Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Rossville Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and documented exit-seeking/wandering behavior left the building without appropriate supervision after their elopement devices were repeatedly found off or removed. Records showed one resident had severe memory impairment and lacked capacity, while the other had severe dementia, poor hygiene, malnourishment, and wandering behavior. Staff interviews confirmed the residents exited through the front area, were mistaken for visitors, and were later found near a busy road, with one resident not properly dressed.
Missing Annual Nurse Aide Training Documentation: Documentation review of 5 of 5 GNA personnel files found no evidence that the required 12-hour annual competency training had been completed within the past 12 months for four GNAs, and one GNA only had proof of training from the prior year with no later record. The HR Mgr stated the facility had no documentation in the files or computer showing when the last training occurred, and the NHA said he could not find the records in the previous DON's office.
A privacy curtain was missing between two roommates during care. One resident stated the curtain had been absent for quite some time and wanted a curtain in place. The UM confirmed there was no curtain and that the resident was dependent for care per the MDS.
Failure to Maintain an Effective Grievance System: A resident who was dependent for care was found lying in a soiled, leaking diaper, and the RP later hand-delivered a written grievance to the Administrator. The grievance was not entered on the log, and the facility could not provide documentation that it was investigated or resolved.
Failure to Report Resident Elopement: Two residents identified as elopement risks with wanderguards left the facility and were later found on a sidewalk near a closed restaurant on a heavily traveled road. The evening shift supervisor confirmed the elopement, and the NHA and DON acknowledged the incident was not reported to OHCQ because they believed only abuse-related incidents required reporting.
MDS assessments were inaccurately coded for three residents. One resident’s MAR showed a B12 injection that was not captured on the MDS, another resident’s MDS failed to record a pre-admission fall and later falls after admission, and a third resident’s MDS incorrectly coded wander/elope alarm as no despite TARs showing a wanderguard bracelet worn each shift and the resident being listed as an elopement risk.
Facility staff failed to complete weekly wound assessments with measurements and failed to administer ordered wound treatments for a resident with PVD, a right 4th toe amputation wound, and a right heel wound. The wound NP documented missed evaluations when the resident was out of bed or at dialysis, and the next measured assessment was delayed. Review of the TARs and DON interview confirmed missed wound treatments for both wounds.
The facility failed to keep complete and accurate medical records for an elopement event and for RP notification of a change in condition. Two residents with wanderguards were found off the facility grounds, but the chart lacked documentation of the elopement, the residents’ injuries, and why the bracelets were not on. Staff said the incident was documented in “risk,” not the medical record, and an LPN did not know it also needed charting in the record. The facility also failed to document timely RP notification for a resident with dementia who developed a skin tear; the RP said updates were not consistently provided, and the DON confirmed the missing documentation.
Unsanitary food service on tray line. During the initial kitchen tour, a Dietary Supervisor and a Dietary aide were observed serving breakfast plates on the tray line without hair nets. The Dietary Supervisor confirmed both staff members were not wearing hair nets and acknowledged that staff handling food on the tray line should be wearing them.
The facility failed to ensure governing body oversight of its QAPI program and activities. The DON, who was also the QAPI contact person, said she was not sure who the governing bodies were and stated the governing body and/or executive leadership did not maintain QAPI oversight. The administrator said the facility did not have a governing body overseeing QAPI, then later identified Atlas as the governing body but stated QAPI activities were not reported to them.
Ineffective pest control program with gnats observed in the conference room and laundry area. Surveyors repeatedly saw flying gnats in the conference room throughout the survey and also observed gnats on the dirty side of the laundry area, including near the laundry chute and gray tub. A laundry staff member stated fruit flies were present most of the time and believed they came from dirty laundry, while the Managing Partner acknowledged the concern and said the facility had a monthly pest maintenance program.
Failure to notify physician and resident representative of a new pressure ulcer. A resident developed a facility-acquired Stage 1 pressure ulcer on the left heel, described as intact epithelium with red/pink nonblanchable discoloration. The DON stated the nurse should notify the MD and the resident representative and document the change of condition the same day, but there was no documentation that these notifications occurred.
A resident was hospitalized after an abnormal MRI result and later returned to the facility. Although a transfer notice was signed, the record did not show that the resident or representative was given the bed hold policy, including reserve bed payment. The admin first said the policy had been provided, then later stated it was not given and that nursing staff believed only the transfer notice was required.
A resident’s care plan was not updated to reflect that contact isolation had ended and the resident was actually on EBP for a wound infection while sharing a room with two other residents. In another case, an IDT failed to hold quarterly care plan meetings after the MDS was completed, and several meetings were documented before the MDS assessment was finished. The DON and DSW confirmed the discrepancies.
A resident receiving anticoagulation and other routine medications had several doses given 2 to 6 hours late, including Apixaban, Warfarin, Lexapro, and Metformin, with no documented reason for the delays. An RN and the DON confirmed the med pass window was within 1 hour before or after the scheduled time and that late doses should be documented, but the resident did not refuse meds.
A resident with dysphagia and an aspiration precaution order requiring upright positioning, oral care, small bites and sips, and 1:1 meal assistance was observed lying in bed and trying to eat without staff present. The resident was later seen again alone with a meal tray, and an LPN confirmed the resident was not receiving the ordered continuous feeding assistance; the DON stated that 1:1 feeding requires continuous staff presence.
A resident ordered continuous O2 was observed without oxygen, with tubing on the floor, disconnected from the concentrator, and missing required supplies in the room despite documentation showing it had been administered. Another resident with a tracheostomy had respiratory equipment with dated tubing, an unlabeled hanging fluid bag, and an undated open bottle of distilled water, while staff could not clearly explain the RT service frequency or responsibility for changing the trach-related tubing.
Pain medication was administered without following ordered pain parameters and without physician orders for non-pharmacological interventions. One resident received PRN oxycodone and acetaminophen even when pain scores were below the ordered threshold or when no threshold was documented, and two other residents had pain orders that lacked parameters. The DON stated PRN pain meds were expected to have pain parameters and that non-pharmacological interventions should be ordered.
Failure to report a pharmacist-identified medication irregularity for a resident receiving oxycodone. The pharmacist recommended adding Narcan for the resident, but the facility did not follow through and incorrectly documented that the resident was hospitalized. The DON later confirmed the resident was still in the facility when the recommendation was made.
An unlocked treatment cart was observed with its drawers open and multiple wound care products, ointments, and resident-labeled medications inside. In a separate observation, an open bottle of aspirin 81 mg was left unattended on top of a med cart on a unit, and the unit manager said the nurse responsible reported it was an oversight.
Facility staff failed to keep one resident’s record accurate when the face sheet listed the resident as his/her own RP despite two certificates of incapacity and a surrogate document in the EMR, and staff also could not produce requested psychiatry notes for another resident. The DON confirmed the face sheet was not accurate, and the RCD and DON stated the psych notes were not located.
Failure to document immunization education: Two residents refused pneumococcal and/or influenza vaccines, but their EMRs did not show that education on the benefits and potential side effects had been provided. The DON and IP stated such documentation should be in the EMR, and facility policy required it, but no supporting education documentation was found for the residents reviewed.
Failure to Document Staff COVID-19 Vaccine Education: The facility failed to ensure staff were educated on the benefits and potential side effects of the COVID-19 vaccine and failed to maintain documentation of that education for 1 of 5 staff reviewed. Record review showed an employee had received a COVID-19 booster, but the HRD stated the facility did not keep records of staff COVID-19 education, and the DON acknowledged the concern.
A resident with chronic kidney disease and other conditions died after nursing staff, lacking proper training, administered antibiotics through a permacath. Despite initial refusal, the resident later agreed to the procedure, but the involved LPNs were not adequately trained, leading to a fatal incident when the permacath was not properly clamped.
The facility failed to ensure accurate communication of residents' code status, leading to conflicting documentation and a failure to perform CPR for a resident. This deficiency was evident in three residents, highlighting the facility's inadequate system for managing and communicating code status.
The facility failed to provide an environment free from abuse, resulting in physical and psychosocial harm to a resident. The resident reported rough handling by a night shift GNA, leading to bruising. Multiple residents corroborated the GNA's rough and uncommunicative behavior. The facility failed to document the resident's injuries and did not ensure a thorough investigation.
The facility failed to complete Quarterly MDS assessments for residents within the regulatory time frames, affecting 11 out of 67 residents reviewed. Delays ranged from 16 to 35 days past the ARD, with staff acknowledging challenges with staffing and awareness of the late assessments.
The facility failed to ensure maintenance concerns were reported and addressed, leading to multiple unresolved issues such as damaged walls, cracked floor tiles, and broken corner guards across three out of four units. Despite having a reporting system, no concerns were logged, and staff did not report these issues for three weeks.
The facility staff failed to complete comprehensive MDS assessments within regulatory time frames for eight residents, with delays ranging from 1 to 9 days. Additionally, cognition and mood assessments were not completed for three residents within the required periods. The deficiencies were attributed to staffing challenges and inadequate time management.
The facility staff failed to ensure MDS assessments were accurately coded for several residents, leading to incorrect documentation of diagnoses, medication use, and discharge status. These errors were confirmed by the MDS Coordinator and other staff members during interviews.
Facility staff failed to develop and implement comprehensive, person-centered care plans with measurable goals and non-pharmacological approaches for several residents, including those with specific activity preferences and those receiving multiple psychotropic medications. The care plans lacked detailed interventions and targeted behaviors for which the medications were prescribed.
The facility failed to ensure timely and comprehensive care plan meetings, as well as resident participation in care planning. Several residents had no documented care plan meetings following assessments, and one cognitively intact resident was not invited to their care plan meeting. Additionally, newly admitted residents did not have documented care plan meetings after their admission assessments.
The facility failed to develop and implement an activities program to meet the needs and preferences of residents. Observations and medical record reviews revealed that residents were not engaged in meaningful activities that aligned with their documented interests. Staff interviews indicated a lack of knowledge and implementation of appropriate activities for the residents.
The facility failed to ensure that attending physicians reviewed and responded to pharmacist-identified irregularities and recommendations in a timely manner for two residents. One resident's antidepressant dose was not reduced as recommended, and another resident's PRN medication discontinuation was not addressed promptly.
The facility failed to ensure that primary care and specialty provider notes were placed in the medical record for review by other healthcare professionals. This deficiency affected multiple residents, including those with behavioral issues, communication problems, insulin management, and facility-reported incidents. Missing notes from psychiatric, primary care, and wound physicians were noted, hindering the ability to provide appropriate and timely care.
The facility failed to report abuse allegations to the State Agency within the required 2-hour timeframe in two separate instances. One resident reported physical and verbal abuse by a GNA, and another resident reported verbal abuse. Both reports were delayed, violating state regulations.
The facility failed to thoroughly investigate abuse allegations for two residents. In one case, the investigation lacked interviews with potential witnesses, and in another, no staff were interviewed despite the resident providing a specific date of the alleged abuse.
The facility failed to ensure a dependent resident was groomed in a manner that preserved their dignity. Despite the resident's dependence on staff for all self-care needs and their expressed desire to have facial hair shaved, observations showed the resident with facial hair on multiple occasions. Staff interviews confirmed the oversight, leading to a deficiency in maintaining the resident's dignity.
The facility failed to inform two residents about their right to formulate an advance directive. The Social Service Director confirmed that residents were not provided with written information or assistance, and the facility's policy was not properly followed.
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents who were discharged from Medicare Part A services but had benefit days remaining and intended to remain at the facility receiving non-skilled care. Staff were unfamiliar with the SNFABN forms and did not issue them, leading to the deficiency.
The facility failed to document the preparation and orientation given to a resident to ensure an orderly transfer to an acute care facility. The resident had multiple transfers, and on each occasion, there was no documentation that the resident received an explanation of the transfer or their understanding of it. These concerns were discussed with the DON, who offered no comments.
The facility failed to complete a new PASRR for a resident with Schizoaffective Disorder Bipolar type when it was determined they would remain in the facility for long-term care. The initial PASRR indicated a stay of less than 30 days, but no new PASRR was completed, and the existing form was incomplete. Despite requests, no documentation was provided to indicate that a new PASRR screen was completed.
The facility failed to provide two residents and/or their representatives with a summary of the baseline care plan, including a summary of medications, within 48 hours of admission. The Director of Nurses and Social Services Director confirmed the omission, and no additional documentation was provided to indicate compliance.
The facility failed to provide adequate incontinent care to a dependent resident, as evidenced by missing documentation and reported neglect. The resident's family noted the issue was more frequent on holidays and weekends. Staff interviews confirmed the resident required care twice per shift, but documentation was missing for numerous shifts. A GNA admitted to being too busy to complete all required tasks, and the DON and CCN confirmed the lack of documentation.
The facility failed to ensure timely scheduling of vision and hearing appointments for two residents. One resident had an order for an audiology consult that was not scheduled for over a month, and another resident had an optometry appointment order that was not scheduled for over a year. The deficiencies were confirmed by staff and reported to the Director of Nursing.
The facility failed to re-implement splints for a resident after hospitalization and did not follow orders for palm protectors for another resident, leading to deficiencies in preventing contracture development and maintaining range of motion.
The facility failed to accurately document and address a physician's recommendation for a urology consult for a resident with an indwelling urinary catheter. The discrepancy in documentation led to a delay in scheduling the necessary appointment, which was eventually rectified after the resident reported successful removal of the catheter.
The facility failed to maintain respiratory care equipment for a resident requiring continuous oxygen via nasal cannula. Observations revealed an empty prefilled humidifier bottle, and staff confirmed the shortage of sterile water. The facility's policy required the humidifier to have enough water, but the unit manager was not informed of the supply issue.
A facility provider failed to make their visit notes available after a visit with a resident. The resident received a new order for Ativan for Anxiety, but there was no evidence of a diagnosis of Anxiety in the resident's list of active diagnoses. The DON confirmed that the CRNP saw the resident but failed to provide a provider note detailing the visit.
The facility failed to communicate psychiatric recommendations to the primary care provider and did not report a resident's abnormal behaviors in a timely manner. The resident, with a history of stroke, high blood pressure, diabetes, lung disease, and dementia, exhibited fecal smearing behavior that was not reported to the unit nurse manager or psychiatric NP until months later. Additionally, a recommendation to start a new medication for anxiety was not communicated to the primary care physician, and no follow-up visits were documented.
Two cognitively impaired residents left the facility without supervision
Penalty
Summary
The facility failed to maintain an effective system to prevent two residents with cognitive impairment, exit-seeking behavior, and assessed elopement risk from leaving the building without appropriate supervision. One resident had short-term memory loss, a BIMS score of 7.0 indicating severe impairment, and was determined to lack capacity due to multiple prior chronic lacunar infarcts and a vitamin B12 deficiency. The other resident had severe baseline dementia, poor hygiene, malnourishment, incapacitated status, and documented wandering behavior with continued need for staff supervision. Both residents were assessed for elopement risk and had care plans initiated with wanderguard use and identification pictures at the front desk. The records showed repeated problems with the wanderguards not being on. For one resident, the bracelet was documented as removed on one shift and later documented as not on again; for the other resident, the bracelet was also documented as removed or not on on multiple shifts. The records did not contain documentation explaining why the bracelets were not on or how they were removed. On the day of the incident, the medical record did not contain documentation of the residents’ elopement until later nursing notes that documented wanderguards being applied. Interviews confirmed that the two residents left the facility and were found on a sidewalk near a closed restaurant at a heavily traveled road, with one resident not properly dressed. Staff stated the front door was locked but someone buzzed them out, and the receptionist believed the two individuals were visitors because they were dressed in regular clothing. Staff also stated the residents were exit-seeking and that one resident would put the other in a wheelchair and start walking down the hall, saying they were leaving.
Missing Annual Nurse Aide Training Documentation
Penalty
Summary
The facility failed to ensure nurse aide competency training occurred no less than 12 hours per year as determined in nurse aides' performance reviews. During a complaint survey, documentation review of 5 of 5 Geriatric Nursing Assistant personnel files showed no evidence that the required annual 12-hour training had been completed within the past 12 months for GNA #25, GNA #26, GNA #27, and GNA #29. GNA #28's file contained documentation that the 12-hour yearly training was completed on 5/20/24, but there was no documentation that the training had been completed again since 2024. During the review on 5/15/26, the Human Resources Manager stated there was no documentation in the personnel files or computer showing when the last 12-hour training occurred and said there could be documentation in the previous DON's office, but was not sure. The Nursing Home Administrator later stated he could not find documentation in the previous DON's office related to any 12-hour training for the GNAs.
Missing Privacy Curtain Between Roommates
Penalty
Summary
Facility staff failed to ensure privacy curtains were in place between two roommates during care. During observation, Resident #10 and Resident #13 were found in a room with no privacy curtain separating their beds, and Resident #10 stated the curtain had been missing for quite some time and said he/she wanted a privacy curtain. Review of Resident #10's medical record showed the resident was assessed as dependent for care on the 3/19/26 MDS Section GG0130 Functional Abilities/Self Care. When the Unit Manager was brought to the room, the absence of the curtain was confirmed, along with Resident #10's dependent status for care.
Failure to Maintain an Effective Grievance System
Penalty
Summary
The facility failed to maintain an effective grievance system for residents. Resident #10 was admitted to the facility in 2014 and was assessed by facility staff on the 3/19/26 MDS as dependent for care on Section GG0130 Functional Abilities/Self Care. During interview, the resident’s RP stated that on Christmas day in the afternoon the resident was found lying in a soiled diaper that was leaking onto the resident gown, and that the RP later personally handed a written grievance to the Administrator because it included the names of staff working that day. The RP stated there was no resolution to the grievance. When the Surveyor requested grievance logs from December 2025 through 5/12/26, the logs reviewed by the Administrator contained no grievances for December and none for Resident #10 during the review period. The Administrator acknowledged receiving the grievance, stated Social Work spearheads the grievance process, and said grievances should be recorded on the log and resolved in 48-72 hours if possible, but he was unable to explain why this grievance was not logged. He later stated he could not find any file on the grievance and confirmed there was no documentation showing the grievance was investigated and resolved.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report an elopement incident to the state survey agency, the Office of Health Care Quality (OHCQ), involving two residents who were identified as at risk for elopement. Record review showed both residents had wanderguards applied to their left ankles on 4/13/26 due to identified elopement risk. A complaint alleged that on 4/16/26 at about 5:51 PM, a passerby found the two residents on a sidewalk next to a closed restaurant on a heavily traveled road, down the street from the facility. One resident was reported to have fallen while pushing the other in a wheelchair, and the other resident was described as rambling incoherently and wearing only hospital-style grip socks and no pants. During interview, the evening shift supervisor stated the two residents eloped from the facility on 4/16/26 around 5:55 PM to 6:00 PM after being alerted by the front desk that paramedics were in the lobby. The NHA and DON confirmed the residents left the building that day. When asked about reporting to OHCQ, the NHA stated the incident was not reported because it was not related to abuse and said only abuse incidents were reported. The NHA and DON were informed that the incident should have been reported because the safety and welfare of the two residents were jeopardized.
MDS Assessments Not Accurately Coded
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 3 residents reviewed during a complaint survey. For one resident, the March 2026 MAR documented a Cyanocobalamin 1000 mcg/ml injection on 3/28/26, but the admission MDS with ARD 3/30/26 coded Section N0300 Injections as 0, and the MDS Coordinator confirmed the injection was not captured. The medication is a synthetic form of Vitamin B12 used to treat and prevent Vitamin B12 deficiency. For another resident, the admission MDS with ARD 7/3/25 coded Section J1700 fall history as no, even though the resident had fallen at home on 6/19/25 before admission after being found down and unable to get up; the discharge MDS with ARD 9/23/25 also coded Section J1800 falls since admission as no, despite documentation of falls on 8/17/25, 8/18/25, and 8/21/25. For the third resident, the elopement binder listed the resident as an elopement risk and the TARs documented a wanderguard bracelet worn every shift, but the significant change MDS with ARD 1/17/26 and quarterly MDS with ARD 4/19/26 coded Section P0200 E wander/elope alarm as no; the MDS Coordinator reviewed the records and confirmed the errors.
Failure to Complete Weekly Wound Assessments and Ordered Wound Treatments
Penalty
Summary
Facility staff failed to assess a resident's wounds weekly with measurements. Resident #8 was admitted in January 2026 with peripheral vascular disease and had a wound from a right 4th toe amputation, as well as a right heel wound identified on admission. The wound NP assessed the resident on 1/27/26 and documented assessment, measurements, and treatment orders for both wounds. Subsequent wound NP notes on 2/2/26, 2/4/26, and 2/9/26 stated the resident could not be evaluated because the resident was out of bed or at dialysis, and the next wound assessment with measurements was not completed until 2/11/26, 15 days later. The DON confirmed the facility staff failed to assess the resident's wounds weekly with measurements during that period. Facility staff also failed to administer all ordered wound treatments for the same resident. Review of the January, February, and March 2026 TARs showed that right heel and right 4th toe wound treatments were not administered on 1/28/26, 2/4/26, 2/7/26, and 3/15/26. The DON confirmed during interview that these ordered wound treatments were not given on those dates.
Incomplete Medical Record Documentation for Elopement and RP Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for residents involved in an elopement event and for documentation of notification to a responsible party for a change in condition. During a complaint survey, surveyors reviewed the records of two residents who were found off the facility grounds on a sidewalk near a closed restaurant by a heavily traveled road. The records showed both residents had wanderguards applied for elopement risk, but the April 2026 treatment administration records contained several shifts where the wanderguards were not applied, and there was no documentation explaining why the bracelets were off or how they were removed. The medical records also did not contain documentation of the elopement itself, even though staff later confirmed the residents had left the facility and were located by paramedics. Staff interviews confirmed that the elopement was not documented in the residents’ medical records. An RN stated she did not document the incident and expected the nurse working that evening to do so. An LPN stated she documented the incident in “risk” and did not know she was supposed to document it in the medical record as well. The DON confirmed that “risk” was part of the electronic system but not part of the resident’s medical record, and the facility owner agreed there should have been documentation in the medical record. The record also lacked documentation of the residents’ injuries from the event, including scrapes on the knees for one resident and minor skin tears on the left leg for the other. The facility also failed to document timely notification to a resident’s RP regarding a change in condition. One resident had a diagnosis of dementia and a BIMS score indicating moderate cognitive impairment. The resident developed a skin tear, and the physician was notified and treatment was ordered. However, the medical record did not show notification to the RP until 5 days later. The RP stated the facility did not keep him/her updated on all changes in condition and gave an example of learning about a skin tear only after visiting the resident and seeing wound care being provided. The DON confirmed the facility failed to document notification to the RP in the medical record.
Unsanitary food service on tray line
Penalty
Summary
Food was not served in a sanitary manner during the initial kitchen tour for the recertification/complaint survey. On 11/17/2025 at 7:31 AM, Staff #1, the Dietary Supervisor, and Staff #2, a Dietary aide, were observed on the tray line serving food on breakfast plates without hair nets. During an interview at 7:40 AM, Staff #1 confirmed that both she and Staff #2 were not wearing hair nets and acknowledged that staff working on the tray line who handle food should be wearing hair nets. The Dietary Supervisor was made aware of the concern at that time, and the Administrator and DON were made aware on 11/21/2025 at 3:30 PM.
Failure to Maintain Governing Body Oversight of QAPI
Penalty
Summary
The facility failed to ensure governing body oversight of its Quality Assurance and Performance Improvement (QAPI) program and activities. During the recertification/complaint survey, the DON, who was also identified as the QAPI contact person, stated she was not sure whether the QAPI committee had governing bodies, did not know who the governing bodies were, and said the facility's governing body and/or executive leadership did not maintain oversight of the QAPI program and activities per S483.75(f)(1)-(6). In a separate interview, the administrator stated the facility did not have a governing body overseeing QAPI activities and asked whether one was required. He was informed that federal requirements and the facility's own QAPI policy required such oversight. The administrator later stated that Atlas was the governing body, but that QAPI activities were not reported to them.
Ineffective Pest Control Program With Gnats Observed in Conference Room and Laundry Area
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent or address mice, insects, or other pests. Surveyors observed multiple flying gnats in the facility’s conference room on the first day of entry, and throughout the survey period they continued to observe gnats in that room each day. On 12/21/25, the surveyor raised the concern with the NHA, who stated he had never seen gnats in the conference room, while three surveyors present confirmed they had observed gnats there throughout the survey. During a tour of the laundry area on 11/20/25, surveyors observed gnats flying in both the dirty side rooms, with more seen in the smaller room where the laundry chute emptied into a gray tub. The dirty side also contained two heaping mounds of dirty laundry in the smaller room. A laundry staff member stated that fruit flies were present most of the time and believed they came from the urine in the dirty laundry. The Managing Partner acknowledged the gnats during the observation and stated the facility had an insect/pest maintenance program with Allstate that comes at least once a month.
Failure to Notify Physician and Resident Representative of New Pressure Ulcer
Penalty
Summary
The facility failed to notify the resident's physician and resident representative of a newly identified facility-acquired pressure ulcer for Resident #9. Record review showed that on 11/14/2025, a new pressure ulcer, Stage 1, was identified on the resident's left heel during a wound care consult. The wound was described as intact epithelium with superficial damage and red/pink nonblanchable discoloration, and treatment included Skin Prep and leaving the area open to air. During interviews, the DON stated that when a new wound of unknown origin is identified, the nurse notifies the physician, the resident representative is informed of the wound and treatment plan, and the wound care team also reaches out to the family. The DON further stated that new skin issues should be documented in the e-interact Change of Condition form the same day the wound is identified. However, on 11/21/2025, the DON stated there was no documentation showing that the physician or resident representatives were notified of the resident's newly developed left heel pressure ulcer, and she acknowledged that this was a concern.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative of the facility bed hold policy, including reserve bed payment, for Resident #10 after hospitalization. Resident #10 was hospitalized due to an abnormal MRI result and later returned to the facility. Although a notice of facility-initiated transfer was signed and dated 10/2/25, the record review did not show that a bed hold policy was provided to the resident or the resident's representatives. During interview, the administrator initially stated that a copy of the bed hold policy had been given when the resident was transferred to the hospital, but later reported that it was not given and that nursing staff were not aware they had to provide it, believing only the transfer notification was required.
Care Plans Not Updated to Match Isolation Status and IDT Meetings Held Before MDS Completion
Penalty
Summary
The facility failed to keep Resident #2’s care plan updated to match the resident’s actual isolation status. On 11/19/25, the resident was observed with an enhanced barrier precaution sign posted outside the room due to a wound infection and was sharing a room with two other residents on EBP. However, the care plan still included active contact isolation language stating the resident had MRSA colonized in the wound and another care plan for contact isolation related to multidrug-resistant Pseudomonas aeruginosa, with interventions including placement in a private room. The physician’s order showed contact precautions beginning on 5/19/25 and ending on 6/2/25, but the care plan had not been revised to reflect that the resident was no longer on contact isolation precautions. During interview, the unit manager confirmed the resident was on EBP and acknowledged that the care plan had not been updated. She stated that care plans were updated mostly by herself or the nurses and verified that the resident’s care plan still reflected contact isolation even though the order had ended months earlier. The Director of Nursing was informed of the concern on 11/21/25. The facility also failed to conduct interdisciplinary care plan meetings for Resident #11 at the time of quarterly MDS revision. Review of the record showed MDS assessments completed on 5/14/24, 8/14/24, 11/14/24, 2/14/25, 5/15/25, and 8/15/25, with IDT Care Plan Meeting Notes dated 5/21/24, 8/27/24, 11/11/24, 2/10/25, 5/12/25, and 8/15/25. Three of the care plan meetings were held before the corresponding MDS assessments were completed. The DSW confirmed that the care plan is based on the MDS assessment and stated that care plan meetings should not be held prior to completion of the MDS.
Late Medication Administration Without Documentation
Penalty
Summary
The facility failed to administer medications timely and as ordered for one resident who was receiving anticoagulation therapy for DVT and later CVA-related treatment. The resident was prescribed Apixaban 5 mg twice daily starting 1/30/25, then changed on 10/7/25 to Warfarin 5 mg at bedtime. Review of the medication administration record showed that during September and October 2025, multiple medications were administered 2 to 6 hours late on some days, including Lexapro, Apixaban, Metformin, and Warfarin, with no documentation explaining the delays. During interview, an RN stated the medication pass window was one hour before to one hour after the scheduled time and that late administration should be documented, and she acknowledged the resident did not refuse medications. The DON confirmed the same medication timing policy and stated she had provided education to staff, while being informed that medications were still being given 3 to 6 hours late without documented reasons.
Failure to Provide Ordered 1:1 Feeding Assistance for Resident at Aspiration Risk
Penalty
Summary
The facility failed to assist with feeding for a resident at risk for aspiration. Resident #16 had a physician order for aspiration precautions dated 06/23/2025 that required the resident to be positioned upright during meals, receive oral care before and after meals, have 1:1 meal assistance, take small sips and bites, alternate liquids and solids, allow extra time for swallowing, and stop the meal if coughing or difficulty swallowing occurred. The resident’s care plan, dated 06/24/2025 and revised 07/21/2025, identified an actual or potential aspiration risk related to dysphagia, with coughing or choking during meals or medication swallowing, and included 1:1 assistance with meals as an intervention. During observation, Resident #16 was seen attempting to feed self while lying in bed with no staff member present, and later was again observed lying in bed with a tray of food and no staff member present. An LPN/unit manager defined 1:1 assist as sitting facing the resident, assisting with each bite and drink, and immediately reporting choking, pocketing, or changes to the nurse, and confirmed the resident was alone with a breakfast tray. The DON stated that a physician order and care plan for 1:1 feeding assistance due to aspiration/choking risk requires continuous staff presence with the resident.
Failure to Provide Ordered Oxygen and Tracheostomy Respiratory Care
Penalty
Summary
The facility failed to maintain and administer oxygen for a resident with a physician order for continuous oxygen at 2 L/min via nasal cannula. During observation, the resident was seated in a wheelchair without oxygen in place, and the oxygen tubing was found on the floor next to the bed, not dated, and disconnected from the oxygen concentrator. The resident stated that oxygen causes nosebleeds. Staff confirmed that the resident was not receiving oxygen as ordered and that the tubing should have been bagged, dated, and connected to the concentrator. A later observation found the resident again sitting in a wheelchair without oxygen, and the concentrator in the room had no nasal cannula tubing or water bottle available. The medical record showed the continuous oxygen order and documentation indicating oxygen had been administered on the day and night shifts, but the resident was observed without oxygen during those times. The treatment record also showed a weekly order for oxygen tubing changes, including changing and dating the tubing, washing the filter, and changing and dating the water bottle if applicable, yet the equipment was not present in the room as expected. The facility also failed to provide necessary respiratory care services for another resident with a tracheostomy. The resident was observed with tracheostomy equipment connected to a humidifier machine, a hanging bag of clear fluid dated 10/31/2025 with no descriptive label, an undated open bottle of distilled water stored under the humidifier, and suction tubing and canister dated 11/5/2025. Staff were unable to clearly explain the frequency of respiratory therapist services or who was responsible for changing the tracheostomy-related tubing, while the DON later stated that the RT or unit manager was responsible and acknowledged the concern about the unidentified fluid attached to the humidifier.
Pain Medication Given Without Ordered Parameters
Penalty
Summary
Facility staff failed to follow pain medication parameters and failed to have physician orders for non-pharmacological pain interventions for residents receiving pain medications. For one resident, a physician order dated 10/24/2025 directed oxycodone every 8 hours as needed for pain level 6-10, and a later order for acetaminophen 500 mg, 2 tablets every 8 hours as needed for pain, did not include pain parameters. Review of the MAR showed oxycodone was administered 17 times for pain levels below 6, and acetaminophen was given for pain levels of 6 and 7. The resident reported pain and inadequate pain medication during interview, and the record contained no physician order for non-pharmacological interventions. For another resident, two pain medication orders were present: oxycodone 15 mg every 4 hours as needed for pain and acetaminophen 500 mg, 2 tablets every 8 hours for pain, but neither order included pain parameters and there was no order for non-pharmacological interventions. The resident reported having to wait on pain medications. For a third resident, the physician ordered oxycodone 150 mg every 6 hours as needed for breakthrough pain (6-10), but the MAR showed the medication was administered when the resident reported pain levels of 4 and 5, below the ordered threshold. The DON stated that PRN pain medication should have pain parameters established and followed and that non-pharmacological interventions should be documented as a physician order.
Failure to Report Pharmacist Medication Irregularity
Penalty
Summary
The facility failed to report an irregularity identified by the pharmacist to the attending physician for follow up for Resident #7, who was receiving oxycodone HCl 10 mg every 8 hours for pain and oxycodone HCl 5 mg every 3 hours as needed for breakthrough pain. During review of the monthly pharmacy report, the pharmacist recommended in March 2025 that Narcan be added for the resident, but the facility did not carry out the recommendation and documented that the resident was hospitalized at the time. Review of the census showed the resident was not hospitalized, and the DON later confirmed that the March recommendation was not completed and that the resident remained in the facility when the recommendation was made.
Unsecured treatment cart and unattended medication observed
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when a treatment cart across from a resident room was observed unlocked with its drawers open. The cart contained multiple wound care and topical medications and supplies, including gauze pads, triple antibiotic ointment, hydrocortisone ointment, wound cleanser solution, Lidocaine cream, hydrogel, Mupirocin ointment labeled for Resident #145, Medi honey wound and burn dressing patches, bandage scissors, Vitamin A&D ointment, antifungal cream, Santyl ointment labeled for Resident #102, Nystatin cream, ketoconazole cream, bacitracin, Triamcinolone acetonide cream, terbinafine hydrochloride cream, ACTi vice gel for pain relief, Greer's goo labeled for Resident #42, Bisacodyl suppositories, and two containers of Vashe wound solution labeled for Resident #145 and Resident #117. The surveyor remained at the unlocked cart with the drawers open for several minutes, and no staff approached or spoke to the surveyor until an LPN was notified and then locked the cart. The facility also failed to keep a medication properly secured when an open bottle of aspirin 81 mg containing several white pills was observed unattended on top of a medication cart on the Ocean Pines Unit near a resident room. The unit manager was shown the bottle and informed of the finding, and she stated she would talk to the nurse responsible for the medication cart. The unit manager then spoke with the nurse, who reported that it was an oversight.
Inaccurate resident record and missing psychiatry notes
Penalty
Summary
Facility staff failed to maintain an accurate medical record for Resident #12. The resident’s profile listed the resident as his/her own responsible party, but the medical record also contained two certificates of incapacity signed and dated by two physicians and a surrogate document uploaded into the EMR. During review, the surveyor compared the face sheet, surrogate document, and certificates of incapacity with the DON, who confirmed that the face sheet listing the resident as his/her own responsible party was not accurate. Facility staff also failed to maintain medical records for Resident #11 from other licensed professionals. The surveyor requested psychiatry notes for November and December 2024, but the notes were not located. The Regional Clinical Director stated the facility had not located them and was having someone else look, and the DON later stated the facility did not have those psychiatry notes.
Failure to Document Immunization Education
Penalty
Summary
The facility failed to ensure that residents and/or their resident representatives were provided education regarding the benefits and potential side effects of pneumococcal and influenza immunizations. During record review of 5 residents, 2 residents were identified with immunization refusals documented, but the medical record did not contain documentation showing that education had been provided. One resident refused both the pneumococcal and influenza vaccines, and the immunization record marked education as not provided with no education comments documented. Another resident refused the pneumococcal vaccine, and the record likewise marked education as not provided with no supporting documentation in the chart. The facility’s Infection Preventionist and DON stated that immunization documentation would be found in the Miscellaneous tab of the EMR and that education would be provided when a resident and/or RP declined an immunization. However, review of the facility’s influenza and pneumococcal vaccination policies showed that the resident’s medical record should include documentation that education regarding the benefits and potential side effects was provided. When the surveyor requested documentation supporting education for the two residents, the Infection Preventionist stated the facility did not have education documentation for any of the residents requested and acknowledged the concern.
Failure to Document Staff COVID-19 Vaccine Education
Penalty
Summary
The facility failed to ensure staff were provided education regarding the benefits and potential side effects associated with the COVID-19 vaccine. During the recertification/complaint survey, record review and staff interviews showed this issue for 1 of 5 staff members reviewed for immunizations, identified as Staff #30. Review of Staff #30's health records on 11/21/25 showed she last received a COVID-19 booster on 3/24/22, but there was no documentation that education had ever been provided about the benefits or potential side effects of the COVID-19 vaccine. In an interview, the HRD stated the facility did not maintain records of staff COVID-19 education, and the DON later verified and acknowledged the concern that staff COVID-19 education was not maintained.
Failure to Ensure Nursing Staff Competency in Permacath Access
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skills to access a permacath for the IV administration of antibiotics. This deficiency was evident in the case of a resident who was admitted to the facility for hemodialysis and had a permacath placed prior to discharge from the hospital. Despite the resident's initial refusal to use the permacath for antibiotic administration, the resident later agreed, and the nursing staff proceeded without proper training or competency verification. The resident's medical history included chronic kidney disease, heart disease, high blood pressure, blindness, and diabetes, and the resident was cognitively intact with a BIMS score of 15/15. The nursing staff, including LPNs, administered the antibiotic Zosyn through the permacath without adequate training. One LPN reported that they had administered the antibiotic through the dialysis site based on instructions from another LPN, who had received minimal guidance from a dialysis nurse. The NP confirmed that only one nurse had received training from the dialysis staff, which included basic instructions on clamping and sterile technique. However, the trained nurse did not administer the antibiotic doses, and the untrained nurse who did administer the doses was not comfortable with the procedure. On the day of the incident, an LPN attempted to administer the antibiotic but encountered issues with the infusion machine. The LPN left the resident briefly, and upon returning, found the resident unresponsive with blood present. Despite efforts to stop the bleeding, the resident was pronounced dead by paramedics. The facility's investigation revealed that the LPN had forgotten to clamp the permacath site, leading to the resident's death. The facility lacked documentation of basic IV skills assessment for the involved LPN prior to the incident, highlighting a significant gap in staff competency and training.
Removal Plan
- Management of Central Venous device complications
- Change in Condition
- Licensed Nurses Skills and Techniques Evaluation - Phlebotomy/infusion therapy
- Do not access the dialysis site: permacath or fistula
- Providers were educated not to write orders for floor nurses to access dialysis catheters
- All like residents in the facility with IV access or dialysis access devices were evaluated
- A quality assurance (QA) plan was put in place for ongoing monitoring of the planned interventions
- LPN, Staff #34 was put on the do not return list and a report was submitted to the state board of nursing
Failure to Ensure Accurate Communication of Code Status
Penalty
Summary
The facility failed to ensure that a resident's wishes regarding cardiopulmonary resuscitation (CPR) were clearly and accurately communicated to staff. This deficiency was evident for three residents reviewed for advance directives or death. Specifically, Resident #184 had conflicting documentation regarding their code status, with an electronic health record indicating Full Code and a paper chart MOLST indicating No CPR. The unit nurse manager struck out the Full Code order without proper verification, leading to a failure to perform CPR when the resident's breathing ceased, resulting in Immediate Jeopardy for Resident #184. Resident #53 also experienced a similar issue where the electronic health record indicated Full Code, but the paper chart MOLST indicated No CPR. The assigned nurse initially believed the resident was Full Code based on the electronic record but later confirmed the MOLST indicated No CPR. This discrepancy highlighted the facility's failure to ensure consistent and accurate documentation of code status across different records. Resident #91's case revealed the existence of two active MOLSTs with conflicting orders for No CPR. One MOLST was found in the paper chart, and another in the dialysis communication book, each with different No CPR options. This inconsistency further demonstrated the facility's inadequate system for managing and communicating residents' code status, putting residents at risk of not receiving appropriate life-sustaining treatment as per their wishes.
Removal Plan
- 100% of current alert and oriented residents re-interviewed by Social Worker to confirm their code status.
- Residents with Advance Directives will have them honored.
- Residents with responsible parties will be contacted by Social Services to confirm resident code status.
- If any changes are requested the medical providers will be contacted to make the change.
- System Change: Current scanned-in copies of the MOLST will be moved to the Do Not Use Section.
- System Change: Current MOLST previously removed will be returned to the residents' charts by the medical records designee.
- System Change: Current MOLST will be placed in the resident's chart located at each nurse's station by the charge nurse with each new admission, re-admission and change of status.
- The medical director will educate the physicians when there is a revised MOLST to flag the chart, notify nursing leadership of changes to the MOLST and void the old MOLST.
- Nursing leadership will review the MOLST to ensure the old one is voided and the revised one is in the resident chart. Nursing leadership will ensure old MOLST is voided. Changes in code status will be documented on the twenty-four-hour report.
- Physician orders reflecting the resident code status in the EHR will say: See MOLST.
- 100% audit was completed to validate current code status say: See MOLST by the DON.
- Nurses will be educated on the process by the DON or designee.
- The medical director will educate the medical providers on ensuring they confirm and document the residents' wishes on the MOLST.
- The medical director will educate the medical providers that the NPs are responsible for notifying the attending physicians of MOLST changes.
- The NHA or designee will re-educate the medical providers on the importance of notifying the Unit Manager, Supervisor, ADON, or DON regarding changes in the MOLST.
- The DON or designee educated current nurses on the facility's policy for initiating CPR and location of code status for each resident, which is in the resident's chart on each unit.
- Agency nursing staff will be educated prior to start of their shift by DON, nursing supervisor or designee.
- Social Service will audit new admissions, re-admissions to compare the resident's MOLST to the physician orders for accuracy to assure it reflects See MOLST. This is ongoing.
Failure to Provide an Environment Free from Abuse
Penalty
Summary
The facility failed to provide an environment free from abuse, resulting in physical and psychosocial harm to Resident #505. The resident, who had moderate cognitive impairment, reported that a night shift GNA (GNA #9) was rough during care, yanking covers off, grabbing the resident's arms, and pushing them to roll over. This rough handling led to bruising on the resident's arms, which was later confirmed by another GNA (GNA #10) who noticed the bruises during a shower and reported the incident. Multiple residents corroborated the rough and uncommunicative behavior of GNA #9 during care, further substantiating the abuse allegations. The facility's investigation revealed that the bruises on Resident #505 were new and had not been present the day before the alleged abuse. Despite this, the facility failed to document the resident's change in condition and the injuries in the medical record. Additionally, the facility did not ensure that a nurse practitioner or physician examined the resident following the abuse allegation and injuries. The psychiatric provider who saw the resident after the incident was not aware of the recent abuse allegations and injuries, as this information was not documented in the medical record. Interviews with other residents indicated that GNA #9 had a pattern of neglectful and rough behavior. Residents reported that GNA #9 would turn off call lights without providing care, complain about residents' needs, and handle residents roughly. Despite these reports, the facility did not thoroughly investigate all the allegations or obtain statements from all relevant staff members. The facility's failure to document the abuse allegations and injuries in the medical record and to conduct a comprehensive investigation contributed to the deficiency.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to complete Quarterly Minimum Data Set (MDS) assessments for residents within the regulatory time frames, which is required to facilitate appropriate care planning and maintain current assessment records. This deficiency was identified for 11 out of 67 residents reviewed during the survey. The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs, which drives resident care planning decisions. The completion date of the Quarterly assessment must be within 92 days of the MDS Completion Date of the last OBRA assessment and no later than 14 days after the ARD. However, the facility did not meet these requirements for the specified residents, with delays ranging from 16 to 35 days past the ARD. During interviews, the Nursing Home Administrator acknowledged the challenges with staffing and mentioned that the corporate person in charge of MDS was aware of the situation and was trying to get help to catch up with the assessments. An MDS Coordinator also confirmed awareness of the late MDSs. Specific examples include Resident #85's Quarterly MDS assessment being completed 21 days after the ARD, Resident #28's assessment being 24 days late, and Resident #65's assessment being 33 days late, among others. These delays indicate a systemic issue in meeting the regulatory time frames for MDS assessments, impacting the facility's ability to maintain current and accurate resident assessment records.
Failure to Address Maintenance Concerns
Penalty
Summary
The facility failed to have an effective system in place to ensure that maintenance concerns are reported and addressed. During an initial tour, surveyors observed multiple maintenance issues across three out of four units, including damaged walls, cracked floor tiles, broken corner guards, and non-functional clocks. These issues were visible in several rooms and were not reported or addressed by the facility staff. For instance, in one room, the lower part of the wall under the window was damaged, and in another, several floor tiles were cracked. Additionally, a resident complained about a non-functional clock, which was confirmed by the surveyor. Upon further inspection, additional maintenance issues were noted, such as separated grout and exposed drywall metal corner beads. The Maintenance Director confirmed these observations and indicated that the damage was primarily caused by residents hitting the walls with their wheelchairs. Despite having a system called TELS for reporting and managing maintenance concerns, the Maintenance Director reported having zero orders or concerns at the time of the survey. The Director of Nursing was informed that these environmental issues had not been identified or reported by any staff to maintenance in the last three weeks.
Failure to Complete Timely and Comprehensive MDS Assessments
Penalty
Summary
The facility staff failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory time frames, which are essential for appropriate care planning and maintaining current and accurate assessment records. This deficiency was evident for eight residents, where the Admission MDS assessments were completed late, ranging from 1 to 9 days past the required 14-day period. For instance, Resident #98's Admission MDS assessment was completed 7 days late, and Resident #281's was 9 days late. The Director of Nursing and the Nursing Home Administrator acknowledged the delays, attributing them to staffing challenges within the MDS department. Additionally, the facility staff failed to assess residents' cognition and mood on comprehensive and quarterly MDS assessments. This was observed in three residents, where sections C (Cognitive Patterns) and D (Mood) were not assessed within the required time frames. For example, Resident #235's cognitive and mood assessments were completed after the MDS ARD date, and Resident #241's assessments were also not completed within the look-back period. The Social Service Director confirmed these lapses, noting that the assessments were conducted outside the required observation periods. Interviews with the MDS Coordinator and the Social Service Director revealed that the responsibility for completing these assessments was not adequately managed, leading to incomplete MDS records. The MDS Coordinator admitted to needing better time management, while the Social Service Director acknowledged the failure to complete assessments within the designated periods. These deficiencies highlight significant lapses in the facility's assessment processes, impacting the accuracy and timeliness of resident care planning.
Inaccurate MDS Assessments
Penalty
Summary
The facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for several residents. For Resident #65, the MDS assessment inaccurately documented an active diagnosis of deep vein thrombosis (DVT) and recorded incorrect antibiotic and oxygen use. The MDS Coordinator confirmed these errors during an interview and acknowledged the need for modifications. Similarly, Resident #98's MDS assessment failed to capture oxygen use and inaccurately documented anticoagulant medication use, which was confirmed as an error by the MDS Coordinator. Resident #91's MDS assessment inaccurately reflected the resident's dental status. The resident reported having upper dentures but lacked a denture cup, and the initial admission nursing assessment did not indicate the presence of dentures. Staff interviews and a review of the resident's hard chart and speech therapy evaluation failed to document the presence of dentures, which was later confirmed by the nurse unit manager and the Director of Nursing. Resident #129's discharge MDS inaccurately documented the discharge status, indicating the resident was discharged to a hospital instead of home. This error was confirmed by the MDS Coordinator. Additionally, Resident #54's MDS assessment failed to capture the resident's active diagnoses of depression and bipolar disorder, despite documentation in the medical record and physician orders indicating the resident was on antidepressant medication. The MDS Coordinator acknowledged the need to modify the MDS to reflect the correct diagnoses.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans with measurable goals and non-pharmacological approaches for several residents. For Resident #63, the medical record review revealed that the resident had specific preferences for activities such as reading, listening to music, and attending religious activities. However, the current care plan did not address these preferences, and the Activity Director confirmed the absence of such a care plan during the survey. Despite an interdisciplinary care plan meeting, no documentation was provided to indicate that the resident's activity preferences were addressed prior to the survey exit date. For Resident #54, the medical record review showed that the resident was receiving multiple psychotropic medications, including antipsychotics, an antidepressant, and an anti-anxiety medication. The care plan for this resident did not include comprehensive, resident-centered measurable goals and interventions that addressed the use of these medications, the targeted behaviors for which they were prescribed, or non-pharmacological approaches. The Director of Nursing (DON) was made aware of these concerns but offered no further comments. Similarly, Resident #21's care plan was found to be inadequate. The resident, who had diagnoses including schizophrenia, major depressive disorder, bipolar disorder, and dementia, was receiving multiple psychotropic medications. The care plan did not specify the resident's behaviors for which these medications were prescribed and lacked non-pharmaceutical interventions. The DON was informed of these issues but did not provide any comments at the time of the survey.
Failure to Conduct and Document Care Plan Meetings
Penalty
Summary
The facility failed to ensure interdisciplinary team meetings to review and revise care plans following each assessment. This was evident for several residents, including one who was admitted in February 2023 and had no documentation of a care plan meeting between June and September 2023. Another resident, admitted in 2022, had a care plan meeting in December 2023, but there was no documentation indicating that the care plan was updated to reflect a recent ENT appointment and recommendation for a hearing aid. Additionally, a resident admitted in 2020 had no care plan meeting scheduled after a December 2023 MDS assessment. The facility also failed to ensure that residents and their representatives had the opportunity to participate in the development, review, and revision of care plans. One resident, admitted in August 2023, was cognitively intact but was not invited to their care plan meeting. Another resident, with severe cognitive impairment, had a care plan that was not comprehensive and lacked specific, measurable goals. The facility did not evaluate the resident's progress or response to care plan interventions following quarterly assessments. Furthermore, the facility did not conduct care plan meetings for newly admitted residents. One resident, admitted in December 2023, had no documentation of a care plan meeting following their admission assessment. The Social Service Director acknowledged the oversight but could not provide additional documentation to confirm that the meeting had occurred. These deficiencies highlight the facility's failure to adhere to regulatory requirements for timely and comprehensive care planning.
Failure to Implement Resident-Centered Activities Program
Penalty
Summary
The facility failed to develop and implement an activities program to meet the needs and preferences of residents. This deficiency was evident for four of the six residents reviewed for activities. Observations and medical record reviews revealed that residents were not engaged in meaningful activities that aligned with their documented interests and preferences. For instance, Resident #43, who enjoys music and religious programming, was found lying in bed without any engagement in these activities. The activity logs for Resident #43 only recorded leisure cart visits, which did not include the resident's preferred activities. Interviews with staff indicated a lack of knowledge and implementation of appropriate activities for this resident. Similarly, Resident #71, who has a diagnosis of dementia and enjoys quilting, children, television, music, and puzzle words, was observed not participating in any meaningful activities. The activity logs for this resident also failed to show engagement in their preferred activities. Staff interviews revealed that activities were not personalized based on the resident's preferences, and there was no rationale provided for this oversight. Resident #63, who has a diagnosis of Schizoaffective Disorder Bipolar type and lung disease, was observed in bed without any engagement in activities. The resident expressed a desire to attend activities and physical therapy. However, the care plan did not address the resident's activity preferences, and the activity logs only recorded occasional leisure cart visits. Staff interviews confirmed a lack of access to the resident's assessment and inadequate documentation of activity provision. Resident #91 also reported not participating in activities for a couple of months, despite enjoying bingo. The activity logs for this resident only recorded leisure cart visits, and there was no additional documentation to confirm participation in other activities.
Failure to Address Pharmacist Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and responded to pharmacist-identified irregularities and recommendations in a timely manner. For Resident #65, a medication regimen review (MRR) was completed on 8/9/23 with a recommendation to attempt a gradual dose reduction of an antidepressant. However, the attending physician did not review or respond to this recommendation, and the antidepressant dose remained unchanged. The Director of Nursing (DON) confirmed that the MRR was not addressed with the provider, and the attending physician indicated that the nurses did not inform him of the MRR. For Resident #53, the facility did not have documentation of monthly pharmacy reviews for October, November, or December 2023 initially. Although the DON later provided documentation for November and December, the October review revealed a recommendation to discontinue a PRN medication, which was not addressed by the physician. The corporate nurse confirmed that there was no written policy or procedure specifying a timeframe for addressing MRR recommendations. The surveyor noted the failure to ensure pharmacy recommendations were addressed in a timely manner.
Failure to Maintain Comprehensive Medical Records
Penalty
Summary
The facility failed to ensure that primary care and specialty provider notes were placed in the medical record for review by other healthcare professionals. This deficiency was evident in multiple cases, including residents with behavioral and emotional status issues, communication and sensory problems, insulin management, and facility-reported incidents. For instance, Resident #106 had an order for a psychiatric consult in July 2023, but no documentation was found to indicate the resident was seen until the psychiatric nurse practitioner provided notes later. Similarly, Resident #63's electronic health record lacked psychiatric notes for a visit conducted in January 2024, despite an order for a psych consult in September 2023. Resident #53's medical record revealed a lack of primary care physician notes since October 2023, despite a nurse's progress note indicating the resident was seen by the physician in November 2023. Additionally, Resident #59's record showed missing wound physician notes for November and December 2023, even though nursing progress notes indicated the resident was seen by a wound physician during those months. The facility provided multiple copies of primary care physician notes but failed to include the requested wound physician notes. Further deficiencies were noted in the records of Residents #184 and #183. Resident #184's medical record lacked progress notes from a nurse practitioner involved in the resident's care during an incident in August 2022. Similarly, Resident #183's record did not contain legible or typed notes from an oncologist for several appointments in 2023. The facility's failure to ensure that these critical medical notes were available in the residents' records hindered the ability of healthcare professionals to provide appropriate and timely care.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency, the Office of Health Care Quality (OHCQ), within the required timeframe of 2 hours. In the first instance, a resident reported being belittled and physically mishandled by a geriatric nursing assistant (GNA) during the night shift. The Nursing Home Administrator (NHA) was informed of the allegation at 11:17 AM on 1/10/24, but the report was not forwarded to the state agency until 7:28 PM the same day, exceeding the 2-hour reporting requirement. This delay was acknowledged by the Director of Nursing (DON) during a discussion on 1/24/24. In the second instance, another resident made an allegation of verbal abuse against a GNA on 12/19/23 at 9:00 PM. The facility's investigation documentation revealed that the allegation was not reported to the OHCQ until 1:07 PM on 12/20/23, again failing to meet the 2-hour reporting requirement. The DON confirmed that the Administrator was made aware of the accusation only on 12/20/23, which led to the delayed reporting. Both instances highlight the facility's failure to comply with timely reporting regulations for abuse allegations.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure that abuse allegations were thoroughly investigated for two residents. For the first resident, admitted in June 2023, a self-report indicated that during a meeting in July 2023, the resident and a family member reported that a night nurse had squeezed the resident's hand. However, the facility's investigation documentation did not include interviews with potential witnesses other than the resident and the nurse involved. There was no documentation of an interview with the geriatric nursing assistant assigned to the resident at the time of the alleged event, nor was there any information on whether the resident had a roommate. Despite the Nursing Home Administrator's indication that additional documentation would be sought, no further documentation was provided by the time of the survey exit on February 2, 2024. For the second resident, who had resided at the facility for several years, a self-report revealed that during an interview for another abuse investigation, the resident reported that an aide had been pulling and tugging on them while providing care on a specific date. The final investigation report was submitted to the licensing agency, but the facility's investigation documentation failed to show that any staff were interviewed before the conclusion of the investigation. When asked about the expectations for an abuse investigation when a resident provides a specific date but not a name, the Director of Nursing stated that everyone working that day would be interviewed. However, the investigation did not reflect this procedure, as no staff interviews were documented before the investigation's conclusion.
Failure to Maintain Resident's Dignity Through Proper Grooming
Penalty
Summary
The facility failed to ensure that a dependent resident was groomed in a manner that preserved the resident's dignity. Observations on two separate occasions showed that Resident #71 was lying in bed with facial hair on the chin and upper lip. The resident's Minimum Data Set (MDS) assessment indicated that they depended on staff for all self-care needs, including grooming and personal hygiene. The resident also had moderately impaired cognition and a diagnosis of dementia. Despite this, the resident's plan of care and Geriatric Nurse Aide (GNA) task documentation did not reflect a preference for facial hair, and the resident expressed a desire to have their facial hair shaved during an interview. Interviews with staff confirmed that Resident #71 depended on staff for all care needs and that the resident's facial hair should have been shaved according to their preference. Staff #49, a GNA, acknowledged the presence of facial hair and indicated they would shave it after the surveyor's intervention. The Nurse Manager and the Director of Nursing (DON) both stated that the resident's facial hair should have been shaved if it was not documented in the plan of care to leave it. This failure to groom the resident according to their preference resulted in a deficiency in maintaining the resident's dignity.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to ensure that residents were informed of their right to formulate an advance directive. This deficiency was identified for two residents. One resident, admitted in August 2023, had no documentation in their medical record indicating they had been informed about their right to formulate an advance directive. The Social Service Director (SSD) confirmed that the social service assessment tool used at the time did not include a section for advance directives, although it has since been updated to include this information. The SSD also stated that social services did not provide residents with written information or assistance in formulating advance directives, instead directing them to external resources like the internet or banks for financial power of attorney (POA) information. Another resident, admitted in December 2023, also had no advance directive in place and was not provided with educational materials or state forms to complete one. The SSD confirmed that the facility's policy on advance directives was different from what they had been taught, indicating a lack of proper training and adherence to the facility's policy. The SSD acknowledged that residents were not given the necessary information or assistance to formulate advance directives, which is a violation of their rights.
Failure to Provide SNFABN to Residents
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to residents who were discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This deficiency was identified for two residents who continued to stay in the facility after their Medicare coverage ended. The review of records showed that these residents did not receive the required SNFABNs, which are meant to inform them of their financial liability for non-covered services and their appeal rights. During interviews, the Social Services Director and a Social Service Coordinator both confirmed that they were unfamiliar with the SNFABN forms and did not issue them to residents. The facility's policy on Advance Beneficiary Notices states that an ABN should be issued prior to furnishing non-covered care, but this was not followed. The lack of awareness and failure to issue the SNFABNs led to the deficiency noted by the surveyors.
Failure to Document Resident Preparation for Transfer
Penalty
Summary
The facility failed to document the preparation and orientation given to residents to ensure an orderly transfer to an acute care facility. This deficiency was evident for one resident who was admitted in December 2023 and had multiple transfers to an acute care facility. On one occasion, the nurse documented a critical low lab and a physician's order for a blood transfusion, but there was no documentation that the resident received an explanation of the transfer or their understanding of it. On another occasion, the nurse documented a change in the resident's mental status and a recommendation for hospital transfer, but again, there was no documentation of an explanation given to the resident or their understanding. These concerns were discussed with the Director of Nurses, who offered no comments at that time.
Failure to Complete New PASRR for Long-Term Resident
Penalty
Summary
The facility failed to ensure a new Preadmission Screening and Resident Review (PASRR) was completed when it was determined that a resident would remain in the facility for long-term care. The resident, who was originally admitted in June 2022 with a diagnosis of Schizoaffective Disorder Bipolar type, had a brief hospitalization in August 2023 and was readmitted to the facility. The initial PASRR indicated that the resident's stay would be less than 30 days, but no new PASRR was completed when it became evident that the resident would remain for a longer period. The PASRR form on file was incomplete, lacking a signature and date, and no previous PASRR was found in the electronic health record (EHR). The social service coordinator confirmed that the only PASRR present was dated 9/1/23 and lacked a signature. Despite requests, no documentation was provided to indicate that a new PASRR screen was completed in 2022 when it was evident that the resident would remain in the facility for more than 30 days. The psychiatric nurse practitioner confirmed that the resident had a past psychiatric admission but could not provide additional information regarding the dates. The social service director acknowledged that a new PASRR should be completed if a resident transitions to long-term care but was unable to provide evidence that this was done. The Director of Nursing was informed of the concern, but as of the survey exit, no documentation was provided to indicate that a new PASRR screen was completed. This deficiency was evident for one resident reviewed for PASRR during the survey.
Failure to Provide Baseline Care Plan and Medication Summary
Penalty
Summary
The facility failed to provide residents and/or their representatives with a summary of the baseline care plan that included a summary of the resident's medications within 48 hours of admission. This deficiency was identified for two residents. For the first resident, the Director of Nurses stated that baseline care plans were developed upon admission and provided during the care plan meeting. However, a review of the resident's medical record revealed no documentation that a summary of the resident's medications had been provided. The Social Services Director confirmed that only the care plan was given, without any additional documents, including the medication summary. For the second resident, there was no documentation found to indicate that a care plan meeting had been conducted or that the resident had received a copy of the baseline care plan along with a summary of medications. The resident could not recall receiving these documents. The Social Services Director was made aware of the concerns but no additional documentation was provided by the time of the survey exit to indicate compliance with the requirement to provide the baseline care plan and medication summary within 48 hours of admission.
Failure to Provide Incontinent Care
Penalty
Summary
The facility failed to provide adequate incontinent care to a dependent resident, as evidenced by multiple instances of missing documentation and reported neglect. Resident #282, who was admitted for rehabilitation and relied entirely on staff for activities of daily living, did not receive documented incontinent care on several shifts across multiple days. This issue was highlighted by the resident's family member, who noted that the lack of care was more frequent on holidays and weekends. Interviews with staff confirmed that the resident required incontinent care twice per shift, but documentation was missing for numerous shifts, indicating a failure to provide the necessary care. Further investigation revealed that Geriatric Nursing Assistant (GNA) #42 admitted to being too busy to complete all required documentation during shifts and sometimes carried over documentation to the next day. The GNA also acknowledged that there were shifts where incontinent care was not provided to all residents under their care. The Director of Nursing (DON) and Corporate Clinical Nurse (CCN) reviewed the incontinent care task sheets and confirmed the lack of documentation, with no additional information or documentation provided to address the concerns.
Failure to Schedule Vision and Hearing Appointments
Penalty
Summary
The facility failed to ensure timely scheduling of vision and hearing appointments for two residents. Resident #68, who has diagnoses including dementia and heart failure, had an order for an in-house audiology consult for hearing aids on 12/1/23. However, by 1/10/24, there was no documentation indicating that the appointment had been scheduled or completed. The unit nurse manager and medical records clerk confirmed that the appointment was only scheduled on 1/17/24, indicating a delay in the process. The care plans did not reflect the ENT appointment or the need for a hearing aid, and the communication system for scheduling appointments appeared ineffective, as noted by the staff's reliance on a communication board that may not have been updated promptly. The Director of Nursing was made aware of this issue on 1/31/24. Resident #59, who is cognitively intact, reported not having seen an eye doctor for three years despite having an active order for an optometry appointment dated 10/7/22. The unit nurse manager confirmed that the resident had not had an optometry appointment since the order was placed and that an appointment was only scheduled on 1/17/24. This delay in scheduling was acknowledged by the unit nurse manager, who noted that the facility previously had an in-house provider but now makes outside appointments. The Director of Nursing was informed of this deficiency on 1/31/24.
Failure to Implement and Follow Orders for Contracture Prevention
Penalty
Summary
The facility failed to ensure that splints for the prevention of contracture development were re-implemented for a resident after a brief hospitalization. Resident #63 was readmitted to the facility in August 2023, but the splint order was not re-established until January 2024. Observations and record reviews revealed that the resident's wrist brace was not being used as recommended, and there was no documentation indicating the splints had been used since the readmission. The Occupational Therapist confirmed the recommendation for the splints but was unaware that they had not been re-evaluated or used since the resident's readmission. Additionally, the facility failed to ensure that a resident with a limited range of motion received treatment and services as ordered by the attending provider. Resident #43 had contractures in both hands and was recommended to use palm protectors. However, observations showed that the resident only had a palm protector on the right hand, and staff interviews confirmed that the left hand was not being treated as ordered. The attending provider's order for palm protectors was not being followed, and the resident's care plan was not adequately implemented. These deficiencies were evident for two residents reviewed for positioning and mobility. The facility did not ensure that the necessary treatments and services were provided to prevent further decline in the residents' range of motion, leading to a failure in maintaining their physical health and well-being as required by their care plans and medical orders.
Failure to Document and Address Physician's Recommendation for Urology Consult
Penalty
Summary
The facility failed to accurately document and address a physician's recommendation for a resident to receive a urology consult. This deficiency was identified for a resident who was admitted with an indwelling urinary catheter. The resident had a physician consultation at a local hospital, but the facility did not obtain the written recommendation from the consultation. The progress notes inaccurately documented the referral information, leading to a delay in scheduling the urology appointment. The Director of Nursing (DON) confirmed the discrepancy between the progress note and the actual referral recommendation. Interviews with staff revealed that it was the responsibility of the resident's nurse to ensure that documentation from consulting physicians was obtained and available for review. The deficiency was further highlighted when the resident reported successful removal of the indwelling urinary catheter, which was confirmed by a urology consultation. The facility eventually scheduled the urology appointment, but the initial failure to document and act on the physician's recommendation led to a delay in appropriate care for the resident.
Failure to Maintain Respiratory Care Equipment
Penalty
Summary
The facility failed to maintain respiratory care equipment for a resident who required continuous oxygen via nasal cannula. An observation on 1/10/24 at 9:14 AM revealed that the tubing or nasal cannula was neither initialed nor dated, and the prefilled humidifier with sterile water attached to the resident's oxygen concentrator was empty. The resident mentioned that the night shift nurse had informed them that there were no more prefilled humidifier water bottles available. A subsequent observation at 10:55 AM confirmed that the humidifier bottle remained empty, and the RN present verified that the sterile water was finished. The facility's oxygen administration policy, reviewed on 1/17/24, stated that the humidifying jar should have enough water to bubble as oxygen flows through. Interviews with staff indicated that the night shift nurse was responsible for changing the humidifier water weekly, and it should have been replaced on 1/10/24. The unit manager expected nurses to change the humidifier water whenever it was low or empty and should have been notified if there was no supply. However, the unit manager was not made aware of the shortage of prefilled humidifier water bottles.
Provider Visit Note Unavailable
Penalty
Summary
A facility provider failed to make their visit notes available after a visit with a resident. This was evident for one resident reviewed for provider visit note availability during a facility's revisit survey. The medical record review revealed that the resident received a new order for Ativan for Anxiety, but there was no evidence of a diagnosis of Anxiety in the resident's list of active diagnoses. An interview with the DON confirmed that the CRNP saw the resident but failed to provide a provider note detailing the visit. The surveyor expressed concern that the facility failed to place a provider visit note in the resident's medical record in a reasonable amount of time after the provider's visit.
Failure to Communicate Psychiatric Recommendations and Report Abnormal Behaviors
Penalty
Summary
The facility failed to ensure that recommendations from the psychiatric provider were reported to the primary care provider and did not report abnormal behaviors in a timely manner. This deficiency was evident in the case of a resident with a history of stroke, high blood pressure, diabetes, lung disease, and dementia. The resident had an order for a psychiatric consult in July, but there was no documentation indicating that the resident was seen as a result of this order. When the psychiatric nurse practitioner (NP) did see the resident on July 31st, the NP recommended starting a new medication, Buspar, for anxiety. However, there was no documentation to show that this recommendation was communicated to the primary care physician, and no order for Buspar was found in the medical record following the visit. The corporate nurse confirmed that the recommendation was not reviewed with the primary care providers, and no follow-up visits by the psychiatric NP were documented between August 1st and January 10th of the following year. Additionally, the facility failed to report abnormal behaviors exhibited by the resident in a timely manner. The resident was observed smearing feces on multiple occasions, a behavior that was documented by the Geriatric Nursing Assistants (GNAs) starting in mid-November. Despite this, the unit nurse manager was not aware of the behavior until January 11th, when it was first reported to her. The psychiatric NP was also not informed of the fecal smearing behavior until January 15th, when the resident was seen for an urgent visit. The NP noted that the resident had been smearing feces and deferred further medication adjustments until lab results were reviewed. The unit nurse manager confirmed that the resident's behavior had not been previously reported to her, and the psychiatric NP confirmed that she was not made aware of the behavior until the urgent visit. The facility also failed to hold an interdisciplinary care plan meeting for the resident since May of the previous year. The lack of communication and timely reporting of the resident's abnormal behaviors and the psychiatric NP's recommendations contributed to the deficiency. The Director of Nursing was made aware of these concerns, including the failure to follow up on the psychiatric NP's recommendation, the failure to notify the primary care provider, and the failure to report the incidents of fecal smearing to either the psychiatric or primary care provider.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,584 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Franklin Woods Center | 1 mi | ★★★★★ | 0 | 0 |
| Oakwood Snf Llc | 2.1 mi | ★★★★★ | 59 | 0 |
| Autumn Lake Healthcare At Riverview | 2.3 mi | ★★★★★ | 5 | 0 |
| Autumn Lake Healthcare At Overlea | 2.8 mi | ★★★★★ | 5 | 0 |
| Autumn Lake Healthcare Post-acute Care Center | 3.2 mi | ★★★★★ | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.