Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waldorf Center during CMS and state inspections, most recent first.
Surveyors found that medical records containing PHI were stored in a shared warehouse used for general storage, where open and closed boxes of records had resident names, MRNs, and assessments freely visible on box exteriors and file covers. The warehouse was unlocked for surveyors by maintenance staff, and the Director of Maintenance reported that central supply, housekeeping, and dietary staff had access. The DON later confirmed that maintenance and environmental services did not need access to PHI, yet acknowledged that multiple non-clinical staff, including maintenance and environmental services leadership, had keys to the warehouse where these records were kept.
Surveyors identified multiple infection control failures, including an activities assistant placing a personal cell phone on a resident’s bed, improper storage and management of biohazard waste in a warehouse where clean medical supplies, gloves, drinking cups, and other items were stored without separation or off-floor protection, and disorganized handling of clean and soiled linens. In the clean laundry area, uncovered facility linens and unidentified resident garments were piled, leaning on walls, and in some cases touching the floor. In the soiled laundry area, overflowing unlined bins and containers held unbagged resident laundry and facility linens piled high against walls in an odorous room, with only one functioning washing machine contributing to the accumulation of soiled items.
Environmental cleanliness and maintenance issues were observed in multiple resident rooms and a hallway, including stained roller blinds, a closet door off its hinges, a dirty stained extra mattress left uncovered beside a resident’s bed, spackled bathroom walls needing paint, peeling wallpaper, exposed wall piping, stained carpet, missing light parts, a bathroom floor not cleaned after sink repair, and damaged closet doors with missing hanging hardware. The maintenance director and UM confirmed several of the concerns, and one resident was sleeping in bed while the stained mattress remained uncovered next to the bed.
Unsanitary food storage and kitchen sanitation deficiencies: The facility had multiple sanitation and food safety failures, including an unclean handwashing sink, damaged walls and ceiling areas, an unclean ice machine with an uncovered ice scoop left on top, ice buildup in the freezer, and food items stored without dates or labels. Staff also observed uncovered or improperly stored foods, open spice containers, a warm opened milk container, a personal care basin stored with resident food, and a dietary aide plating food without a hair net while a kitchen window with a broken screen was open near food prep areas.
Incomplete and conflicting documentation affected several residents’ records. Three residents had incomplete fall risk assessments, one resident’s trach collar order did not match the oxygen setting being used and observed, two residents had inconsistent smoking evaluations and care plans that did not clearly show whether they were independent or supervised smokers, and one resident’s social service documentation repeated cognitive decline language despite a BIMS of 15/15 and a physician finding of adequate decision-making capacity.
Surveyors found that MDS assessments were inaccurately coded for tobacco use for two residents. Both residents told surveyors they were smokers, and facility smoking lists and prior Smoking Evaluations identified them as independent smokers. Despite this, their annual MDS assessments documented "No" for tobacco use in section J1300, indicating that known information about their smoking status was not accurately reflected in the MDS.
Surveyors found that the facility did not develop complete, person-centered care plans for a resident at risk for falls and two residents who were independent smokers. For the fall-risk resident with a history of CVA and impaired mobility, the care plan goal of avoiding falls with injury lacked specific, measurable interventions, including incomplete directions about fall mat use and which personal items should be kept within reach. For the two independent smokers, smoking assessments and goals for safe smoking were documented, but the care plans did not include any specific interventions or services to support those goals.
An LPN administered a PRN oxycodone dose to a resident for pain but failed to document the administration on the MAR, even though the narcotic control book showed the medication was signed out. In separate med pass observations, the same LPN gave multiple 9:00 AM scheduled medications, including metformin, Eliquis, antihypertensives, diuretics, GI meds, supplements, and inhaled therapy, to two residents more than an hour late, with the eMAR highlighting the overdue status. The LPN acknowledged the late administration and cited responsibility for two hallways of residents.
Failure to Maintain Resident Dignity: One resident was found lying in feces and urine-soiled brief and bedding, and stated they had asked for help with hygiene but were left in their bowel movement for hours. Another resident was repeatedly observed wearing pants that were far too large and tied in knots, with the closet containing only oversized clothing and no size information documented on the inventory form.
A resident who was non-verbal and communicated by typing words reported that staff removed their wheelchair at night and did not allow them to call their spouse. The resident said they wanted the wheelchair kept at bedside and believed it was taken away as punishment, while staff said the wheelchair had been moved at night because the resident was at risk for falls and would not call for assistance. Staff also stated they would call the resident’s spouse on speaker so the resident could communicate by typing.
Missing Written Transfer and Bed Hold Notifications: Two residents were transferred to the hospital, but the record did not show that their resident representatives received written notice of the transfer or the facility’s bed hold policy. The BOM later produced bed hold forms, but they were incomplete and did not include private pay bed hold information, and there was no documentation that the forms were actually provided to the resident representatives.
A resident receiving enteral nutrition through a feeding tube had an unlabeled formula container and an unlabeled flush bag observed by the surveyor. The resident had physician orders for NPO status, continuous Jevity 1.5 CAL via pump, and scheduled flushes, and an LPN and the DON both acknowledged that the tube feed and flush bag should have been labeled.
Bed rails were observed in use for two residents, but the records did not show a current Bed Safety Evaluation supporting their use, informed consent from the resident or representative, or a physician order. One resident’s chart included a care plan noting bed rails as an enabler, while prior evaluations for both residents stated side rails were not recommended or not indicated. The resident interviewed said the rails helped with repositioning, and staff stated bed rails were used as enablers.
Improper labeling and storage of refrigerated tuberculin was observed in the B wing med room. An RN was present when surveyors found one opened multidose bottle with an outdated date label and another opened bottle with no date-opened label. The RN stated meds must be labeled when opened and discarded after 30 days, and pharmacy guidance identified tuberculin tests as having a 30-day expiration after opening when refrigerated.
The facility failed to ensure proper cleaning and air drying of food preparation equipment, potentially affecting 103 residents. The AMD confirmed that the meat slicer had food remnants and several pans were stacked wet, contrary to facility policies requiring equipment to be cleaned and air dried before storage.
The facility failed to properly dispose of garbage in the dumpster area, affecting 110 residents and staff. An observation revealed an open dumpster and a ripped trash bag on the ground. The AMD confirmed that dumpsters should be closed and trash bags placed inside. The facility's policy requires trash to be contained in covered, leak-proof containers and disposed of in external receptacles, with the area kept free of debris.
The facility failed to provide residents with preplanned menus and alternative food options, resulting in residents not being able to choose their meals. Interviews and observations revealed that residents were not consistently informed of their meal options, especially those in isolation or unable to leave their rooms. Staff acknowledged the lack of a formal policy for menu distribution and preference collection, leading to meals not aligning with residents' preferences.
The facility failed to address resident council concerns about meal menus and food preferences. Residents reported that their requests for weekly meal menus and consideration of their food preferences were repeatedly ignored. Despite documentation of these issues in resident council meeting notes, no resolution was implemented. Interviews revealed a lack of communication and follow-up by the Activity Manager, District Dietary Manager, and Administrator, and the facility lacked a policy to address resident group concerns.
The facility failed to follow infection control measures for two residents, increasing the risk of COVID transmission. An LPN did not sanitize hands after removing PPE in a COVID-positive resident's room, and a GNA mishandled trash and soiled laundry. Another LPN did not perform hand hygiene between glove changes during wound care for a resident on Enhanced Barrier Precautions.
The facility failed to maintain a clean and comfortable environment, with issues such as unpainted walls, peeling laminate, and damaged wheelchairs observed. Additionally, a resident's gold ring went missing after being placed in a medication cart for safekeeping, leading to an investigation and the termination of an LPN for gross misconduct. The facility lacked a policy for protecting residents' property.
The facility failed to report allegations of abuse to the Office of Health Care Quality within the required 2-hour timeframe for two residents. In one instance, a staff member reported witnessing another staff member hitting a resident, but the report was delayed by seven days. In another case, a resident alleged that an LPN waved her finger in their face, but the report was delayed until the following day due to distractions from surveyors in the building.
The facility failed to thoroughly investigate an alleged abuse incident involving a resident. A staff member reported witnessing another staff member hitting a resident's hand, but the investigation was incomplete. It lacked the reporting staff's statement and did not include statements from other staff or residents who interacted with the accused staff member. The Administrator and DON confirmed the investigation's inadequacy.
The facility failed to hold quarterly care plan meetings and involve residents or their representatives in care planning. One resident had no care plan meetings in the past year, while another had only one meeting during their stay. The DON confirmed these deficiencies, and facility policies were not provided during the survey.
A facility failed to schedule a follow-up colonoscopy for a resident with gastrostomy status, GERD, and peptic ulcer, as ordered by a physician. A consultation report recommended a repeat colonoscopy due to poor colon preparation, but no documentation of the procedure was found. Staff interviews revealed that the responsibility for scheduling appointments lay with the unit manager or nurse, but the DON confirmed that the follow-up was not scheduled or performed.
A resident with a Stage IV pressure ulcer on the sacrum did not receive timely wound care as per physician orders. Upon admission and subsequent readmissions, there were significant delays in initiating the prescribed wound treatments, ranging from seven to ten days. These delays were confirmed by the DON, highlighting a pattern of non-compliance with wound care protocols.
A resident with a left second toe amputation did not receive proper wound care as ordered by the physician. The facility staff failed to cleanse and dress the surgical site on multiple occasions, and there were no nursing progress notes or wound notes to confirm that the care was provided. This deficiency was identified during a complaint survey.
A facility failed to administer prescribed respiratory inhalers for a resident with COPD/Asthma exacerbation, as indicated by blank spaces on the MAR for specific dates. The resident's care plan, which included administering aerosol treatments, was not followed. The DON confirmed that the nurse responsible no longer worked at the facility, and there was no documentation to confirm the treatments were provided.
A facility failed to document the administration of PRN Dilaudid (Hydromorphone) for a resident and did not monitor the resident's pain level or the medication's efficacy. The medication was removed from the controlled lock box on several occasions, but these administrations were not recorded on the MAR, as confirmed by the Administrator.
During a complaint survey, facility staff failed to keep medication and treatment carts locked when unattended. On the B wing, two medication carts were found unlocked and unattended, with accessible drawers containing resident medications. Additionally, a treatment cart was found unlocked on both the B and A wings, containing medicated ointments and other supplies. Staff members were informed but seemed unaware or indifferent to the issue. The facility's policy requires medication supplies to remain locked when not in use.
Facility staff failed to follow up with outside resources for a resident's oral surgery post-operative instructions. The resident had three teeth extracted and was given written instructions, but these were not documented in the medical record. An interview confirmed the lack of follow-up with the oral surgeon.
The facility lacked an effective pest control program, resulting in a widespread gnat problem. A resident complained about gnats in their wheelchair, and another resident's meal was affected by gnats. The issue was confirmed by a CMA and observed in the NHA's office. The NHA admitted the facility only recently secured a pest control contract.
A cognitively intact resident was not invited to their care plan meetings, despite having full decision-making capacity. The resident's mother attended the meetings instead, and discussions about the resident's care were held with her. Facility staff misunderstood the resident's competency status, leading to this oversight.
A facility failed to provide written notification of transfer to a resident or their family/representative. A resident, who was severely cognitively impaired and dependent on ADLs, was transferred to the emergency room after sustaining a head injury. The facility did not provide written notification of this transfer, and the Administrator confirmed that such notifications were not being issued.
A resident with mental disorders and intellectual disabilities did not receive a required PASARR Level II evaluation after remaining in the facility for over 40 days. The resident's medical records showed moderate cognitive impairment and impulsive behaviors, but the facility failed to request the necessary screening from the State Agency, as confirmed by staff interviews.
Two residents, both cognitively intact but dependent on staff for ADLs, were found with long and soiled fingernails. Despite being reliant on staff for personal hygiene, their nails remained untrimmed and dirty over several days. An LPN and the DON confirmed that GNAs were responsible for nail care, but the facility failed to provide a policy for ADL care upon request.
A resident with impaired range of motion in the left upper extremity did not consistently receive a prescribed hand splint, as observed during multiple checks. The resident was unable to apply the splint independently and staff were unaware of the order. The Director of Rehab confirmed the splint was missing, and the Director of Nursing stated that nursing staff were responsible for implementing the care plan, which was not followed.
A pharmacist failed to monitor adverse consequences and target behaviors for a resident prescribed Seroquel for agitation, despite the resident's severe cognitive impairment and Alzheimer's diagnosis. The Medication Regimen Review did not address the use of Seroquel or the need for monitoring, and the pharmacist could not provide specific information due to database access issues.
A facility failed to monitor the use of Seroquel for a resident with Alzheimer's and Parkinsonism, who was prescribed the medication for agitation despite no signs of distress. The care plan lacked specific monitoring for side effects or target behaviors, and observations showed the resident was calm. The DON confirmed the absence of adequate monitoring, violating the facility's medication management policy.
Unsecured Storage of Medical Records with Visible PHI in Shared Warehouse
Penalty
Summary
The facility failed to ensure privacy and confidentiality of medical records when surveyors observed resident medical records stored in an unsecured warehouse building. During a dual surveyor observation conducted in connection with a complaint investigation, the Director of Maintenance and Assistant Director of Maintenance unlocked the warehouse, where surveyors saw several open boxes of medical records in different areas of the warehouse with freely visible protected health information, including resident names and medical record assessments. In another area of the warehouse, surveyors observed approximately 11 closed boxes of medical records with papers affixed to the exterior showing visible resident names and medical record numbers, as well as medical record files sitting on top of the boxes with names and other information written on the outside of the files. During the same observation, the Director of Maintenance stated that the warehouse was used by "everybody" to put items in and that it served as additional storage. When surveyors asked who had access to the warehouse, the Director of Maintenance identified the central supply staff, housekeeping, and dietary staff as having access. In a subsequent interview, the DON confirmed that maintenance and environmental services staff did not need access to medical records or protected health information, yet reported that the Maintenance Director, Environmental Services Director, Medical Records/Supply person, and Maintenance Assistant all had keys or access to the warehouse where the medical information was stored. These observations and interviews established that medical records containing protected health information were stored in a location accessible to multiple non-clinical staff, with resident-identifying information openly visible.
Inadequate Infection Control in Warehouse Storage, Laundry Handling, and Resident Care Area
Penalty
Summary
The deficiency involves failures in basic infection prevention and control practices, beginning with improper handling of personal items in a resident care area. An activities assistant placed their personal cell phone directly onto a resident’s bed while accessing the resident’s furniture with a key. The assistant acknowledged that the phone was personal, and the concern was recognized by the facility’s Director of Nursing, who stated the assistant had been rushed and not thinking when placing the phone on the bed. Additional deficiencies were identified in the facility’s warehouse storage area during a dual surveyor observation conducted with the Director and Assistant Director of Maintenance. Surveyors observed biohazard waste stored in the same area as open boxes of clean medical gloves and other clean medical supplies, with boxed biohazard waste stacked against boxes of clean items. An opened box of drinking cups and cup lids was stored on the floor near a plastic container of used belongings, including a worn and cracked wheelchair armrest. Lancets, medical tape, and various expired syringes were present without separation of clean and dirty items, and boxed medical supplies such as gloves, incontinence briefs, wound cleanser, and dressing supplies were stored directly on the floor. The Infection Preventionist confirmed that these storage and biohazard management conditions were not acceptable and stated that biohazard waste should never be stored with clean items. Further infection control concerns were identified in the clean and soiled laundry processing areas. In the clean laundry area, surveyors observed an uncovered metal linen cart with facility blankets, towels, washcloths, and sheets piled high, leaning on the wall, and stored close to the floor. There was also an uncovered laundry basket with a pile of clean, unfolded, unidentified resident laundry overflowing and leaning against the wall, along with three additional uncovered containers of unidentified resident laundry under folding tables, one of which had items touching the floor. In the soiled laundry area, multiple unlined large trash bins were overflowing with unbagged resident laundry and facility linens piled high and touching the wall, along with additional containers and a tilt truck filled with bagged and unbagged soiled linens, and the room was described as odorous. The Environmental Services Manager and District EVS Manager confirmed these conditions and the associated infection control concerns, noting that only one of two washing machines was operational, contributing to the volume of soiled laundry present.
Environmental cleanliness and room maintenance deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms and a hallway on the A Wing Unit. During the surveyor’s tour, several windows had cream-colored roller blinds with black discoloration embedded in the material, and one blind also had dried food-like particles of dark brown, tan, and orange stains scattered throughout it. In another room, the sliding closet door was off its hinges and leaned in the closet, the resident’s headboard/footboard was on the floor and later replaced, and a dirty blue twin-sized mattress with white and brown stains was observed leaning against the wall between the closet and bathroom and later placed next to the resident’s bed while the resident was sleeping. The closet remained without a door, leaving the resident’s belongings without enclosed privacy, and the mattress was described as an extra mattress used as an extension of the resident’s bed for fall precaution while in bed. Additional environmental concerns were observed in another resident bathroom, where a large spackled area extended above the baseboards and up approximately two-thirds of the left, right, and front walls opposite the sink and toilet and needed paint. In the hallway, one light was out, wallpaper was peeling, areas of wall were cut out with a pipe sticking out, and the carpet had several stained areas throughout. Other room concerns included a missing closet door, a missing bulb and cover at the head of a bed light, a bathroom floor that had not been cleaned after sink repair work, a large hole in a closet door, and a missing pole for hanging clothes. The maintenance director and assistant maintenance director confirmed the observations, and the maintenance director stated he was new and working with staff to address the issues as soon as possible. The unit manager also acknowledged the missing closet door and broken headboard/footboard in one room, and stated the closet door was to be repaired and replaced. The surveyor’s findings were discussed with administration at the exit conference.
Unsanitary food storage and kitchen sanitation deficiencies
Penalty
Summary
The facility failed to ensure sanitary practices were followed and food was stored in accordance with professional standards for food service safety. During the kitchen tour, the handwashing sink was observed to be unclean with debris on the sink surfaces and on the wall below the hand soap dispenser, and the walls behind and adjacent to the sink had an open uncovered area of disrepair with missing wall tiles and cove molding, exposed drywall, and dust and debris present. The ice machine storage bin lid was unclean, a clear ice scoop was left resting on top of the ice machine without a container, and the walk-in freezer had areas of ice accumulation, including an icicle extending from the food holding rack to the floor. Multiple food storage and labeling concerns were observed in the kitchen and nutrition areas. Packages of turkey breast and pork meat were labeled with use-by dates that had passed, a box of chicken breast had no date labeling, and an opened bag of chicken breasts had no date or labeling. In the walk-in refrigerator, sliced cheese was left partially uncovered, condiment containers of chopped onions had no labeling or date, pitchers of red and brown liquid had no labeling, and containers of peach cobbler had no label or date. Additional observations included an area of brown liquid on a food prep table, spice containers left open to air, custard cup dishes with food particles present, a pumpkin pie labeled with a use-by date that had passed, and an unlabeled bag of potato wedges with a hole in the bag and exposed to air. Further observations showed unsanitary conditions and food handling issues in the nutrition rooms and tray line areas. A personal care basin filled with ice and a container of applesauce were stored with resident food and supplements in the A wing nutrition refrigerator, a white ring of film was present on the C wing nutrition room sink, and the C wing nutrition room had a movable floor tile, a missing floor tile, visible soiling, separated cove molding, and exposed wall damage with debris. An opened container of milk was left unattended on the counter and felt warm to the touch. During tray line service, a dietary aide was plating resident food without a hair net, and a kitchen window was freely open to outside air with a bent and broken screen adjacent to food prep areas where bread slices were being prepared.
Incomplete and conflicting resident documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for multiple residents during the annual survey. Three residents had incomplete Fall Risk Evaluations that did not accurately assess gait/balance, medications, history, current status, or predisposing conditions needed to determine fall risk. The surveyor reviewed the assessments for these residents and found that the documentation did not fully reflect the residents’ current condition at the time the evaluations were completed. The facility also had a discrepancy between the documented and observed oxygen settings for a resident with a trach collar. The medical record contained a physician order for 80% FIO2, 3 liters, and 20 PSI, while the resident was observed on multiple occasions at 80% FIO2, 2.5 liters, and 20 PSI. Staff interviews confirmed the resident was actually receiving 2.5 liters, and the respiratory therapist stated the resident should be on 2.5 liters, showing that the record did not match the resident’s actual respiratory setting. Two residents who were identified as smokers had inconsistent smoking documentation. Their smoking evaluations contained conflicting statements about whether they were independent smokers or required supervised smoking, and each resident had two current smoking care plans with differing focuses, one indicating independent smoking and the other indicating smoking with supervision. The documentation did not clearly establish the residents’ actual smoking status. In addition, a resident’s social service assessments repeated language stating that advanced care planning information had been provided but the resident was unable to complete it due to continued cognitive decline, even though the resident’s current BIMS score was 15/15 and a physician certification indicated adequate decision-making capacity.
Inaccurate MDS Coding of Resident Tobacco Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments were accurately coded to reflect residents’ current tobacco use status. Two residents who were identified as smokers through interviews with the surveyor and facility documentation were coded as non-smokers on their annual MDS assessments. One resident reported to the surveyor that they were a smoker, and the facility’s smoking list and a prior Smoking Evaluation dated 9/2/2025 identified this resident as an independent smoker. However, the resident’s annual MDS assessment completed on 9/22/2025 documented “No” for tobacco use in section J1300. Similarly, another resident informed the surveyor that they were a smoker, and the facility’s smoking list and a Smoking Evaluation dated 12/3/2025 showed that this resident was also an independent smoker. Despite this, the resident’s annual MDS assessment completed on 12/06/2025 recorded “No” for tobacco use in section J1300. During interviews, the MDS Coordinator acknowledged that tobacco use should have been captured on the annual MDS for one of the residents, and the Corporate Clinical Lead was informed by the surveyor that the other resident’s annual MDS did not reflect current tobacco use. These findings demonstrate that existing information about residents’ smoking status was not accurately incorporated into their MDS assessments.
Incomplete and Non-Specific Care Plans for Fall Risk and Independent Smokers
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive, individualized care plans for multiple residents. For one resident reviewed for change in condition, the care plan included a focus of risk for falls related to CVA and impaired mobility, with a goal of no falls with injury for 90 days. However, specific interventions were left incomplete: the intervention for fall mats did not indicate the number or sides to be used, and the intervention directing staff to place personal items within reach did not specify which personal items. During review, the DON acknowledged that this care plan was not sufficiently personalized or specific to the resident’s needs. For two residents reviewed for accidents who were identified as independent smokers, the facility failed to develop complete person-centered care plans that included specific interventions. Both residents had smoking evaluations indicating they were independent smokers, and each had a care plan focus stating that the resident may smoke independently per smoking assessment, with goals that the resident would smoke safely by the next review or for 90 days. Despite this, the care plans did not include any detailed interventions describing the specific care and services to be implemented to meet the stated goals for safe smoking. This lack of defined interventions for independent smokers was confirmed during record review and staff interview.
Failure to Document PRN Narcotic and Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves failure to follow professional standards of practice during medication administration and documentation. During an observation, an LPN removed and administered a 5 mg oxycodone tablet to a resident who complained of an upset stomach and headache, signing the narcotic control book when removing the medication from the narcotic drawer. Subsequent medical record review showed the resident had a PRN order for oxycodone 5 mg by mouth every four hours as needed for pain rated 4–6, but the medication administration record (MAR) did not show that the oxycodone dose was documented as administered, despite confirmation in the narcotic book that it had been signed out for that resident. Additional deficiencies were identified during medication pass observations for two other residents when an LPN administered multiple scheduled medications significantly later than the ordered time. For one resident, medications including metformin, Eliquis, aspirin, metoprolol, amlodipine, cetirizine, furosemide, omeprazole, a multivitamin, and fluticasone inhalation were scheduled for 9:00 AM but were administered at 10:30 AM, with the electronic MAR screen highlighted in pink to indicate they were not given at the scheduled time. For another resident, medications and supplements including protein liquid, amlodipine, metoprolol, a multivitamin with minerals, sodium bicarbonate, Vitron-C, and omeprazole were also scheduled for 9:00 AM but were administered at 10:45 AM, again with the computer screen highlighted in pink. The LPN acknowledged in both cases that the medications were given outside the scheduled ordered time and explained she was responsible for two hallways of residents.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain dignity for a resident who was observed lying in a copious amount of feces and yellow and brown soiling, with areas that appeared both dry and moist on the incontinence brief and extending onto the bed pad, with feces visibly present on the bed pad next to the resident’s right hip. During interview, the resident stated they felt uncomfortable about their hygiene and had been left in their bowel movement for a few hours, and reported that nursing staff had not returned after being told they needed assistance into a clean gown and to be cleaned up. After surveyor intervention, the Administrator directed nursing staff to attend to the resident’s incontinence care and personal hygiene. The resident later reported they had told a GNA they needed assistance and did not receive it, and the assigned UM/LPN confirmed they had taken the assignment that morning because the nurse had called out last minute and that one nurse and one GNA had called out on the shift. The facility also failed to ensure a resident was treated with dignity and respect when the resident was observed in pants that were extremely too big and tied in a knot in front. On a later observation, the resident was again wearing jeans that were too big with a knot wrapped around the buckle area, and the resident’s closet contained jeans and pants all sized 44, many with knots in the front, along with some sweatpants. The DON stated she did not know how long the pants had been too big and referred the surveyor to the unit manager. The unit manager stated the resident’s responsible party was responsible for getting clothes that fit and said the RP had been notified that new pants and a belt were needed, while also stating the last time the RP brought clothes was in September 2025. The inventory form for the clothing brought in did not list the sizes received.
Resident Autonomy and Wheelchair Access Not Supported
Penalty
Summary
The facility failed to ensure that a resident had the opportunity to exercise autonomy regarding matters important in their life. Resident #11, who was non-verbal and communicated with staff by typing words on a paper typewriter, told the surveyor that staff took away their wheelchair at night and did not allow them to call their spouse. The resident also stated that they wanted to keep their wheelchair at the bedside and said staff removed it at night as a punishment, leaving them unable to go to the bathroom. During the surveyor’s interview with the resident and staff, the GNA stated she did not take the wheelchair away and said the resident often wanted to remain in the wheelchair at the end of her shift. The unit manager stated staff had been moving the wheelchair at night to prevent the resident from trying to get up alone because the resident was at risk for falls and would not call for assistance. The unit manager also stated that staff would call the resident’s spouse on the phone, and if the spouse answered, the call would be placed on speaker so the resident could type words to communicate.
Missing Written Transfer and Bed Hold Notifications
Penalty
Summary
The facility failed to provide written notification to the resident and/or resident representative when two residents were transferred to the hospital, and failed to provide written notification of the facility’s bed hold policy at the time of transfer. For Resident #23, the surveyor found that the resident was transferred to the hospital and was not their own resident representative, but the electronic and paper record did not contain documentation showing that the resident or resident representative received written notice of the transfer or the bed hold policy. The facility’s policy stated that prior to transfer, the patient and representative would be notified verbally and then in writing, with a copy placed in the medical record. For Resident #100, the surveyor found the resident was transferred to the hospital and was not their own representative, but the record also lacked documentation that written transfer notification and bed hold information were provided. The facility’s bed hold policy stated that the resident representative should receive the Bed Hold Notice of Policy and Authorization form, including private pay bed hold information, and have an opportunity to confirm or deny private pay bed hold within 24 hours of transfer. The Business Office Manager later provided bed hold forms for both residents, but the forms were incomplete and did not include private pay information, and there was no documentation to verify that the resident representatives received the forms.
Unlabeled Tube Feeding Formula and Flush Bag
Penalty
Summary
The facility failed to ensure that the tube feeding formula container and the bag of flush were labeled for Resident #65, who was receiving enteral nutrition through a feeding tube for nutritional support due to a medical condition. During observation on 1/15/2026 at 9:24 AM, the resident was observed receiving tube feeding, and the surveyor found that the formula container with attached tubing was not labeled with the resident’s name, formula name/type, date/time hung, or administration rate/method. The clear bag of flush was also not labeled with the resident’s name, the volume and type of flush, or the date/time hung. Record review showed physician orders for NPO status, continuous Jevity 1.5 CAL via pump at 50 mL per hour with a downtime from 12 PM to 6 PM, and flushes of 225 mL every 6 hours. An LPN confirmed the tube feed had been hung at 6 PM on 1/14/2026 and should have been labeled when hung, and the DON also acknowledged that both the tube feeding formula container and the bag of flush should have been labeled.
Bed Rail Use Without Required Assessment, Consent, or Order
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the safe use of bed rails, that informed consent was obtained from the resident or resident representative before bed rail use, and that a physician's order was in place for the use of bed rails. This was identified for 2 of 8 residents reviewed for accidents during the recertification survey. Bed rails were observed in use for Resident #15 and Resident #23, with black quarter-sized bed rails raised at the top of the bed on both sides for each resident. Record review showed that Resident #15 had a Bed Safety Evaluation dated [DATE] stating that no side rail use was recommended, and a care plan dated 12/12/2025 included an intervention for bed rails used as an enabler. However, the record did not show an updated Bed Safety Evaluation, consent from the resident representative, or a physician order for the current use of bed rails. Resident #23 also had a Bed Safety Evaluation dated [DATE] stating that bed rails were not indicated, and the record likewise lacked documentation of resident or resident representative consent and a physician order for bed rail use. During interview, Resident #23 stated that the bed rails helped with repositioning in bed. Facility staff stated that quarter-sized bed rails were used as enablers and that a Bed Safety Evaluation, consent, and physician order would be obtained for their use, but these documents were not present in the records reviewed.
Improper Labeling and Storage of Refrigerated Tuberculin
Penalty
Summary
The facility failed to store biologicals in accordance with guidance and failed to ensure that medications opened and refrigerated had a date-opened label. During an observation of the B wing medication room with an RN present, surveyors found an opened multidose bottle of Tuberculin Purified Protein Derivative with a written date label of 1/9/25 and another opened multidose bottle of Tuberculin Purified Protein Derivative with no date label indicating when it was opened. The RN stated that medications are to be labeled upon opening and discarded after 30 days. The facility also provided pharmacy guidance identifying tuberculin tests as having a 30-day expiration after opening when refrigerated. The DON was informed of the concern and stated staff are to follow facility policy and guidance, including dating medications upon opening and discarding expired medications.
Improper Cleaning and Drying of Kitchen Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and air drying of food preparation equipment, which could potentially increase the risk of foodborne illness for 103 of the 110 residents receiving dietary services. During an observation, the Account Manager Dietary (AMD) confirmed that the meat slicer blade had food remnants on it and needed cleaning before use. The AMD stated that it was expected for the meat slicer to be properly cleaned after each use, as per the facility's policy, which mandates that all food contact equipment be cleaned and sanitized after each use. Additionally, during another observation, the AMD confirmed that several pans, which were cleaned and stacked for use, were still wet and had not been allowed to air dry before storage. The facility's policy requires all cookware and service ware to be air dried prior to storage. These deficiencies in cleaning and drying procedures were observed and confirmed by the AMD, highlighting a failure to adhere to the facility's established policies for maintaining sanitary conditions in food preparation areas.
Improper Garbage Disposal in Dumpster Area
Penalty
Summary
The facility failed to ensure proper disposal and containment of garbage in the dumpster area, affecting 110 residents and staff. During an observation, it was noted that one of the two dumpsters used for trash and recycling was left open, and a large trash bag was found ripped open on the ground between the dumpsters. The Account Manager Dietary (AMD) confirmed that dumpsters should be closed and trash bags should be placed inside the dumpsters, not left on the ground. The facility's policy, dated September 2017, mandates that all trash be contained in covered, leak-proof containers to prevent cross-contamination and be properly disposed of in external receptacles, with the surrounding area kept free of debris.
Failure to Provide Meal Choice and Menu Information
Penalty
Summary
The facility failed to provide preplanned menus and a list of alternative foods to residents, resulting in a lack of opportunity for residents to choose their meals. This deficiency was observed in four residents, all of whom were cognitively intact and capable of making their own meal choices. The residents reported not being asked about their meal preferences and not being informed of the available menu options. This led to residents receiving meals that did not align with their preferences, such as one resident preferring oatmeal but receiving scrambled eggs instead. Interviews with staff revealed a lack of a formal policy for distributing menus and collecting residents' meal preferences. The District Manager of Dietary and the Director of Nursing both acknowledged that there was no established process for ensuring residents were informed of their meal options. The nursing department was supposed to distribute menus and collect preferences, but this was not consistently done, especially for residents in isolation or those unable to leave their rooms. Observations further confirmed the inconsistency in meal service. Residents in isolation did not receive menus during their isolation period, and some residents received meals that did not match the menu or their preferences. The dietary manager stated that menus were posted in common areas, but this did not address the needs of residents who remained in their rooms. The facility's failure to ensure residents were informed of their meal options and preferences contributed to the deficiency.
Failure to Address Resident Council Concerns on Meal Preferences
Penalty
Summary
The facility failed to address the concerns and requests of the resident council regarding meal menus and food preferences. Five residents who regularly attended the resident council meetings expressed that their requests for weekly meal menus and consideration of their food preferences had been repeatedly ignored. During a group interview, residents reported that they had not received any rationale for their unmet requests, and their concerns were documented in the resident council meeting notes over several months without resolution. The Activity Manager (AM) had documented plans to address these issues, such as providing menus and surveying residents for meal preferences, but these actions were not implemented. Interviews with facility staff revealed a lack of communication and follow-up on the residents' grievances. The AM acknowledged awareness of the residents' requests but could not provide documentation of any communication with the dietary department. The District Dietary Manager (DM) was aware of the concerns but had not acted on proposed solutions, such as the mock plate discussion. The Administrator was also aware of the issues but had not ensured that the dietary staff responded to the resident council's concerns. The facility lacked a policy to address resident group concerns, contributing to the ongoing deficiency.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control measures for two residents, increasing the risk of COVID transmission and cross-contamination. For Resident 31, a physician ordered strict isolation and droplet precautions due to a COVID-positive diagnosis. However, during wound treatment, an LPN did not sanitize or wash her hands after removing PPE in the resident's room, citing a non-functional sanitizer dispenser. Additionally, a GNA improperly handled trash and soiled laundry from the resident's room, placing them on the hallway floor and failing to label the laundry for separate washing, which was confirmed by the laundry worker and the Infection Preventionist. For another resident, R1, who was on Enhanced Barrier Precautions due to a feeding tube, urinary catheter, and non-healing pressure ulcers, an LPN failed to perform hand hygiene between glove changes during wound care. The LPN changed gloves multiple times without sanitizing her hands, even after touching the dresser and bed rails. This was verified by another LPN assisting with the procedure and the Infection Preventionist, who confirmed that hand hygiene was expected between all glove changes.
Deficiencies in Facility Maintenance and Resident Property Protection
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment in two of the three nursing units and the dining room. Observations revealed unpainted spackled areas, peeling laminate on dresser drawers, and stained privacy curtains in resident rooms. Additionally, wheelchairs in the dining room had missing or damaged armrests, exposing the padding underneath. The Maintenance Director acknowledged the issues with the wheelchairs and stated that audits are conducted every two months, but the Nursing Home Administrator could not provide invoices for replacement parts. The facility also failed to protect a resident's personal property from loss or theft. A grievance was filed by a family member regarding a missing gold ring belonging to a deceased resident. The ring was initially secured by the facility but was later reported missing after being placed in a medication cart for safekeeping. The investigation revealed that the last known staff member to have possession of the ring failed to inform the oncoming nurse of its location, leading to its disappearance. The facility was unable to determine if the staff member took the ring, but he was terminated for gross misconduct. The facility did not provide a policy related to protecting residents' property, and the investigation into the missing ring involved staff interviews and re-education on handling personal property. The incident was reported to local law enforcement, the State Agency, and the Long-Term Care Ombudsman. Despite these actions, the facility was unable to locate the missing ring, and the family was informed of the situation.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe. This deficiency was identified during an annual survey for two residents. In the first case, a staff member reported witnessing another staff member hitting a resident's hand, but the incident was reported to OHCQ seven days later. The Director of Nursing and Administrator confirmed the delay in reporting. In the second case, a resident alleged that an LPN waved her finger in the resident's face. The allegation was reported to the Nursing Home Administrator by a surveyor, but the report to OHCQ was delayed until the following day. The Nursing Home Administrator attributed the delay to being distracted by surveyors in the building.
Incomplete Investigation of Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. On 8/14/24, a review of a facility-reported incident revealed that a staff member reported witnessing another staff member hitting a resident's hand on 5/19/22. The facility's investigation was found to be incomplete as it did not include the name or statement of the reporting staff member, nor did it contain statements from other staff who were present on the day of the alleged incident, except for the accused staff member. Additionally, the facility did not obtain statements from other residents who received care from the accused staff member to determine if there were further concerns of abuse. An interview with the Administrator and Director of Nursing confirmed that the facility staff failed to complete a thorough investigation of the alleged abuse incident.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for residents and did not invite residents or their representatives to participate in the development of their care plans. This deficiency was identified for three residents during the review. For one resident, admitted with diagnoses including nontraumatic intracranial hemorrhage and chronic kidney disease, there was no record of any care plan conference being held, despite the availability of baseline and comprehensive care plans. A family member confirmed not being invited to any care plan meetings, and the Social Services Coordinator acknowledged that care plan meetings had not been held for this resident in the past year. Additionally, another resident had only one care plan meeting during their stay, and a third resident had no care plan meetings after an initial one, until their discharge. The Director of Nursing confirmed the absence of quarterly care plan meetings for these residents. Facility policies regarding care plans and meetings were requested but not provided during the survey.
Failure to Schedule Follow-Up Colonoscopy
Penalty
Summary
The facility failed to schedule a follow-up colonoscopy for a resident as per the physician's orders. The resident, admitted in August 2022, had diagnoses including gastrostomy status, GERD, and peptic ulcer. A consultation report dated April 19, 2023, indicated poor colon preparation and recommended a repeat colonoscopy in one month. The report included a note to schedule the procedure, but there was no documentation of the follow-up colonoscopy being performed. Interviews with staff revealed that the responsibility for scheduling such appointments lay with the unit manager or nurse on the unit. However, the Director of Nursing confirmed that no follow-up colonoscopy was scheduled or performed, and the last recorded visit to the GI office was in December 2023 for G-tube removal.
Failure to Provide Timely Wound Care for Resident
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident with a Stage IV pressure ulcer on the sacrum. Upon admission to the facility, the resident had a physician's order for wound treatment twice daily, but the treatment was not initiated until seven days after admission. This delay in treatment was documented in the resident's Treatment Administration Record (TAR) for December 2023. Further deficiencies were noted upon the resident's readmissions from hospital stays. On two separate occasions, the facility staff failed to begin the ordered wound treatment for the sacral wound in a timely manner. After a hospital stay in April 2024, the treatment was delayed by seven days, and following another hospital stay at the end of April 2024, the treatment was delayed by ten days. These delays were confirmed by the Director of Nursing during an interview, indicating a pattern of non-compliance with physician orders for wound care.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility staff failed to provide proper foot care and treatment for a resident, which was identified during a complaint survey. The resident was admitted with a diagnosis of amputation of the left second toe. On 8/16/23, a physician ordered specific wound care instructions for the surgical site, including cleansing with wound cleanser, patting dry, and covering with a dry dressing daily during the day shift. However, medical records revealed that on multiple dates, including 8/16, 8/18, 8/20, 8/23, and 8/26, the surgical site was not cleaned and dressed as ordered by the physician. An interview with the Director of Nursing on 8/20/24 confirmed that there were no nursing progress notes or wound notes in the medical record to indicate that the wound care was performed according to the physician's orders. This lack of documentation and adherence to the prescribed wound care regimen led to the deficiency identified in the report.
Failure to Administer Respiratory Inhalers as Ordered
Penalty
Summary
The facility failed to administer respiratory inhalers as ordered for a resident who required respiratory treatment. This deficiency was identified during a review of a complaint, medical records, and staff interviews. The resident in question had a history of respiratory failure secondary to COPD/Asthma exacerbation and was admitted to the facility from the hospital. The resident was prescribed Budesonide and Ipratropium-Albuterol inhalers to be administered twice daily for shortness of breath and wheezing. However, the Medication Administration Record (MAR) for March and April 2023 showed that the inhalers were not administered on specific dates, as indicated by blank spaces on the MAR. The care plan for the resident, which included administering aerosol treatments as ordered, was not followed. During an interview with the Director of Nursing (DON), it was revealed that the nurse responsible for administering the inhalers on the dates in question no longer worked at the facility, and there was no documentation in the nurse's notes to confirm that the respiratory treatments were provided. This lack of documentation and failure to administer the prescribed inhalers as ordered led to the identified deficiency.
Failure to Document and Monitor PRN Pain Medication Administration
Penalty
Summary
The facility failed to consistently document the administration of an as-needed (PRN) pain medication, Dilaudid (Hydromorphone), for a resident, as evidenced during a complaint survey. The resident's primary physician had ordered the medication to be given every six hours as needed for pain. However, a review of the Controlled Medication Utilization Record showed that the medication was removed from the controlled lock box on several occasions in December 2023 and January 2024, but the administration was not documented on the Medication Administration Record (MAR). Additionally, the resident's pain level and the efficacy of the medication were not monitored. An interview with the Administrator confirmed that the facility staff failed to ensure the medication was given as needed for pain.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Facility staff failed to keep medication and treatment carts locked when unattended, as observed during a complaint survey. On the B wing nursing unit, an unlocked and unattended medication cart was found in the hallway outside the clean utility room. This cart remained unlocked and unattended for at least 13 minutes, during which time the surveyor was able to open all drawers containing resident medications. Another medication cart in the same hallway was also found unlocked and unattended, with accessible drawers containing medications. Licensed Practical Nurse (LPN) #1 was informed of the situation but seemed unaware of the issue. Additionally, an unlocked and unattended treatment cart was observed on the opposite hallway of the B wing nursing unit, containing medicated ointments and treatment modalities. Registered Nurse (RN) #2 was informed of the unlocked carts. On the A wing nursing unit, another unlocked and unattended treatment cart was found, containing scissors, bandages, prescription ointments, creams, and medicated dressings. LPN #9 was informed and responded with indifference. The facility's Medication Storage Policy, reviewed by the surveyor, clearly stated that medication supplies should remain locked when not in use or attended by authorized personnel. The Director of Nursing (DON) was informed of these observations.
Failure to Follow Up on Oral Surgery Post-Op Instructions
Penalty
Summary
The facility staff failed to follow up with outside resources for the care of a resident, specifically regarding oral surgery post-operative instructions. This deficiency was identified during a complaint survey involving one of the 45 residents reviewed. The resident was transported to an oral surgeon by a friend and had three teeth extracted. Although the resident was given written post-operative instructions, these instructions were not documented in the resident's medical record. An interview with the Administrator confirmed that the facility staff did not follow up with the oral surgeon to obtain the post-operative instructions.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous gnats throughout the building. During a complaint survey, gnats were observed in one of the three nursing units and public areas. A resident complained about gnats in their wheelchair, with at least ten gnats flying around the seat. A Certified Medicine Aide confirmed the gnat problem was widespread in the facility. In the dining room, another resident's lunch tray was observed with gnats flying on the fruit cocktail and BBQ sandwich. Additionally, gnats were seen in the Nursing Home Administrator's office, where surveyors were stationed for six days. The Nursing Home Administrator admitted that the facility did not have a pest control contract prior to the recent engagement of a new pest control company. Pest control logs were requested, but it was revealed that the facility had only secured a pest control contract in the past month, indicating a lack of prior pest management measures.
Failure to Include Competent Resident in Care Plan Meetings
Penalty
Summary
The facility failed to invite a cognitively intact resident, identified as Resident 41, to participate in their care plan meetings. Despite having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating full cognitive capacity, the resident was not informed or invited to the care plan meeting. Instead, the resident's mother attended the meeting, and discussions regarding the resident's care, including a referral to the rehab department and full code status, were held with her. Interviews with facility staff revealed a misunderstanding regarding the resident's competency status. The Social Services Coordinator incorrectly assumed the resident was not competent, despite documentation showing the resident had adequate decision-making capacity. The Director of Nursing confirmed that competent residents should be invited to their care plan meetings. The facility's policies on determining decision-makers and care plan meetings were requested but not provided by the time of the survey exit.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident or their family/representative, which was identified during a review of one of three residents hospitalized among 31 sampled residents. The resident in question, identified as R471, was severely cognitively impaired and dependent on all Activities of Daily Living (ADLs) except eating. On 10/07/23, a nurse's note documented that R471 was found with a head injury, bleeding from the forehead, after reportedly rolling over and hitting their head on the side rail. The resident was sent to the emergency room for further evaluation and returned to the facility without being admitted to the hospital. Upon reviewing the electronic medical record (EMR) and the resident's hard chart, it was found that no written notification of the transfer was provided to the family. During an interview, the facility's Administrator confirmed that the facility had not been providing written notifications of transfers to residents and/or their representatives. This oversight had the potential to leave residents or their representatives unaware of the transfer details and their rights to appeal.
Failure to Conduct PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure an accurate pre-admission screening and resident review (PASARR) Level II evaluation for a resident with mental disorders or intellectual disabilities. The resident, identified as R81, was admitted with diagnoses including moderate intellectual disabilities, bipolar disorder, schizoaffective disorder, unspecified psychosis, and anxiety disorder. Despite these conditions, the facility did not request a PASARR Level II screening from the State Agency after the resident remained in the facility for more than 40 days, as required by the exempted hospital discharge screening. The resident's medical records indicated a moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of six out of 15. The care plan documented impulsive behaviors and impaired communication, highlighting the need for a comprehensive evaluation. Interviews with the Social Worker and Administrator confirmed the oversight, acknowledging the lack of a PASARR Level II evaluation and the absence of a facility policy related to PASARR, which contributed to the deficiency.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, both of whom were cognitively intact but dependent on staff for activities of daily living (ADLs). The first resident, who had multiple sclerosis and functional quadriplegia, was observed with fingernails half an inch long and soiled with a black substance. Despite being totally dependent on staff for all ADLs, the resident's nails remained untrimmed and dirty over several days. The Licensed Practical Nurse (LPN) and Unit Manager confirmed the condition of the nails and stated that Geriatric Nursing Aides (GNAs) were responsible for nail care, as outlined in the GNA Plan of Care. Similarly, the second resident, who had limited mobility and was also dependent on staff for ADLs, was observed with fingernails half to one inch long and soiled. The resident expressed frustration over the condition of their nails. Observations over multiple days showed no improvement until the final day when the nails were trimmed and cleaned. The Director of Nursing (DON) confirmed that GNAs were responsible for nail care during resident showers or baths. The facility did not provide a policy for ADL care upon request before the survey exit.
Failure to Apply Hand Splint for Resident
Penalty
Summary
The facility failed to consistently apply a hand splint for a resident, identified as R72, who was at risk of further contractures due to impaired range of motion in the left upper extremity. The resident's electronic medical record indicated a physician's order for a left hand roll splint to be worn for four consecutive hours during the day shift, as well as a care plan for restorative splint assistance. However, during multiple observations, R72 was seen without the splint, and the resident reported not knowing where the splint was and being unable to put it on independently. Staff members, including a Geriatric Nurse Aide (GNA) and a Licensed Practical Nurse (LPN), were unaware of the splint order and could not locate the splint. The Director of Rehab confirmed that the splint could not be found, necessitating a reevaluation by therapy. The Director of Nursing verified that the nursing staff, particularly the GNAs, were responsible for implementing the restorative nursing care plan interventions, including the application of splints. The facility's policy on restorative nursing indicated that such programs should be coordinated by nursing or in collaboration with rehabilitation, with a licensed nurse supervising the activities. Despite these guidelines, the failure to apply the splint as ordered increased the risk of further loss of mobility and contractures for the resident.
Pharmacist's Failure to Monitor Antipsychotic Use
Penalty
Summary
The pharmacist failed to identify and monitor adverse consequences and target behaviors for a resident receiving antipsychotic medication. The resident, who was severely cognitively impaired with a BIMS score of three out of 15, was admitted with diagnoses including Alzheimer's disease and Parkinsonism, without any hallucinations, delusions, or aggressive behaviors. Despite this, a physician's order was placed for Seroquel, an antipsychotic medication, to address agitation. However, there was no consistent monitoring of the target behavior of agitation or adverse consequences associated with Seroquel use, especially given the resident's Alzheimer's diagnosis. The Medication Regimen Review conducted on a later date failed to address the use of Seroquel for agitation or the need for monitoring adverse consequences and target behaviors. The pharmacist only recommended discontinuing a Lidocaine patch due to nonuse. During an interview, the pharmacist was unable to provide specific information about the resident due to a lack of access to his computer database. The facility's policy required the attending physician and consultant pharmacist to re-evaluate psychotropic medication use and monitor for effectiveness and potential adverse consequences, which was not adhered to in this case.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and manage the use of psychotropic medication for a resident, identified as R107, who was severely cognitively impaired with Alzheimer's disease and Parkinsonism. Despite the absence of hallucinations, delusions, or aggressive behaviors, R107 was prescribed Seroquel, an antipsychotic medication, for agitation. The facility's care plan, initiated after the medication was prescribed, lacked specific side effects or target behaviors to monitor, and there was no plan for non-pharmacological interventions prior to using the antipsychotic medication. Observations and interviews with family members and staff indicated that R107 did not exhibit signs of agitation or distress during the review period. However, the facility's records, including the Medication Administration Record and Progress Notes, showed inconsistent monitoring of the target behavior of agitation and potential adverse effects of Seroquel. The Director of Nursing confirmed the lack of specific monitoring for adverse side effects or behaviors associated with the medication, which was contrary to the facility's medication management policy.
What surveyors are citing around you — mapped
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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 549 citations issued within 25 miles in the last 12 months — including the 7 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 Waldorf
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Restore Health Rehabilitation Center | 1.3 mi | ★★★★★ | 3 | 0 |
| Green Acres Nursing And Rehab | 4.8 mi | ★★★★★ | 17 | 0 |
| Complete Care At Laplata Llc | 5.2 mi | ★★★★★ | 12 | 0 |
| Ft Washington Rehabilitation And Wellness Center | 9.1 mi | ★★★★★ | 35 | 0 |
| Autumn Lake Healthcare At Bradford Oaks | 10.9 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.