Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Westgate Hills Rehab & Healthcare Ctr during CMS and state inspections, most recent first.
Failure to Thoroughly Investigate Sexual Abuse Allegation: A resident with cognitive impairment and significant ADL needs alleged that a CNA touched them inappropriately during care and tried to rape them. The facility’s file contained conflicting resident accounts, staff statements, SBAR documentation, and police-related information, but did not show how those discrepancies were reconciled before the allegation was labeled unsubstantiated. The investigation also lacked evidence of the police report and did not document whether staff questionnaire responses were based on direct observation of the care interaction.
Resident meal tickets were not followed during the lunch tray line. Surveyors observed multiple residents receiving items that did not match their tickets, including brownies instead of cake, missing ordered fruit and beverages, sugar on a tray marked no sugar, gravy on a tray marked no gravy, and planned entrees or starches being substituted when the tickets called for different items. The FSD stated that the kitchen ran out of some planned foods and served substitutions instead of the items indicated on the meal tickets.
Incomplete and conflicting documentation affected advance directives, smoking care, oxygen orders, diagnosis records, and treatment charting. Multiple residents had no documented evidence that advance directive information was offered, two residents had contradictory smoking interventions, one resident had conflicting oxygen tubing orders being signed on the MAR, another resident’s chart lacked an active glaucoma diagnosis despite references in the care plan and medication order, and an LPN documented Aquaphor as given even though the treatment had not been applied.
A facility failed to protect resident dignity when the first-floor staffing assignment board identified residents as "Feeders" instead of using the term "assist." Surveyors observed the term on the board in connection with several room numbers, and an LPN and the DON acknowledged that staff should never refer to residents this way.
The facility failed to consistently identify and notify the correct RP or guardian and did not document informed consent for care plan changes for several residents. One resident with intermittent confusion had bed rails applied without RP consent, another had the wrong RP listed and contacted for care planning, and two residents who lacked decision-making capacity had no documented health care guardian in the record. Interviews with SW and the DON confirmed the missing or incorrect representative and guardian documentation.
Failure to formulate an advance directive for a resident. The surveyor could not locate any advance directive in the record, and the Social Services Assessment stated that advance directives had not been reviewed and that the resident did not have one. An LPN/staff member later confirmed no advance directive could be found and stated it was not discussed or offered at the resident’s last quarterly care plan meeting; the DON acknowledged the concern.
Facility staff failed to ensure that a resident's representative received written transfer notice when a resident who lacked decision-making capacity was transferred to the hospital. The EHR contained no evidence of the notice, and the SW described the usual process of phone contact and mailing the notice, but the DON confirmed there was no documentation that the representative received it.
Two residents had inaccurate MDS coding. One resident receiving hemodialysis had no access site documented on the admission MDS, and an MDS Coordinator stated she did not code dialysis catheters or ports unless used for chemo, antibiotics, or IV fluids. Another resident on hospice had hospice care noted, but the MDS was not updated to accurately capture the resident’s specific hospice diagnoses.
Missing Dementia Care Plan: A resident with dementia did not have a dementia care plan in the record during survey review. The surveyor could not find a plan for dementia care, and the DON confirmed the facility did not have one even though one was expected.
Missed and Delayed Care Plan Meetings: The facility failed to hold required interdisciplinary care plan meetings after MDS assessments for two residents. One resident had a care plan meeting scheduled, but the surveyor found no documentation that it occurred after the meeting was moved at family request, and the resident also had a quarterly MDS. Another resident’s care plan meeting was conducted outside the required quarterly timeframe, with the SW acknowledging a seven-month gap between meetings and that the prior SW had not held meetings regularly.
Failure to follow an active turn-and-reposition order was identified for a resident with stage 3 pressure ulcers to the sacrum and buttock. The resident was observed lying on the back multiple times across two days, while the TAR showed the order was signed off as completed on day shift. An LPN stated the nurse and GNA were expected to turn and reposition the resident throughout the shift before signing off the order.
Missed and undocumented ordered treatments and assessments were found for three residents. One resident had repeated blank TAR entries for a wound treatment order, another had blank TAR entries for daily wound care to the foot and sacrum, and a third resident with COPD, asthma, respiratory failure, and O2 dependence had multiple MAR entries left unsigned for inhaled medication, O2 use, respiratory checks, ear protectors, and shift assessments. An LPN stated the care was completed but could not explain the blank entries, and the DON acknowledged the concern.
A resident’s G-tube flush order was incomplete because it directed staff to flush the tube q6h for hydration but did not specify what to flush with or the amount. During interview, the DON acknowledged the order was incomplete and should have included the flush amount.
Oxygen was provided at rates that did not match the residents’ orders. One resident’s concentrator was observed at 4.5 l/min even though the order was for 3 l/min, and no humidification bottle was present despite documentation showing weekly changes. Another resident’s oxygen was observed at 3.5 l/min while the active order was for 2 l/min. An LPN confirmed the ordered rates, and the DON acknowledged the concern.
The facility failed to ensure annual performance reviews and related in-service education were completed for two CNAs. Record review showed the employee files lacked documentation of the required yearly reviews and associated in-service education, and HR later confirmed the facility could not provide the missing records.
Medication administration errors exceeded the required threshold, with 5 errors in 26 opportunities for a 19% error rate. During observed med passes, a CMA gave a resident 250 mg vitamin C instead of the ordered 500 mg, gave another resident chewable aspirin instead of EC aspirin and 400 mg guaifenesin instead of the ordered 600 mg ER form, and gave a third resident chewable aspirin instead of DR aspirin; Tylenol administered to that resident was also not signed off on the MAR.
A facility failed to provide palatable food at an appetizing temperature during lunch service. Surveyors observed the tray line, test tray, and resident tray delivery, then had the Assistant Dietary Director check temperatures on the test tray; the tilapia was 108.5°F, mashed potatoes and gravy were 116.2°F, and sauteed mixed squash was 130.7°F. Two surveyors tasted the entree and sides and found them not palatable and not at an appetizing temperature.
Food Items Stored Opened and Undated: Kitchen observations found opened food in the refrigerator, freezer, and dry storage without labels or dates, including pizza slices, PB&J sandwiches, tomato juice, fish patties, veal, beef patties, biscuits, peanut butter, and multiple seasonings. Staff stated opened or prepared items were expected to be labeled, dated, and sealed, and the FSD said the manager was responsible for ensuring items were labeled and dated and for discarding items past their best-by date.
A resident identified in the chart as receiving hospice services stated hospice was not being received, and the EHR lacked the hospice plan of care, hospice med orders, hospice physician orders, hospice election form, and physician certification of terminal illness. The DON later confirmed the hospice records had to be obtained from the hospice provider and were not available in the resident’s record before the surveyor’s request.
Failure to follow standard precautions and EBP was observed during resident care and equipment handling. A CMA used the same portable BP machine and cuff on two residents without disinfection between uses, and a CNA provided care to a resident on EBP without wearing a protective gown despite an EBP sign posted on the door. Staff also handled a spill with bare hands before touching clean-area surfaces and supplies, and the IP stated staff are expected to perform proper hand hygiene.
Call lights were not kept within reach for multiple residents. Surveyors observed two residents with call bells out of reach or hidden, and both were dependent on staff and unable to reach them. In another room, a resident was found in bed with the call light on the floor while reporting pain and waiting for medication; an LPN confirmed the call light should have been within reach.
Missing QAPI training documentation was identified for two CNAs during the annual survey. Record review showed no evidence that either CNA completed the required annual QAPI training, and HR later confirmed the facility could not provide the documentation.
Missing Infection Control Training Documentation: The facility failed to maintain documented evidence that a CNA completed annual infection control training. During the annual survey, review of the CNA’s employee file showed no proof of 2025 infection control training, and HR later acknowledged the facility could not provide the required documentation. The Staff Educator stated infection control is part of annual training and competency requirements for nursing aides.
Missing Compliance and Ethics Training Documentation: Record review showed that three CNAs did not have documented evidence of required annual compliance and ethics training in their employee files. The Staff Educator stated she had developed a training program after her hire, but HR later acknowledged the facility could not provide the missing training records.
The facility failed to post the required daily staffing information when surveyors observed the lobby staffing sign still dated several days earlier at one of two desk areas checked. The Administrator and DON were shown the posted sign and acknowledged that it had not been updated over the weekend.
Surveyors found that two residents did not receive care and treatment in accordance with professional standards, including lack of documentation before administering Nitroglycerin and inconsistent skin assessments leading to delayed wound care for a resident with MASD and a stage 3 pressure ulcer. Staff interviews confirmed documentation errors and delays in notifying practitioners and implementing wound care orders.
A resident with dementia and behavioral disturbances exhibited worsening agitation and wandering, but staff failed to assess or document these behaviors or implement behavior monitoring, relying instead on verbal reports. The DON confirmed that required documentation was missing from the medical record.
The facility did not ensure that the call bell system on the second floor was fully functional, resulting in the absence of an audible alert for staff when a resident activated the call bell. A resident with a tracheostomy reported extended wait times for assistance, and staff confirmed they could not hear the call bell sound. The deficiency was confirmed through observations, interviews, and review of complaints.
A resident with legal blindness reported being verbally abused by a GNA after a prolonged wait for assistance, with the incident witnessed by the resident's roommate. The facility's investigation was incomplete, lacking proper documentation of interviews with the alleged victim, witnesses, and staff, and no follow-up was conducted when another resident indicated awareness of abuse.
A facility failed to report an injury of unknown origin involving a resident to the State Agency within the required two-hour timeframe, instead reporting the incident nearly four hours after discovery. This delay was identified during a complaint survey through record review and staff interviews.
Facility staff did not thoroughly investigate allegations involving two residents, including concerns about care, hygiene, and verbal abuse. In both cases, not all issues raised by complainants were addressed, documentation was incomplete or missing, and required follow-up on potential abuse was not performed. The lack of comprehensive investigation and documentation resulted in unresolved allegations and inconclusive findings.
A resident dependent on staff for personal hygiene and incontinence care was left unbathed and soiled on multiple occasions. Documentation showed only two bed baths for the month instead of the scheduled nine, and there were significant gaps in incontinence care records. Staff interviews confirmed required documentation procedures were not followed, and the facility could not provide evidence that the resident received the necessary care as scheduled.
A resident developed a pressure injury on the right knee due to prolonged use of a knee brace without consistent skin assessments. Although the care plan called for regular skin checks under the immobilizer, documentation of these assessments was lacking for over a month, and staff interviews confirmed that such checks were expected regardless of specific orders. The deficiency was identified when the wound was discovered during a skin evaluation, revealing a lapse in preventive care.
A resident with a history of multiple falls and identified as high risk did not have all care plan fall prevention interventions in place. Observations showed the call pad was not within reach or on the correct side of the bed as required, and staff confirmed these interventions were not consistently implemented.
A resident experienced multiple incontinent episodes, but the GNA documented 'Not Applicable' for toileting hygiene instead of indicating whether care was provided or refused. The DON confirmed that staff should use the 'Resident Refused' option when care is declined, but the GNA reported being unable to do so and selected 'NA' instead, resulting in incomplete and inaccurate medical records.
Surveyors identified multiple instances of improper food storage and labeling, including unlabeled and unsecured food items in the kitchen refrigerator and freezer, as well as in the dry storage area. Additionally, the 2nd floor nourishment refrigerator contained a bag of deli meats without proper labeling or dating, despite staff-only access.
The facility failed to accurately document assessments for two residents. One resident's MDS assessment listed only a stage 3 pressure ulcer, despite wound care notes indicating both a stage 3 and a stage 2 ulcer. Another resident's discharge assessment incorrectly recorded a transfer to a hospital, while records showed the resident was discharged home. These errors were confirmed by MDS staff.
A newly admitted resident who had recently been hospitalized for an acute subdural hematoma did not receive a summary of the initial Baseline Care Plan (BCP) within 48 hours of admission. Although the BCP was developed and entered into the medical record, there was no evidence it was shared with the resident, who expressed concern about not receiving information on their diet and swallowing plan. Staff interviews confirmed the BCP was not presented as required.
Surveyors identified that two residents did not have comprehensive, individualized care plans addressing their specific needs, including incomplete documentation for medical conditions and delayed care planning for transfer assistance after a fall. Facility staff confirmed that care plans were either incomplete or not developed in a timely manner.
The facility did not hold care plan meetings after comprehensive assessments for two residents and failed to invite them to participate, with only their guardians being contacted. Documentation was lacking for both the meetings and the rationale for not including the residents.
A resident with significant medical and cognitive needs, confined to their room, was observed multiple times without engagement in meaningful activities, despite a care plan indicating the need for personalized interventions. Documentation revealed only three one-to-one activity visits over two months, and staff acknowledged the lack of ongoing, individualized activities for this resident.
A resident experienced decreased vision and was scheduled for a follow-up with an eye specialist, but there was no documentation that the appointment occurred. Interviews revealed that Medical Records staff, responsible for scheduling and transportation, were unaware of the appointment, resulting in the missed follow-up.
A resident with limited mobility and contractures did not receive prescribed knee extension braces and hand splints as ordered, and there was no documentation of their application. The DON confirmed that the orders were not transferred to the TAR, resulting in a lack of evidence that the treatments were provided.
A resident with involuntary lower extremity movement and poor spatial awareness was not provided with a perimeter mattress as required by their care plan after a room change. The omission was confirmed through observation and staff interviews, and the resident experienced two falls from bed in the new room where the mattress was not in place.
A resident with neuropathic pain was readmitted from the hospital, and although hospital discharge instructions recommended continuing gabapentin, the medication was discontinued on the day of readmission. The NP's progress note initially indicated gabapentin should be continued, but there was no documentation or rationale for its discontinuation, and the NP later could not recall the reason for stopping the medication.
A resident with shortness of breath did not receive an additional 40 mg dose of furosemide as recommended by the provider. The medication was not documented as given, and staff could not provide evidence or a rationale for the omission. The DON confirmed that the nurse did not follow expected documentation practices.
A resident's medication regimen review reports completed by the pharmacist were not included in the medical record, and there was no process to ensure the primary care provider's review and documentation of actions taken. Staff interviews confirmed that while reports were reviewed and signed by the NP, they were not consistently filed in the resident's record, and the DON had to retrieve them from the pharmacist.
A surveyor found an unattended and unlocked medication cart in a hallway, with multiple drawers containing medications accessible. A nurse, who was responsible for the cart and managing two carts due to staff absence, confirmed the cart should have been locked and stated it was left open by accident.
A surveyor observed a significant buildup of plastic bags, leaves, pine needles, and plastic cups behind the dumpster used by kitchen staff, indicating improper disposal and maintenance of the outdoor garbage area. The Director of Maintenance confirmed that this accumulation should not be present.
Surveyors found that clean clothing belonging to residents who were hospitalized or had expired was stored in green bags within the dirty laundry room. The Environmental Director confirmed the clothes were clean, and the DON was notified of the risk for accidental contamination due to this storage practice, which did not minimize the potential spread of infection.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to have evidence that an allegation of sexual abuse involving one resident was thoroughly investigated. The resident had diagnoses including depression, adjustment disorder with depressed mood, muscle weakness, a history of DVT/PE, and multiple musculoskeletal conditions. The care plan reflected impaired cognitive function with a BIMS score less than 13, impaired balance, two-person assistance for bed mobility and dressing, and a full mechanical lift transfer. After the alleged incident, the care plan was updated to note that the resident preferred no male CNAs and later that the resident preferred a female caregiver only. The allegation was reported after a CNA told an LPN that the resident said the CNA was inappropriate while providing ADL care. The facility’s initial report stated the CNA was placed on administrative leave and that notifications and interviews were pending. The follow-up investigation concluded the allegation was unsubstantiated, relying on the resident’s cognitive impairment, lack of visible injury, police contact, staff statements, and the resident’s inconsistent statements. The record also included a PCP assessment noting no trauma, bruising, redness, pain, or evidence of insertion, and a psych NP note describing baseline forgetfulness/cognitive impairment and no confirmed dementia diagnosis at that time. The investigation file contained materially different accounts of what occurred. One statement documented that the resident accused the CNA of inappropriate touching during care and said the CNA tried to rape them. Another statement documented that the resident said the CNA was uncomfortable with the care being provided and that another CNA completed the care. The SBAR documented that the resident initially alleged inappropriate touching during perineal care and later denied that the CNA got in bed or on top of them or exposed themself. Staff questionnaires did not document whether the respondents were present during the care interaction or whether their responses were based on direct observation. The facility also did not provide evidence of the police report, did not document whether coaching concerns were confirmed, and did not show how it reconciled the conflicting accounts before concluding the allegation was unsubstantiated. When interviewed by the surveyor, the resident gave an account generally consistent with the complaint statement and a staff member’s written statement, describing that the CNA was on top of them, touched them inappropriately, attempted to insert his penis, and left after the resident yelled for them to stop.
Resident Meal Tickets Not Followed During Tray Line
Penalty
Summary
The facility failed to ensure resident menu tickets were followed during the lunch tray line observation. Surveyors observed that the kitchen lunch tray line began with dessert prepared as brownies, but many residents had meal tickets indicating cake with icing and were served brownies instead. The Food Services Director stated that there was not enough cake to provide the residents based on the planned meal menu tickets, so brownies were served. Surveyors also observed multiple other mismatches between resident menu tickets and the food placed on trays, including residents who were supposed to receive diet cookies, fresh fruit, no sugar, no gravy, an alternative entree, a fruit cup, banana and ice water, or specific beverage and fruit items, but did not receive those items as indicated on their tickets. Additional observations showed that a resident whose ticket indicated not to send sugar had two packets of sugar on the tray, a resident who did not like chicken thighs was plated chicken thighs, and a resident whose ticket indicated no gravy received gravy on the chicken. The Food Services Director also stated that the kitchen had run out of au gratin potatoes and chicken thighs, and substitutions were made, including regular mashed potatoes and veal, even when resident meal tickets indicated otherwise. The Food Services Director further stated that the cook reviews resident meal tickets and is expected to prepare special requests, and that the expectation was to prepare the tray or plate as indicated on the resident meal menu ticket.
Incomplete and Conflicting Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records related to advance directives for multiple residents. For five residents reviewed for advance directives, the medical record documentation showed that some residents did not have an advance directive and that advance directives had either not been reviewed or were marked as reviewed, but the records did not contain any indication that the residents were offered information to formulate an advance directive. The Director of Social Services stated that residents were asked about advance directives on admission or readmission and that information would be offered if they did not have one, but the records reviewed did not show that this offer had been documented for the residents identified. The facility also had conflicting and incomplete documentation related to smoking and oxygen care. For two residents reviewed for smoking, the care plans contained contradictory interventions, with one intervention stating the residents could smoke independently and store smoking materials in their rooms, while another stated the facility would store their nicotine products and supplies. For one resident, the MAR contained two active oxygen tubing and humidifier change orders that conflicted with each other, including different days and shifts for the weekly change, and staff were signing both orders. An LPN stated that the day shift order was correct but could not explain how the order was determined. In addition, one resident’s medical record did not contain an active diagnosis for glaucoma even though the care plan and a medication order referred to glaucoma. The DON acknowledged that the diagnosis had not been updated in the record. Another resident had Aquaphor ordered twice daily for both upper and lower extremities, and the MAR showed the treatment was documented as given, but the surveyor observed the resident’s lower extremities exposed with rough, cracked, and flaky skin. The LPN later stated the treatment had not been applied because she was waiting for the resident to be bathed, and she could not explain why administration had been documented when it was not done.
Dignity Concern on Staffing Assignment Board
Penalty
Summary
The facility failed to protect residents' dignity by using the term "Feeders" on the first-floor staffing assignment board to identify residents assigned for feeding assistance. On 05/18/2026, the surveyor observed the staffing board at the first-floor nurses station listing "Feeders" with room numbers 103, 115, 116, 119, and 108 in the upper left-hand corner. On 05/20/2026, the surveyor again observed the staffing board showing the word "Feeders" under Employee Name with room numbers 103, 108, 115, and 119 next to the assigned nurse's name. During interview, the Unit Manager LPN stated that the word feeder should never be used on the assignment board and that staff are supposed to use the word assist. The DON acknowledged the concern and stated staff should never refer to residents as Feeders.
Failure to Involve Correct Representatives in Care Decisions
Penalty
Summary
The facility failed to identify and notify residents’ health care representatives or guardians of changes to the plan of care and failed to involve them in the consent process for several residents. During the annual survey, this was identified for 4 of 76 residents reviewed for resident rights and representative involvement. The findings involved residents with confusion, lack of decision-making capacity, or unclear representative documentation, and the record reviews and interviews showed that the facility did not consistently document or verify the correct responsible party or guardian. For one resident, staff assessed the need for bed rails, documented that bilateral grab bars were indicated, and initiated a care plan intervention to educate the resident and resident representative about the risks and benefits of bed rails, including entrapment. The resident was intermittently confused, and a social work note stated the listed RP could not be contacted because the number was invalid. The facility policy required informing the resident or representative about the benefits and hazards of bed rails and obtaining informed consent before use, and the acting DON confirmed that the resident’s RP did not give consent before the bed rails were applied. For another resident, the medical record listed the wrong RP, and staff contacted that incorrect person regarding care plan meetings and change-in-condition notifications. A social worker confirmed the listed name and number were not the actual RP and stated the spouse was the RP and had been involved in the plan of care, but there was no reference to the spouse’s name or number in the record. Two additional residents lacked evidence of an appointed health care guardian despite documentation that they had no decision-making capacity; one resident had diagnoses including cognitive communication deficit and intellectual disabilities, and the other had been certified by the physician as lacking decision-making capacity shortly after admission. Social work interviews confirmed that the facility did not have guardianship documentation and that the records did not show evidence of staff helping obtain a health care guardian.
Failure to Formulate Advance Directive
Penalty
Summary
The facility failed to formulate an advance directive for Resident #74. During record review, the surveyor could not locate an advance directive for the resident, and the Social Services Assessment stated that advance directives had not been reviewed and that the resident did not have one. Staff #5 stated that advance directives are documented on admission or created as needed and referred the surveyor to the Social Service Assessment and progress notes for documentation, but later stated that no advance directive could be found for Resident #74. Staff #5 also stated that he/she did not ask or offer Resident #74 an advance directive during the resident's last quarterly care plan meeting. The Director of Nursing acknowledged the concern.
Failure to Provide Written Transfer Notice to Resident Representative
Penalty
Summary
Facility staff failed to ensure that the resident's representative received a written notice of transfer for Resident #6, who lacked decision-making capacity and was transferred to the hospital in December 2025. Review of the electronic health record showed no evidence that the resident's representative was provided written transfer notice. During interview, the SW described the facility's process of contacting the representative by phone and mailing a transfer notice if the representative was not present at the time of transfer, but the surveyor requested documentation showing that this occurred for Resident #6. The DON later stated that the facility had no evidence or documentation indicating that written transfer notice had been provided to the resident's representative.
Inaccurate MDS Coding for Dialysis Access and Hospice Diagnoses
Penalty
Summary
Facility staff failed to ensure residents’ diagnoses and clinical needs were accurately captured on MDS assessments at admission and during assessment modifications. For Resident #6, the EHR showed the resident was transferred to the hospital in December 2025 and readmitted in January 2026. The admission MDS indicated the resident received hemodialysis, but it did not identify the access site used for hemodialysis. During interview, the MDS Coordinator stated she does not code dialysis catheters or ports unless they are used for chemotherapy, antibiotics, or IV fluids. For Resident #67, the medical record showed the resident transitioned to hospice services on 11/24/2025. The MDS completed on 12/05/2025 noted hospice care, but the MDS Coordinator did not update the assessment to accurately capture the resident’s specific hospice diagnoses. When the surveyor presented the concerns to the MDS Coordinator and Administrator, both acknowledged the concern related to the MDS assessments.
Missing Dementia Care Plan
Penalty
Summary
Facility failed to develop and implement a patient-centered comprehensive care plan to meet the needs of Resident #13, who had a diagnosis of dementia. During record review on 05/19/2026 at 10:00 AM, the surveyor noted the diagnosis of dementia but did not find a care plan for dementia care in the resident's record. The surveyor requested the DON provide a dementia care plan, and on 05/19/2026 at 11:11 AM, the DON stated the facility did not have a care plan for dementia care and that one was expected to be in place.
Missed and Delayed Care Plan Meetings
Penalty
Summary
The facility failed to hold care plan meetings after completion of the MDS assessment for 2 residents reviewed for care planning. For Resident #4, the record showed a care plan meeting was scheduled for 3/24/26, but the surveyor could not find documentation that a care plan meeting actually occurred after that date. The resident also had a quarterly MDS assessment on 4/27/26. When interviewed, the SW stated the meeting had been moved to 4/1/26 at the family’s request, but no additional care plan meetings were held and care plan meetings are supposed to occur after MDS assessments. For Resident #88, the SW explained that care plan meetings are conducted quarterly, annually, and at the request of the resident or resident representative. The surveyor informed the SW that seven months had passed between meetings, and the SW acknowledged the resident’s care plan meeting was conducted outside the required quarterly timeframe. The SW stated the previous social worker failed to conduct meetings regularly. A social work progress note also showed an interdisciplinary team care plan meeting was scheduled for 4/21/26.
Failure to Follow Turn-and-Reposition Order for Resident with Stage 3 Pressure Ulcers
Penalty
Summary
The facility failed to ensure staff maintained professional standards of practice when an active turn-and-reposition order was signed off as completed. Resident #9 had a sacral wound and a wound on the buttock, both documented on 5/15/26 as stage 3 pressure ulcers. The resident also had an active order to turn and reposition every two hours and as needed. During observations on 5/19/26 and 5/20/26, Resident #9 was repeatedly found in bed lying on the back at 8:17 AM, 10:26 AM, and 12:36 PM on 5/19/26, and at 7:03 AM, 9:02 AM, and 11:02 AM on 5/20/26. Review of the TAR on 5/22/26 showed the turn-and-reposition order was signed off as completed on 5/18/26 and 5/19/26 day shift, indicating it had been documented as done throughout the shift. An LPN stated that the nurse and GNA assigned to the resident were expected to turn and reposition the resident as ordered throughout the shift and that the nurse would ask the GNA if the resident had been turned before signing off the order as completed. The Acting DON was informed of the concern and indicated understanding.
Missed and Undocumented Ordered Treatments and Assessments
Penalty
Summary
The facility failed to ensure that ordered treatments and care were provided and documented in accordance with residents’ comprehensive care plans and professional standards of practice for three residents. For Resident #11, the record showed an order for right elbow wound treatment with betadine solution and a foam dressing daily starting on 4/17/25, but the April and May TARs had multiple blank days, including 4/17/26, 4/23/26, 4/27/26, 4/29/26, 4/30/26, 5/6/26, 5/8/26, 5/12/26, and 5/13/26. Resident #16 stated during interview that dressing changes were not always completed. The record showed daily wound care orders for the right lateral foot and sacrum written on 5/7/26, but the May TAR had blank entries for both treatments on 5/8/26, 5/12/26, and 5/13/26. For Resident #74, who had COPD, asthma, acute and chronic respiratory failure, and dependence on supplemental oxygen, the MAR showed multiple assessments and treatments that were not signed off as completed on various dates in May 2026, including Advair Diskus, shortness-of-breath checks when lying flat, oxygen at 5 L/min via nasal cannula, foam ear protectors for oxygen tubing, and shift-by-shift observation for changes in physical or mental condition. Staff stated the treatments and assessments were completed, but could not explain the numerous blank entries.
Incomplete G-Tube Flush Order
Penalty
Summary
The facility failed to flush a gastrostomy tube in accordance with professional standards of practice for one resident reviewed for G-tube flushing. During record review, an order dated 2/5/2025 at 18:00 directed staff to flush the G-tube every 6 hours four times a day for hydration, but the order did not specify what solution to use or how much to flush the tube with. During interview, the DON acknowledged that the order was incomplete and stated that it should have specified the amount in the order.
Oxygen Delivered at Rates Inconsistent With Orders
Penalty
Summary
Facility staff failed to ensure respiratory care was provided in accordance with the residents’ prescribed oxygen orders. For one resident, the surveyor observed the oxygen concentrator dialed at 4.5 l/min even though the order was for 3 l/min via nasal cannula. No humidification bottle was present, the tubing was directly attached to the concentrator, and no label was noted on the tubing. When the LPN checked the order, he confirmed the prescribed rate was 3 l/min and adjusted the oxygen to the correct setting after assessing the resident. The resident stated he/she had not adjusted the rate and that the concentrator was out of reach. The record review for that resident showed an order for 3 l/min oxygen via nasal cannula and a separate order for the oxygen tubing and humidifier to be changed weekly and labeled with the date changed. The TAR showed staff were signing off that both the tubing and humidification bottle were changed and labeled weekly, even though the resident stated he/she preferred not to use humidification and no humidification bottle was observed. For a second resident, the surveyor observed oxygen running at 3.5 l/min on multiple occasions while the active order in the medical record was for 2 l/min. An LPN later confirmed the ordered rate was 2 l/min, and the DON acknowledged the concern when it was reviewed.
Missing CNA Annual Performance Reviews and In-Service Education
Penalty
Summary
The facility failed to ensure annual performance reviews and related in-service education were completed for certified nurse aides. During the annual survey, record review showed that the employee files for CNA #9 and CNA #12 did not contain documented evidence of an annual performance review or related in-service education based on the outcomes of the 2025 performance review. In an interview, Human Resources stated that CNA annual performance reviews are completed yearly based on the employee’s hire month and that unit managers and/or the DON are notified of upcoming reviews, but the facility was unable to provide the missing documentation for these two CNA employees.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent during a medication pass observation. Surveyors identified 5 medication errors out of 26 opportunities, resulting in a 19% error rate. The errors involved medication administration from floor stock and included incorrect dose, incorrect form, and omitted documentation during observed medication passes. During observation, CMA #23 administered 250 mg vitamin C to Resident #106 when the MAR ordered 500 mg. CMA #23 also gave Resident #104 81 mg chewable aspirin instead of the ordered enteric-coated aspirin, and 400 mg guaifenesin instead of the ordered 600 mg extended-release form. CMA #24 administered chewable aspirin to Resident #40 when the order was for delayed-release aspirin, and the Tylenol given to Resident #40 was not signed off on the MAR at the time of review. Both CMAs confirmed the incorrect medication forms and/or doses were given from floor stock, and CMA #24 acknowledged the Tylenol had not been documented as administered.
Food Served at Unappetizing Temperature
Penalty
Summary
The facility failed to provide palatable food at an appetizing temperature during lunch service. Surveyors observed the kitchen tray line begin at 11:46 AM, the test tray plate was prepared at 12:33 PM, and it arrived on the unit at 12:36 PM. The last resident lunch tray was delivered at 12:46 PM. When the surveyor asked the Assistant Dietary Director to take temperatures of the food on the test tray at 12:47 PM, the tilapia measured 108.5 degrees Fahrenheit, the mashed potatoes and gravy measured 116.2 degrees Fahrenheit, and the sauteed mixed squash measured 130.7 degrees Fahrenheit. At 12:50 PM, two surveyors tasted the entree and sides and found they were not palatable and not at an appetizing temperature. The concern was reviewed with the Food Services Director at 1:28 PM.
Food Items Stored Opened and Undated
Penalty
Summary
The facility failed to ensure food was stored in accordance with professional standards of practice for food service safety. During the initial kitchen tour, an observation of the refrigerator at 7:08 AM found a ziplock bag containing approximately 5 pizza slices, 2 peanut butter and jelly sandwiches marked as used by 5/16/26, and an opened container of tomato juice, all of which were opened and had no label or date. At 7:10 AM, the freezer contained whole grain breaded alaska [NAME] square (fish patty), a tilapia filet that appeared freezer burnt, golden breaded veal, beef patties, and biscuits, all opened and exposed to freezer air without a label or date. At 7:13 AM, the dry storage room contained 3 four-pound containers of peanut butter and multiple seasoning containers, including ground nutmeg, pickling spice, parsley flakes, thyme, garlic salt, kansas city steak seasoning, fish seasoning, italian seasoning, black pepper, ground ginger, barbeque seasoning, and cajun seasoning, all opened without a labeled date. A Dietary Aide stated that when opening a new container for the first time, staff were expected to label it with the date and ensure it was sealed closed, and that the same expectation applied to prepared items such as sandwiches or extra food. The Food Services Director stated the manager was responsible for ensuring items were labeled and dated and for discarding items past their best-by date.
Missing Hospice Documentation in Resident Record
Penalty
Summary
Facility staff failed to ensure that hospice documentation was available in the medical record for Resident #3, who was identified in the chart as receiving hospice services. During an interview, the resident stated that hospice services were not being received, despite the medical record indicating otherwise. A review of the resident’s electronic medical record failed to show evidence of a hospice plan of care, hospice medication orders, hospice physician orders, a hospice election form, or physician certification of terminal illness. When the surveyor asked about the missing records, the DON stated that hospice records had to be obtained from the hospice provider, and later provided the hospice comprehensive care plan and related hospice documents after they were transmitted to the facility that day.
Failure to Follow Standard Precautions and EBP
Penalty
Summary
The facility failed to follow standard precautions and enhanced barrier precautions during resident care and equipment use. A CMA prepared medications for one resident and then took that resident’s blood pressure with a portable blood pressure machine and cuff. Shortly afterward, the same CMA used the same portable blood pressure machine and cuff for another resident without any observed disinfection between residents. During interview, the CMA confirmed that equipment is expected to be disinfected between resident uses and stated she had forgotten to do so. The facility also failed to follow enhanced barrier precautions for a resident with a hemodialysis port, a left hip wound, and enteral feedings. An EBP sign was posted on the resident’s door, but a CNA was observed providing care in the room without wearing a personal protective gown. The resident’s record showed orders to assess the hemodialysis port site three times daily, treat the left hip wound daily, and administer enteral feedings four times daily, and an order dated 04/14/2026 directed staff to implement EBP for the resident due to the hemodialysis port and wound. In addition, during a spill cleanup, a staff member touched a dirty towel with bare hands, then touched the clean utility closet door handle and retrieved clean supplies before putting on gloves and cleaning the spill. The Infection Preventionist stated that the expectation is for all staff to perform proper hand hygiene, and the Administrator and Infection Preventionist acknowledged the concern.
Call Lights Not Kept Within Reach of Residents
Penalty
Summary
The facility failed to ensure that residents had access to their call bells in the bathroom and bathing area, and survey observations found call lights out of reach or not visible for multiple residents. On 05/18/2026, Resident #1’s call bell was not within reach and was not visible to the surveyor, and Resident #63’s call bell was also not within reach or visible. During a dual observation, the LPN initially could not locate Resident #1’s call bell and later found it hanging on the wall where it was plugged in, out of reach and out of sight of the resident. Resident #63’s call bell was found behind the head of the bed tangled in the bed remote controller. Review of the medical record showed that Resident #1 and Resident #63 were dependent on staff and would not be able to get out of bed or reach the call bells where they were found. In a separate observation, Resident #44 was found lying in bed with the call light on the floor and stated he/she was in pain and waiting for the nurse to come with pain medication; the resident also reported not knowing where the call light was. The LPN confirmed the call light should have been in reach and not on the floor.
Missing QAPI Training Documentation for Two CNAs
Penalty
Summary
Mandatory QAPI training was not documented for 2 of 5 employee files reviewed during the annual survey. A review of the employee records for CNA1 #9 and CNA1 #6 on 05/20/2026 showed no documented evidence that either CNA completed the required 2025 QAPI training. During an interview, the Staff Educator stated that annual training and competency requirements for nursing assistants include QAPI and explained that she had developed a training program since her hire in December 2025 to help ensure compliance with annual training requirements. The surveyor informed the Staff Educator and HR that the 2025 QAPI training documents were missing for both CNAs, and on 05/21/2026 HR acknowledged the facility was unable to provide documented evidence of the annual QAPI training for CNA1 #9 and CNA1 #6.
Missing Infection Control Training Documentation
Penalty
Summary
The facility failed to ensure staff received infection control training as part of its infection prevention and control program, which includes mandatory training with written standards, policies, and procedures. During the annual survey, record review showed that Certified Nursing Assistant 1 (CNA1) #12’s employee file did not contain documented evidence of infection control training completed in 2025. In an interview, the Staff Educator stated that annual training and competency requirements for nursing aides include infection control and explained that she had developed a training program since her hire in December 2025 to support compliance with annual training requirements. Human Resources later acknowledged that the facility was unable to provide documented evidence of annual infection control training for CNA1 #12.
Missing Compliance and Ethics Training Documentation
Penalty
Summary
The facility failed to ensure staff received compliance and ethics training, as evidenced by record reviews and staff interviews during the annual survey. A review of the employee files for three CNAs showed no documented evidence that compliance and ethics training had been completed in 2025. During an interview, the Staff Educator stated she had developed a training program since her hire in December 2025 to meet annual training requirements, and the surveyor informed both the Staff Educator and HR of the missing training records. On the following day, HR acknowledged the facility was unable to provide documented evidence of the required annual compliance and ethics training for the three CNAs.
Failure to Update Daily Staffing Posting
Penalty
Summary
The facility failed to post the daily required staffing information. Surveyors observed that the staffing sign at the front desk in the lobby was dated Friday, May 15, 2026, when it was viewed on 05/18/2026 at 7:33 AM. The deficiency was identified at 1 of 2 desk areas observed for staff posting. The Administrator and DON were shown a picture of the lobby sign on 05/19/2026 at 2:00 PM and acknowledged that the signage had not been updated over the weekend.
Failure to Document Assessments and Timely Wound Care Interventions
Penalty
Summary
Surveyors identified deficiencies related to the facility's failure to accurately document assessments and ensure residents received treatment and care in accordance with professional standards. For one resident, Nitroglycerin was administered on multiple occasions without documentation of symptoms or assessments prior to administration. Interviews with the DON and an LPN confirmed that any change in condition, such as chest pain, should be documented in the electronic medical record, and that all steps taken in response to unusual symptoms should be recorded. However, the medical record lacked this required documentation. Another resident was found to have inconsistencies in skin assessment documentation within 24 hours of readmission. The admitting nurse documented intact skin, while subsequent assessments by the wound care nurse and nurse practitioner identified a stage 3 pressure ulcer and Moisture Associated Skin Damage (MASD) on the left buttock. The wound care nurse later explained that there was a user error in documentation, resulting in inaccurate records. Additionally, there was no evidence that the facility notified the resident's primary care practitioner of the wound upon readmission or that wound care treatment was initiated at that time, despite recommendations from the nurse practitioner. Wound care orders were not implemented until several days after readmission. Review of the GNA flowsheet and interviews with staff revealed further discrepancies, as documentation indicated no skin impairment for several days, despite clinical notes to the contrary. The facility's process for admission and wound care assessment was described by staff, but the records showed that required assessments and timely interventions were not consistently completed or documented. The DON confirmed that the hospital discharge summary did not indicate a wound, yet the resident developed significant skin impairment shortly after readmission, with delayed initiation of appropriate wound care.
Failure to Assess and Document Behavioral Health Needs
Penalty
Summary
The facility failed to assess or document the behaviors of a resident diagnosed with dementia with behavioral disturbance. Despite the resident exhibiting worsening agitation, wandering, and behaviors such as entering other residents' rooms and touching their belongings, there was no documentation or behavior monitoring order in the medical record. The resident was prescribed medications for behavioral health needs upon admission, but the facility did not implement or record any behavior monitoring as required. Interviews with facility staff revealed that information about the resident's behavioral issues was communicated verbally rather than documented. The Psychiatric Nurse Practitioner confirmed awareness of the resident's aggressive behaviors through verbal reports only, and the DON acknowledged that behavior monitoring should have been documented in the Treatment Administration Record. Upon review, the DON verified the absence of any assessment or documentation of the resident's behaviors in the medical record.
Failure to Maintain Audible Call Bell System in Resident Areas
Penalty
Summary
The facility failed to maintain a fully functioning call bell system on the second floor, as evidenced by the lack of an audible call bell sound in the hallways and at the nurses' station. During the survey, the call bell light was observed to be on outside a resident's room, but no audible alert was heard by staff in the area. Staff confirmed that they did not hear any call bell sound, and the Maintenance Director later acknowledged that the sound on the second floor was significantly lower than on the first floor. The issue had not been previously reported to maintenance, and the problem was identified as new, with the last inspection showing no issues. A resident with a tracheostomy reported that they had called for a nurse to assist with suctioning and experienced long wait times for call bell responses, sometimes up to an hour. The surveyor observed staff present at the nurses' station who did not respond to the call bell light, further indicating that the system was not functioning as intended to alert staff to resident needs. The deficiency was identified through complaint review, direct observation, and staff and resident interviews.
Failure to Protect Resident from Verbal Abuse and Inadequate Investigation
Penalty
Summary
Facility staff failed to ensure that a resident was free from verbal abuse, as evidenced by an incident involving a resident with legal blindness who reported being verbally abused by a Geriatric Nursing Assistant (GNA). The resident stated that after waiting over two hours for assistance to use the bathroom, an argument ensued during which the GNA called the resident a derogatory name related to their blindness. The resident's roommate was present during the incident. The Social Service Director confirmed that neither the resident nor their roommate had a history of fabricating complaints or causing trouble. The facility's investigation into the incident was insufficient. The Administrator relied on staff and resident questionnaires, but did not conduct or document thorough interviews with the alleged victim, witnesses, or staff involved. Although another resident also indicated awareness of abuse, there was no documentation of follow-up to clarify this response. The Administrator acknowledged that interviews were not properly documented and was unable to provide evidence supporting staff denials of the abuse allegation.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency (SA) within the required two-hour timeframe after discovering the incident. Record review showed that the facility became aware of a resident's injury at 7:20 AM and did not report it to the SA until 11:02 AM, resulting in a delay of approximately 3 hours and 42 minutes. This delay exceeded the regulatory requirement for timely reporting of such incidents. The deficiency was identified during a complaint survey and was confirmed through review of the facility's investigation packet and interviews with facility staff.
Failure to Conduct Thorough Investigations of Alleged Violations
Penalty
Summary
Facility staff failed to conduct thorough investigations into alleged violations involving two residents. In the first case, an email complaint was received by the Administrator and DON detailing concerns about a resident's care, including issues with medications, oxygen, nutrition, hydration, hygiene, and personal care. The investigation file was missing the original complaint email, and when it was later provided, it was found that not all concerns listed by the complainant were addressed in the facility's investigation. Documentation showed significant gaps in incontinence care, with records indicating the resident may have gone over 12 hours without being changed on multiple occasions. The facility was unable to provide additional documentation to confirm that care was provided more frequently than recorded, and did not investigate all concerns raised, such as those related to medication and oxygen. In the second case, a resident reported to the Social Service Director that a GNA was verbally aggressive during a specific shift. The investigation file indicated that interviews were conducted, but there was no documentation of these interviews except for the alleged perpetrator. Staff and resident questionnaires were used, but responses indicating possible abuse were not followed up as required. The resident involved, who is legally blind, described a delay in assistance and reported being verbally abused by the GNA, with a roommate present as a witness. The facility's investigation did not include documented interviews with all relevant staff, witnesses, or the alleged victim, and the Administrator acknowledged that interviews were not properly documented. In both cases, the facility's investigations were incomplete, lacking documentation and follow-up on all allegations and failing to address all concerns raised by complainants. The absence of thorough documentation and failure to investigate all aspects of the complaints led to inconclusive findings and unaddressed allegations regarding resident care and staff conduct.
Failure to Provide and Document Required ADL and Incontinence Care
Penalty
Summary
Facility staff failed to provide adequate care and assistance with activities of daily living (ADLs) for a resident who was dependent on staff for personal hygiene and incontinence care. The deficiency was identified when it was found that the resident was left unbathed and soiled with urine and bowel movement on multiple occasions, as reported by a complainant. Documentation review revealed that the resident was scheduled to receive showers twice weekly, but records showed only two bed baths documented for the entire month when there should have been nine entries. Additionally, there were significant gaps in the documentation of incontinence care, with long periods between recorded care events. Interviews with facility staff, including a Geriatric Nursing Assistant (GNA) and the Assistant Director of Nursing (ADON), confirmed that staff are required to document showers, refusals, and incontinence care in both electronic records and shower logbooks, and to notify nursing staff of any refusals. However, the facility was unable to provide documentation verifying that the resident received the required care as scheduled. The lack of documentation and the observations of the resident being left soiled indicate that the facility did not ensure consistent provision and recording of necessary ADL and incontinence care for the resident.
Failure to Prevent Pressure Injury Under Orthopedic Device
Penalty
Summary
A deficiency was identified when a resident developed a pressure injury on the right lateral knee, attributed to the use of a knee brace. The resident had an order to wear a right hinge-knee brace locked in extension at all times, with no range of motion allowed. Although there was an initial order to assess the skin under the brace and report abnormalities, this order was discontinued after a few days, and no further documentation of skin assessments was found in the progress notes or treatment administration record for over a month. The care plan included an intervention to check the right knee skin under the immobilizer every shift and notify the medical provider of any abnormalities, but there was no evidence that this intervention was consistently implemented during the period in question. Staff interviews revealed that the standard practice was to assess the skin before and after placement of orthopedic devices, ideally every two to four hours, regardless of whether there was a specific order. However, in this case, the lack of documented skin checks and the absence of ongoing assessment orders contributed to the development of an avoidable pressure injury. The wound was first identified during a skin and wound evaluation, at which point recommendations were made to check the skin daily, consult orthopedics, and consider alternative bracing or additional padding.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when a facility failed to implement fall prevention interventions for a resident who had experienced multiple falls and was assessed as high risk for falls. The resident's care plan included specific interventions such as frequent rounding, bilateral fall mats, and ensuring a call pad was within reach and placed on the side of the bed where the resident was most likely to fall. Despite these documented interventions, observations by the surveyor on two separate occasions revealed that the call pad was not within the resident's reach and was not positioned on the correct side of the bed, as required by the care plan. Instead, the call pad was found on top of a suctioning container and, at another time, on top of an oxygen humidifier machine. Interviews with the resident's representative and facility staff, including the ADON, confirmed that the call pad was not consistently placed according to the care plan. The resident's representative provided photographic evidence of the improper placement, and the ADON acknowledged that the required interventions were not in place at the time of the observations. The administrator and DON were notified of these concerns regarding the lack of adherence to fall prevention measures for the resident.
Failure to Accurately Document Toileting Hygiene After Incontinent Episodes
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, as evidenced by discrepancies in documentation related to toileting hygiene following incontinent episodes. Specifically, the resident experienced bladder and bowel incontinence on several occasions during the night shift, but the Geriatric Nursing Assistant (GNA) documented 'Not Applicable' (NA) for the Toileting Hygiene task instead of indicating whether care was provided or refused. The Director of Nursing (DON) confirmed that the expectation is for GNAs to document if care was provided or if the resident refused care, using the 'Resident Refused' (RR) option when applicable. During interviews, the GNA responsible for the documentation stated that 'NA' was used when a task did not apply, but in this case, the GNA intended to document a refusal but was unable to do so and therefore selected 'NA.' This resulted in incomplete and inaccurate records regarding the resident's care after incontinent episodes, as the documentation did not accurately reflect whether hygiene care was provided or refused by the resident.
Improper Food Storage and Labeling Practices Identified
Penalty
Summary
Facility staff failed to properly store food in accordance with professional standards for food service and safety. During a kitchen inspection, surveyors observed two containers of cottage cheese in the refrigerator, both labeled with received and sell-by dates, and a small block of lunch meat labeled only with an opened and use-by date, but lacking product identification. Additionally, a package of hot dogs was found unsecured and open to air. In the freezer, a water bottle containing a dark liquid was present without a label, and a cut of meat was stored in a pan with cellophane that was not airtight, resulting in visible freezer burn. In the dry storage area, opened packages of ziti and long pasta were found without labels indicating when they were opened or when they should be used by. On a separate unit, the 2nd floor nourishment refrigerator was inspected and found to contain two plastic bags of deli meats. One bag was labeled with a resident room number, but the other lacked any label or date, making it unclear who it belonged to or how long it had been stored. Staff confirmed that only staff had access to the refrigerator and acknowledged that the unlabeled bag should have been properly identified and dated.
Inaccurate Documentation of Resident Assessments
Penalty
Summary
The facility failed to accurately document assessments in the medical records of two residents. For one resident, the Minimum Data Set (MDS) assessment recorded only one stage 3 pressure ulcer, while a prior wound nurse note documented both a stage 3 sacral wound and a stage 2 left hip wound upon readmission. The discrepancy was confirmed during an interview with MDS staff, who acknowledged the error in documentation. For another resident, the MDS discharge assessment indicated a transfer to a short-term general hospital, but the discharge summary stated the resident was stable and discharged home with a spouse. This inconsistency was also confirmed by MDS staff, who stated the discharge location was documented in error.
Failure to Provide Baseline Care Plan Summary to New Admission
Penalty
Summary
The facility failed to inform a newly admitted resident of a summary of the initial Baseline Care Plan (BCP) within 48 hours of admission, as required. The BCP, which should include essential healthcare information to address immediate needs and reduce the risk of negative outcomes, was developed and entered into the medical record, but there was no evidence that the summary was shared or provided to the resident. The resident, who had recently been hospitalized for an acute subdural hematoma, expressed concern about not receiving information regarding their diet and swallowing plan of care. Interviews with staff revealed that the assigned social worker was a new hire and had only documented discharge planning, with no documentation of the BCP being presented to the resident. The Director of Nursing confirmed that the BCP was not shared as expected.
Failure to Develop Comprehensive, Person-Centered Care Plans for Residents at Risk for Falls
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents reviewed for falls. For one resident, the care plans initiated were incomplete and did not specify the reasons for the interventions, such as oral/dental health problems, use of anti-psychotic and anti-depressant medications, risk for respiratory complications, and the presence of an automatic implanted cardiac defibrillator. The care plans lacked individualized details and did not address the specific needs of the resident, as confirmed by the Director of Nursing during an interview. For another resident, there was a delay in developing a care plan related to transfer assistance following a fall that occurred while using a sliding board. Although the resident was initially deemed safe to use the sliding board independently with supervision, a re-evaluation later determined that one staff assist was required for transfers. The care plan reflecting this change was not developed until after the fall, and both the Director of Rehabilitation and the Unit Manager acknowledged that the care plan should have been created earlier.
Failure to Conduct Timely Care Plan Meetings and Involve Residents
Penalty
Summary
The facility failed to conduct care plan meetings following each comprehensive assessment and did not invite residents to participate in their care plan meetings. Specifically, for two out of four residents reviewed, there was no evidence that care plan meetings were held after their Minimum Data Set (MDS) assessments, nor was there documentation explaining why the residents were not invited to participate. In one case, a resident reported not being invited to a care plan meeting for an extended period, and attendance records confirmed the absence of the resident at previous meetings, with only the guardian participating via telephone. Further review of records showed that after the resident's MDS assessments, there were no attendance logs or documentation of care plan meetings being conducted. The Director of Social Services confirmed that no care plan meetings were held after the specified assessments and could not provide documentation for the lack of resident participation. This failure to conduct timely care plan meetings and involve residents as required was evident in the reviewed cases.
Failure to Provide Ongoing Personalized Activities for Room-Bound Resident
Penalty
Summary
A deficiency was identified when a resident, who was confined to their room due to a recent cerebral infarction resulting in a new tracheostomy and feeding tube, was observed on multiple occasions lying in bed, staring at the walls, and falling asleep without any activity staff present or nearby. The resident had a history of diabetes mellitus and depression, and their care plan indicated a need for more personalized activities due to a new low cognitive baseline and several chronic disease processes. Despite this, documentation showed that the resident received only three one-to-one activity visits over a two-month period. Interviews with the Activity Director confirmed that residents unable to participate in group or social activities were supposed to receive frequent, meaningful, ongoing personalized activities. However, after reviewing the activity records, the Activity Director acknowledged that there was a lack of meaningful one-to-one activities provided to this resident. The Director of Nursing was also made aware of this deficit in meeting the resident's needs for personalized activities.
Failure to Ensure Resident Attended Scheduled Eye Specialist Appointment
Penalty
Summary
A deficiency was identified when a resident reported decreased vision since admission, and a review of their medical records showed a missed follow-up appointment with an eye specialist. The resident was scheduled for an eye appointment, as documented in a progress note, but there was no evidence that the appointment occurred. Interviews with facility staff revealed that the Medical Records department was responsible for scheduling follow-up appointments and transportation, but the staff member in charge was unaware of the scheduled eye appointment. The Administrator confirmed the lack of documentation regarding the resident's attendance at the appointment.
Failure to Provide and Document Prescribed ROM Devices
Penalty
Summary
A deficiency was identified when a resident with limited mobility and a history of contractures was not provided with the prescribed treatments to maintain or improve range of motion. The resident had physician orders for bilateral knee extension braces to be worn for six hours daily as tolerated, and for resting hand splints to be applied to both hands for up to two hours at a time after hand hygiene. Multiple observations by the surveyor revealed that the resident was not wearing the prescribed braces or splints, and the resident was consistently seen with knees pulled to the chest and contracted fingers. A review of the resident's medical record showed no documentation that the splints or braces were applied as ordered. During interviews, the DON confirmed that the use of braces and splints should be documented, but acknowledged that the orders for these treatments were never transferred to the Treatment Administration Record (TAR), resulting in a lack of documentation and evidence that the treatments were provided as prescribed.
Failure to Provide Care Planned Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a necessary intervention for a resident identified as a fall risk. The resident had a care plan in place due to involuntary movement of both lower extremities and unawareness of personal boundaries, which included the use of a perimeter mattress for spatial awareness and border definition. After the resident was moved to a new room, the perimeter mattress was not provided, despite being listed as a required intervention in the care plan. Observations confirmed the absence of the perimeter mattress, and staff interviews revealed uncertainty about why the mattress did not transfer with the resident. The resident experienced two documented falls from bed in the new room where the perimeter mattress was not in use. The spouse of the resident reported multiple falls and noted that the special mattress had previously helped keep the resident in bed. The Director of Nursing confirmed the resident was not provided with the perimeter mattress as care planned and was unaware of the reason for this omission. The deficiency was identified through observations, staff interviews, and review of the resident's medical record and fall history.
Failure to Accurately Review and Prescribe Medications After Resident Readmission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a medical provider thoroughly reviewed and accurately prescribed medications following a resident's readmission from the hospital. The resident, who had a history of neuropathic pain, was readmitted on the same day that their gabapentin order was discontinued. Hospital discharge paperwork recommended continuing gabapentin for neuropathic pain, but the medication was not listed among those to be continued, discontinued, or newly started. Upon readmission, the nurse practitioner's progress note indicated gabapentin should be continued, but there was no subsequent documentation or rationale for discontinuing the medication. Further review revealed that the nurse practitioner could not recall the reason for discontinuing gabapentin and stated that the resident did not report pain during assessment, nor was there any communication about uncontrolled pain. The omission of gabapentin was later identified as a missed order, but at the time of the deficiency, the medication was not provided as recommended in the hospital discharge instructions and as indicated in the provider's initial progress note.
Failure to Administer Ordered Medication and Document Administration
Penalty
Summary
A deficiency occurred when a resident experiencing shortness of breath did not receive an additional 40 mg dose of furosemide as recommended by the provider. The recommendation was documented in an SBAR note, but a review of the medication administration record showed no evidence that the medication was administered. When requested, facility staff were unable to provide documentation or a rationale for the omission. Interviews with the Administrator and DON confirmed that the medication was not given and that the nurse responsible did not follow the facility's expected practice for documenting administered medications.
Failure to Document and Track Medication Irregularity Reports in Resident Record
Penalty
Summary
The facility failed to ensure that a process was in place for medication irregularity reports generated by the pharmacist to be reviewed by the primary care physician and for the actions taken based on those recommendations to be documented in the resident's medical record. Specifically, for one resident, pharmacy medication regimen reviews were completed on three separate occasions, but the corresponding reports were not found in the resident's electronic medical record. The Director of Nursing (DON) had to obtain these reports directly from the pharmacist, indicating they were not properly filed or accessible as part of the resident's official record. Interviews with facility staff revealed that the process involved the DON or a nurse printing the pharmacist's reports and providing them to the nurse practitioner (NP) for review. The NP would review, document decisions, and sign the reports before returning them to the DON or nurse for implementation of any indicated orders. However, there was no clear process for ensuring that these reports and the responses to them were incorporated into the resident's medical record, as confirmed by both the NP and the DON.
Unsecured Medication Cart Found Unlocked in Hallway
Penalty
Summary
A surveyor observed an unlocked medication cart in the hallway between two resident rooms during a random observation on the second floor. The surveyor was able to open the top drawer and found multiple medications and supplies, as well as access all seven other drawers containing medications. Staff confirmed that the cart was the responsibility of a nurse who was working with two medication carts due to a Certified Medication Aide calling out sick and a subsequent reassignment of duties. The nurse acknowledged that the cart should not have been left open and stated it was left unlocked by accident.
Improper Maintenance of Outdoor Garbage Storage Area
Penalty
Summary
The facility failed to maintain the outdoor garbage storage area in a sanitary manner to prevent the harboring of pests. During an observation, a surveyor noted a significant accumulation of plastic bags, leaves, pine needles, and plastic cups, approximately six inches high, located between the dumpster and the concrete wall behind it. This accumulation was found in the area used by kitchen staff for garbage disposal, just outside the kitchen receiving doors. In an interview, the Director of Maintenance acknowledged that the accumulation should not be present in that area.
Improper Storage of Clean Resident Clothing in Laundry Room
Penalty
Summary
During the recertification survey's infection control investigation, surveyors observed six green bags containing clean clothes stored in the facility's dirty laundry room. Staff interviews confirmed that these clothes belonged to residents who were either hospitalized or had expired. The Environmental Director acknowledged that the clothes in the bags were clean, and the Director of Nursing was informed of the potential risk for accidental contamination due to the storage method. The facility failed to ensure that clean residents' clothing was stored in a manner that minimized the potential spread of infection, as required by infection prevention and control protocols.
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Illustrative
What surveyors actually found near you
We read the 1,806 citations issued within 25 miles in the last 12 months — including the 9 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Future Care Irvington | 0.6 mi | ★★★★★ | 0 | 0 |
| Ridgeway Rehab Center | 0.8 mi | ★★★★★ | 28 | 0 |
| Frederick Villa Healthcare | 1.1 mi | ★★★★★ | 21 | 0 |
| Little Sisters Of The Poor | 1.1 mi | ★★★★★ | 0 | 0 |
| Charlestown Community Inc | 1.2 mi | ★★★★★ | 22 | 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 August 2026) and official state health department websites.