. These issues were confirmed by the Dietary Manager and discussed with the administration team.
The facility failed to maintain accurate medical records, complete an abuse investigation, and provide access to closed records. A resident's care plan inaccurately listed them as at risk for wandering, and an abuse allegation lacked proper documentation. Additionally, staff improperly signed off on care, leading to record inaccuracies.
The facility failed to maintain a working call bell system, affecting a resident and two rooms. During a survey, call lights were observed going off, and the call light monitor showed a system failure for two rooms. A resident's call bell was also found non-functional. The Regional Administrator was informed of these issues.
The facility failed to post staffing information in accessible locations on the Watersedge and Sudbrook units. Surveyors noted the absence of posted information on multiple occasions, and staff interviews revealed that the information was kept in a binder rather than being publicly displayed. Despite staff familiarity with their schedules, the requirement to post staffing information was not met, and the administration was informed of these deficiencies.
The facility's QAPI program was found ineffective during a survey, revealing deficiencies such as failure to provide pain medication to a resident with a suspected fracture, inadequate supervision of residents with wandering histories, and issues with a malfunctioning call bell system. Additionally, a staff member was terminated for not following ADL protocols, and the DON failed to document QA meetings and improvement plans for identified concerns.
The facility failed to ensure the QAA committee met quarterly to address concerns and evaluate action plans. A review of QAPI meeting attendance sheets revealed missing records for several months. The DON acknowledged the failure to meet monthly and quarterly standards from July to November 2023. This issue was discussed with the Administration team.
The facility failed to maintain resident dignity and respect, as observed during a survey. A resident with blindness and dementia had urinals left on the floor, and staff were seen using cell phones while assisting two residents with meals. These actions indicate a lack of respect and dignity in resident care.
A resident was neglected when a GNA failed to assist with ADLs, leaving the resident's dinner tray out of reach. This action resulted in the resident being unable to access their meal and receive necessary assistance, as required.
A facility failed to thoroughly investigate an abuse allegation involving a resident with a fracture of the right tibia and fibula. The DON described the investigation process, which includes notifying law enforcement if the injury is considered abuse. However, law enforcement was not notified, and the facility could not provide documentation of interviews due to a change in ownership, leaving the current administration without necessary records.
A facility failed to provide a resident and their representative with a complete summary of the initial baseline care plan, which should have included goals, medications, dietary instructions, and services. The absence of documentation was confirmed by the DON during an interview.
A facility failed to develop a care plan for a resident at risk for wandering, diagnosed with vascular dementia. The resident was found outside the building, and although a wandering assessment indicated a risk, no care plan was in place until after the incident. The DON acknowledged the oversight during the survey.
A resident with a swollen wrist and confirmed fracture did not receive documented pain medication for nearly a day, despite having a standing order. The facility staff failed to document medication administration immediately, leading to an incomplete medical record. The DON was informed, but no additional documentation was provided.
A resident with pressure ulcers did not receive updated wound care as prescribed by the wound consultant. Despite changes in treatment orders, nursing staff continued outdated practices, applying Santyl and medihoney to the sacrum and skin prep to the heels, contrary to the consultant's instructions. The wound consultant was unaware of these discrepancies until informed by a surveyor.
Two residents at risk for wandering eloped from the facility due to inadequate supervision. One resident, with aphasia and hemiplegia, was found outside in the parking lot, while another, with Alzheimer's, was found at the ambulance entrance. Both incidents occurred due to a lack of proper care plans and supervision, highlighting deficiencies in the facility's safety measures.
A deficiency occurred when a pharmacist's recommendation for a TSH and T4 lab test for a resident was not addressed by the physician or medical director. The DON confirmed the lack of follow-up, and it was later found that the recommendation was made in error, with only a CBC being correctly ordered and drawn.
The facility failed to ensure that all staff participated in mandatory abuse training, as evidenced by a GNA who did not complete the required training. Despite the facility's policy requiring annual training, a review of employee files and training records showed no documentation of the GNA's participation. Interviews with staff confirmed the requirement for abuse training, yet the GNA's file lacked evidence of completion.
The facility failed to document that a GNA received required abuse training within the past year, as discovered during a recertification survey. This was highlighted by an incident of alleged verbal abuse involving a resident, with the last recorded training for the GNA being over a year prior. The facility, under new ownership, could not provide the necessary documentation due to lack of access to previous records.
A resident with severe cognitive impairment and a suspected fracture did not receive pain medication despite exhibiting signs of pain and having a PRN order for Tylenol. An LPN delayed the x-ray order, and the resident was later found to have leg fractures. EMS was called, and the resident was transferred to the hospital. The DON confirmed that pain medication should have been given.
A resident reported not receiving menus or food choices, leading to dissatisfaction with meals. Staff interviews confirmed that the facility failed to provide accurate menus and alternative options, with discrepancies in the menu cycle being followed. The issue was acknowledged by the Dietary Manager and Regional Director of Nursing.
Allergy to Acetaminophen Overlooked When Prescribing Pain Medication
Penalty
Summary
The deficiency involves a resident with multiple diagnoses, including cerebral infarction with resulting hemiplegia and hemiparesis, conversion disorder with seizures or convulsions, anxiety disorder, borderline personality disorder, and vascular dementia, who was severely cognitively impaired and dependent on staff for all ADLs. Clinical record review showed that this resident’s allergy to acetaminophen was documented in progress notes on several occasions shortly after admission. Despite this, a physician progress note later documented the same allergy list, including acetaminophen and eggs, and in the same entry ordered scheduled Tylenol (acetaminophen) for pain management, along with continuation of tramadol and an increased dose frequency of gabapentin. The resident’s daughter, who was the MPOA, reported that the facility’s medical director prescribed acetaminophen despite the known allergy. During interviews, the medical director stated that it was his practice to complete a chart review and obtain and review a resident’s history before assessment, but on the date in question he was covering for another physician, the resident was experiencing discomfort, and he prescribed acetaminophen. He acknowledged that he missed the documented allergy and stated that nursing staff and the pharmacy also did not identify the error. Facility leadership confirmed that the medication error was not identified and documented at the time it occurred and that the issue only came to their attention months later when the resident’s daughter formally reported the incident.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program in several areas. A GNA was observed clipping his fingernails in the Sudbrook unit dining room while residents were seated in the area participating in activities, and fingernail clippings were falling onto the floor. When interviewed, the GNA stated he had taken his 15-minute break, and the RNHA and NHA later confirmed that staff personal hygiene tasks were not expected to be performed in a public space such as the dining room. The facility also failed to prevent oxygen tubing from resting on the floor for a resident receiving 1.5L of oxygen via nasal cannula; the tubing was observed touching the floor on two separate occasions, and an LPN and the DON confirmed that the tubing should not touch the floor for infection control purposes. The facility also had infection control policies titled Infection Control, Isolation Precautions, Antibiotic Stewardship, Pneumococcal Vaccine, and Influenza Vaccine that did not contain review or revision dates, and the DON, who also served as the Infection Preventionist, stated he had not reviewed or revised the policies since starting in December 2024. In addition, a resident under Transmission-Based Precautions had MRSA identified by bone biopsy on re-admission, and the hospital discharge summary stated to follow up with infectious disease within 1 week. Although the facility initiated contact isolation, there was no documentation of follow-up assessments or care related to the MRSA, and the record contained no Infectious Disease consultation, CT scan, or follow-up evaluation by the attending physician.
Missing Annual GNA Performance Reviews
Penalty
Summary
The facility failed to complete required annual performance reviews for Geriatric Nursing Assistants (GNAs) and failed to keep those reviews in the employees’ files. Review of employee records and staff interviews showed that 8 of 10 GNA files reviewed did not contain a 2025 performance review, including GNA #36, #40, #41, #33, #42, #34, #37, and #38. The report states that performance reviews are to be completed at least every 12 months to identify specific in-service education based on the outcome of the individual review. The surveyor requested complete employee files for GNA #18 and GNA #20, and the NHA stated the files provided were complete. Review of both files showed no 2025 performance review. The DON initially stated he had not personally completed one and was unsure whether any staff had completed a GNA performance review in the building. Later, after repeated requests, the DON provided copies of performance reviews for GNA #18 and GNA #20, but they were not found in the employees’ files. The DON and HRD gave conflicting accounts of where the reviews were located, with one stating they were in the HR office and the other stating they were in the previous DON’s office. Additional file reviews confirmed the same issue for the other GNAs reviewed: their files contained older performance reviews from prior years, but no 2025 review was present. Staff interviews also showed uncertainty about who conducted the reviews and whether they had been completed. Two staff members stated they had not had a performance evaluation since the facility changed ownership, and the DON and RA gave differing statements about who was responsible for conducting GNA performance reviews and where the records were kept.
Incomplete Monthly MRRs and Missed Medication Documentation Review
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed monthly Medication Regimen Reviews (MRRs) and failed to maintain policies and procedures that addressed the time frames for the MRR process and the steps to follow when an irregularity required immediate action. During interviews, the DON stated the facility’s process was for the pharmacist’s recommendations to be printed, handed to providers, and then returned for filing, but also acknowledged that the written policies did not technically include time frames for each step. The DON further stated the facility expected providers to respond before the next monthly review, but the documentation reviewed by surveyors did not consistently show completed reviews or timely provider responses. For Resident #7, surveyors requested MRR documentation covering multiple months and found that the facility could not initially produce the requested completed reviews. The records that were eventually reviewed showed numerous pharmacist recommendations that were not completed by a provider, including months with no checked response boxes, no signatures, or no dates. The surveyor also observed that the MRRs were not being completed monthly, as one review occurred on 6/4/25 and the next was not until 7/17/25, and another occurred on 8/10/25 with the next not until 9/28/25. The DON acknowledged that these were not monthly reviews. In addition, one pharmacist recommendation from 8/5/24 for levothyroxine noted that the last TSH was from 6/2023 and suggested checking a TSH with the next labs; the provider agreed and signed, but no evidence was provided that the lab was obtained before the next monthly review. For Resident #8, the pharmacist had previously identified that the indication for Seroquel needed review because it had been listed for Bipolar, and the attending physician accepted that recommendation and changed the order indication from Schizophrenia to Bipolar. However, later MRRs failed to identify that the Seroquel indication again became inaccurately documented as Schizophrenia from 7/08/25 to 9/23/25. The DON confirmed that the resident’s Seroquel was being used for Bipolar Disorder and validated the concern that the pharmacist did not identify the inaccurate indication during the later monthly reviews.
Unsecured and Improperly Stored/Labeled Medications
Penalty
Summary
The facility failed to ensure medications were secured when a surveyor observed unsecured medications at the bedside and on the floor. In one room, a white tablet was observed on the floor of a resident’s room, and the resident stated the tablet had been dropped while taking medication and that the nurse did not respond when called. In another room across the hall, a nurse retrieved a small white medicine cup from the bedside table that contained one capsule after stating she had administered four capsules earlier and had intended to return later because the resident took a long time to take medications. The nurse acknowledged that leaving medications at the bedside was not consistent with policy and stated she had made a mistake. The facility also failed to store and label medications in accordance with accepted professional principles during a medication storage review of carts and nursing supply rooms. Surveyors observed open bottles of floor-stock Sennoside and Acetaminophen without open dates, expired IV fluids in a nursing supply room, and needles stored outside their original packaging. On another medication cart, a container of Vitamin D tablets was unlabeled, and a bottle of liquid multivitamin iron supplement had an incomplete/open date with an illegible expiration date. The DON was present during the storage and labeling review and was made aware of the concerns at the conclusion of the task.
Kitchen Food Labeling and Dating Deficiency
Penalty
Summary
The facility failed to ensure that nourishment items in the kitchen were properly labeled, dated, and expired items were discarded. During an initial tour of the kitchen, the surveyor observed multiple food items with expired or incomplete labeling, including turkey with a use-by date of 11/20/25, jelly with a use-by date of 11/24, Woeber's Salad Style Mustard labeled 4/18, orange cheese with no use-by date, Chef's Wonder Instant Soup labeled 11/20/25, Cross Valley Farms Caseras with a use-by date of 11/12/25, and loose potatoes in a white plastic container with a use-by date of 11/30/25. The surveyor also observed loose lettuce, green bell peppers, and cabbage in white plastic containers with no labeling or dates present to indicate preparation or expiration dates. Additional items observed included a plastic container labeled Breadcrumbs Nov. 1, 2025 to Nov. 30, 2025 and a plastic container labeled Flour Nov. 1, 2025 to Nov. 30, 2025. In an interview, the Dietary Manager acknowledged the concerns and stated that it was everybody's responsibility to date items when they are opened and that he expected items to have the right label on each product. He also stated that the expectation was to have an open date and an expiration date, and he could not say that all kitchen staff had been trained on proper labeling. When asked whether lack of training could have contributed to the labeling problems, he acknowledged the concern.
Missing Required QAPI Meeting Attendance
Penalty
Summary
The facility failed to ensure key essential personnel were present during monthly Quality Assurance (QA) meetings, as shown by review of 11 monthly QA meeting attendance sheets during the recertification/complaint survey. Surveyors found that the Medical Director's signature was missing for January, April, June, July, and August 2025, and the Infection Preventionist's signature was missing for May 2025. During interviews, the DON stated that the facility administrator and himself were responsible for QAPI and explained that monthly QAPI meetings should include the Medical Director, Administrator, DON, Infection Preventionist, Social Worker, Therapy team, Activity Director, Dietitian, and Nursing Aides. In a follow-up interview with the NHA, DON, and Regional Administrator, the surveyor reviewed the QAPI attendance sheets and they verified the missing signatures, and the NHA validated the findings.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program. During the initial tour, a resident stated that mice were a big problem in the facility, pointed under a radiator where sticky mouse traps were observed, and reported seeing up to five mice at a time running across the floor, including mice with insulation from the walls on them. The resident also stated that a person who laid the traps said there was a hole in the wall and that mice could be heard in the walls. An outside agency staff member also expressed concern about an ongoing mice infestation and stated that mouse traps were all over the facility, with these concerns continuing for over 2 to 3 years. Facility staff stated that pest issues were addressed through Allstate service visits twice a week and that staff were instructed to place concerns in log binders at nurse stations, the front desk, and the kitchen. Review of Allstate service inspection reports and pest management logs documented repeated mouse activity in multiple areas, including dry storage, resident rooms, dining areas, locker rooms, common areas, nurse stations, and under heaters, as well as prior roach activity in the movie theater room and locker rooms. When the NHA was asked about the mouse issue and what additional interventions had been put in place, he stated he was not aware of the issue and that Allstate handled it.
Late Submission of Abuse Investigation Results to OHCQ
Penalty
Summary
The facility failed to report the results of an investigation into an alleged resident-to-resident altercation that resulted in serious bodily injury to the Office of Health Care Quality (OHCQ) within the required 5 working days. Specifically, a resident reported being punched in the face and having their wheelchair overturned by another resident. Following the incident, the affected resident requested hospital evaluation and was found to have an acute fracture of the 5th metatarsal in the left foot. The initial incident report was submitted to OHCQ as required, but the follow-up investigation report was not submitted until more than 5 working days after the incident was identified. During the survey, discrepancies were found in the facility's documentation regarding the submission date of the follow-up report. Two versions of the follow-up investigation report were provided, each with different submission dates and times, and the facility was unable to provide an email confirmation of the submission as requested by the surveyor. Verification with OHCQ confirmed that the follow-up report was received late, beyond the regulatory timeframe. The Nursing Home Administrator and previous DON could not explain the inconsistencies in the documentation.
Failure to Document Advance Directive and Capacity Evaluation
Penalty
Summary
Advance directives were not discussed and documented for a resident whose decision-making capacity was not clearly established in the medical record. During screening, the surveyor attempted to interview the resident, but the resident was mumbling and the surveyor could not determine the resident’s current cognitive status. Review of the medical record showed that a MOLST form had been completed by the resident as full code on admission, but there was no Advance Directive or Physician’s Certificate of Incapacity documented in the record. The Social Worker stated that facility staff assess all residents’ advance directive status on admission by asking for existing documents or helping residents complete one. He also confirmed that, regardless of cognitive level, the facility should evaluate capacity using two physicians. In a later interview, the Social Worker verified that the facility did not have the resident’s Advance Directive or incapacity evaluations in the medical record.
Failure to Document Grievance Resolution Communication
Penalty
Summary
The facility failed to follow its grievance process and failed to document that the resolution of a resident grievance was communicated to the resident. During the survey, the Nursing Home Administrator and Regional Nursing Home Administrator identified the Social Services Director as the grievance official, and the Social Services Director stated that grievance forms are posted throughout the building, completed forms are forwarded to him, and he addresses the issue with the involved department and shares the findings. However, review of the grievance form for one resident dated 11/15/24 showed that the bottom portion of the form was incomplete, with blank lines for "Resolution communicated to," "Copy Offered," and "Response to Investigation." The facility's grievance policy stated that once the resolution is completed, the responsible party/resident will be notified. When the Social Services Director was later shown the grievance form, he stated that the resolution had been communicated to the resident because he communicated it to her, but he acknowledged that the form did not show where that communication was documented. The surveyor identified this as a concern, and the facility failed to demonstrate on the grievance record that the resident had been notified of the resolution.
Psychotropic Medication Monitoring and PRN Evaluation Deficiencies
Penalty
Summary
The facility failed to ensure monitoring of a psychotropic medication for one resident and failed to ensure another resident’s medication regimen was free from unnecessary medications. For one resident diagnosed with depression, the record showed an order for duloxetine 20 mg twice daily, but review of the chart did not reveal a behavior monitoring order. During interviews, the DON stated that psychotropic medications require behavior monitoring and that such monitoring should appear on the TAR, but when the resident’s orders were reviewed together, the DON acknowledged that no behavior monitoring order was present. The only related order found was for monitoring and reporting tremors, dizziness, and other side effects every 12 hours for drug side effects monitoring. For another resident admitted with anxiety, the record showed scheduled lorazepam twice daily along with multiple PRN lorazepam orders over several weeks. Review of the medical record found no documentation of an evaluation by the attending physician or psychiatry services before the PRN orders placed on 10/17/25 and 11/05/25. Although the attending physician documented an increase in the routine lorazepam dose at one point, there was no documented assessment or evaluation regarding the PRN dosage. The DON stated the facility had a psychiatric NP who assessed residents weekly and that PRN psychotropic orders were limited to 14 days and required re-evaluation, but the surveyor found that one PRN order entered by a nurse was not verified by a provider until several days later. The DON later validated the findings.
Failure to Provide Written Hospital Transfer and Bed-Hold Notices
Penalty
Summary
Facility staff failed to provide written notice to residents and/or their resident representatives when residents were transferred to the hospital, including written notice that specified the duration of the bed-hold policy and the resident’s return to the facility. This was identified for 2 residents reviewed during the recertification/complaint survey. For Resident #128, the clinical record showed the resident was sent to the hospital on 9/20/2025 after an alleged assault with injury, but there was no documented evidence that the facility provided written notice at the time of transfer. For Resident #89, the clinical record showed the resident was sent to the hospital on [DATE], but there was no evidence that the resident and/or family received written notice of the hospitalization. During interview, staff stated that the nurse sends clinical transfer documents such as vital signs, a written summary, face sheet, MOLST, medication reconciliation, recent labs, history and physical, and SBAR, but was unaware whether bed-hold policy information was included. The DON stated the facility did not have a bed-hold policy and said residents had no issues returning to the facility. In a separate interview, the DON stated that residents and families were told verbally when a resident went to the hospital, but acknowledged uncertainty about whether written copies were available.
MDS Assessments Failed to Include Active Diagnoses
Penalty
Summary
The facility failed to accurately code MDS assessments for two residents during the recertification/complaint survey. For one resident admitted in May 2025 with a diagnosis of bipolar disorder, the initial MDS documented bipolar disorder as an active diagnosis, but a subsequent MDS did not code bipolar disorder under active diagnoses. During interview, the DON reviewed the MDS records and confirmed that the resident had been diagnosed with bipolar disorder since admission and agreed it should have been documented as an active diagnosis. For another resident admitted with schizoaffective disorder, the clinical record showed the diagnosis, but the MDS Section I did not include schizoaffective disorder among the listed diagnoses. The Psychiatric Nurse Practitioner stated she was aware of the diagnosis and said olanzapine was ordered to treat schizoaffective disorder as well as bipolar disorder, but she was not sure why the diagnosis was omitted and attributed it to oversight. In the same resident’s record, a vision consult completed on 5/29/25 identified a newly diagnosed visually significant cataract with a plan to refer for cataract removal to improve vision, yet the annual MDS did not mention cataracts under Section I. The DON reviewed the consult and the MDS and acknowledged that the cataract diagnosis was not listed.
Failure to Follow PASARR Level II Recommendations and Refer for Psychiatric Review
Penalty
Summary
The facility failed to incorporate recommendations from a PASARR Level II determination and evaluation report into the resident’s care and failed to refer the resident to the appropriate state-designated authority when newly evident or possible serious mental disorders were identified. Resident #83 was admitted with diagnoses including paranoid personality disorder and delusional disorders, and the PASARR Level II report approved admission to a Maryland nursing facility with a recommendation for psychiatric care (outpatient) with an individualized treatment plan. Record review showed that on 11/25/24 the nurse practitioner documented that the resident was alert and oriented x 3 but had tangential speech and grandiose delusions and requested a psychiatry consult for capacity evaluation. Additional progress notes on 12/2/24 and 12/6/24 documented chronic delusions and paranoia with a psych consult requested, and on 12/9/24 the resident continued to have paranoia and delusions with another psych consult request. Nursing documentation on 12/13/24 noted the resident was delusional at times but had no aggression. A later nursing note on 12/31/24 documented consent obtained from the niece and a referral faxed to the facility’s psychiatry provider. The resident was not seen by a psychiatric provider until 42 days after admission and 39 days after the nurse practitioner’s request for psych evaluation. The record also showed a new during-stay diagnosis of adjustment disorder with mixed anxiety and depressed mood dated 4/12/25, approximately 5 months after admission. During interviews, the Regional Nursing Home Administrator stated there was no PASARR policy and that the facility just followed the regulations. The Social Services Director stated the expectation was that psych would follow up upon admission, acknowledged that the resident was first seen by psych almost 2 months after admission, and stated he was not seeing documentation that the resident’s records were sent to AERS after the later diagnosis was identified.
Failure to Complete PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that PASARR screening was completed prior to or upon admission for two residents reviewed during the survey. For Resident #13, a medical record review on 12/02/25 showed that there was no completed PASARR at admission. During an interview on 12/03/25, the Social Worker confirmed that the facility should review a resident’s PASARR status upon admission, and the surveyor requested the documentation. On 12/08/25, the Social Worker confirmed that the facility did not have Resident #13’s completed PASARR on file. For Resident #5, a review of the clinical record on 12/3/25 showed that a PASARR was not in the chart. During an interview on 12/5/25, the first-floor unit manager checked both the electronic clinical record and the hard chart but could not find a PASARR. She stated she would need to call the Social Worker. Later that day, the Unit Manager reported that she still could not locate a PASARR, the Social Worker was not sure if one had been done, and the Medical Records coordinator was asked to search. The PASARR for Resident #5 was not presented to the team prior to exit.
Missing Baseline Care Plan and Medication List
Penalty
Summary
The facility failed to ensure that a written summary of the baseline care plan, including a current medication list, was provided to the resident and/or resident representative and documented in the medical record for Resident #98. The resident was admitted to the facility on the reported admission date, and review of the medical record showed no baseline care plan for the resident. During an interview, the Social Services Director described the facility’s baseline care plan process as involving the SSD, activities staff, and nursing meeting with the resident and trying to complete it within 48 to 72 hours, with the resident and/or representative signing it and receiving a copy. He stated that he was responsible for obtaining signatures and providing copies, and that if family was not available in person, the plan would be reviewed by phone and sent by email. When the surveyor requested Resident #98’s baseline care plan and evidence that it had been provided to the resident and/or representative, the SSD stated that he did not see one for the resident.
Failure to Develop and Implement Care Plans for UTI, Pneumonia, and Behavioral Monitoring
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for residents with identified clinical needs and failed to ensure that interventions agreed to in a care plan were initiated. For one resident, records showed a positive urine culture for UTI and an order for Ciprofloxacin for 5 days, and later the resident reported clamminess and slight pain with urination and requested testing for UTI; however, the care plan contained no documented evidence addressing prevention or treatment related to UTIs. The DON stated that the care plan should have been updated to reflect the UTI diagnosis and acknowledged the concern. For another resident, the medical record showed a diagnosis of pneumonia and an order for Amoxicillin for pneumonia and sinus infection for 7 days, but the care plan contained no documented evidence addressing prevention or treatment interventions for pneumonia. In a third resident's record, the care plan directed staff to monitor and record specific target behaviors related to depression, anxiety, and schizoaffective disorder, but the TAR listed different behaviors to monitor, including worrying, delusions, tearfulness, emotional distress, hallucinations, crying, and sadness, and did not match the behaviors identified in the care plan.
Delayed Incontinence Care
Penalty
Summary
The facility failed to ensure that a dependent resident’s personal hygiene needs were met by providing timely incontinence care. Resident #9 told the surveyor that he/she had not been changed since the previous shift at about 6:00 AM and stated that it was the norm to not be changed until after 11:00 AM during the day shift. The resident explained that after being changed early in the morning, he/she would remain wet while staff were serving breakfast and feeding residents, and would have to ask to be changed later in the morning in order to get ready for therapy. During the survey, RN #9 stated that residents who wear incontinence briefs should be changed every 2 hours or sooner if needed, and acknowledged that not being changed frequently enough could lead to skin issues such as skin breakdown and urinary tract infections. The surveyor and RN #9 found that Resident #9 had not been changed since around 6:00 AM, more than 5.5 hours earlier, and RN #9 confirmed this was a concern. RN #9 later reported that GNA #38 said she had seen the surveyor and that was why she did not come in and change the resident. GNA #38 stated that residents are checked and changed every 2 hours unless they say they are not wet, and the Unit Manager stated the expectation was to check every 2 hours, or about 5 to 6 times in a 12-hour shift.
Missed Medical Appointments and Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident received treatment and care by assisting with transportation to medical appointments. Resident #9 reported that the facility would not complete the paperwork needed to renew mobility transportation and told the resident that both transportation options could not be used, which resulted in missed appointments. The resident stated that the missed visits included appointments with a vascular doctor and an ENT doctor, and that a third appointment was cancelled by the facility and never rescheduled. Interview and record review showed that the resident had an ENT appointment on 6/2/2025 that was cancelled and later documentation noted the appointment was to be rescheduled. A progress note also stated the resident continued to report right neck and ear pain after the ENT appointment was cancelled for an unknown reason. The resident’s chart further showed a vascular appointment was missed on 9/24/2025, and the resident was upset about missing it; that appointment was later rescheduled and attended on 10/12/2025. The resident’s otolaryngologist office confirmed that two ENT appointments, one on 6/2/2025 and a rescheduled visit on 6/18/2025, were missed and that the office did not cancel them. The facility also failed to meet professional standards of practice during medication administration. During observation of the medication pass, an LPN prepared Enulose solution for one resident but poured it from a container labeled with another resident’s name. The nurse attempted to administer the medication, but the resident refused. Interviews with nursing staff confirmed that another resident’s medication would not be used as a substitute and that Enulose/Lactulose was not usually floor stock but was ordered for specific residents.
Failure to Provide Ordered Vision Assistive Devices
Penalty
Summary
The facility failed to ensure that Resident #9 received assistive devices to maintain vision abilities. During an interview, the resident stated that he/she had been fitted for glasses but never received them, and the resident was not observed with glasses at bedside. A progress note dated 7/29/2025 documented that the resident went to an in-house eye appointment, returned without glasses, and that the appointment was only for measuring the frame with no new appointment scheduled at that time. Record review also showed a 6/25/2025 visual acuity exam noting mild to moderate cataract with a plan that the resident preferred observation at that time. However, a later nursing quarterly charting entry stated that vision was adequate and that the resident wore glasses. Staff #12 stated she was not aware of the resident's vision concern and confirmed the resident did not have glasses. The DON stated that ophthalmology visits occurred twice yearly and that documentation was usually emailed to social work or nursing, but the surveyor could not locate documentation showing recommendations after the resident's eye visits or support that the resident refused glasses or that the facility provided the assistive devices.
Failure to Monitor and Change Colostomy Bag as Needed
Penalty
Summary
The facility failed to ensure appropriate colostomy care for Resident #2, who required monitoring and changing of the colostomy bag as needed. During interview, the resident stated that staff did not check the colostomy bag more than once per shift. The resident also reported that on 12/4/25 at about 10:30 AM the colostomy bag exploded and was not changed until 3:00 PM, leaving feces all over the resident’s body, pants, and shoes. A physical therapist who worked with the resident that day stated she saw the resident before noon, had to put the resident’s pants on, and confirmed that the resident had a history of an open or overflowing colostomy bag, including times when the resident did not have a bag on at all.
Failure to Timely Address Significant Weight Loss
Penalty
Summary
The facility failed to timely address significant weight loss for Resident #6. The resident’s documented weights showed an 18.6 lb. loss, or 9.1%, from 203 lb. on 5/01/25 to 184.4 lb. on 5/30/25. The resident had been transferred to the hospital on 5/21/25 and later readmitted, but there was no assessment or documented intervention in the chart related to the significant weight change, and the first dietitian note after readmission was not documented until 6/27/25. A second weight loss was documented on 8/05/25, when the resident weighed 175.4 lb., a 9.6 lb. loss, or 5.1%, from 7/03/25. This occurred after another hospitalization from 8/01/25 to 8/04/25, and there was no follow-up weight check until a month later. The dietitian stated the facility should have completed weekly re-checks for a month and documented assessment and interventions after identifying weight loss, and the DON validated the concern that the resident’s weight changes were not closely monitored and were not addressed in a timely manner. The facility also failed to timely address significant weight loss for Resident #13. The resident’s weights showed a drop from 95.5 lb. on 9/08/25 to 90.2 lb. on 9/16/25, a 5.5% loss in one week. A physician progress note was written on 9/18/25 without addressing the significant weight loss, and the dietitian did not document a progress note until 9/25/25, a week after the weight loss was first noted. The dietitian stated staff were made aware of residents’ weight loss through nursing weight documentation and weekly meetings, and verified that this resident’s significant weight loss was not addressed in a timely manner. The DON also validated the concern.
Respiratory Care Deficiency: Oxygen Order, Labeling, and Flow Rate Errors
Penalty
Summary
Facility staff failed to provide necessary respiratory care services for Resident #6, who had an order to receive oxygen at 2 L/min via nasal cannula continuously. During observation on 12/01/25, the resident was receiving oxygen at 1.5 L/minute through a nasal cannula, and the oxygen tubing was not labeled. A later observation on 12/05/25 again found the tubing unlabeled and the oxygen still being infused at 1.5 L/minute instead of the ordered 2 L/minute. Review of the medical record on 12/05/25 showed that the oxygen order did not include a documented indication for the therapy. During interview, an LPN stated that nurses are responsible for managing residents’ oxygen therapy, including setting the correct amount of oxygen, changing tubing weekly, and dating the label. The LPN stated the resident needed oxygen for COPD, but confirmed that this reason was not included in the oxygen order. The DON was informed of the findings and validated the concerns.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not consistently served at a palatable and safe temperature for residents. Based on resident interviews and observation of test trays, staff failed to ensure hot meals were served hot enough and that cold items were served at an appropriate temperature. Five residents in the survey sample were identified in connection with this concern, including residents who reported that the food was often cold and that they had requested microwaves, which administration said were against company policy. During a tray observation, two test trays were ordered from the kitchen and delivered to the unit at 12:30 PM. When the first tray was checked at 12:55 PM, the lasagna measured 128 F and the broccoli 118 F; the lemonade measured 54 F and the milk 53 F. When the tray was checked again at 1:17 PM, the lasagna measured 132 F, the broccoli 110 F, the lemonade 56 F, and the milk 54 F. The Dietary Director acknowledged that the temperatures were either too cold or too warm. He also stated that when residents returned trays for reheating, the kitchen did not reheat the food but scraped off the old food and replaced it with a new plate of food.
Medical records contained another resident’s documents and medication indications did not match diagnoses
Penalty
Summary
The facility failed to maintain medical records in the most accurate form for residents and failed to ensure that residents’ medication indications were documented. During review of one resident’s paper chart, another resident’s face sheet and discharge summary were found filed in the chart. When the Unit Manager was asked whose records they were, she identified them as belonging to another resident in a different room and stated they were not accurate records for the resident whose chart they were in. She acknowledged the concern and said she would move them to the correct chart. The facility also failed to document a diagnosis that matched the indication for Seroquel orders for two residents. One resident had Seroquel orders for schizophrenia, but review of the medical record did not reveal a schizophrenia diagnosis; the DON confirmed the diagnosis was not listed in PCC. Another resident had a diagnosis of bipolar disorder, not schizophrenia, yet the Seroquel order from July through September was indicated for schizophrenia. The DON verified that the order was incorrectly indicated for schizophrenia. In a separate review of another resident’s record, Seroquel orders for schizophrenia were present even though the diagnosis of schizophrenia was not listed in the diagnosis tab, and the NP stated the medication had been continued because the resident came to the facility on those medications and referenced prior psych history notes and a discharge summary noting a history of schizophrenia that the daughter could not confirm.
Antibiotic stewardship log incomplete and antibiotic started before culture results
Penalty
Summary
The facility failed to properly monitor and track antibiotic usage and resistance data. During review of the antibiotic stewardship log, the spreadsheet included resident names, room numbers, infection sites, and prescribing clinicians, but it did not consistently document the duration of antibiotic use, and several entries in the organism identified section were left blank or marked as no. The DON, who also served as the Infection Preventionist, reviewed the log with the surveyor and validated that the documentation did not address essential elements of antibiotic tracking. The deficiency also involved Resident #7, who had been receiving Cephalexin 250 mg daily for UTI prophylaxis since November 2023. A new order for Bactrim 800-160 mg for a UTI was started on 10/22/25 for three days, and the first dose was given that evening. The urine culture had been collected on 10/19/25, but the results were not reported until 10/23/25 at 10:08 AM, showing that the antibiotic was initiated before the infecting organism was identified by the laboratory. The DON stated the facility typically contacts the physician and starts antibiotics only after culture results are received, but later confirmed there was no provider documentation to justify the Bactrim order before the lab report.
Failure to Document COVID-19 Vaccine Education and Vaccination Status
Penalty
Summary
The facility failed to document education to residents regarding the benefits, risks, and potential side effects of the COVID-19 vaccine, and it also failed to maintain required documentation of staff COVID-19 vaccination status. During a review of five residents' immunization records, Resident #89, who had been admitted in October 2025, had no COVID-19 vaccination record on file. The medical record also contained no documentation showing that education about the COVID-19 vaccine had been provided to this resident. During review of newly hired employees' health records, four of five staff members, identified as Staff #19, #51, #52, and #53, lacked documentation of COVID-19 vaccination status in their employee health files. The DON, who also served as the Infection Preventionist, stated that resident immunization status is reviewed on admission using hospital records or ImmuNet and that the facility offers or provides vaccinations based on that information. The DON also stated that HR is responsible for reviewing new employees' vaccination status at the time of hire, followed by nursing staff review, and validated the lack of documentation identified by the surveyor.
Inaccessible Call Bell
Penalty
Summary
The facility failed to ensure residents had access to call bells, as evidenced by Resident #12 during the surveyor’s initial tour of the facility on 12/1/25. The resident’s call bell was observed to be inaccessible, lying on the floor and behind the resident’s bedside table, and a later dual observation confirmed that the call bell remained on the floor and behind the nightstand. During an interview, RN #49 stated that all residents should have an accessible call bell within reach, and when asked whether this call bell was accessible and within reach, she stated no. The surveyor identified this as a concern, and RN #49 acknowledged and confirmed understanding of the concern.
Incomplete and Late Posting of Required Staffing Information
Penalty
Summary
The facility failed to include all required staffing information on the daily nursing schedules and failed to post the staffing information at the beginning of each shift. During review of the schedules for 12/5/25 through 12/8/25, the documents did not include the facility name, resident census, or the total number and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift, including RNs, LPNs/LVNs, and CNAs. In interviews, the Staffing Coordinator/Medical Records staff confirmed that the schedules did not contain the facility name, resident census, or the required staffing totals and hours. Surveyor observation also found that the staffing information posted in the reception area was dated 12/9/25 rather than the current day, and the Nursing Home Administrator confirmed that it was not posted by the beginning of the 7:00 AM shift. The Regional Administrator acknowledged the posting was not updated, and the Nursing Home Administrator further confirmed that the current staffing information still lacked the required facility name, resident census, and staffing totals and actual hours for RNs, LPNs/LVNs, and CNAs.
Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report allegations of possible abuse and neglect to the appropriate authorities within the required timeframe. Specifically, the facility did not notify local law enforcement within two hours when a resident was identified with an injury of unknown source, a fracture, and failed to notify the state agency of potential abuse/neglect incidents within the same timeframe. This deficiency was evident in four out of nine residents reviewed during the recertification survey. Resident #255, who suffered from dementia and was unable to communicate, was found with swelling and bruising on the left lower leg. Despite the discovery of a fracture in the resident's tibia and fibula, the facility did not report the injury to local law enforcement. Additionally, the facility delayed reporting an incident involving Resident #69 to the state agency, submitting the report outside the required two-hour window. Further deficiencies were noted in the facility's handling of incidents involving Resident #54 and Resident #10. Resident #54, diagnosed with severe cognitive impairment, eloped from a locked unit, and the incident was reported to the state agency more than two hours after it occurred. Similarly, an allegation of sexual abuse involving Resident #10 was reported to the Office of Health Care Quality (OHCQ) after the required timeframe. These reporting delays were discussed with the facility's administrative team during the survey process.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies related to food storage, preparation, and sanitation during a recertification survey. Observations revealed that multiple food items, including canned goods and spice containers, lacked expiration dates, and several items were expired, such as thickened orange juice, hashbrown potatoes, and breakfast syrup. The Dietary Manager confirmed these findings and acknowledged that the items should have been labeled and expired items discarded. Additionally, staff were observed not adhering to sanitary conditions, as some were not wearing hairnets or beard restraints, and there was a lack of available hairnets at the kitchen entry. Further deficiencies were noted in the facility's testing supplies for kitchen sanitation. The Hydrion pH and sanitizer test strips used to evaluate the dishwasher's water sanitation concentration were found to be expired. These issues were discussed with the administration team, highlighting the facility's failure to maintain professional standards for food safety and sanitation.
Deficiencies in Medical Record Maintenance and Abuse Investigation
Penalty
Summary
The facility failed to accurately maintain medical records for a resident diagnosed with Alzheimer's Dementia. The resident's care plan indicated a risk for wandering and elopement, but the resident was not included on the facility's list of residents at risk for these behaviors. The Director of Nursing was unaware of this discrepancy until it was pointed out by the survey team, and it was later determined that the resident was not at risk, necessitating a correction to the care plan. The facility also failed to maintain a complete investigation file for an allegation of staff-to-resident abuse. A family member reported the abuse, but the facility's records only contained a police report case number, with no evidence of an internal investigation or reporting to the State Survey Agency or local Ombudsman. The Director of Nursing confirmed the lack of documentation and attributed it to a change in facility ownership, which resulted in missing records from the previous administration. Additionally, the facility was unable to provide surveyors with full access to closed electronic medical records for several residents discharged before the change in ownership. This lack of access prevented validation of care provided during specific shifts. Furthermore, there was an issue with staff members improperly signing off on care provided by others, as evidenced by a staff member charting care under another's login, leading to inaccuracies in the electronic medical records.
Failure to Maintain Working Call Bell System
Penalty
Summary
The facility failed to maintain a working call bell system, as observed during a survey. This deficiency was evident for one resident and two rooms out of the total surveyed. During observation rounds, call lights were noted to be going off at the Meadowood nursing station, and the call light monitor indicated a system failure for two specific rooms. Additionally, when a surveyor pressed the call bell for a resident, it did not function. The Regional Administrator was informed of these observations and acknowledged the issue.
Failure to Post Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted in a prominent place readily accessible to residents and visitors on two of its units, Watersedge and Sudbrook. On multiple occasions, surveyors observed that staffing information was not posted on these units. On April 4, 2024, staffing information was missing from both units, and staff interviews revealed a lack of awareness or adherence to the posting requirement. A Geriatric Nursing Assistant mentioned that despite the absence of posted information, staff were familiar with their schedules. However, this does not comply with the requirement to have staffing information visibly posted. Further observations on April 15 and April 16, 2024, confirmed the continued absence of posted staffing information on the Sudbrook and Watersedge units, respectively. Interviews with staff, including an LPN, indicated that the staffing information was kept in a binder inside the nurse's station rather than being posted publicly. On April 17, 2024, the surveyor again noted the absence of posted staffing information on the Watersedge unit. An LPN acknowledged the expectation to post staffing information at the beginning of each shift and identified the nurse responsible for the task, who admitted to not posting the information. The administration was informed of these concerns at the survey exit meeting on April 18, 2024.
Deficiencies in QAPI Program and Resident Care
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program, as evidenced by several deficiencies identified during a survey conducted from April 4, 2024, to April 18, 2024. These deficiencies included a failure to provide pain medication to a resident with a suspected fracture, inadequate supervision of residents with a history of wandering, a malfunctioning call bell system, and issues related to neglect and abuse allegations. Specifically, an employee was terminated in December 2023 for not following protocols for providing Activities of Daily Living (ADL) assistance to a resident. During an interview with the Director of Nursing (DON) on April 18, 2024, it was revealed that the facility's Quality Assurance (QA) committee meetings were not consistently documented, with missing records from July 2023 through November 2023. The DON admitted that the neglect and abuse incident involving a resident in December 2023 was not presented to the QA team in January 2024 as it should have been. Furthermore, the DON was unable to provide documentation of staff education or the facility's improvement plan following the incident, indicating a lack of effective processes to address and prevent recurrence of identified concerns.
QAA Committee Meeting Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly to address identified concerns and evaluate the effectiveness of their action plan. This deficiency was identified during a review of the facility's Quality Assurance Performance and Improvement (QAPI) meeting attendance sheets. The survey team requested copies of the QAPI monthly attendance sheets for January 2023 through February 2024, and the facility provided attendance sheets for only a few months, specifically December 2022, January 2023, February 2023, April 2023, June 2023, January 2024, and February 2024. During an interview, the Director of Nursing (DON) stated that the internal team members are expected to meet monthly, while vendors or outside resources are invited quarterly. However, the DON acknowledged that the facility did not meet the standard requirements for meeting monthly and quarterly for the months of July 2023 through November 2023. This issue was discussed with the Administration team at the time of the survey exit.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by several observations during the recertification survey. In one instance, a surveyor observed two urinals on the floor in a resident's room, one of which contained amber-colored fluid. The resident, who has diagnoses of blindness and dementia, was yelling for a nurse to assist with shaving. The resident stated that a nurse had placed the urinal on the floor, but the LPN interviewed was unaware of who was responsible. The urinals remained on the floor during a follow-up observation. In another instance, during a lunch meal observation, a staff member was seen standing over a resident while assisting with eating and simultaneously using a cell phone. The same staff member then assisted another resident with their meal, placing the cell phone on the table and interacting with it during the process. The charge nurse confirmed that the staff member was supposed to accompany another resident to an appointment but was instead asked to assist with the lunch meal. These actions demonstrate a lack of respect and dignity in the care provided to the residents.
Neglect of Resident Due to Inadequate ADL Assistance
Penalty
Summary
The facility failed to protect a resident from neglect when a Geriatric Nurse Assistant (GNA) did not assist the resident with Activities of Daily Living (ADL) as required. The incident involved a resident whose dinner tray was placed on a bedside table across the room, out of the resident's reach, by the GNA. This action prevented the resident from accessing their meal and receiving necessary assistance with ADLs, as requested by the resident. The deficiency was identified during a review of allegations of resident neglect.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an abuse allegation involving a resident with an injury of unknown origin. The incident involved a resident who was admitted with osteoarthritis and was found by a GNA with a swollen and outwardly rotated right lower leg. The resident was subsequently diagnosed with a fracture of the right tibia and fibula after being sent to the emergency room. The facility's investigation process, as described by the DON, includes reporting injuries of unknown origin, conducting staff and resident interviews, reviewing medical records, and notifying law enforcement if the injury is considered abuse. However, in this case, law enforcement was not notified, and the facility could not provide documentation of interviews with staff or the resident. The deficiency was further compounded by the transition in facility ownership, which occurred in January 2024. The current administration, including the Interim Administrator and the DON, reported that the previous owner did not leave a copy of the necessary documentation, such as staff and resident statements. This lack of documentation hindered the facility's ability to demonstrate a comprehensive investigation into the incident, as required by their procedures. The survey team discussed these concerns with the administration team at the time of exit.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a resident and their representative with a complete summary or written summary of the resident's initial baseline care plan. This deficiency was identified for one resident out of 53 reviewed during the survey. The baseline care plan should have included the resident's initial goals, a summary of medications and dietary instructions, services and treatments to be administered, and any updated information based on the comprehensive care plan. A review of the resident's medical record revealed no evidence or documentation that such a summary was provided. During an interview, the Director of Nursing confirmed the absence of documentation showing that the summary was given to the resident or their representative.
Failure to Develop Wandering Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to develop a care plan for a resident at risk for wandering, which was identified during a survey. The deficiency was evident for one resident who was reviewed for accidents. The resident, diagnosed with vascular dementia, was observed outside the building in the adjacent parking lot. Upon admission, a wandering assessment was conducted, indicating the resident was at risk to wander with a score of nine. However, no care plan was developed at that time to address the wandering risk. During an interview, the Director of Nursing (DON) was unable to provide documentation of a wandering care plan for the resident. Instead, an elopement care plan was initiated only after the resident was found outside the building. The DON acknowledged that a care plan should have been developed at the time of the initial wandering assessment upon the resident's admission. This oversight was discussed with the administration team at the time of the survey exit.
Failure to Document Medication Administration
Penalty
Summary
The facility nursing staff failed to adhere to professional standards of nursing practice by not documenting the administration of medications immediately after they were given. This deficiency was identified during a review of records and interviews with facility staff, specifically concerning a resident who was reviewed for abuse. The standard practice is to document medications immediately to ensure accurate records and prevent potential medication errors. However, for one resident, there was no documentation of pain medication administration for nearly an entire day, despite the resident experiencing significant pain and having a swollen wrist. The incident involved a resident who was noted to have a swollen right wrist and complained of pain. The resident was unable to explain the cause of the injury, and an x-ray confirmed a wrist fracture. Despite the resident's condition and the presence of a standing order for pain medication, there was no record of the medication being administered from the time the swelling was noted until the following day. The Director of Nursing was informed of the lack of documentation, but no additional records were provided to the survey team before the survey exit.
Failure to Update Wound Care Orders
Penalty
Summary
The facility nursing staff failed to update a resident's physician-prescribed wound care treatment orders after the facility wound consultant updated the treatment orders following weekly assessments. This deficiency was identified during a recertification survey for a resident who was admitted with a left heel deep tissue injury and bilateral sacrum wounds. The wound consultant provided specific instructions for wound care, including the application of betadine, medihoney, calcium alginate, and foam dressings, which were adjusted during subsequent assessments. Despite these updates, the nursing staff did not reflect these changes in the resident's medication and treatment orders. Instead, they continued to document the application of Santyl ointment and medihoney to the sacrum area and skin prep to the heels, which were not in line with the updated orders. The wound consultant was unaware of this discrepancy until informed by the nurse surveyor, indicating a communication breakdown and failure to adhere to updated treatment protocols.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for residents at risk for wandering, as evidenced by incidents involving two residents. Resident #73, who has aphasia and hemiplegia, was found outside the building in the parking lot. The resident's medical records indicated a risk for wandering, but there was no care plan in place at the time of the incident. The facility's investigation revealed that the resident attempted to follow family members when they were leaving, and staff had to assist the resident back inside. The facility had a new administration team, and the interim administrator was unable to provide additional information about the incident. Resident #54, diagnosed with Alzheimer's and severe cognitive impairment, eloped from the facility and was found outside at the ambulance entrance. The incident report was submitted late, and the police were not notified. The resident's care plan included interventions for wandering and elopement, but the facility failed to adequately supervise the resident, allowing them to follow a visitor off the unit. The facility's documentation was incomplete, lacking proof of staff training and related documents. Both incidents highlight the facility's failure to ensure the safety of residents at risk for wandering. The lack of proper care plans and supervision allowed these residents to elope, posing a significant risk to their safety. The facility's administrative team was informed of these deficiencies during the survey and exit interview.
Deficiency in Medication Regimen Review Process
Penalty
Summary
A deficiency was identified in the medication regimen review process for a resident in the facility. The pharmacist recommended drawing a Thyroid Stimulating Hormone (TSH) lab and a Thyroxine (T4) lab for the resident, which were ordered but not completed. The medical records lacked any action or note from the physician or medical director addressing the pharmacist's recommendation. During an interview, the Director of Nursing (DON) confirmed the absence of a physician's response or follow-up on the pharmacist's recommendation. Later, it was revealed that the pharmacist had made an error in the recommendation, noting that only a Complete Blood Count (CBC) was ordered and drawn, and the lab order for TSH and T4 was made in error.
Failure to Ensure Staff Participation in Mandatory Abuse Training
Penalty
Summary
The facility failed to ensure that all staff participated in mandatory abuse training, as evidenced by the case of a Geriatric Nursing Assistant (GNA) who did not complete the required training. The facility's policy mandates that all employees, including management and volunteers, receive training on abuse, neglect, mistreatment, or misappropriation of resident property upon orientation and annually. However, a review of employee files revealed that GNA #43, hired on June 23, 2023, had no documentation of participation in any abuse training. This was further confirmed by the absence of GNA #43's name on the Reporting Abuse Training Attendance Sheet from February 2024 and the lack of relevant training records in her Relias transcript. Interviews with facility staff, including Staff #9 and the Director of Nursing (DON), confirmed that all clinical staff are required to complete twelve mandatory competencies, including abuse training, before providing care to residents. Despite this requirement, GNA #43's employee file did not contain any evidence of completed abuse training. The administration team was informed of these concerns during the survey exit meeting.
Failure to Document Abuse Training for GNA
Penalty
Summary
The facility failed to provide documentation that a Geriatric Nursing Assistant (GNA) received mandatory abuse training at least once every 12 months, as required. This deficiency was identified during a recertification survey when reviewing the records of four GNA employees, specifically noting that Staff #25 had not received abuse training in the year prior to an alleged incident of verbal abuse involving a resident on 09/30/23. The last recorded training for Staff #25 was on 08/30/2022. Additionally, the facility was unable to locate the investigation documents related to the reported incident of verbal abuse, which was reported on 04/09/24. The Director of Nursing (DON) indicated that the current facility ownership, which took over on 01/01/24, did not have access to previous employee educational records, thus failing to provide evidence of compliance with training requirements.
Failure to Administer Pain Medication for Resident with Fracture
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who complained of pain and had a suspected fracture. The resident, who was admitted with a diagnosis of Dementia and had severe cognitive impairment, exhibited non-verbal signs of pain, including labored breathing, moaning, and facial grimacing. Despite having a PRN order for Tylenol, the resident did not receive any pain medication. An LPN documented the resident's condition and informed the physician, who ordered a stat x-ray. However, the x-ray order was delayed, and the resident was found to have fractures in the left leg. The resident's Medication Administration Record showed no administration of pain medication, even though the resident had a PRN order for Tylenol. EMS was called, and upon their assessment, the resident was found to have a chief complaint of left lower leg pain. The resident was then transferred to the hospital for further evaluation and treatment. Interviews with the Director of Nursing and Regional Director of Nursing confirmed that pain medication should have been administered. The LPN involved stated that it was her practice not to give oral medications when a patient is being transferred to the hospital.
Failure to Provide Accurate Menus and Food Choices
Penalty
Summary
The facility failed to provide a resident with an accurate menu of meals being served and did not offer food preference choices or alternative food options. During an interview, the resident expressed dissatisfaction, stating that they were not given menus and had no choices regarding their meals. The resident reported that if they did not like the food served, no alternatives were offered. This issue was confirmed during interviews with staff, who acknowledged that menus were supposed to be reviewed with residents and that alternative options should be available. Further investigation revealed discrepancies in the menu cycle being followed. The Dietary Manager and a Registered Nurse confirmed that the incorrect menu cycle was posted in the kitchen, and no menus were available in the resident's room for reference. The staff admitted that the menu cycle was not being updated as required, leading to confusion and lack of choice for the residents. These findings were brought to the attention of the Dietary Manager and the Regional Director of Nursing, who acknowledged the issues.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,756 citations issued within 25 miles in the last 12 months — including the 6 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 Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lochearn Nursing Home, Llc | 0.9 mi | ★★★★★ | 17 | 0 |
| King David Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 22 | 0 |
| Courtland, Llc | 1.7 mi | ★★★★★ | 6 | 0 |
| Autumn Lake Healthcare At Pikesville | 1.7 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Arlington West | 2.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Resorts Of Augsburg.
100% money-back within 48 hours.
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.