Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Turtle Creek Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
An LPN failed to notify the provider when a resident had repeated extremely high BS readings, including values over 500 mg/dL, and the MAR showed no documentation of provider notification or repeat BS checks. The resident had orders for AC/HS finger stick testing, and the RD of Clinical Services stated a nurse should recognize the significance of very high BS and call the provider even without a specific order.
Failure to Thoroughly Investigate Allegation of Neglect: The facility did not thoroughly investigate an allegation that a resident was left to feed self with the door closed and spilled food on self. Although the investigation file stated that interviews were completed and skin assessments were done for non-interviewable residents, survey review found no evidence of resident interviews or skin assessments in the records provided, and the NHA and Clinical VP acknowledged the missing documentation.
Two residents on EBP had posted signs in their rooms, but no gown-and-glove PPE was available on the supply racks for staff to use during high-contact care. In addition, the laundry room’s washer drainage system was overflowing into the floor area, and staff reported the wastewater problem had been ongoing for weeks, with clean linens and laundry staff exposed to the wet area.
The facility failed to keep a resident’s care plan consistent with the most recent MOLST, resulting in conflicting documentation where the MOLST indicated full code while the care plan and active orders still showed DNR, and the assigned nurse stated she would follow the outdated DNR status. In addition, the facility did not hold required interdisciplinary care plan meetings within the mandated timeframe after MDS assessments for two residents, with no care conference notes documented following those assessments and a social worker operating under an incorrect understanding of the timing requirements and the need for a guardian’s presence.
A resident who considered group activities and going outside for fresh air to be very important had a care plan directing staff to encourage participation in group, entertainment, religious, and outdoor activities and to invite the resident to scheduled programs. Observations showed the resident in their room watching TV, and a complaint alleged the resident was receiving less attention than others. Review of activity and medical records for multiple months showed no documentation that group or outdoor activities were provided, attended, or refused, despite the Activity Director stating that such activities occur daily and refusals are documented.
Failure to maintain resident dignity during mealtime assistance. During meal observations, staff were seen feeding two residents while standing over them as they lay in bed, despite one resident having limited ROM and needing full assistance and another having a stroke history with right-sided weakness and full care needs. One CNA said she was unaware standing was a dignity concern, and another said she preferred to stand while feeding the resident; the DON and VP of clinical operations stated staff were expected to sit at eye level while assisting with meals.
A resident with moderately impaired cognition and dementia lacked capacity for medical decisions and had a son named as the decision-maker. The record showed an earlier MOLST for Attempt CPR that was later voided, followed by an active MOLST for NO CPR, but there was no documentation that the provider discussed the change with the resident's representative; the DON confirmed the discussion had not occurred, and the provider acknowledged missing it.
Failure to Provide Written Transfer Notice: A resident with a mental disorder was sent to the hospital, but the record did not show that the resident or the resident's representative received the required written transfer notice. The DON stated the bed hold policy is provided and the eInteract Transfer goes with the resident, but that form was only a summary sent to the hospital and did not include the required notice details, including appeal rights. Corporate nursing later confirmed the facility could not find a transfer notice for the resident.
A resident with diagnoses including schizoaffective disorder, bipolar disorder, delusional disorder, and unspecified psychosis did not have a completed Level I PASARR beyond a 30-day short-stay exemption. Surveyors found only documentation tied to a recent hospitalization, with no evidence of a Level I review to determine whether a Level II eval was needed for the resident’s ongoing stay. The Social Services Director could not clearly explain the facility’s PASARR process or provide a facility-specific policy, and later confirmed there was no additional evidence of a completed Level I PASARR.
An LPN failed to administer medications as ordered for multiple residents, including leaving prepared meds unlabeled in a non-resident-specific drawer, preparing the wrong magnesium product and dose, and missing a late gabapentin dose flagged in the eMAR. Surveyor intervention was needed to identify the discrepancies, and the DON acknowledged the concern related to professional standards.
Conflicting MOLST Code Status Orders: A resident had two active MOLST forms with conflicting CPR instructions, with the EHR and current medical orders indicating DNR while the hard chart contained a MOLST directing CPR. A nurse confirmed the mismatch between the hard chart and EHR, and the NP also acknowledged the conflicting active MOLST information.
A resident with leukopenia had orders for Zarxio based on WBC results and CBC monitoring, but the facility did not ensure the CBCs were obtained as ordered when the Zarxio schedule changed. The MAR and nursing notes showed missed or undocumented Zarxio administrations, use of outdated WBC results, and periods where no current CBC was available to guide the medication.
A resident at high risk for pressure injuries had an air mattress in use, but the control unit was set at 550 lbs despite the resident weighing about 252 lbs. Nursing and maintenance each stated the other department was responsible for the resident-specific setting, and the DON was unsure how maintenance received that information. The NHA acknowledged there was a disconnect in the process for air mattress settings.
Delayed scheduling of urology appointments for suprapubic catheter care. A resident with a suprapubic catheter had monthly catheter-change orders, but the record showed missed and delayed urology follow-up, with no documentation of timely rescheduling attempts after an appointment was canceled and no evidence of follow-up scheduling for several months. Staff interviews confirmed unit managers handled outside appointment scheduling, and the DON expected documentation of calls and efforts to obtain earlier appointments.
A resident receiving scheduled oxycodone for chronic pain reported severe pain after the facility ran out of the medication. The MAR showed multiple missed doses, and the charge nurse said the doses were not given because pharmacy delivery was delayed and staff did not use the available Pyxis supply. The DON stated there was no documentation that staff tried to access the emergency stock or notified the provider before the concern was raised to the surveyor.
Medication administration errors exceeded the allowable rate, with an LPN failing to follow physician orders and accepted standards of practice. An LPN left three medications for one resident unlabeled and unsecured in the med cart while administering meds to another resident, gave a house stock magnesium supplement instead of the correct dose for another resident, and initially missed a late gabapentin dose flagged in the eMAR for a third resident until surveyor intervention.
Incomplete hospice documentation was found for a resident receiving hospice care for a terminal diagnosis. The resident’s chart contained only limited hospice paperwork, while staff gave conflicting accounts about whether hospice visit notes were kept in the record. Although the hospice agreement required complete and timely records to be shared with the facility, the resident’s medical record did not contain the hospice documentation that was later printed and provided by SSD.
The facility failed to prevent multiple known smokers from smoking in their rooms and hallways despite documented non-compliance, behavioral issues, and prior staff observations. One resident with psychosis and a history of non-compliance was repeatedly seen smoking in a room and hallway and later refused assessment after smoke was found coming from the mattress. Another resident with tobacco use was documented picking cigarette butts from the trash, smoking in rooms, bathroom, and hallway, and verbally refusing to stop despite repeated redirection. A third resident with tobacco use and multiple psychiatric diagnoses was observed smoking in the room. Staff reported residents blocking doors while holding lit cigarettes, aggressive behavior when staff attempted to confiscate smoking materials, and at least one instance where observed in-room smoking was not reported. Leadership acknowledged that residents were not supposed to have smoking materials in their rooms and that cigarettes and lighters were to be stored and dispensed at designated smoking times, yet residents continued to obtain and keep smoking materials in their rooms, leading to a room fire.
Surveyors found that not all staff had received mandatory QAPI training. During review of five randomly selected employee education files, one staff member hired several months earlier had no documented QAPI training. The Administrator confirmed there was no evidence that this staff member had completed the required QAPI education.
Surveyors found that the facility did not ensure all staff received required annual Compliance and Ethics training. Review of five randomly selected employee education files showed that one employee hired more than a year earlier had no documented Compliance and Ethics training during the review period. The administrator confirmed there was no evidence that this staff member had completed the mandatory annual training.
Surveyors found that a nurse aide hired in mid-2024 had no documented completion of the required 12 hours of annual in‑service training, including dementia management and abuse prevention, during the review period. Education records for several nurse aides were examined, and one aide’s file lacked any evidence of the mandated training hours. The Administrator confirmed that there was no documentation showing this aide had received the required education.
Surveyors found that staff did not consistently label or date food items in the kitchen and nourishment rooms, with multiple instances of undated canned goods, improperly stored leftovers, and open or unlabeled bags of food in refrigerators and freezers. Dietary and nursing staff acknowledged these lapses, and employee food was also found stored in resident refrigerators.
Surveyors found that multiple resident bathrooms lacked blinds, curtains, or frosted windows, resulting in inadequate privacy. A family member raised concerns, and surveyors confirmed that bathrooms were visible from outside. The MD was unaware of any window coverings ever being used, and the DON acknowledged the issue.
Surveyors observed that linen carts contained only minimal towels and washcloths, and staff reported frequently needing to retrieve additional linens from the laundry due to ongoing shortages. Laundry staff confirmed a lack of sufficient towels, washcloths, and gowns, and the Regional Environmental Director stated that the facility's linen supply was below the expected standard.
A resident alleged physical abuse by a GNA, and although an investigation was initiated, the accused staff member continued to work regular shifts with residents during the investigation. Facility policy required suspension of accused staff pending investigation, but review of personnel records and timecards confirmed no suspension was issued.
A resident's right to self-determination was not honored when staff deferred to a health care proxy for consent without documented evidence of incapacity, despite the resident's ability to communicate and a MOLST form indicating their wishes. The DON was unable to provide prior documentation of incapacity, and only produced an evaluation after the issue was raised.
A resident's preference for female healthcare providers was not documented in the care plan, despite staff and management being aware of the request. The omission was confirmed through interviews with the resident, staff, and the DON, as well as a review of the medical record.
Facility staff did not update a resident's MOLST form after a court-appointed legal guardian was established, leaving the outdated form listing the resident as the decision maker. The oversight was discovered when staff reviewed the record and found both the old MOLST and the court order in the file, with the DON confirming the error.
Facility staff did not document ongoing re-assessments or attempts at less restrictive alternatives for a resident using a half gate as a physical restraint. The resident, who had cognitive and safety awareness deficits, had a care plan requiring regular evaluation of restraint use, but only a single quarterly assessment was provided, with no evidence of continued re-evaluation as required by facility policy.
A resident was discharged home, as confirmed by both the medical record and discharge summary, but the MDS assessment incorrectly documented the discharge as being to a short-term general hospital. The MDS Coordinator acknowledged the error during an interview.
Surveyors found that two residents did not receive wound care treatments in accordance with current orders and wound team recommendations. In both cases, discrepancies existed between the wound NP's documented recommendations and the treatments recorded on the TAR, including outdated or incorrect wound care products and frequencies. The DON confirmed that changes in nursing staff responsible for wound care orders contributed to these inconsistencies.
The facility did not maintain adequate nursing staff on weekends, leading to delayed or unanswered call lights as reported by multiple residents. Staffing records showed that nursing hours per patient day were consistently below required levels on weekends, and the DON confirmed that staff call-outs could not always be replaced during these times.
A resident did not receive multiple doses of their prescribed Pregabalin for neuropathic pain because the medication was not available or was awaiting pharmacy delivery. Medication Administration Records and progress notes confirmed several missed doses, and the DON acknowledged that the medication should have been available.
Surveyors found that two residents' medication regimen reviews identified by the consulting pharmacist were not addressed or documented by the provider in a timely manner. In both cases, recommendations for medication order changes or laboratory monitoring were delayed, and there was no clear documentation in the medical record showing that the provider reviewed or responded to the pharmacist's recommendations.
A medication pass observation revealed that an LPN administered discontinued medications and incorrect dosages to two residents, resulting in a medication error rate of 12%, which exceeds the acceptable threshold of less than 5%.
Surveyors found that two residents received medications that had been discontinued, with the discontinued drugs still stored in the medication cart. Additionally, a resident's Methadone medication was missing an expiration date on its label, and this information was not documented elsewhere. Staff confirmed these deficiencies in medication storage and labeling.
The facility did not properly maintain the outdoor garbage storage area, as four mattresses and other materials were left piled next to the dumpsters used by the kitchen. The Maintenance Director confirmed the presence of potential vermin habitats nearby and stated that the mattresses had not been disposed of in the dumpster because the garbage removal company would not take them.
A resident's medical record contained an error in PASARR documentation, where a Level I screen was marked as positive for SMI, indicating a need for Level II screening, despite only two of three required questions being marked 'yes.' The DON was unsure about the requirement and deferred to the Social Worker, who later confirmed the positive result was marked in error. This resulted in incomplete and inaccurate medical recordkeeping.
Surveyors found that the facility failed to maintain a clean, comfortable, and homelike environment, with an exterior kitchen door showing an unrepaired opening, crumbling drywall and water stains in two resident rooms, and a protruding nail in a resident shower room. The Maintenance Director and DON acknowledged these maintenance concerns during interviews.
A resident with a history of hemiplegia and muscle contractures was injured when a GNA ignored their request not to be repositioned in bed, resulting in a fractured finger. Despite initial x-rays showing no fracture, further evaluation confirmed the injury. The GNA, who had a history of conduct issues, was terminated following the incident.
The facility did not employ a full-time licensed social worker despite having 140 certified beds, leading to unresolved issues for residents. Complaints revealed a lack of communication and coordination in care plans and discharge processes after the previous social worker left. The social work assistant, who was not licensed, was overwhelmed and handling all residents alone. Attempts to recruit a licensed social worker were unsuccessful, and supervision was provided by a corporate staff member not present full-time.
Facility staff failed to maintain a sanitary and comfortable environment, with deficiencies observed in resident rooms and common areas. Issues included unsanitary conditions, disrepair of furniture and fixtures, and lack of essential supplies. A corporate nurse acknowledged the concerns, including mold presence.
The facility failed to report allegations of abuse to the OHCQ within the required 2-hour timeframe for five incidents. These included cases where residents reported being hit, spit on, or experiencing pain due to staff actions. The facility's investigations lacked email confirmations of report submissions, and interviews with the DON revealed a failure to maintain proper documentation.
The facility failed to conduct quarterly care plan meetings for several residents, as required. This deficiency was identified during a complaint survey, where it was found that seven residents did not have their care plans reviewed and revised quarterly. The lack of meetings was confirmed through interviews with the DON and review of medical records. Additionally, responsible parties reported communication issues and difficulties in coordinating discharge plans due to the absence of care plan meetings.
The facility failed to administer medications as ordered for several residents, including Methadone for a resident with opioid dependence and Midodrine for a resident with hypotension. Additionally, a resident with dry eye syndrome did not receive timely treatment, and another resident's risk for elopement was inaccurately assessed.
A resident with a Stage III sacral pressure ulcer was not reassessed weekly by the facility staff, as required. The Wound Nurse Practitioner initially assessed the wound and documented its measurements, but the staff failed to reassess the wound on a specified date. The resident was later discharged to the hospital. The DON confirmed the failure to reassess the wound.
Facility staff were observed pulling two residents backwards down hallways, compromising their dignity. An LPN pulled a resident from the dining room to their room, while a GNA moved another resident to an activity room without knowing their name. These actions were confirmed as dignity issues by a staff member.
Facility staff failed to notify a resident's physician of a low blood pressure reading of 73/49 mmHg. Despite the critical nature of this reading, there was no documentation of physician notification. The DON confirmed that the physician should have been informed, but the medical record lacked evidence of such communication.
A facility failed to provide a baseline care plan to a resident and their representative within 48 hours of admission, as required. This plan should include initial goals, physician orders, therapy, dietary, and social services. A review found no evidence of the plan being provided, and a Regional Nurse confirmed the oversight, indicating a lapse in communication and documentation.
Facility staff did not include a resident's risk of elopement in their care plan, despite the resident leaving the facility unaccompanied and being found attempting to exit again. The DON confirmed the absence of a care plan addressing this risk.
Failure to Notify Provider of Extremely High Blood Glucose
Penalty
Summary
Facility staff failed to notify the practitioner when Resident #2 was assessed to have extremely high blood glucose levels. The resident had physician orders written on 5/9/26 for finger stick blood sugar testing before meals and at bedtime, and the MAR documented multiple elevated readings between 5/11/26 and 5/14/26, including values of 515 and 524 mg/dL. The report states that blood glucose results above 600 mg/dL are considered a life-threatening medical emergency, and the Regional Director of Clinical Services indicated that a physician order to notify the provider for finger stick blood sugar levels higher than 400 was not written until 5/13/26. Review of the medical record did not reveal documentation that the nurses notified the physician or on-call provider of the resident's extremely high blood sugar results. When the surveyor requested documentation of provider notification, none was provided. During interview, an LPN stated she should call the doctor and recheck the blood sugar when results are extremely high, but acknowledged she did not document repeat blood sugar levels or provider notification and said she was a new nurse still learning the policies. The Regional Director of Clinical Services stated she would expect a licensed nurse to recognize the significance of extremely high blood sugar levels and call a provider even without an order.
Failure to Thoroughly Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving Resident #4, who was non-verbal. The self-report alleged the resident was left to feed him/herself with the door closed and spilled food on him/herself. The incident was reported to the facility on 3/25/26, and the facility’s investigation file documented that a skin assessment was completed on Resident #4 and other non-interviewable residents, and that interviewable residents were interviewed. However, continued review of the investigation documents found no evidence that interviews had actually been conducted with interviewable residents and no evidence that skin assessments had been completed for any non-interviewable residents. During interviews with the NHA and the Clinical VP, both were informed that the supporting documentation was missing, and the NHA stated he was still looking for it. By the time the survey ended, no documentation of resident interviews or skin assessments of non-interviewable residents had been provided.
Missing EBP PPE and Laundry Wastewater Exposure
Penalty
Summary
The facility failed to ensure that PPE was available for staff to use when providing Enhanced Barrier Precautions for two residents. Resident #73 had a history that included acute osteomyelitis of the right lower extremity, traumatic amputation of two or more right lesser toes, atherosclerosis of native arteries of the extremities with gangrene, cellulitis of the right lower extremity, and moderate protein-calorie malnutrition. Resident #9 had a history that included hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes, a stage 4 pressure ulcer, dysphagia, adult failure to thrive, vascular dementia, a G-tube, and hospice care. Although EBP signs were posted on both residents’ room doors, no PPE was observed on the supply racks outside or immediately inside the rooms, and staff confirmed that PPE was not available for use. The facility’s revised EBP policy required gown and glove use during high-contact care activities such as dressing, bathing, transferring, hygiene, linen changes, brief changes, toileting, device care, and wound care. The facility also failed to protect the clean area of the laundry room, including clean linens and laundry staff, from exposure to wastewater from the washing machines. During observation, three washing machines drained into a canal-like concrete structure behind them, and the floor and base of the washers were wet from overflow. The wet area extended about 2.5 feet in front of the washers and about 5 feet to the left side. A laundry staff member stated the drain was not draining fast enough, causing wastewater to overflow, and reported that she had to step onto the wet floor to access the washers. She also stated the problem had started a couple of weeks earlier and that management was already aware. The NHA and Maintenance Director confirmed the drain problem and stated that a temporary pump had been installed, but the wastewater was still observed overflowing and creating a concern for cross contamination with clean linens.
Failure to Update Code Status in Care Plan and Hold Timely Interdisciplinary Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s care plan to reflect the most current Medical Orders for Life-Sustaining Treatment (MOLST). For one resident, the most recent MOLST form indicated that cardiopulmonary resuscitation (CPR) should be attempted in the event of cardiac or pulmonary arrest, meaning the resident was full code and had capacity to make medical decisions. However, the resident’s care plan, initiated and later revised on prior dates, continued to list the resident’s code status as do not resuscitate (DNR) and referenced the MOLST as the basis for that status. The active medical orders in the record also showed a DNR order, creating conflicting documentation between the MOLST and the care plan/medical orders. When interviewed, the nurse assigned to the resident confirmed there was conflicting information regarding the code status and stated that, if the resident’s heart stopped, she would not provide CPR, basing her decision on the current care plan and medical orders that indicated DNR. A nurse practitioner later confirmed that the resident was actually full code and that the resident had decision-making capacity, and also confirmed the presence of conflicting code status information in the record. A social worker’s note documented that a care plan meeting had been held and that the code status was reviewed and indicated as DNR, but the care plan itself still reflected DNR status even after the MOLST had been changed to full code. The deficiency also includes the facility’s failure to ensure that interdisciplinary care plan meetings were held within the required timeframe following completion of Minimum Data Set (MDS) assessments. For one resident, an MDS assessment was completed, but there was no care conference note indicating that a care plan meeting occurred after that assessment. For another resident, a quarterly MDS assessment was completed, but the last documented care conference note predated that assessment, and no subsequent care plan meeting was documented. The social worker reported that care plan meetings were held on specific weekdays and believed she had a window of seven days before or after the assessment reference date to hold the meeting, and she also stated she was trying to schedule a meeting with the resident’s guardian and believed the guardian needed to be present. Review of the record showed only a progress note about a behavior concern, with no indication that a care plan meeting occurred or that the care plan was reviewed or discussed following the MDS assessment.
Failure to Provide and Document Care-Planned Group and Outdoor Activities
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision and documentation of activities based on a resident’s comprehensive assessment and care plan. Record review of the resident’s most recent comprehensive assessment (reference date 7/15/25, Section F) showed it was very important to the resident to participate in group activities and to go outside for fresh air when the weather was good. The resident’s activity care plan included interventions such as encouraging attendance at entertainment programs, large and small group activities, volunteer demonstrations, religious activities, and inviting the resident to scheduled activities. During observations on two separate dates, the resident was seen in their room watching TV, and there was a complaint allegation that staff were mistreating the resident by showing other residents more attention. A review of the April 2026 activity calendar and participation records on 4/17/26 did not show any documentation that the resident attended group or outdoor activities, nor that such activities were offered and refused. The Activity Director stated that the resident usually preferred independent activities in their room and reported that refusals are documented and that group activities occur daily. However, when the Activity Director reviewed the resident’s medical record with the surveyor, he confirmed there was no documentation for March or April 2026 indicating that the resident had attended or refused group and/or outdoor activities. This lack of documentation and evidence of implementation of the care-planned activities formed the basis of the deficiency.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to treat residents with respect and dignity during mealtime. During a breakfast observation in the Potomac Unit, staff fed a resident who had limited ROM in both upper extremities and required full assistance with self-care needs while the resident was lying in bed, and the nursing assistant remained standing beside the bed even though chairs were present in the room. The nursing assistant stated she was unaware that feeding a resident while standing was a dignity concern, and the DON later stated that staff were expected to sit at eye level when assisting residents with eating and avoid standing to maintain dignity. A second meal observation in the Chesapeake unit showed another nursing assistant standing over a resident who was lying in bed while assisting with breakfast. That resident had a history of stroke with right-sided weakness and required full assistance with care needs. When asked what was expected while assisting with feeding, the nursing assistant stated that she preferred to stand whenever she assisted with feeding the resident. The vice president of clinical operations later stated that staff were expected to sit while feeding residents to respect residents' dignity.
Failure to Discuss MOLST Change With Resident Representative
Penalty
Summary
The facility failed to ensure that advance directives were discussed with residents and/or their responsible representatives when new orders for life-sustaining treatment were implemented. This deficiency involved one resident whose record showed moderately impaired cognition, a BIM score of 12, and an attending provider assessment stating the resident lacked capacity to make medical decisions due to dementia. The resident also had an advance directive naming the son as the decision-maker. The record showed an earlier MOLST signed by the provider that ordered Attempt CPR and documented discussion with the resident's health care agent, but the form was labeled VOIDED by the facility without documentation on the form itself indicating it was voided. A later active MOLST ordered NO CPR for cardiac and/or pulmonary arrest, but the record lacked documentation that the provider discussed this change with the resident and/or representative. The DON reviewed the record and confirmed the current MOLST order had not been discussed with the resident's representative, and the attending provider acknowledged missing that discussion.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to ensure that Resident #4 and the resident's representative were provided written notice of transfer when the resident was sent to the hospital. The resident's medical record showed diagnoses including a mental disorder and identified a representative as an emergency contact. The resident was transferred to the hospital on 12/30/25 and admitted, but review of the record on 4/21/25 did not reveal documentation that the required transfer notice information had been provided to the resident or the resident's representative related to that transfer. Interview with the DON on 4/21/26 at 1:52 PM indicated that the bed hold policy is provided and representatives are notified that their loved one is being sent to the hospital, but the DON stated that the eInteract Transfer goes with the resident and did not think social work provided anything other than the bed hold notice. Review of the eInteract Transfer form showed it was a summary of information sent to the hospital and did not include the required written transfer notification information, including appeal rights. Corporate Nurse #9 later confirmed that they could not find a notice of transfer for this resident, although she stated the facility has a paper form used for this notification and staff sometimes cannot find the paper.
PASARR Screening Not Completed for Resident With Serious Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a PASARR screening was completed for Resident #59. The resident’s record showed a history that included NSTEMI, delusional disorders, bipolar disorder, encephalopathy, paranoid personality disorder, unspecified psychosis, and type II diabetes. The resident was admitted from Holy Cross Hospital with diagnoses including schizoaffective disorder, bipolar type, and NSTEMI, and the record also reflected frequent hospitalizations and episodes in which the resident called 911 from the facility to be transported by EMS for various reasons. Survey review found no indication that a Level I PASARR screening had been completed for the resident beyond a 30-day short-stay exemption dated 12/14/2025. The PASARR documentation provided related to a recent hospitalization and did not show a Level I evaluation to determine whether a Level II review was needed for the resident to remain long-term at the facility. During interviews, the Social Services Director was unable to clearly define a facility-specific PASARR process or provide a facility policy, and later confirmed there was no additional evidence that the resident had a Level I PASARR evaluation completed beyond the initial 30-day exemption.
Medication Administration Errors and Failure to Follow Physician Orders
Penalty
Summary
The facility failed to ensure physician-ordered medications were administered as prescribed, including the correct medication, dose, and timing, for 3 residents observed during medication administration. During observation, an LPN prepared medications for one resident that included levetiracetam 750 mg, divalproex sodium 500 mg, and lactulose 30 mL, left them unlabeled, and placed them in a non-resident-specific drawer before proceeding to administer medications for another resident. The same LPN also prepared magnesium 500 mg for a resident when the physician order was for magnesium oxide 400 mg (240 mg elemental magnesium) once daily, and the discrepancy was identified after surveyor intervention. During medication administration for a third resident, a hard stop alert in the eMAR indicated a late dose of gabapentin, but the LPN did not initially acknowledge or administer the medication. After surveyor intervention, the LPN reviewed the eMAR and identified the missed medication. The report states these observations were separate from the calculated medication error rate and reflected failure to implement physician orders as written. The DON later acknowledged the concern related to professional standards.
Conflicting MOLST Code Status Orders
Penalty
Summary
The facility failed to have an effective system in place to ensure that residents had only one active Maryland Order for Life-Sustaining Treatment (MOLST). This was identified for one resident reviewed for advance directives. A review of the resident’s electronic health record showed a MOLST indicating do not attempt CPR if cardiac and/or pulmonary arrest occurs, and the resident’s facesheet and current medical orders also indicated DNR. However, no other MOLST was found in the electronic record at that time. When the resident’s hard chart was reviewed, another MOLST was found that indicated attempt CPR if cardiac and/or pulmonary arrest occurs. A nurse confirmed that the hard chart contained a MOLST with code status information that conflicted with the electronic record and medical orders. The nurse stated she would follow what was indicated in the electronic record if the resident’s heart stopped. The nurse practitioner also confirmed that there were two active and conflicting MOLST entries and stated the resident was full code and had capacity to make medical decisions. A later review of the record showed a social work note from a care plan meeting where the code status was reviewed and indicated as DNR.
Failure to Obtain Ordered CBCs and Document Zarxio Administration
Penalty
Summary
The facility failed to ensure ordered CBC lab tests were obtained to determine whether Zarxio should be administered for a resident with leukopenia. Resident #40 had a low WBC count and an order for Zarxio every 14 days when the WBC was less than 4, along with an order for CBC testing every two weeks and faxing the results to the pharmacy for Neupogen delivery. The record showed a WBC of 2.7 on 2/12/26 and Zarxio was administered, but when the Zarxio order was changed on 2/22/26 to every 7 days when the WBC was less than 4, there was no documentation that the CBC order was changed at the same time. The MAR and nursing notes showed multiple instances where Zarxio was scheduled but not clearly administered or documented, and the corresponding CBC results were not available when needed. Zarxio was scheduled on 2/22/26 with no documentation of administration or nursing note, and no CBC was documented when due later in February. On 3/1/26, staff documented Zarxio was given but entered NA in the WBC result space; the most recent CBC in the record was from 2/12/26. The resident’s WBC was 3.9 on 3/5/26, but Zarxio was not documented as given on 3/8/26. On 3/15/26, staff documented that the lab had not yet resulted a 3/13/26 CBC and Zarxio was not given. A CBC dated 3/20/26 showed WBC 4.0, after which Zarxio was not given on 3/29/26 and later entries in April also showed Zarxio not administered or documented as expected, with no CBC obtained after 3/20/26 until the order was later updated to weekly CBCs and weekly Zarxio administration.
Air Mattress Settings Not Matched to Resident Weight
Penalty
Summary
The facility failed to ensure that a resident at high risk for pressure injuries received appropriate services for treatment and prevention. Resident #45, who had been in the facility since early 2018 and had a Braden Scale score of 11.0 indicating high risk, was observed in bed on an air mattress with the control unit set at 550 lbs. The resident’s most recent documented weight was 252.4 lbs., and the medical record included an order for nursing to check the air mattress to be set per manufacturer guidelines and to check for proper placement and function every shift. During interviews, the nurse assigned to the resident stated that the mattress order meant checking that it was plugged in, inflated, and without leaks or alarms, and confirmed that the mattress weight setting should have been changed because the resident weighed in the 250 lb. range. The nurse stated maintenance was responsible for the weight setting and cycle time. The DON also stated the mattress was maintenance’s responsibility but was unsure how maintenance was informed of the resident-specific setting. The Maintenance Director stated his staff installed the mattress and set it to static to fully inflate, but said nursing was responsible for the specific weight setting and cycle time, and that maintenance did not receive resident-specific information such as the resident’s name or weight. The NHA acknowledged that no one in the facility was checking to ensure air mattress settings were appropriate to the resident using them.
Delayed Scheduling of Urology Appointments for Suprapubic Catheter Care
Penalty
Summary
The facility failed to ensure timely scheduling of urology appointments for monthly suprapubic catheter changes for one resident with a suprapubic catheter. The resident had an order in effect to have the catheter changed monthly at the urologist office, and the record showed the resident was seen by urology with a recommendation to follow up in 4 weeks for another catheter change. A nursing note documented the next appointment was scheduled, but when the resident returned from that appointment, the note stated the appointment did not take place because the doctor was absent and that it would be rescheduled the next day. The medical record did not show the resident was seen again by urology until several months later, and after that visit there was no documentation of attempts to schedule follow-up urology appointments in the following months. Later, an order was entered for another urology consult, but the resident refused one scheduled appointment because they did not want to get up early to prepare for it. During interview, the Unit Nurse Manager stated unit managers were responsible for scheduling outside appointments and described the process used, while the DON stated staff should document the call, notify the provider, and work with the office to obtain an earlier appointment if needed. Corporate nursing review confirmed there was no additional documentation regarding scheduling the urology appointment.
Failure to Provide Ordered Pain Medication
Penalty
Summary
Safe, appropriate pain management was not provided to a cognitively intact resident who was receiving routine oxycodone 5 mg every 6 hours for chronic pain. The resident reported severe pain and stated that the facility had run out of the pain medication and would not use an emergency box upstairs for the resident. The medication administration record showed missed doses on 4/12/26 at 6:00 AM, 12:00 PM, and 6:00 PM, and on 4/13/26 at 12:00 AM, 6:00 AM, and 6:00 PM. A one-time oxycodone 5 mg tablet was given on 4/13/26 at 12:07 PM by the charge nurse. The charge nurse stated the routine narcotic was not given from 4/12/26 at 6:00 AM until 4/13/26 at 6:00 PM because it had not been delivered by the pharmacy, and the capsule form was not available in the Pyxis, so it was not used. The DON stated nurses should check the Pyxis when there is a medication delivery concern, inform the provider to obtain an order, and then obtain the supply from the Pyxis using a code from the pharmacy. The DON provided a Pyxis stock list that included oxycodone 5 mg tablets, oxycodone 10 mg tablets, and oxycodone/acetaminophen 5/325 mg tablets, and stated there was no documentation that staff attempted to access the emergency supply or that the provider was informed before the resident raised the concern to the surveyor.
Medication Administration Errors Exceeded Allowable Rate
Penalty
Summary
Medication administration was not performed in accordance with physician orders and accepted standards of practice, resulting in a medication error rate of 17.24% (5 errors out of 29 opportunities), which exceeded the allowable 5% error rate. During a medication pass observation on 4/15/26 at 2:25 AM, an LPN partially dispensed Resident #38’s medications, including Levetiracetam 750 mg, Divalproex sodium DR 500 mg, and Lactulose 30 mL, and left the unlabeled medications in a non-resident-specific drawer in the medication cart while proceeding to administer medications to another resident; these actions accounted for three errors. Later that morning, the same LPN obtained and dispensed a house stock Magnesium 500 mg supplement for Resident #3, then removed it after surveyor intervention and obtained the correct dose, accounting for one error. At 10:00 AM, during medication administration for Resident #55, the LPN received a hard stop alert in the eMAR for a late Gabapentin dose but did not initially acknowledge or administer it until the surveyor intervened and the missed dose was identified, accounting for one error. On 4/21/26, the DON acknowledged the concern related to the deficient medication administration practice.
Incomplete Hospice Documentation
Penalty
Summary
The facility failed to ensure complete and accurate hospice documentation was maintained and readily accessible for one resident receiving hospice services. Resident #9 had a terminal diagnosis of cerebral atherosclerosis and had been on hospice care with Heartland Hospice since 7/4/2025. A record review on 4/15/26 found only a hospice care plan conference dated 10/7/25 in the electronic medical record, covering benefit period dates 10/2/25 through 12/20/25, with no additional hospice documentation located in either electronic format or on hard copy. During interviews, the Director of Social Services stated that Heartland provided handwritten visit documentation that was kept in the resident’s chart under the “Hospice” tab at the nurses’ station, but the surveyor could not locate such documentation in the record. An LPN stated that Heartland Hospice documented electronically via tablet and provided a verification signature line to facility staff, which conflicted with the SSD’s statement. The facility agreement with Heartland required access to all hospice service records and stated that Heartland would provide complete and timely medical records, yet the resident’s chart did not contain hospice visit documentation. Printed hospice records later provided by SSD #4 included certification period documentation, a comprehensive assessment and plan of care, and hospice physician orders, but these had not previously been maintained in the resident’s medical record and did not include hospice nursing visit summaries.
Failure to Control Resident Smoking in Rooms Resulting in Fire
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective system to prevent residents from smoking in their rooms, which resulted in a fire in a resident room. One resident with diagnoses including unspecified psychosis and non-compliance with medication was documented on a change in condition note as being observed continuously smoking in the room and hallway, refusing redirection and continuing to smoke in the room shared with another resident. A subsequent behavior note indicated this same resident refused a head-to-toe assessment three times after the fire marshal noted smoke coming from the resident’s mattress. Staff interviews confirmed that this resident had been seen smoking in the room on multiple occasions in the week prior to the fire. Another resident, admitted with a diagnosis including tobacco use, was documented in multiple change in condition notes as picking cigarette butts from the trash on the smoke porch and being observed smoking multiple times in the room, bathroom, another resident’s room, and the hallway. This resident was repeatedly redirected but refused to comply, stating they had the right to smoke anywhere and did not care about the adverse effects of smoke on non-smokers. Nursing documentation also noted that this resident continued to smoke in the room, cursed at staff when confronted, and would not yield to teaching. Staff interviews corroborated that this resident had been seen smoking in the room in the week prior to the fire and that attempts to obtain smoking materials were met with aggression and refusal. A third resident, with diagnoses including tobacco use, intermittent explosive disorder, opioid abuse, bipolar disorder, and generalized anxiety disorder, was documented in a nursing note as being observed smoking in the room and receiving education about the danger of such behavior. Despite a facility policy that residents could not have smoking materials in their rooms and that smoking materials were to be stored on a cart and obtained from social services or nursing at designated times, staff interviews revealed that residents were still able to obtain and keep smoking materials. One staff member reported seeing two residents with lit cigarettes in the hallway who then went into a room and blocked the door, and another staff member reported finding a resident smoking in the room on two separate occasions, once without reporting it because no one was present at the nurses’ station. After the fire, a resident previously known to smoke in the room was observed with two cigarette lighters on the bedside table, confirmed by the nurse, indicating ongoing access to smoking materials in resident rooms. Interviews with the ADON, DON, and social worker showed that facility leadership was aware that some residents were non-compliant smokers and that residents with known behaviors of smoking in their rooms existed prior to the fire. The ADON acknowledged that residents were supposed to have their cigarettes and lighters stored on a cart and be supervised on the smoke porch, but stated that some residents did not follow the rules and that the facility used behavioral contracts and medical/psych consults when residents did not comply. The DON stated that residents sometimes secretly brought smoking materials into the building and that no one knew how the resident involved in the fire obtained them. The social worker confirmed that certain residents had known behaviors of smoking in their rooms and that no residents were supposed to have smoking materials in their rooms. Observation of the unit showed posted smoking schedules that left a long period with no scheduled smoking times, while multiple residents with tobacco use and behavioral issues continued to smoke in their rooms and hallways despite staff awareness and prior documentation, culminating in a fire in a resident room.
Removal Plan
- Review the facility smoking policy with all identified smoking residents.
- Ask all residents to turn in all smoking materials.
- Visually inspect all resident rooms for smoking materials.
- Place any collected smoking materials in the smoker's box.
- Assign Residents #1, #2, and #3 to one-on-one supervision due to refusal to turn in smoking materials.
- Maintain one-on-one supervision for Residents #1, #2, and #3 until they no longer have smoking materials in their possession and demonstrate no behaviors of smoking in their rooms.
- Educate all staff that residents may not have any smoking materials on them.
- Educate all staff that residents may only smoke at designated smoking times in the designated area.
- Educate all staff that if they become aware of a resident smoking in their room or having smoking materials on them, they are to ask the resident for the materials.
- Require that if a resident refuses to turn in smoking materials, the resident is placed on one-on-one supervision immediately and the staff member notifies the Executive Director or nursing supervisor.
- Audit nursing notes of identified residents who smoke in the daily clinical meeting for documentation of illegal smoking activity.
- Inspect the room of each resident identified as a smoker for smoking materials or evidence of smoking in the room.
- Have the Executive Director audit all Ambassador round reports for residents identified as smokers.
- Have the Director of Nursing audit all nurses' notes to evaluate whether violations of the smoking policy have been discovered.
- Submit audit results to the Quality Assurance and Performance Improvement Committee for review and approval.
Failure to Provide Mandatory QAPI Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received mandatory Quality Assurance and Performance Improvement (QAPI) training. During a complaint survey, surveyors reviewed QAPI education records for five randomly selected employees on 2/9/26. One employee, identified as Staff #20, hired on 7/31/24, had no documented completion of QAPI training in their education records. In an interview on 2/9/26 at 2:13 PM, the Administrator confirmed there was no evidence that this staff member had received the required QAPI training.
Failure to Provide Mandatory Annual Compliance and Ethics Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received mandatory annual Compliance and Ethics training, as evidenced by the education record of one employee. During a complaint survey, surveyors reviewed education records for five randomly selected employees for the period from January 2025 through February 2026. For Staff #20, who was hired on 7/31/24, there was no documentation showing completion of Compliance and Ethics training during that review period. In an interview on 2/9/26 at 2:13 PM, the Administrator confirmed there was no evidence that this staff member had received the required annual Compliance and Ethics training. This deficiency was identified for 1 of 5 employees whose records were reviewed for compliance with the facility’s mandatory Compliance and Ethics education requirements.
Failure to Provide Required Annual Training in Dementia Management and Abuse Prevention
Penalty
Summary
The facility failed to ensure that a nurse aide received the required 12 hours of annual training that included dementia management and abuse prevention. During a complaint survey, surveyors reviewed education records for five randomly selected nurse aides on 2/9/26. For one nurse aide hired on 7/31/24 (Staff #20), review of education records from January 2025 through February 2026 showed no evidence that this staff member had completed 12 hours of training, nor that the training included dementia management and abuse prevention. In an interview on 2/9/26 at 2:13 PM, the Administrator confirmed there was no evidence that this nurse aide had received the required annual training during that period.
Improper Food Storage and Labeling in Kitchen and Nourishment Rooms
Penalty
Summary
Facility staff failed to properly store food in accordance with professional standards for food service and safety, as observed during kitchen and nourishment room inspections. In the kitchen's dry storage, several canned goods, including sliced peaches and mandarin oranges, were found without received or expiration dates. Containers of flour were also missing dates, and some items in the kitchen cooler, such as cut pineapple and what appeared to be butter and sausage patties, were either past their use-by dates or lacked proper labeling and dating. In the kitchen freezer, multiple opened bags of food items, including cheese omelets, turkey patties, breaded chicken portions, croissants, and Italian steak rolls, were found without labels or dates indicating when they were opened, and some were left open to air. In the nourishment rooms on both the first and second floors, food items in resident refrigerators were found without proper labeling or dating. Items included a water bottle with an unknown yellow substance, bags of food labeled only with room numbers and missing dates, and takeout containers with outdated labels. Additionally, employee food was found stored in resident refrigerators, which is not permitted. These deficiencies were confirmed through interviews with dietary and nursing staff, who acknowledged the lack of compliance with labeling, dating, and storage protocols.
Inadequate Privacy in Resident Bathrooms Due to Uncovered Windows
Penalty
Summary
Surveyors identified a deficiency related to inadequate privacy in resident bathrooms throughout the facility. During interviews and observations, it was noted that multiple resident bathrooms on the ground floor lacked blinds or curtains on the windows, and the windows were not frosted, allowing visibility from outside. Brackets for blinds or curtains were present but not in use. A family member of a resident expressed concerns about bathroom privacy, and during an exterior tour, surveyors confirmed that the interiors of these bathrooms were visible from outside. The Maintenance Director stated he was unaware of any blinds or curtains ever being used in these bathrooms, and the DON acknowledged the privacy concerns.
Inadequate Linen Supply for Resident Care
Penalty
Summary
The facility failed to provide an adequate supply of linens, including towels and washcloths, for residents. During multiple observations, surveyors noted that linen carts in the hallways contained only one or two towels and washcloths. Geriatric Nursing Assistants reported that while they could provide care, they often needed to go to the laundry to obtain additional linens. Laundry staff confirmed a persistent shortage of laundry items, particularly washcloths, towels, and gowns, and stated that there was not enough laundry available when staff requested it. The Regional Environmental Director acknowledged that the facility's linen supply was below the expected Periodic Automatic Replacement (PAR) level, which is set at three linen changes per resident per day, and that the facility was currently well below this standard.
Failure to Suspend Accused Staff During Abuse Investigation
Penalty
Summary
The facility failed to prevent further potential abuse during an active investigation of alleged staff-to-resident abuse. On 2/18/21, a resident reported to county police that a Geriatric Nursing Assistant (GNA) had punched them in the face four times. The facility initiated an investigation on the same day and ultimately concluded the allegation as not verified. However, during the investigation period, the accused staff member continued to work regular shifts with residents. A review of the facility's abuse prevention policy revealed that accused staff members are to be suspended pending the outcome of an abuse investigation. Examination of the staff member's personnel file and timecard confirmed that no suspension was issued and the staff member worked multiple shifts during the investigation. The Director of Nursing acknowledged that it was not acceptable for the accused staff member to continue working with residents during the investigation.
Failure to Honor Resident's Right to Self-Determination Due to Lack of Capacity Documentation
Penalty
Summary
The facility failed to honor a resident's right to self-determination and decision-making regarding their care. A review of the resident's medical record showed that the resident had a Maryland Order for Life Sustaining Treatment (MOLST) form indicating a personal decision to receive CPR in the event of cardiac arrest. Despite being non-verbal, the resident was able to communicate effectively through text and demonstrated cognitive ability through written communication. However, a social history assessment documented that the resident did not have decision-making capacity and named a health care proxy, and a nurse practitioner obtained consent for procedures from the resident's Power of Attorney without documented evidence that the resident was incapable of making their own decisions. Further investigation revealed that there was no documentation in the medical record to support that the resident was not their own decision maker at the time consent was obtained from the proxy. When asked, the Director of Nursing was unable to produce prior documentation of incapacity and only provided a current evaluation after the surveyor's request. This sequence of events indicated that the resident's right to make their own decisions was not properly recognized or honored, as appropriate evaluations to determine decision-making capacity were not in place prior to deferring to a health care proxy.
Failure to Document and Honor Resident's Provider Gender Preference
Penalty
Summary
The facility failed to update the care plan to reflect a resident's preference for female healthcare providers. During an interview, the resident reported that their preference for female providers was not honored. A review of the resident's medical record did not show any documentation of this preference. Staff confirmed that the resident had requested only female healthcare providers and that both staff and management were aware of this preference. The Director of Nursing also acknowledged that the care plan was not updated to include the resident's stated preference.
Failure to Update MOLST After Guardian Appointment
Penalty
Summary
Facility staff failed to ensure the accuracy of a Medical Orders for Life-Sustaining Treatment (MOLST) order for one resident. The MOLST form in the resident's record was from 2020 and listed the resident as the decision maker for medical treatments. However, a legal court order appointing a guardian for the resident was issued in June 2022, making the resident no longer the authorized decision maker. Despite the presence of the court order in the medical file, the MOLST was not updated to reflect the new legal guardian as the decision maker. Interviews with facility staff revealed that the unit manager had not reviewed the resident's record and was unaware of the discrepancy until it was brought to her attention. The Director of Nursing acknowledged that staff failed to incorporate the court-appointed legal guardian order and did not update the MOLST accordingly. This oversight resulted in the resident's MOLST not accurately reflecting the current legal authority for medical decision-making.
Failure to Document Ongoing Re-Assessment of Physical Restraint Use
Penalty
Summary
Facility staff failed to document ongoing re-assessments to determine the necessity of a physical restraint for a resident who utilized a half gate across their doorway. The resident, who had a history of anoxic brain damage, aphasia, attention and concentration deficits, lack of awareness of boundaries, and poor safety awareness, was observed interacting with the gate and moving about their room. The resident's care plan included the use of the half gate restraint to prevent entry into other rooms and to maintain safety, with interventions specifying quarterly and as-needed evaluations of restraint use, as well as documentation of continued risk, benefits, and reasons for restraint use. Upon review, the surveyor found that the facility's policy required documentation of medical symptoms warranting restraint use, attempts at less restrictive alternatives, and ongoing re-evaluation of the restraint's necessity and effectiveness. However, the facility was unable to provide evidence of ongoing re-evaluation or documentation of less restrictive interventions for the resident. The only documentation provided was a quarterly assessment, and no further records were produced upon request.
Inaccurate Coding of Resident Discharge Status on MDS Assessment
Penalty
Summary
The facility failed to accurately code a resident's discharge status on the Minimum Data Set (MDS) assessment. Medical record review showed that the resident had an order to be discharged home and a discharge summary confirming discharge to home. However, the MDS assessment documented the resident as being discharged to a short-term general hospital. During an interview, the MDS Coordinator confirmed that the MDS was inaccurately completed, as the resident was actually discharged home.
Failure to Follow Wound Care Orders and Recommendations
Penalty
Summary
The facility failed to provide wound care treatments in accordance with the residents' current plans of care and the recommendations of the wound care team. For one resident, there were discrepancies in the treatment orders for a left buttock wound, where both an outdated Medihoney treatment and a new calcium alginate treatment were documented as being performed on the same day, despite the older order not being discontinued. Additionally, the treatment for a right upper arm skin tear was not updated to reflect the wound nurse practitioner's recommendation for a different frequency. The wound nurse practitioner’s notes did not support the use of Medihoney or the daily frequency for the right arm wound, yet these treatments were still being documented as completed. For another resident, the treatment administration record did not match the wound nurse practitioner's recommendations for a right knee skin tear. The practitioner's notes consistently recommended cleansing with normal saline, applying Hydrogel, and securing with an ABD pad and rolled gauze, but the order in the record specified cleansing with soap and water and using border gauze instead. The discrepancies were identified during interviews and record reviews, with the DON confirming that the nurse responsible for wound care orders was on leave and that other nurses were taking over the responsibility, leading to inconsistencies between the wound team's recommendations and the treatments being administered and documented.
Insufficient Weekend Nursing Staff Resulting in Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff on weekends to meet the needs of all residents, as evidenced by staffing records and resident interviews. Residents reported that staff were either not answering or were late in answering call lights on weekends. Staffing reports reviewed for the period from late December to early February showed that weekend nursing hours per patient day (HPPD) consistently fell below 3.0, with several specific dates documented where required hours were not met. This shortfall in staffing was directly linked to the inability to replace staff who called out on weekends. The Director of Nursing (DoN) confirmed that staffing was managed by an external agency during weekday business hours, while facility administration handled after-hours and weekend staffing. The DoN acknowledged that, despite efforts, the facility was unable to replace staff for weekend call-outs, resulting in insufficient staffing levels. The deficiency was substantiated by both resident complaints and documented staffing shortfalls.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for one resident. The resident reported not receiving their prescribed Pregabalin, a medication for neuropathic pain, on multiple occasions. Review of the Medication Administration Records for November 2024, December 2024, and January 2025 showed several missed doses, which were coded as 'other/see progress notes' or 'held/see progress notes.' Further examination of the progress notes revealed that in five instances, the medication was not available or was awaiting delivery from the pharmacy. The Director of Nursing confirmed that the resident should not have experienced unavailability of their medication.
Failure to Timely Address and Document Pharmacist Medication Irregularity Recommendations
Penalty
Summary
The facility failed to ensure timely action and proper documentation regarding pharmacist-identified medication regimen irregularities for two residents. For one resident, pharmacy reviews identified irregularities on two occasions, recommending changes to medication orders. However, the Director of Nursing (DON) did not receive these recommendations until nearly a month after the first irregularity was identified, despite the resident being seen by the attending physician multiple times in the interim. The physician did not document any review or action taken regarding the pharmacist's recommendations in the resident's medical record until the recommendations were finally addressed, well after the identified irregularities. For another resident, the pharmacist recommended a laboratory test for a medication level, but there was no documentation that the provider reviewed or acted on this recommendation during the next visit. The laboratory order was not placed until a week after the provider had seen the resident, and there was no documentation in the progress notes acknowledging the pharmacist's recommendation. The lack of timely action and documentation made it difficult to determine when the provider was notified of the recommendations and whether they were addressed appropriately.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication administration observation, resulting in a 12% error rate. Specifically, a Licensed Practical Nurse (LPN) administered 1 tablet of Ibuprofen 600mg and 2 tablets of Tizanidine 4mg to a resident, despite the Ibuprofen order having been discontinued several days prior and the correct Tizanidine dose being 6mg, not 8mg as given. Additionally, the same LPN administered Vitron C to another resident after the order for this supplement had also been discontinued. These errors were confirmed through medical record review and staff interview.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors identified that medications were not properly stored and labeled in the facility. During medication administration, an LPN was observed administering Ibuprofen 600mg to one resident and Vitron C to another, despite both medications having been discontinued according to the residents' medical records. The discontinued medications were found stored in the medication cart, and the LPN confirmed their presence. The Assistant Director of Nursing also acknowledged that discontinued medications should not be kept in the medication carts. Additionally, during a medication storage observation, a resident's Methadone medication was found without an expiration date on its label. Staff confirmed the absence of the expiration date, and a review of the methadone log form also failed to show this information. These findings demonstrate that the facility did not ensure all drugs and biologicals were properly labeled and stored according to accepted professional standards.
Improper Disposal of Garbage and Refuse Near Dumpster
Penalty
Summary
The facility failed to maintain the outdoor garbage storage area in a manner that would prevent the harboring of pests. During a tour of the outdoor dumpster used by the kitchen, four mattresses were observed piled next to the dumpsters, along with other materials surrounding them. The Maintenance Director confirmed that the wooded area near the building was a habitat for various types of vermin and acknowledged that the mattresses had been left outside because the garbage removal company would not take them. The Maintenance Director was unable to state how long the mattresses had been there and confirmed that the items had not been placed in the dumpster.
Incomplete and Inaccurate PASARR Documentation for a Resident
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards by not ensuring complete and accurate documentation for one resident. Specifically, a review of the resident's medical record revealed that a Level I Preadmission Screening and Resident Review (PASARR) evaluation was completed, with a positive response documented in the Severe Mental Illness (SMI) section, which would require a Level II screening. However, only two out of three required questions were marked as 'yes,' and the instructions indicated that all three questions must be marked 'yes' for a positive result. During interviews, the DON indicated uncertainty about whether the resident required a Level II screening and deferred to the Social Worker. The Social Service Assistant later clarified that the need for Level II screening was marked in error and that the resident did not actually require it. This discrepancy demonstrates a failure to maintain accurate and complete medical records as required by professional standards.
Deficient Maintenance of Facility Environment in Kitchen and Resident Areas
Penalty
Summary
Surveyors identified deficiencies in the facility's maintenance of a clean, comfortable, and homelike environment in both the kitchen and resident areas. Specifically, an exterior door used by kitchen staff to access the garbage disposal area was found to have an opening at the junction of the wall and the right corner of the door, allowing light from outside to enter. The Director of Maintenance acknowledged that the area had previously been repaired with concrete, but the repair had failed due to rough handling of the door, resulting in the open area reappearing. Additional deficiencies were observed in two resident rooms and a resident shower room. In one resident room, surveyors noted crumbling drywall in the bathroom window, multiple repair patches and water stains on the ceiling tile, and extensive scratches on the wall next to one of the beds. In the shower room across from the resident room, a nail was found protruding from the wall between two shower stalls, approximately 12 inches off the ground. The Maintenance Director confirmed that staff are expected to report such issues via maintenance logs or direct communication, and the DON acknowledged the maintenance concerns during interviews.
Failure to Honor Resident's Wishes Leads to Injury
Penalty
Summary
The facility failed to honor a resident's wishes regarding bed mobility, leading to an incident where a staff member caused harm to the resident. The resident, who had a history of hemiplegia, hemiparesis, and muscle contractures, expressed a desire not to be repositioned in bed. Despite this, a geriatric nursing assistant (GNA) attempted to turn the resident by pulling on their contracted fingers, resulting in a fracture of the resident's finger. The incident was documented in a facility-reported incident and medical records, which revealed that the resident experienced pain and swelling in the affected fingers. An initial x-ray conducted at the facility showed no fracture, but the resident insisted on further evaluation at the emergency room, where a fracture was confirmed. The resident reported ongoing pain and discomfort, particularly during weather changes, and expressed dissatisfaction with the handling of the situation by the GNA. Interviews with facility staff, including the Director of Nursing and the Nursing Home Administrator, indicated that the GNA involved had a history of conduct issues, including previous complaints of verbal abuse and falsification of documentation. The GNA was ultimately terminated following the incident. The resident described the GNA as rough and unyielding in their approach, which contributed to the incident and subsequent harm.
Failure to Employ Full-Time Licensed Social Worker
Penalty
Summary
The facility failed to employ a full-time licensed social worker despite having more than 120 certified beds, which is a requirement. The facility was licensed for 140 certified beds, and the absence of a full-time social worker was evident from the complaints and interviews conducted. A responsible party for one resident complained about the lack of communication from the social work department after the previous social worker left, leading to unresolved issues regarding the resident's care. Another responsible party reported difficulties in coordinating a discharge plan for a resident who had been in the facility since 2022, with no progress made after the previous social worker left. Interviews with staff revealed that the social work assistant, who was not a licensed social worker, was overwhelmed and handling all residents by herself. She was still pursuing her bachelor's degree and was not fully aware of the procedures for notifying family members about care plan meetings. The facility had been without a licensed full-time social worker since December 2022, despite attempts to recruit candidates. Supervision was provided by a corporate staff member who was not present in the facility on a full-time basis.
Environmental Deficiencies in Resident Rooms and Common Areas
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment for residents, as evidenced by multiple deficiencies observed during a complaint survey. In one instance, a resident's room was found to be unsanitary, with a toilet seat in disrepair, a malodorous atmosphere, and a floor that was soiled and sticky. The bathroom lacked essential supplies such as toilet tissue and hand towels, and the resident's closet compartments were in disrepair. Another resident's room had a bottom sheet with holes and stains, a molding strip hanging down, soiled window blinds, and a radiator with mold-like material. Additionally, the room's lamp was broken and dirty, and the over-bed tray table had missing laminate. Further observations revealed environmental concerns throughout the facility, including a hallway with base molding pulled away from the wall, dining room wheelchairs with cracked vinyl armrests, and a resident's room with cracked linoleum tiles and peeling drywall. Another room had a missing nightstand door and damaged laminate on the footboard. These findings were discussed with the corporate nurse, who acknowledged the concerns, including the presence of mold in the radiator.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required 2-hour timeframe to the Office of Health Care Quality (OHCQ) for five incidents. In one case, a resident reported to a hospital social worker that they had been hit by a staff member, but the facility's report was not received by OHCQ until the following day. Another incident involved a resident who communicated via phone that they had been spit on by a staff member, but the facility's report lacked a submission time, and no email confirmation was available. Additionally, a resident complained of pain and swelling after a staff member allegedly pulled their hand, but the facility could not confirm the report was sent within the required timeframe. Further incidents included a resident who reported pain after a GNA ignored their request not to be turned, resulting in swelling and pain in their hand. The facility's investigation did not produce an email confirmation of the report submission. Lastly, a GNA was informed by police to stay away from a resident after an alleged abuse incident, but the facility delayed reporting this to OHCQ. Interviews with the Director of Nursing (DON) revealed a lack of email confirmations for the report submissions, indicating a failure to adhere to reporting protocols.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility staff failed to conduct quarterly care plan meetings for several residents, as required. This deficiency was identified during a complaint survey, where it was found that seven residents did not have their care plans reviewed and revised quarterly. The care plans are essential for providing individualized care and ensuring that the interventions are accurate and appropriate for each resident. The lack of quarterly meetings was confirmed through interviews with the Director of Nursing and review of medical records. For Resident #5, there were no quarterly care plan meetings from admission in July 2022 until July 2024. Similarly, Resident #9 did not have any care plan meetings from April 2023 until discharge, and Resident #10 lacked meetings from admission in January 2024 until discharge. Resident #17 did not have any meetings from February 2023 until September 2024, and a meeting was only held after surveyor intervention. These lapses were confirmed by the Director of Nursing and the Administrator. Additionally, Resident #4's responsible party reported a lack of communication from the social work department after the social worker left, and no care plan meetings were held after September 2023. Resident #1's responsible party faced difficulties in coordinating a discharge plan due to the absence of care plan meetings after June 2023. Resident #2's medical record also lacked evidence of care plan meetings since admission in June 2023. These issues were discussed with the Corporate Administrator and Nurse during the exit conference.
Medication Administration and Risk Assessment Failures
Penalty
Summary
The facility failed to provide adequate care for several residents, as evidenced by multiple deficiencies in medication administration and risk assessment. Resident #7, diagnosed with opioid dependence, did not receive Methadone as ordered by the physician on numerous occasions in July and August 2024. This failure was confirmed by the Regional Nurse. Similarly, Resident #8 did not receive prescribed medications for seizures and gastrointestinal ulcers on two consecutive days in July 2024, as confirmed by the Director of Nursing. Resident #10, who was diagnosed with bilateral dry eye syndrome, did not receive prescribed artificial tears and lid scrubs in a timely manner. The eye doctor recommended these treatments on March 22, 2024, but they were not administered until April 16, 2024. This delay in treatment was confirmed by the Director of Nursing. Additionally, Resident #24's risk for elopement was inaccurately assessed, as the resident had a history of leaving the facility without notifying staff, yet this was not documented correctly in the Wandering Observation Tool. Resident #3, who was admitted with hypotension and other conditions, received Midodrine despite having a systolic blood pressure above the physician-ordered parameters. The medication was administered when the resident's blood pressure was 130/70, contrary to the order to hold the medication if the systolic blood pressure exceeded 120. This error was confirmed by Staff #13, who acknowledged the failure to follow the care plan related to medication administration.
Failure to Reassess Pressure Ulcer
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for Resident #40. The resident was readmitted to the facility with a Stage III pressure ulcer on the sacrum. The Wound Nurse Practitioner assessed the wound and documented its measurements on 3/3/24. However, the facility staff did not reassess the sacral pressure wound weekly as required, specifically failing to do so on 3/10/24. The resident was subsequently discharged to the hospital on 3/15/24. An interview with the Director of Nursing confirmed the failure to reassess the wound on the specified date.
Dignity Violation: Residents Pulled Backwards in Hallways
Penalty
Summary
Facility staff failed to treat residents in a dignified manner, as evidenced by two separate incidents observed during a complaint survey. In the first incident, a licensed practical nurse (LPN) was observed pulling a resident backwards down two hallways from the dining room to the resident's room. In the second incident, a geriatric nursing assistant (GNA) was seen pulling another resident backwards down a hallway and into an activity room. When questioned by a surveyor, the GNA was unable to identify the resident by name, and the resident had to state their own name. These observations were confirmed as dignity issues by a staff member during an interview.
Failure to Notify Physician of Low Blood Pressure
Penalty
Summary
The facility staff failed to notify a resident's physician of a significant change in the resident's condition, specifically a low blood pressure reading. The medical record review revealed that the resident was admitted to the facility and later transferred to the hospital, not returning to the facility. On a specific date, the resident's blood pressure was recorded as 73/49 mmHg, which is below the normal range. Despite this critical reading, there was no documentation indicating that the physician was notified of the low blood pressure. An interview with the Director of Nursing confirmed that the physician should have been informed of this change in the resident's status, but there was no evidence of such notification in the medical record.
Failure to Provide Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to provide a baseline care plan to a resident and their representative within 48 hours of admission, as required. This deficiency was identified during a complaint survey involving three residents, with one resident specifically affected. The baseline care plan is crucial as it outlines the initial goals, physician orders, therapy services, dietary services, and social services intended for the resident. In this case, the medical record review revealed no evidence that the resident or their representative received this summary within the stipulated timeframe. An interview with the Regional Nurse confirmed the oversight, highlighting a lapse in communication and documentation processes at the facility.
Failure to Address Elopement Risk in Care Plan
Penalty
Summary
The facility staff failed to ensure that a resident's care plan included individual care needs and interventions, specifically for the risk of elopement. This deficiency was identified during a complaint survey for one resident out of 51 reviewed. The medical record review revealed that the resident left the facility without notifying staff to visit a family member's house. Additionally, a nurse's note indicated that the resident was found sitting alone by an exit door, requesting to leave, but was reminded of a medical order prohibiting unaccompanied exits. Despite these incidents, the resident's care plan did not address the risk of elopement, which was confirmed by the Director of Nursing during an interview.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,300 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kensington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Oakview | 0.8 mi | ★★★★★ | 0 | 0 |
| Montcare At Wheaton | 1.3 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Arcola | 1.9 mi | ★★★★★ | 23 | 0 |
| Complete Care At Wheaton | 1.9 mi | ★★★★★ | 11 | 0 |
| Woodside Rehab & Nursing | 2.2 mi | ★★★★★ | 7 | 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 August 2026) and official state health department websites.