Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shady Grove Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with AFib, HTN, hypotension, and ESRD on HD had orders for Metoprolol ER with hold parameters and Midodrine PRN for hypotension. Nursing staff administered Metoprolol on multiple occasions despite BP readings above the hold threshold and failed to obtain and document BP every 8 hours for 14 days to determine whether Midodrine was indicated.
Incorrect MOLST Form Scanned Into Resident Record: A resident’s chart contained another resident’s MOLST form instead of the correct document that came with the resident from the hospital. The record review found the wrong form had been scanned into the resident’s EMR, creating a mismatch between the resident’s actual MOLST and the document in the chart.
Food storage and kitchen sanitation were not maintained in a safe and sanitary manner. A dining area refrigerator had dried spills, crumbs, and an unlabeled container, and the kitchen tour found a hand sink without cold water, missing cove base tiles, large drywall gaps, leaking drain lines from food prep sinks, unsecured 3-compartment sink faucets, and a conveyor dish machine with steam, vapor, heat, and mold-like buildup on nearby walls and caulk.
Medication administration and documentation were not handled according to procedure for multiple residents. A resident and another resident were observed self-administering meds without staff present, but there was no documentation that either had been assessed for self-administration. Two other residents had MAR entries showing missed or unclear doses, including blank entries and codes without supporting documentation. In another instance, an LPN administered several meds to a resident but documented them later all at once rather than at the time of administration.
A resident who wanted to leave AMA was reportedly blocked by staff from exiting with a family member, and staff told the resident they could not leave because a PICC line was in place. Nursing staff educated the resident about completing IV therapy and the risks of leaving, but the resident continued to insist on going home. A disagreement occurred when an unfamiliar individual arrived to pick up the resident, and law enforcement was contacted before the resident was cleared to leave.
A resident’s inhalers were ordered to be kept at the bedside, but the facility did not document an interdisciplinary assessment or care plan showing the resident was approved to self-administer medications. The resident reported staff removed the inhaler after surveyors arrived, and an LPN and UM later brought the inhaler for administration. The DON confirmed the required process had not been completed for the resident to self-administer meds.
Unsafe and Poorly Maintained Resident Rooms: Surveyors observed multiple room environment issues, including a running toilet, rusted sink, overflowing trash, stained privacy curtains, water-stained ceiling tiles, a dent behind a bed, and a flickering bathroom light. In other rooms, a windowsill was detached with a protruding nail, closet doors were damaged or missing, a toilet seat was missing, and bathroom walls had speckles; the ADM and Maintenance Director acknowledged the concerns.
The facility failed to provide written bed hold notice upon hospital transfer for two residents reviewed. One resident with decision-making capacity was transferred for a GI bleed, but the EHR did not show written bed hold information was given at transfer; instead, the DON produced an unsigned, undated form and an email sent only to the resident’s emergency contact. Another resident, identified as their own responsible party, also had no record of receiving written bed hold information when transferred, and the only documentation provided was a later SWA note stating the SW contacted the resident about the bed hold policy.
Failure to Provide Baseline Care Plan Summary: The facility did not provide a summary of the baseline care plan to the resident and/or the resident's representative for two residents reviewed. Records for one resident showed no evidence of receipt, and a meeting sign-in sheet only documented staff attendance. For another resident, the chart also lacked evidence that the summary was provided, and the DON and Discharge Planner acknowledged it was not.
A facility failed to hold care plan meetings with an interdisciplinary team for 3 residents reviewed. Attendance sheets showed only social services and the resident and/or RP were present, and the DON confirmed this was not the expected process for care planning after MDS completion.
Failure to provide timely skin treatment and document ordered care. One resident with a history of herpes reported sores in the private and buttocks areas with discomfort during urination, and an NP exam identified two new wounds with treatment recommendations, but the orders were not entered until a week later. Another resident at risk for pressure ulcers had wound care recommendations for pressure reduction, turning/repositioning, and elbow off-loading, but surveyors found no documentation that the cares were provided; the DON could not produce signed-off records.
A resident who was documented as totally dependent for bed mobility and needing 2-person assistance reported that a CNA woke him/her early in the morning and was rough during cares. PT notes and a provider note showed the resident required moderate to maximum assist of 2 for rolling and full staff performance for bed mobility, yet the facility’s investigation stated the CNA assisted the resident alone.
A resident receiving IV therapy had a central line dressing that was not changed according to MD orders. The resident reported the dressing had not been changed since admission, and the surveyor observed a loose, cloudy dressing with an old date on the site. The EHR showed orders for weekly dressing changes, weekly measurement of the catheter, and labeling/initialing after each change, but the dressing had not been maintained as ordered.
A resident with a care plan for pain related to falls and abdominal pain had PRN morphine ordered only for severe pain rated 7-10 and PRN tramadol ordered for pain. The MAR showed morphine was given when pain was rated 5/10, and tramadol was administered one minute later. The DON was interviewed about the two pain meds being given at the same time and one being given outside the ordered pain scale range.
A provider failed to accurately review and document the care plans, progress notes, and medication regimens for two residents. One resident’s psych notes listed Olanzapine at the wrong frequency and omitted Mirtazapine in one note, while the medical note later listed an outdated Olanzapine dose. Another resident’s progress note omitted active PRN pain meds, included an inactive lidocaine patch, and referenced lidocaine patches in the pain plan despite no active order.
Delayed Response to Resident Call Bell: Staff failed to respond promptly to a resident's call bell after the resident requested water and no water was at the bedside. A CNA and an LPN were observed nearby, but neither responded for 20 minutes; the CNA said she thought the call light was broken, and the LPN said she was passing medications. The DON stated call bells should be answered within 15 minutes and later said the system was functional and someone should have responded.
Expired Medications Found in Medication Storage Room: During survey observation of the Ambassador Unit medication room, multiple medications and inhalation products were found with expired dates or missing required open dates, including Breo Ellipta and Budesonide inhalation suspension. Some foil packs were opened without documented open dates, and the Nurse Unit Manager stated unit managers are responsible for weekly checks of the medication storage room for expired medications. The surveyor informed the Nurse Unit Manager and DON of the findings.
A resident with a dairy intolerance did not receive an adequate breakfast substitute when cheesy eggs were removed from the tray, leaving only cereal, milk, juice, coffee, and a biscuit with no protein. The resident said he/she wanted meat, eggs, or something of substance, and the dietitian later agreed the biscuit was not an equivalent replacement and that protein should have been included.
Inaccurate documentation was found for two residents. One resident with a central line reported the dressing had not been changed since admission, and the surveyor observed a loose, cloudy dressing while the chart showed weekly care had been documented as completed. Another resident’s NP note identified two new wounds, but the skin assessment records repeatedly documented no new skin conditions.
Infection control practices were not maintained in utility areas and during medication administration. A commercial-grade hand sink was missing from the soiled laundry room, the second-floor janitor's/soiled utility closet had a blocked mop basin and missing cleaning chemicals, and an LPN used the same portable BP cuff on multiple residents without disinfecting it between uses while administering medications.
Improper Airflow in Soiled Laundry Room: During an annual survey, the surveyor observed that the mechanically operated ventilation system in the soiled laundry room did not have negative pressure airflow. The Maintenance Director stated that replacement roof exhaust fans had been ordered, and the next day the surveyor verified that the fans had been delivered.
The facility failed to have a Medication Regimen Review policy with time frames for when urgent irregularity recommendations should be acted upon. Surveyors reviewed the pharmacy policy and found that while a consulted pharmacist was to complete monthly MRRs and report within 24 hours, the policy did not set a timeframe or standard for emergent needs. The policy stated that medication-related irregularities would be documented and reported to the DON, Medical Director, and/or prescriber as appropriate, with notification mode based on severity and consultation between the pharmacist and DON.
A resident left the premises without staff knowledge, was later found by a bystander bleeding from a fall at a nearby bus stop, and was transported by EMS to a hospital for a traumatic head injury after reporting use of an anticoagulant. Earlier that day, the DON and a unit manager had seen the resident outside in a wheelchair speaking with another person. During a fire drill and subsequent head count, staff discovered the resident was missing, searched the premises, and contacted family, eventually learning the resident had fallen off-site and been taken to the hospital. The DON reported that the incident was not reported to the State Agency because the resident was alert and oriented, not considered an elopement risk, did not require supervision, had decision-making capacity, and was located within about an hour.
A resident with a suprapubic catheter was observed on multiple occasions without the catheter tubing secured to the leg, leading to frequent disconnection and urine leakage that saturated bed linens. Despite available supplies, staff did not provide a securement device, and the resident reported ongoing discomfort and inconvenience.
Staff did not adhere to infection prevention protocols during perineal care for two residents with complex medical needs, including improper hand hygiene, failure to change gloves between tasks, use of double gloves, and inappropriate handling of catheter equipment and soiled materials. These actions were inconsistent with facility policy and were confirmed by both observation and staff interviews.
A resident with severe cognitive and physical impairments, fully dependent on staff, sustained a comminuted femur fracture after being transferred by a CNA using a mechanical lift without a second staff member, contrary to facility policy and manufacturer guidelines. The CNA acted alone due to a busy shift and space constraints, and there was confusion among staff regarding sling selection and compatibility. The injury was discovered after the resident showed signs of pain and swelling, highlighting failures in staff training, supervision, and adherence to transfer protocols.
A resident was found with multiple medications at bedside, including prescription and over-the-counter drugs, without documented assessment or authorization for self-administration as required by facility policy. The resident, who was cognitively intact and independent, expressed a desire to self-administer but had not been evaluated for this ability. Staff were unaware of the medications at bedside, and the care plan and physician orders did not address self-administration or bedside storage.
The facility did not assess nonverbal or cognitively impaired residents during an abuse investigation, despite policy requiring a thorough investigation of all potential victims. The DON confirmed that these residents were not evaluated, resulting in an incomplete investigation.
The facility exceeded the acceptable medication error rate when two LPNs administered insulin to a resident with diabetes without priming the Tresiba FlexTouch pen, as required by manufacturer instructions and facility policy. Staff interviews revealed a misunderstanding of proper insulin administration procedures, contributing to a 6.66% medication error rate.
Facility staff did not consistently review or update residents' care plans to reflect current interventions, particularly for those with respiratory needs, and failed to hold required annual and quarterly care plan meetings. Several residents were not given the opportunity to participate in care planning, and some were unaware of their care plans or discharge status. Staff confirmed that care plan meetings had not been completed as required, and documentation to support timely meetings was lacking.
Facility staff did not consistently report allegations of abuse, neglect, or theft to the state agency within the required two-hour timeframe. In several cases, reports were delayed or documentation of timely reporting was missing, and some final investigation results were not submitted within five working days. Interviews revealed confusion among staff regarding reporting requirements.
A resident who returned from the hospital with a leg fracture did not have a care plan developed to address the new diagnosis until several weeks after the injury. Although the physician assessed the fracture and discussed the plan with staff, the comprehensive care plan was not updated in a timely manner, as confirmed by the DON and Social Worker.
The facility did not provide required supervision or maintain accurate assessments for residents who smoke, resulting in residents using the smoking area unsupervised and without necessary safety equipment, despite documentation indicating some required supervision and/or a smoking apron. Staff interviews revealed a lack of awareness and inaccurate recordkeeping regarding residents' supervision needs.
Kitchen staff did not consistently label or date opened food items, left some foods uncovered in storage, and failed to ensure all staff wore proper hair coverings. Additionally, food was not thawed properly in the refrigerator, and exposed food items were observed during a survey.
Staff failed to follow professional standards by not completing or documenting required weights for a resident on GLP-1 medication, administering medications late to another resident, and not documenting PICC line dressing changes or correctly entering wound vac orders. Additionally, a resident with cognitive decline was not reevaluated for decision-making ability, and another was prescribed risperidone for an incorrect diagnosis, with the order later updated by a provider.
Staff failed to accurately document and update residents' personal belongings, with inventory forms not reflecting actual items present and missing grievance documentation. Medical records for several residents were incomplete or inaccurate, including missing or outdated smoking assessments, improper documentation of narcotic administration, and incorrect medication administration codes. Staff also signed off on care tasks before completion and maintained outdated orders, resulting in records that did not accurately reflect residents' current care or status.
A facility failed to establish and implement adequate written policies and procedures for investigating and reporting abuse allegations. The existing policy lacked guidance on identifying unobserved abuse, interviewing all involved parties, and specifying reporting timeframes. In one case, a resident who reported being assaulted and later diagnosed with a leg fracture was not interviewed as part of the facility's investigation, and the allegation could not be verified.
Facility staff did not complete thorough investigations into multiple alleged abuse incidents and an injury of unknown origin. In several cases, investigations lacked proper documentation, including missing or incorrect staffing sheets, absence of staff discipline identification, and failure to interview alleged victims or notify authorities. The DON was unable to provide required investigation files for some incidents, resulting in incomplete records.
Surveyors observed that several residents did not have their call bells within reach, with call bells found on the floor, hanging from the wall, or draped over the side of the bed. Staff interviews confirmed that GNAs are supposed to check call bell accessibility during rounds, but this was not consistently done, resulting in multiple residents being unable to easily request assistance.
A resident with multiple medical conditions and a need for assistance with dressing was repeatedly observed wearing a hospital gown instead of personal clothing, despite expressing a preference to wear their own clothes and having them available. Staff interviews confirmed the resident's need for help and preference, but the resident continued to be seen in a hospital gown during daily activities. The resident's foley bag was also observed on the floor without a privacy cover.
Staff did not consistently obtain or maintain copies of Advance Directives in resident medical records, nor did they always provide or document discussions and information about Advance Directives with residents or their representatives. In several cases, documentation was missing or incomplete, and staff confirmed that required records were not available.
A resident was discharged without receiving the required SNF Beneficiary Notice, which informs individuals of their Medicare/Medicaid coverage and potential financial liability for services not covered. Documentation review confirmed that the necessary notice was not provided prior to discharge, and staff acknowledged the oversight during the survey.
Staff did not ensure a homelike environment by failing to address multiple maintenance issues in resident rooms, including damaged drywall, rust, a leaking faucet, and broken furniture. These deficiencies were observed in several rooms across two units, despite the facility's system for reporting and scheduling repairs.
A resident who experienced an acute leg fracture and required pain management, orthopedic follow-up, and a knee immobilizer did not have this significant medical event accurately reflected in their quarterly MDS assessment. The MDS Coordinator did not update the assessment despite physician documentation, citing internal criteria for capturing new diagnoses. This resulted in an inaccurate assessment record.
Staff failed to complete required PASARR documentation for three residents, including missing Level II screenings when indicated and incomplete Level I forms, as confirmed by record review and staff interviews.
Two residents reported not receiving regular showers as scheduled, with one indicating they had not been offered a shower since admission. Review of electronic medical records showed no documentation of showers being provided, despite facility policy requiring showers to be offered twice weekly and refusals to be documented.
A resident with a history of recurrent UTIs did not receive a timely repeat urine culture after an initial sample was found to be contaminated and the lab recommended a repeat. The delay in obtaining a new sample led to a delay in diagnosis and treatment, as the repeat culture was not ordered until the resident's symptoms worsened.
Two residents did not receive nutrition in accordance with physician orders: one was not given double portions as prescribed, and another received regular texture fruit instead of the required mechanically altered consistency for dysphagia. Staff interviews and meal ticket reviews confirmed that dietary and kitchen staff did not ensure the correct diet orders were followed.
Facility staff failed to provide timely and appropriate pain management for two residents. One resident did not receive prescribed Oxycodone due to delayed medication reordering, resulting in unmanaged pain. Another resident with severe foot pain did not have their pain addressed because the care team was not informed and no pain management plan was documented.
A resident was observed using bilateral enabler bed rails without proper documentation of informed consent. Although the DON stated that consent is obtained before bed rails are used, the consent form did not specify from whom consent was obtained, and the DON could not identify the resident representative who provided consent. Staff are expected to document the name of the individual providing consent, but this was not done.
Failure to Follow BP Parameters and Document BP Before Cardiac Medications
Penalty
Summary
Nursing staff failed to follow physician orders for cardiac medications for one resident with atrial fibrillation, hypertension, hypotension, and end stage renal disease who was also receiving hemodialysis three times a week. The resident had an order for Metoprolol Succinate ER 12.5 mg daily for hypertension with instructions to hold the medication if systolic blood pressure was greater than 110 or heart rate was less than 55. Review of the May 2026 MAR showed the medication was administered on multiple dates even though the documented blood pressures were above the hold parameter, including readings of 120/75, 117/68, 137/72, 126/72, 126/70, 128/77, 118/80, 138/84, 138/76, and 149/84. The record also showed an order for Midodrine HCL 5 mg every 8 hours as needed for hypotension, with instructions to hold if systolic blood pressure was greater than 140 mm/Hg. Review of the May 2026 MAR revealed nursing staff failed to obtain and document the resident's blood pressure every 8 hours for 14 days to determine whether a dose of Midodrine was needed per the physician order.
Incorrect MOLST Form Scanned Into Resident Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for 1 resident reviewed during a complaint survey. Resident #3 was admitted to the facility with a MOLST form completed by the resident and the physician in the hospital on 05/07/2026 that traveled with the resident to the nursing home. On review of the clinical record, a different resident’s MOLST form had been scanned into Resident #3’s electronic medical record. The report states this was a different resident’s form and that it could pose a problem if that form were sent with Resident #3 to the hospital or a doctor’s appointment.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food storage and food service equipment were not maintained in a safe and sanitary manner. On 5/4/2026 at 8:10 AM, a surveyor observed a refrigerator in a dining area on the Ambassador unit with dried tan and red spills covering about one-third of the bottom of the refrigerator, along with crumbs. The same refrigerator also contained a container on the top shelf that lacked a name or date. On 5/8/2026 at 11:30 AM, the Administrator was shown the refrigerator location and a picture from the observation and acknowledged the concern, stating the spills occurred over the weekend. During the annual survey kitchen tour on 05/07/2026 at 9:00 AM, the surveyor and the Healthcare Services Group Regional Manager identified multiple sanitation and maintenance issues in the kitchen. The hand sink near the ware washing station was not dispensing cold water, multiple cove base tiles were missing, there were several 12-inch by 24-inch gaps or holes in the drywall in the kitchen and kitchen manager's office, and the drain lines for two food prep sinks were leaking grey water onto the kitchen floor. The two wall-mounted faucets of the 3-compartment sink were not securely attached to the wall, and the high temperature conveyor dish machine was observed releasing steam, vapor, and heat while the walls and caulked edges showed significant buildup of mold-like substances.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to obtain, document, and administer medications according to procedures that ensure accurate, safe dispensing for four residents. Resident #57 was observed taking pills without a nurse present, and Resident #57 stated that pills are not always left for self-administration. Resident #141 was observed pouring liquid into a nebulizer without staff present, and the family member stated the resident administers albuterol to take it immediately when needed. The DON later stated there was no documentation showing that either resident had been evaluated for self-administration of medications. The facility also failed to document medication administration accurately for Resident #98 and Resident #70. Resident #98 stated that the facility often ran out of medications, and review of the MAR showed lamotrigine and hydroxyzine entries that were left blank or coded without clear documentation of why the medications were not given. For Resident #70, an LPN was observed administering several medications, including a stool softener, probiotic, oral pain medication, and an inhaler, but the MAR showed voltaren external gel signed out in the same time slot even though its application was not observed at that time. The LPN stated medications were signed out together after all were given, and the UM confirmed that medications were expected to be documented at the time of administration.
Resident Prevented From Leaving AMA
Penalty
Summary
Facility staff failed to ensure a resident could exercise the right to leave the facility against medical advice without interference. Complaint #2807564 stated that the resident and the resident’s family member reported staff physically blocked the door and prevented them from leaving on their own, and that staff told the resident they could not leave because a PICC line was in place. The resident’s family member contacted local law enforcement during the incident. A progress note written by the ADON documented that the resident had been admitted to the facility and later expressed dissatisfaction with the care provided and a desire to leave and return home. Nursing staff educated the resident about the importance of staying to complete prescribed IV therapy and explained the risks associated with leaving, and staff also told the resident it was unsafe to leave with a PICC line due to safety and infection risks. The resident acknowledged understanding but continued to insist on leaving, and when an individual arrived to pick up the resident, a disagreement occurred and law enforcement was contacted. The ADON later stated the facility was not comfortable allowing the resident to leave with a PICC line while being escorted by an individual unfamiliar to the facility and asked the resident to remain until law enforcement arrived.
Failure to Document Assessment for Self-Administration of Bedside Inhalers
Penalty
Summary
The facility failed to document that the interdisciplinary team assessed and determined a resident was appropriate to self-administer medication. Resident #70 reported that after the survey team entered the building, staff removed the resident’s inhaler that had been kept at the bedside. During observation, an LPN and the UM brought the resident’s inhaler for administration and then left the room with it. The UM stated that residents could have inhalers left at the bedside and was not aware that Resident #70 wanted to do so. The DON explained that before a resident could self-administer medications and keep them at the bedside, an interdisciplinary team assessment and an order would be required. Review of the record showed orders for Fluticasone Propionate, one puff twice daily for wheezing, and Ventolin (albuterol), 2 puffs every 8 hours as needed for shortness of breath, both stating the medications may be kept at the resident’s bedside. However, no care plan or assessment was found for Resident #70 to self-medicate or keep medications at the bedside. In follow-up interview, the DON confirmed the facility had not completed the process for the resident to self-administer medications and stated she had started the process for Resident #70.
Unsafe and Poorly Maintained Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment with adequate lighting in 6 of 27 rooms observed during the initial tour and throughout the recertification survey. In one room, the bathroom had a running toilet, a rusted sink, a bucket of fluid beneath the sink, an overflowing trashcan, and a tied bag of trash with rags lying on the floor. In another room, the privacy curtains were stained and water stains were present on the ceiling tiles. A different room had a large dent behind the head of Bed A, and another room had a flickering light in the bathroom. The Administrator and Maintenance Director acknowledged these concerns during the survey. Additional observations showed disrepair in resident rooms. One resident's windowsill had detached from the wall, and about one inch of nail was protruding from it. In another resident's room, one armoire closet door was missing and the other was falling off its hinges. The resident also stated the toilet seat was missing, which the surveyor verified, and multiple speckles were observed on the bathroom wall. The Maintenance Director confirmed the windowsill, closet, toilet seat, and wall condition issues during the survey.
Failure to Provide Written Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to ensure residents received written bed hold notice upon hospital transfer for 2 of 4 residents reviewed for discharge process. One resident was transferred to the hospital in April 2026 for a gastrointestinal bleed and stated during interview that they did not receive bed hold notice information at the time of transfer. The resident had decision-making capacity at the time of transfer, but the electronic health record did not show evidence that written bed hold information was provided when the resident left the facility. The DON later produced an unsigned, undated bed hold form that was reportedly sent with the resident, along with an email sent only to the resident’s emergency contact. A second resident was transferred to the hospital in April 2026 and was identified in the record as their own responsible party at the time of transfer. Review of the electronic record did not show evidence that written bed hold information was provided to the resident upon transfer. When documentation was requested, the DON provided a Social Worker Assistant progress note dated 05/06/26 stating that the Social Worker contacted the resident on 05/05/2026 regarding the facility’s bed hold policy.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide the resident and/or the resident's representative with a summary of the baseline care plan for 2 of 5 residents reviewed for baseline care plans during the annual survey. During an interview, the DON stated that the admitting nurse initiates the baseline care plan at bedside with the resident and/or the resident's representative and that a summary is provided, with the unit manager responsible for ensuring the baseline care plans are completed and uploaded into the EHR. For one resident admitted in March 2026, the EHR did not show evidence that a summary of the baseline care plan was provided to the resident and/or representative. The DON later provided a sign-in sheet for the baseline care plan meeting, which showed signatures from an RN supervisor and an RN, but no signature from the resident or the resident's representative. For another resident admitted in October 2024, the record also failed to show evidence that a summary of the baseline care plan was provided to the resident and/or the resident's representative, and both the DON and the Discharge Planner acknowledged that it had not been provided.
Care Plan Meetings Not Held With Interdisciplinary Team
Penalty
Summary
The facility failed to hold care plan meetings composed of an interdisciplinary team after completion of the MDS assessment for 3 of 3 residents reviewed for care planning, identified as Resident #10, #11, and #55. Survey review of the residents’ care plan attendance sheets showed that the meetings held for these residents included only two attendees: one person from the social service department and the resident and/or the Responsible Party. The attendance sheets reviewed were dated 2/20/26, 3/24/26, and 3/10/26. During an interview on 5/6/26 at 1:23 PM, the DON confirmed that care plan meetings should be conducted with an interdisciplinary team and that having only social services staff present was not the expectation.
Failure to Provide Timely Skin Treatment and Document Ordered Care
Penalty
Summary
The facility failed to provide timely treatment and care for a resident with documented skin issues. One resident reported a history of herpes and blisters in the private and buttocks areas that caused discomfort with urination, and stated that a request for medication had been made to the physician in February 2026 but was not successfully addressed. A record review showed the resident was immunocompromised and had been seen by an NP for a comprehensive skin exam, where the resident reported sores present since February, discomfort with urination, and no current treatment. The exam identified two new wounds in the private area and buttocks, with treatment recommendations noted, but the orders were not entered until a week after the NP visit. The facility also failed to document that ordered skin-related care was provided for another resident. That resident’s care plan identified risk for worsening pressure ulcers related to frequent incontinence, immobility, and inability to turn and reposition independently. A weekly wound care note documented that the resident was at high risk for skin breakdown related to decreased mobility and comorbidities and recommended ongoing pressure reduction and turning/repositioning precautions per protocol, including careful off-loading of the elbow off the edge of the bed. Survey review did not find documentation that these cares were provided, and the DON stated that the resident needed to be turned and repositioned often but could not provide documentation that the cares were signed off on or provided.
Failure to Provide Required Two-Person Assistance During ADL Care
Penalty
Summary
The facility failed to adequately assist a dependent resident during ADL cares. During an interview, the resident stated that over the weekend a CNA woke him/her in the early morning and was rough while providing cares. The concern was reported to the DON by the surveyor. The resident’s record showed a PT evaluation and therapy services were ordered, and PT documentation described the resident as needing moderate to maximum assistance of 2 staff for bed mobility training, including rolling left and right. The record also included a provider note documenting the resident’s bed mobility self-performance as totally dependent, requiring full staff performance, and stating that rolling left to right and from lying on the back to either side and back again was dependent, with the helper doing all of the effort or requiring 2 or more helpers. The facility’s investigation concluded the abuse allegation was unsubstantiated and stated that CNA #11 assisted the resident by herself. The DON was interviewed about the concern that the resident was not assisted with 2 staff members as identified in the plan of care during cares provided by the CNA.
Failure to Change Central Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure central line dressings were changed according to physician orders for one resident receiving IV therapy. Resident #117 reported that a central line had been placed while hospitalized and stated the dressing had not been changed since admission to the facility. During observation, the surveyor noted a loose, cloudy dressing covering the central line site, and the dressing was dated 04/07/2026. Review of the resident’s electronic health record showed admission to the facility and physician orders directing staff to change the needless device weekly and as needed, measure the external portion of the central line catheter weekly during dressing changes, and change the transparent dressing weekly during the evening shift. The orders also directed staff to initial and label the dressing after each dressing change. The Director of Nursing explained the facility’s process for central line management, and the surveyor informed her of the observed dressing condition for Resident #117.
Pain Medication Given Outside Ordered Pain Scale and at the Same Time
Penalty
Summary
Safe, appropriate pain management was not provided for Resident #5, who had a care plan revised on 3/5/26 identifying a risk for pain related to a history of falls and abdominal pain, with an intervention to administer medication as ordered. The resident had morphine sulfate 15 mg tablets ordered every 6 hours as needed for severe pain rated 7-10 and tramadol 50 mg tablets ordered every 6 hours as needed for pain. Review of the May MAR showed that on 5/3/26 at 7:27 PM, the resident rated pain as 5 out of 10, yet morphine sulfate was administered even though the order specified use only for severe pain rated 7-10. Tramadol was then administered one minute later at 7:28 PM. On 5/8/26 at 6:00 AM, the DON was interviewed and the concern was reviewed that the two pain medications were given at the same time and that one medication was given outside the pain scale range in the instructions.
Provider Notes and Medication Reviews Were Inaccurate for Two Residents
Penalty
Summary
The medical provider failed to review the resident’s total program of care and accurately document progress notes and medication orders for 2 residents. For one resident, a care plan created for acute signs and symptoms of delirium and risk for adverse reactions related to antipsychotic medications included psychiatric services as needed. The resident’s medication record showed Mirtazapine 7.5 mg nightly and Olanzapine 2.5 mg nightly, later reduced to 1.25 mg nightly in November 2025. However, psychiatric notes documented the Olanzapine dose as 1.25 mg twice a day, and one note did not mention Mirtazapine. Later psychiatric notes continued to list Olanzapine as twice daily, and the medical provider note dated 5/1/26 listed Olanzapine as 2.5 mg nightly, which had not been given since the dose reduction. For another resident, a revised care plan identified risk for pain related to a history of falls and abdominal pain, with an intervention to administer medication as ordered. The resident had active orders for morphine sulfate 15 mg every 6 hours as needed for severe pain and tramadol 50 mg every 6 hours as needed for pain. In the provider progress note dated 4/29/26, the provider documented no change in the resident’s reported pain, but the medication list omitted morphine and tramadol, included a lidocaine patch order that was not active, and the pain plan referenced lidocaine patches. During interview, the DON reviewed the concern that the provider’s notes were not accurate in documenting the plan of care.
Delayed Response to Resident Call Bell
Penalty
Summary
The facility failed to provide sufficient staff to respond to the call system promptly for Resident #14. On 05/04/2026 at 7:44 AM, Resident #14 told the surveyor, "I'm thirsty, I need water," and no water was observed at the bedside. The resident was encouraged to use the call bell to request water, and the surveyor heard the call bell activate with the light on in the room and above the room door in the hall. CNA #8 was observed sitting at the nurse's station outside the room, and LPN #9 was observed at the medication cart in the hall near the room, but no one responded to the call light for 20 minutes. When asked why she did not respond, CNA #8 stated she saw the call light hanging off the wall and thought it was broken, while LPN #9 stated she was passing medications. The DON later stated she expected the call bell to be answered in a maximum of 15 minutes and then stated the call system was functional and someone should have responded.
Expired Medications Found in Medication Storage Room
Penalty
Summary
Expired medications were found in the medication storage room on the Ambassador Unit during the annual survey. An observation of the room revealed multiple medications and biologicals that were past their labeled expiration dates or did not have required open dates documented, including Breo Ellipta inhalation powder with pharmacy instructions to discard six weeks after opening but an opening date of 09/10/2025, Budesonide inhalation suspension with a pharmacy issue date of 10/31/2023 and an expiration date of 04/2025, and Budesonide inhalation suspension packages with opened foil packs that had no open date documented. The room also contained Enoxaparin sodium injection with an expiration date of 03/2026, Breo Ellipta with an expiration date of 02/2026, and Juven with a manufacturer use-by date of 04/01/2026. The observation also identified Budesonide inhalation suspension in a box with five foil packs, two of which were opened, and another Budesonide inhalation suspension package with four foil packs, one opened and no open date documented. During interview, the Nurse Unit Manager stated that unit managers are responsible for weekly checks of the medication storage room for expired medications. The surveyor informed the Nurse Unit Manager and the DON of the expired medications observed in the medication room.
Failure to Provide an Appropriate Breakfast Substitution for a Resident With Dairy Intolerance
Penalty
Summary
The facility failed to accommodate a resident's dairy intolerance by not providing an alternative breakfast option with similar nutritional value. Resident #43 reported not receiving substantial food at breakfast and stated that he/she had a dairy intolerance but continued to receive milk. During observation, the resident's breakfast tray contained rice crunchie cereal, 2% milk, orange juice, coffee, and a biscuit with jelly and margarine, and no source of protein was present. The resident stated a desire for meat, eggs, or something of substance. Staff #27 later confirmed that cheesy eggs had been removed from the tray because of the resident's dairy intolerance and acknowledged that the biscuit was not an equivalent substitution to the eggs and that the resident should have received protein with breakfast.
Inaccurate Documentation of Central Line Care and Skin Assessments
Penalty
Summary
Facility staff failed to ensure accurate documentation of treatments provided to a resident with a central line. Resident #117 reported that the central line had been placed while hospitalized and stated the dressing had not been changed since admission to the facility. During observation, the surveyor saw a loose, cloudy dressing over the central line site, and the dressing was dated 04/07/2026. The resident’s record showed physician orders for weekly and as-needed needleless device changes, weekly measurement of the external catheter portion during dressing changes, weekly transparent dressing changes on the evening shift, and initialing and labeling after each dressing change. The record also showed staff documented completion of the weekly task from 04/13/2026 through 05/05/2026. Facility staff also failed to ensure accurate skin assessment documentation for Resident #83. The Nurse Practitioner documented on 04/28/2026 that the resident had two new wounds during a comprehensive skin exam, but the skin assessment documentation recorded no new skin conditions on 04/24/2026, 04/28/2026, and 05/01/2026. The Director of Nursing acknowledged the concern during the survey review.
Infection Control Lapses in Utility Areas and Medication Administration
Penalty
Summary
The facility failed to maintain infection prevention and control practices in the soiled laundry room and second-floor janitor's/soiled utility closet. During the annual survey, a commercial-grade hand sink was not present in the soiled laundry room, and a utility sink was located in the corner of the room near the paper towel and soap dispensers. The Administrator confirmed that the utility sink was being used for the mop and mop bucket and acknowledged that a commercial-grade hand sink would be installed. On the second floor, the mop basin in the janitor's/soiled utility closet was blocked by a toilet placed in the unit, and the cleaning chemicals in the wall-mounted dispensers were missing. Staff #19 stated that housekeeping technicians were not using the second-floor janitor's/soiled utility closet, and the Administrator and Staff #19 confirmed the closet would be properly maintained for cleaning supplies and chemicals. The facility also failed to use proper infection control technique during medication administration. An LPN prepared medications for one resident, took that resident's blood pressure with a portable blood pressure machine, and then returned to the medication cart when the resident requested to take the medications later. The same LPN then used the same blood pressure cuff on two other residents without disinfecting it between residents, and then prepared and administered medications to one of them. When interviewed, the LPN stated she should have wiped the blood pressure equipment between residents, and the DON was informed of the observations.
Improper Airflow in Soiled Laundry Room
Penalty
Summary
The facility failed to ensure proper airflow in the soiled laundry room. During the annual survey, the surveyor toured the clean and soiled laundry rooms with the Administrator, Maintenance Director, and Environmental Services Director and observed that the mechanically operated ventilation system in the soiled laundry room did not have negative pressure airflow. The Maintenance Director stated that an order for replacement roof exhaust fans had been placed. On the following day, the surveyor verified that the roof exhaust fans had been delivered to the facility, and the Maintenance Director and Administrator acknowledged that installation of the fans would ensure adequate airflow throughout the premises.
Missing Timeframes for Urgent Medication Regimen Review Reporting
Penalty
Summary
The facility failed to have a Medication Regimen Review policy in place with time frames identifying when irregularity recommendations with urgent need should be acted upon. During review of the facility’s pharmacy policies, surveyors found that this issue was evident in 1 of 3 pharmacy policies reviewed. The Medication Regimen Review policy stated that a consulted pharmacist would complete the review at least monthly and provide the report to the facility within 24 hours. The policy also stated that resident-specific irregularities and/or clinically significant medication-related risks would be documented in the medical record and reported to the DON, Medical Director, and/or prescriber as appropriate. However, the policy only stated that the notification mode depended on the severity of the irregularity and would be determined through consultation between the consult pharmacist and the DON. On review of the concern, the surveyor noted that the medication regimen review policy had no timeframe or standard for reporting emergent needs, and at exit no additional facility policy was provided for review.
Failure to Report Resident Elopement With Injury to State Agency
Penalty
Summary
The facility failed to report to the State Agency (OHCQ) an incident of elopement involving one resident. According to the complaint, the resident left the facility premises without staff knowledge, sustained an injury from a fall, and was transported to a hospital. EMS documentation showed that a bystander found the resident bleeding from a fall, assisted the resident to a sitting position, and called 911. EMS assessed the resident as alert and oriented x4, documented that the resident reported being on an anticoagulant, determined that the resident had a traumatic head injury, and transported the resident to a hospital that provides care for traumatic injuries. An aerial map review showed that the bus stop where the resident fell was 335 feet from the facility’s front door. Interviews revealed that on the day of the incident the DON and a Unit Manager observed the resident outside in front of the facility in a wheelchair speaking to a female. Later that day, during a fire drill and subsequent head count, staff realized the resident was not in the facility and initiated a search, determining the resident was not on the premises. The RN Supervisor contacted the resident’s spouse and another family member to locate the resident and learned from a family member that the resident had fallen at a bus stop off facility grounds and had been taken to a hospital by ambulance. During an on-site observation, the NHA stated that the resident had left the wheelchair, ambulated to the bus stop, and fell there. In a subsequent interview, the DON stated that the incident was not reported to OHCQ because the resident was alert and oriented x4, did not require supervision, had decision-making capacity, was not considered an elopement risk, and was located within one hour of being found missing.
Failure to Secure Suprapubic Catheter Resulting in Dislodgement and Urine Leakage
Penalty
Summary
The facility failed to ensure proper securement of a suprapubic catheter for one resident with paraplegia and multiple urinary and renal diagnoses. Observations on two consecutive days revealed that the resident's suprapubic catheter tubing was not secured to the leg with an anchor or stabilization device, as required. The resident reported discomfort and frequent disconnection of the tubing, which led to urine leakage and saturation of bed linens. The care plan for the resident included interventions related to catheter care but did not address the need to assess securement of the tubing. Interviews with staff indicated a lack of communication and follow-through regarding the provision of securement devices. Central Supply confirmed that securement devices were available and had not been requested, while the Unit Manager stated that devices were kept in a locked office and could not explain why one had not been provided to the resident. The resident continued to experience issues with catheter dislodgement and urine leakage due to the absence of a securement device.
Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
Staff failed to follow the facility's infection prevention and control program during perineal care for two residents with complex medical needs, including suprapubic catheters and pressure ulcers. Observations revealed that staff did not perform proper hand hygiene between glove changes, used double gloving instead of single gloves, and did not change gloves when moving between contaminated and clean body sites. In one instance, staff wiped the resident's genitals and buttocks without changing gloves or performing hand hygiene, and failed to apply a moisture barrier after care. Additionally, soiled incontinence pads were handled in a manner that could spread contamination, and catheter care was performed without appropriate handwashing or glove changes. For another resident, staff did not perform hand hygiene before donning gloves and handled catheter collection bags inappropriately by placing them in a trash can and then reusing them. Wash cloths for perineal care were placed on an unprotected chair, and staff touched soiled briefs and then their own hands without changing gloves. During perineal care, staff wiped fecal matter and then the resident's back with the same gloves, further violating infection control protocols. These actions were inconsistent with the facility's policies, which require handwashing at appropriate times, glove changes between contaminated and clean sites, and the use of protective barriers during care. Interviews with staff and management confirmed a lack of adherence to established infection control procedures. Staff admitted to not using basins with soap and water for catheter care, double gloving due to misunderstanding, and not following proper glove and hand hygiene protocols. Management acknowledged the deficiencies and described the correct procedures, indicating that staff actions during the observed care did not meet facility expectations or policy requirements.
Failure to Follow Mechanical Lift Policy Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow both facility policy and manufacturer guidelines for the use of a mechanical lift during the transfer of a resident who was completely dependent on staff for all activities of daily living and mobility. The facility's policy required two trained staff to assist with mechanical lift transfers and to follow the manufacturer's guidelines. However, a certified nursing assistant (CNA) transferred the resident alone, despite knowing the policy, due to a hectic workday and the perception that other staff were unavailable. The CNA also reported that the resident's room was small and not suitable for transferring with both the mechanical lift and the chair present, leading her to move the chair into the hallway and maneuver the resident out of the room by herself. The resident involved had severe cognitive and physical impairments, including anoxic brain damage, hemiplegia, contractures, and was bedbound. The resident was unable to communicate pain verbally and was highly dependent on staff for care. During the transfer, the CNA reported that the resident exhibited jerking movements, but she believed she had prevented the resident from coming into contact with any objects. The CNA also selected a sling for the lift based on her own judgment, without clear guidance or oversight, and there was confusion among staff regarding the compatibility and sizing of slings and lifts. Interviews revealed that staff were not consistently trained or observed in the use of mechanical lifts, and there was a lack of clarity about which slings should be used with which lifts, as well as how to select the appropriate sling size. Following the transfer, the resident was found to have a severely comminuted and displaced fracture of the right femur, which required hospital transfer and treatment. Documentation and interviews indicated that the injury was discovered after staff noticed swelling, warmth, and discoloration of the resident's leg, and the resident exhibited facial expressions of pain. The incident was further complicated by inconsistent training, lack of oversight, and confusion regarding equipment use, as well as the failure to adhere to the facility's own policy requiring two staff for mechanical lift transfers.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to assess and properly authorize a resident for self-administration of medication, despite the presence of multiple medications at the resident's bedside. Facility policy required that residents requesting to self-administer medication undergo a safety assessment and interdisciplinary team review before being permitted to keep medications at bedside. However, the resident in question had medications including trazadone, Tylenol ES, Imodium, saline nasal spray, and Aspercreme at their bedside without any documented assessment, care plan intervention, or physician order allowing self-administration or bedside storage of these medications. The resident, who had a history of depression, GERD, and facial fractures, was cognitively intact and functionally independent according to the most recent MDS. The resident reported using trazadone at bedtime and Tylenol for pain, and expressed a desire to self-administer medication, but stated they had not been assessed for this ability by nursing staff. The care plan only directed staff to administer medications as ordered and did not address self-administration. Medication orders did not include permission for bedside storage or self-administration, and some medications present at the bedside were not listed in the active orders. Multiple staff members, including RNs and CNAs, reported being unaware of any medications at the resident's bedside and had not observed or reported them during their assigned shifts. When the medications were eventually discovered, staff acknowledged that medications should not have been present at the bedside without proper assessment and authorization. The DON confirmed that only one resident in the facility had been assessed and approved for self-administration, and it was not this resident.
Failure to Assess Nonverbal and Cognitively Impaired Residents During Abuse Investigation
Penalty
Summary
The facility failed to ensure that nonverbal and/or cognitively impaired residents were assessed during an abuse investigation. According to facility policy, the Administrator and/or Director of Nursing (DON) are required to immediately initiate a thorough internal investigation of any alleged abuse, which includes collecting evidence and interviewing alleged victims and witnesses. In this case, a resident reported physical abuse, prompting the suspension of a male staff member and interviews with staff and other residents on the same hallway. However, the investigation documentation revealed that two residents were unable to speak and one was unable to answer, and there was no evidence that these nonverbal or cognitively impaired residents were assessed as part of the investigation. During an interview, the DON confirmed that she could not verify whether nonverbal or cognitively impaired residents were assessed during the investigation. She acknowledged that she should have assessed these residents and admitted that a thorough investigation was not completed. The facility's failure to include assessments of nonverbal and cognitively impaired residents during the abuse investigation constituted a deficiency in following their own investigative protocols.
Failure to Prime Insulin Pen Results in Medication Errors Above 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with 2 errors identified out of 30 observed opportunities, resulting in a 6.66% error rate. Both errors involved the administration of insulin using a Tresiba FlexTouch pen to a resident with type 2 diabetes mellitus and a history of daily insulin use. During two separate medication passes, LPNs prepared and administered the insulin without priming the needle, contrary to the manufacturer's instructions and facility policy, which require priming to ensure accurate dosing. Interviews with staff revealed a lack of understanding regarding the necessity of priming the insulin pen, with one LPN stating it was unnecessary and the ADON initially supporting this view to avoid wasting insulin. However, upon reviewing the manufacturer's instructions, the ADON acknowledged that priming should occur before administration. The DON also confirmed the expectation that air should be removed from the needle prior to insulin administration. These actions and inactions led to the identified medication errors affecting a resident with moderate cognitive impairment and a diagnosis of diabetes mellitus.
Failure to Review, Revise, and Conduct Timely Care Plan Meetings
Penalty
Summary
Facility staff failed to ensure that residents' person-centered care plans were reviewed and revised in response to current interventions, particularly for those with complex respiratory needs. For example, one resident with chronic respiratory failure and a tracheostomy did not have their care plan updated to reflect current respiratory therapy recommendations, such as specific trach care procedures, oxygen requirements, and emergency protocols. Additionally, physician orders for certain respiratory interventions were missing from the care plan, and the care plan did not include all necessary details to address the resident's current condition. The facility also failed to consistently offer residents the opportunity to participate in the care planning process by not holding required annual and quarterly care plan meetings. Multiple residents' records showed significant gaps between care plan meetings, with some not having a meeting for nearly a year despite quarterly MDS assessments being completed. Documentation to support that care plan meetings were held in a timely manner was not provided when requested, and interviews with staff confirmed that care plan meetings had not been consistently conducted as required. Further, some residents were unaware of their plan of care or had not been involved in discharge planning discussions. In one case, a resident reported not being informed about their care plan or discharge status, and another resident's complaint about missing property and lack of discharge planning assistance was not substantiated with documentation. Staff interviews revealed that the facility had only recently identified these deficiencies and acknowledged that care plan meetings were not being completed as required.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
Facility staff failed to notify the state agency of allegations of abuse, neglect, or theft within the required two-hour timeframe in multiple cases. In six out of twelve facility-reported incidents reviewed, staff either delayed reporting or did not provide documentation showing timely notification. Specific incidents included allegations of sexual abuse, physical abuse, and injury of unknown origin. In several cases, the initial reports to the state agency were submitted several hours after staff became aware of the allegations, exceeding the mandated two-hour window. Additionally, some final investigation reports were not submitted within the required five working days. Interviews with facility leadership, including the Administrator and Director of Nursing (DON), revealed a lack of understanding or inconsistent application of the reporting requirements. Some staff believed only confirmed injuries or certain categories of incidents required immediate reporting, while others reported all incidents by the end of the day. Documentation reviews confirmed that in several cases, the facility either failed to report within the required timeframe or could not provide evidence of timely reporting, as required by regulations.
Failure to Timely Develop Care Plan for New Diagnosis
Penalty
Summary
The facility failed to develop a care plan to address a resident's new medical diagnosis following a leg fracture. After the resident sustained a leg fracture and was transported to the emergency department, they returned to the facility, where the physician assessed the injury and discussed the assessment and plan with staff. However, a review of the resident's medical records revealed that the comprehensive care plan did not address the leg fracture until several weeks after the incident. Interviews with the DON and Social Worker confirmed that care plans were not being completed during this period, and no care plan was developed for the resident's fracture in a timely manner.
Failure to Provide Supervision and Accurate Assessments for Smoking Residents
Penalty
Summary
The facility failed to ensure appropriate precautions and supervision for residents who smoke, as well as to maintain accurate and updated smoking assessments and care plans. Observations revealed that residents were smoking outside without staff supervision during times not designated for supervised smoking, despite posted schedules indicating when supervision should occur. Multiple residents were seen possessing their own smoking materials and using the smoking area without staff present. The facility's smoker list, as of 2/26/2025, indicated that all residents identified as smokers did not require supervision or special equipment, but further review of medical records showed discrepancies. Specifically, some residents required supervision and/or a smoking apron, and one resident had no smoking assessment at all. Interviews with recreation staff and the DON revealed a lack of awareness regarding which residents required supervision or equipment while smoking. Staff stated that no residents needed supervision or aprons, contradicting documentation and medical records. The DON confirmed that nursing staff were not completing smoking assessments accurately or updating them to reflect residents' current needs. The facility's process for updating the smoker list during morning meetings was not effective in ensuring accurate and current assessments, leading to residents being unsupervised while smoking despite documented needs for supervision and safety equipment.
Improper Food Storage, Labeling, and Staff Hygiene in Kitchen
Penalty
Summary
Kitchen staff failed to properly store and label food items, did not ensure all staff wore appropriate hair coverings, and did not thaw food correctly in the refrigerator. During a kitchen tour, a dietary aide was observed with exposed hair while wearing a knitted hat. The freezer contained multiple opened, unlabeled, and undated food items, including pepperoni, veggie patties, hot dogs, breaded oysters, tilapia, and shrimp, with some items left uncovered. In the refrigerator, there was undated and exposed American cheese and a box of un-thawed chicken on a sheet pan with a red substance. These issues were observed and brought to the attention of dietary staff and the kitchen manager during the survey.
Failure to Adhere to Professional Standards in Physician Orders, Medication Administration, and Documentation
Penalty
Summary
Facility staff failed to adhere to professional nursing standards in several key areas, including the implementation of physician orders, medication administration, and documentation. For one resident, weekly weights ordered for monitoring GLP-1 medications were not documented on multiple occasions, and there were no nursing notes explaining the missed weights. Another resident experienced repeated late administration of scheduled medications, with documentation showing significant delays beyond the expected administration window. The DON confirmed that nurses are expected to follow physician orders and administer medications within a specific timeframe, but could not provide explanations for the lapses. Additional deficiencies were identified in wound care management and documentation. One resident with a PICC line had no documented dressing changes from the time of insertion until discontinuation, despite standard practice requiring weekly and as-needed changes. The same resident also had a wound vac order that was incorrectly entered, resulting in a missed dressing change at the start of the order period. The DON acknowledged these errors and confirmed that the orders should have been implemented as written. Further review revealed failures in the assessment and documentation of residents' decision-making abilities and medication indications. A resident with significant cognitive decline, as indicated by a low BIMS score on the MDS assessment, was not reevaluated for decision-making capacity as required. Another resident was prescribed risperidone with an indication of schizophrenia, but the medical record only supported a diagnosis of schizoaffective disorder. The psychiatric provider noted the discrepancy and later updated the medication order to reflect the correct diagnosis.
Deficient Documentation and Inaccurate Medical Records
Penalty
Summary
Facility staff failed to accurately document and maintain records of residents' personal belongings, as evidenced by the case of a resident whose inventory forms indicated no belongings, despite the presence of clothing in their room. Additionally, there was no grievance form on file regarding the resident's missing shoes, and inventory sheets were not updated when new items were brought in. This demonstrates a lack of adherence to procedures for tracking and safeguarding resident property. The facility also did not maintain accurate and up-to-date medical records for several residents. Discrepancies were found in the documentation of smoking assessments and equipment needs, with some residents requiring supervision or special equipment for smoking not properly documented in their records. Furthermore, a resident's narcotic medication was administered after the order had been discontinued, and the administration was not recorded in the electronic medical record due to the discontinued status. In another instance, an LPN inaccurately documented medication administration codes, marking residents as sleeping instead of indicating that medications were given. Additional deficiencies included staff signing off on care tasks, such as showers, before they were completed, and maintaining outdated or inaccurate orders in residents' records, such as orders for oxygen or tube feeding that were no longer applicable. These actions and omissions resulted in medical records that did not accurately reflect residents' current status or care provided, failing to meet accepted professional standards for recordkeeping.
Failure to Develop and Implement Comprehensive Abuse Investigation and Reporting Policies
Penalty
Summary
The facility failed to develop and implement comprehensive written policies and procedures for investigating and reporting allegations of abuse. The existing abuse policy did not provide guidance on how staff should identify abuse that was not directly observed, nor did it outline procedures for interviewing all relevant parties, including the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the incident. Additionally, the policy lacked specific timeframes for reporting alleged abuse. Interviews with the DON and Administrator revealed inconsistent understanding of reporting requirements, with the DON stating that only confirmed injuries were reported within 2 hours and other allegations by the end of the day, while the Administrator indicated all incidents were reported within 24 hours and those with bodily injuries within 2 hours. A review of an incident involving a resident who was hospitalized for a scheduled leg fracture repair surgery revealed further deficiencies. The resident had reported to a hospital nurse liaison that they were assaulted by a staff member, resulting in a leg fracture. The facility's incident report showed that the alleged victim was not interviewed, and the allegation of abuse could not be verified. The resident stated that they had informed the Unit Manager about the incident and requested hospital transport due to ongoing leg pain, but initial x-rays at the facility did not show a fracture. The lack of a thorough investigation and failure to interview the alleged victim contributed to the deficiency.
Failure to Conduct and Document Thorough Abuse Investigations
Penalty
Summary
Facility staff failed to conduct thorough investigations into alleged incidents of abuse and an injury of unknown origin, as evidenced in four out of twelve facility-reported investigations reviewed during the recertification survey. In one case, a resident reported an alleged incident of sexual abuse, but the investigation lacked clear identification of staff interviewed, and the staffing sheet provided did not correspond to the date of the alleged incident, making it impossible to confirm a comprehensive investigation. The Director of Nursing (DON) acknowledged completing the investigation but could not provide adequate documentation to verify the process. The facility's standard for a thorough investigation, as described by the Administrator, includes interviewing all present staff and witnesses, but this was not demonstrated in the documentation provided. In another case, an alleged assault resulting in a fracture was reported, but the facility failed to interview the alleged victim and did not notify law enforcement or required agencies. Additionally, for two other incidents involving allegations of abuse, the facility was unable to provide any investigation documentation or related records when requested by the surveyor. The DON confirmed the inability to locate these files and acknowledged the facility's responsibility to maintain thorough and accurate records for all reported incidents.
Failure to Ensure Resident Access to Call Bells
Penalty
Summary
Facility staff failed to ensure that residents had access to their call bells to notify staff for assistance when needed. During initial observation rounds, multiple residents were found without their call bells within reach. Specific instances included call bells found on the floor near beds, hanging from the call bell system on the wall, or draped over the side of the bed. These observations were confirmed by Geriatric Nursing Assistants (GNAs) present at the time. The issue was observed with seven residents during the survey period. Interviews with staff revealed that GNAs are expected to check on residents and ensure call bells are close to them during their rounds. However, despite these procedures, several residents were still found without accessible call bells. The Director of Nursing was made aware of the situation after the surveyor's findings. The deficiency was identified based on direct observations and staff interviews, indicating a lapse in ensuring residents' ability to request assistance when needed.
Resident Preference for Personal Clothing Not Honored
Penalty
Summary
Facility staff failed to ensure that a resident was dressed in their personal clothing as preferred, despite the resident having personal clothing available in their closet. Multiple observations over several days showed the resident awake in bed, eating lunch, and waiting for breakfast while wearing a hospital gown. The resident was admitted with multiple medical conditions, including generalized weakness, and required assistance with personal care and dressing. Interviews confirmed that the resident preferred to be out of bed and dressed in their own clothing, and staff acknowledged the resident's need for assistance. Despite these preferences and needs, the resident continued to be observed in a hospital gown during various times of the day, both in bed and in common areas. Additionally, during one observation, the resident's foley bag was noted to be on the floor without a privacy cover. These findings indicate that staff did not honor the resident's right to self-determination and choice regarding personal attire, as required.
Failure to Obtain, Maintain, and Document Advance Directives
Penalty
Summary
Facility staff failed to ensure that copies of residents' Advance Directives were obtained and maintained in the medical records, and did not consistently provide or document discussions and information about Advance Directives with residents or their representatives. For one resident, the Discharge Planning Psychosocial Assessment indicated the presence of an Advance Directive, but no written document was found in the electronic medical record, and staff confirmed that a copy was not available. For another resident, there was no documentation of an Advance Directive or any indication that the topic had been discussed. In a third case, the assessment noted the absence of an Advance Directive, but there was no evidence that the facility provided information to the resident or representative about initiating one. Interviews with the social worker revealed that the facility's process is to ask about Advance Directives at admission and to provide information if one is not in place, but documentation supporting these actions was missing for the residents reviewed. The Director of Nursing confirmed the absence of required documentation for at least one resident. These findings were based on record reviews and staff interviews, and were evident in three out of ten residents reviewed for Advance Directives.
Failure to Provide SNF Beneficiary Notice Prior to Discharge
Penalty
Summary
Facility staff failed to provide a required Skilled Nursing Facility (SNF) Beneficiary Notice to a resident prior to discharge. During a recertification survey, it was found that out of three resident records reviewed for proper discharge documentation, one resident did not receive the SNF Beneficiary Notice, which is necessary to inform residents of their Medicare/Medicaid coverage and potential liability for non-covered services. Documentation provided by the Medical Social Worker (MSW) confirmed that while one resident was discharged voluntarily, two others, including the resident in question, were not given the required notice before discharge. The MSW acknowledged the omission when questioned by the surveyor.
Failure to Maintain Homelike Environment Due to Unaddressed Room Repairs
Penalty
Summary
Facility staff failed to maintain a homelike environment for residents by not making timely repairs in resident rooms, as evidenced by multiple observations during survey rounds. Specific deficiencies included rust on bathroom tiles, damaged and missing drywall behind beds and below windows, a bathroom faucet that could not be turned off and had a steady flow of water, an armoire that was hanging by its hinge and could not be closed, and exposed corner bead near a privacy curtain. These issues were observed in several rooms across two of three facility units. During an interview, the Director of Maintenance stated that staff report maintenance concerns through a records system accessible to all staff and that a preventative maintenance schedule is in place, with routine room checks for concerns.
Failure to Accurately Document Significant Change on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's quarterly assessment was accurately documented on the Minimum Data Set (MDS). Specifically, a resident who had sustained an acute comminuted fracture of the left leg, as documented in physician progress notes, did not have this significant medical event reflected in their quarterly MDS assessment. The resident's medical records included physician notes detailing the fracture, pain management, orthopedic follow-up, and a recommendation for surgery, as well as the use of a knee immobilizer. During an interview, the MDS Coordinator explained that updates to the Resident Assessment Instrument (RAI) are made based on physician notes within a 60-day look-back period, and that new diagnoses are only captured if there are two documented changes in the resident's condition. Despite the presence of clear documentation regarding the fracture and subsequent care, the coordinator did not update the resident's quarterly assessment to reflect this significant change. The deficiency was identified when the surveyor noted the omission and questioned the staff about the lack of documentation on the MDS.
Incomplete PASARR Documentation for Residents with Mental Disorders or Intellectual Disabilities
Penalty
Summary
Facility staff failed to ensure that Preadmission Screening and Resident Review (PASARR) forms were completed correctly for three out of four residents reviewed. Specifically, two residents had Level I PASARR screenings indicating the need for a Level II screening, but there was no documentation of a completed Level II PASARR in their medical records. For another resident, only section A of the Level I PASARR was completed, with the remainder of the screening left incomplete as prompted by the form. Interviews with the facility's social worker confirmed the absence of required documentation and an inability to explain the incomplete PASARR form. The social worker acknowledged that certain diagnoses should have triggered further screening and was unable to provide the necessary documentation for the identified residents. The deficiency was identified through record review and staff interviews, with the lack of proper PASARR documentation directly observed in the residents' medical records.
Failure to Provide Regular Showers to Residents
Penalty
Summary
Facility staff failed to ensure that residents received regular showers, as evidenced by two residents who reported not receiving showers as scheduled. One resident stated they had not received a shower since admission and had never been asked if they wanted one, despite being scheduled for showers on specific days and having intact cognition as indicated by a BIMS score of 14/15. Review of the electronic medical records for both residents showed no documentation verifying that showers had been provided as scheduled. The Director of Nursing confirmed that residents were supposed to be offered showers twice a week, and that refusals should be documented, but there was no evidence this process was followed for the affected residents.
Failure to Timely Repeat Urine Culture Following Contaminated Sample
Penalty
Summary
A deficiency occurred when the facility failed to reorder a urine culture for a resident with a history of recurrent urinary tract infections (UTIs) after an initial urine sample was found to be contaminated. The resident had previously complained of pain while voiding, prompting a physician order for a urinalysis and culture. The urinalysis showed abnormal results, and the laboratory specifically recommended a repeat culture due to contamination. However, there was no documentation of a repeat urine culture being ordered or collected at that time. The delay in obtaining a repeat urine culture resulted in a lack of timely diagnosis and treatment for the resident, who continued to experience symptoms. It was not until the resident's condition changed and symptoms increased that a new order for urinalysis and culture was placed, leading to the eventual diagnosis and treatment of a UTI. Interviews with staff confirmed that abnormal results are typically communicated to physicians, but in this case, the recommended follow-up was not completed until a significant delay had occurred.
Failure to Provide Physician-Ordered Diets and Appropriate Food Consistency
Penalty
Summary
Facility staff failed to provide adequate nutrition and follow physician diet orders for two residents. One resident with an active order for a regular diet with double portions consistently did not receive double portions at meals, as confirmed by both the resident and review of meal tickets, which did not indicate the double portion requirement. Despite the resident's repeated reports to dietary staff and management, the issue persisted, and meal tickets continued to reflect only regular portions, contrary to the physician's order and dietary notes. Another resident, who had a diet order for dysphagia with mechanically altered texture and thin liquids, was observed receiving a lunch tray with regular texture sliced peaches, which were not appropriate for their ordered diet. The resident was also missing several teeth, further necessitating the need for mechanically altered food. Staff interviews confirmed that the meal ticket listed sliced canned peaches instead of the required diced or mechanical soft peaches, and responsibility for ensuring correct food consistency was acknowledged to be shared among dietary aides, kitchen staff, and nursing staff.
Failure to Ensure Timely and Appropriate Pain Management
Penalty
Summary
Facility staff failed to ensure that residents had a sufficient supply of prescribed pain medication and that their pain was appropriately addressed. One resident, who was prescribed Oxycodone HCl 20mg every six hours as needed, reported that the facility frequently ran out of this medication, resulting in unmanaged pain. Documentation confirmed that the resident did not receive the medication as ordered over a weekend due to delayed reordering by nursing staff, who often waited until the last dose before initiating a refill. Narcotic count sheets and interviews with staff confirmed a lapse in medication availability and administration during this period. Another resident was observed crying in pain, and a wound consult documented severe bilateral foot pain rated 10 out of 10. The nurse practitioner assessed the pain but did not document a plan to address it and stated she was waiting for diagnostic imaging results before addressing the pain. The nurse responsible for the resident's care was not informed of the pain concern, as there was no documented recommendation for pain medication. This resulted in the resident's pain not being managed in a timely manner.
Failure to Obtain Proper Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain proper informed consent prior to the use of bed rails for a resident. Observation showed the resident in bed with bilateral enabler bed rails. During an interview, the DON stated that consent is obtained before bed rails are initiated, but when documentation was reviewed, the consent form only indicated that consent was obtained without specifying from whom (the resident or their representative). Further, the DON was unable to identify which resident representative had provided consent, and acknowledged that staff are expected to document the name of the individual from whom consent was obtained for it to be considered valid.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,178 citations issued within 25 miles in the last 12 months — including the 13 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rockville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ingleside At King Farm | 1 mi | ★★★★★ | 13 | 0 |
| Collingswood Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 3 | 0 |
| The Village At Rockville | 1.7 mi | ★★★★★ | 25 | 0 |
| Sterling Care Rockville Nursing | 1.9 mi | ★★★★★ | 29 | 0 |
| Potomac Valley Rehabilitation And Healthcare | 2.7 mi | ★★★★★ | 21 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.