Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Wicomico Nursing Home during CMS and state inspections, most recent first.
Failure to document a legally authorized decision maker for a resident lacking decision-making capacity. The resident had two physician certifications showing incapacity, but the chart contained no evidence of an authorized surrogate. The SWD stated the resident's sister had been making decisions because the children were not involved, but the facility did not obtain documentation establishing the sister as the legally authorized decision maker.
Failure to turn and reposition two residents every 2 hours was identified during survey observations and record review. One resident had an order for q2h turning and repositioning and was repeatedly observed lying on his/her back despite being signed off as repositioned, while another resident was care planned for q2h turning and repositioning but was also repeatedly observed lying on his/her back. An RN and a GNA stated that residents needing this assistance were expected to be turned and repositioned every 2 hours.
Expired medications were found in medication carts and a medication fridge during survey observations. In one cart, an LPN observed expired Aspirin, Tylenol, Benadryl, Hemoccult solution, and bacteriostatic sodium chloride, and a Bisacodyl suppository was also stored in the cart even though staff said it should have been kept in the fridge. The fridge contained 20 expired Bisacodyl suppositories. Staff stated that nurses and all staff were responsible for proper storage and removing expired medications.
Laundry infection control practices were not followed when a dirty laundry cart contained unbagged resident clothing and staff used a resident hospital gown as PPE instead of the facility’s disposable gowns. The laundry room vent was off, and in the clean laundry area, holes in the ceiling with exposed insulation were observed directly above clean folded clothes. The ADON and DON acknowledged the concerns during the survey.
A facility failed to submit the final investigation report of an alleged abuse incident to the OHCQ within the required timeframe. A resident was found with unexplained discoloration on her hands and forearm. Although the initial report was submitted within 24 hours, the final report was not submitted within 5 working days. The ADON confirmed the absence of documentation for the 5-day conclusion report.
A resident in an LTC facility was administered the antibiotic Cefepime twice daily instead of the prescribed once daily, over three days. This error was confirmed by the resident's physician and the facility pharmacy manager, highlighting a failure in medication administration and documentation.
A facility failed to maintain an accurate medical record for a resident, as a physician certification form was found with a date discrepancy and missing resident identification. The nurse practitioner could not explain the omission, and the issue was discussed with the facility's administration.
A facility failed to ensure resident safety during wheelchair transport and fall prevention, resulting in harm. A resident with osteoporosis was injured due to the absence of leg rests on their wheelchair, leading to a fracture. Another resident, at high risk for falls, experienced multiple falls without updates to their care plan. Additionally, a third resident was observed being transported without leg rests, contrary to facility policy. Staff interviews confirmed lapses in protocol adherence and documentation.
A resident experienced significant dental pain and weight loss due to the facility's failure to provide timely dental care. Despite being prescribed antibiotics and pain medication, the resident was not seen by the dental group due to time constraints and insurance issues. Interviews revealed a lack of communication and coordination among staff, contributing to the delay in treatment.
The facility failed to update and revise care plans for several residents after changes in their needs or incidents occurred. For example, a resident's care plan did not include the use of Geri-sleeves despite a physician's order, and another resident's care plan lacked updates after a fall, omitting the use of fall mats and leg rests. Interviews with staff revealed inconsistent documentation and updating of care plans, contributing to the deficiencies identified.
A resident was left completely exposed during a bed bath, with neither the privacy curtain nor the window curtain pulled, making her visible from the hallway and outside. The GNA confirmed the oversight, and the DON acknowledged the facility's expectation for privacy and dignity during care.
A resident with severe cognitive impairment was found in a bed with a wheelchair placed against the head of the bed, restricting movement and acting as a physical restraint. This setup was not part of the resident's care plan and was not listed as an appropriate restrictive device in the facility's policy. Staff interviews revealed that the wheelchair was placed to prevent falls, but it was not intended to be used as a restraint.
The facility failed to report allegations of abuse and injury within required timeframes. In one case, a resident with a bruise on the eye was not reported to OHCQ within 2 hours, and in another, a resident's injury was not reported within 24 hours. The DON acknowledged the delays, citing frequent bruising and medication use for one resident, but this did not justify the reporting failures.
The facility failed to thoroughly investigate two incidents involving residents. In one case, a resident's eye discoloration was not reported by staff until days after it was first noticed by the resident's daughter. In another case, a resident's fall was not fully investigated as interviews with the GNAs who found the resident were missing. The DON and ADON acknowledged the investigations were incomplete.
A resident's behaviors, including wandering and aggression, were not accurately coded in the MDS assessments, despite being documented in medical records. The social worker, overwhelmed by workload, had assistance from another individual who failed to code the behaviors correctly, leading to the deficiency.
Two residents' CPAP and nebulizer masks were left uncovered on dressers, increasing infection risk. A nurse confirmed the masks should have been bagged for infection control, but this was not done. The DON noted a lack of policy on mask storage, despite recent updates to cleaning procedures.
Failure to Document a Legally Authorized Decision Maker
Penalty
Summary
The facility failed to ensure that care and treatment decisions for a resident assessed to lack decision-making capacity were made by a legally authorized representative. Resident #7 had two signed Physician Certifications Related to Medical Conditions, Decision Making, and Treatment Limitations documenting that the resident lacked adequate decision-making capacity. Despite this, the medical record contained no evidence of a legally authorized representative to make decisions for the resident. During interview, the Social Work Director confirmed that the resident had two certifications of incapacity and stated that, because the resident's children were not involved, the resident's sister had been making decisions for the resident, but the facility did not obtain documentation establishing the sister as a legally authorized surrogate decision maker.
Failure to Turn and Reposition Residents Every Two Hours
Penalty
Summary
The facility failed to ensure that residents who required assistance with turning and repositioning were turned and repositioned at least every two hours. Resident #3 had an order to be turned and repositioned every two hours, but on 02/04/2026 was observed lying on his/her back at 9:11 AM, 11:23 AM, and again at 1:23 PM, despite record review at 1:17 PM showing the resident had been signed off as turned and repositioned. During interviews on 02/04/2026, a Registered Nurse and a Geriatric Nursing Assistant stated that residents needing this assistance were expected to be turned and repositioned every two hours. Resident #4 was care planned for turning and repositioning every two hours, but was observed lying on his/her back at 9:12 AM, 11:24 AM, and 1:24 PM on 02/04/2026. The concerns were brought to the Director of Nursing at 3:59 PM, and she indicated that she understood.
Expired Medications Found in Medication Carts and Refrigerator
Penalty
Summary
Expired medications were found stored in medication carts and a medication refrigerator during the annual survey. In the 100s unit medication cart, the surveyor observed a bottle of Aspirin 325 mg with an expiration date of 12/2025. Staff #7 stated that nurses were responsible for checking the cart every shift for expired medications. In the 500s unit medication cart, the surveyor observed multiple expired medications, including Aspirin 325 mg with an expiration date of 12/2024, Tylenol Extra Strength with an expiration date of 9/2025, Benadryl 25 mg with an expiration date of 11/2025, Hemoccult solution with an expiration date of 8/2025, and Bacteriostatic 0.9% sodium chloride with an expiration date of 11/1/2025. The 500s unit cart also contained a Bisacodyl suppository without an expiration date visible in the cart, and Staff #15 stated it was not supposed to be stored there but should be kept in the fridge. When the medication refrigerator was then observed, 20 expired Bisacodyl suppositories were found with an expiration date of 9/9/2025. During follow-up interview, Staff #15 stated that it was everyone's responsibility to ensure medications were stored properly and that expired medications were removed and discarded. The DON and facility administrator were notified of the concerns.
Laundry Infection Control Lapses
Penalty
Summary
The facility failed to use appropriate infection control practices while handling laundry in the dirty laundry room area. During the surveyor’s observation, a laundry cart was half-way filled with clothes that were not bagged, and a cart near the wall contained 2 hospital gowns and gloves. Staff #2 stated the clothes were dirty and belonged to different residents, and said she was waiting for more resident clothes to be brought in because the machine only allows a certain load weight to wash. When asked what PPE was being worn, staff pointed to gloves and a resident hospital gown. Staff #2 also stated the laundry room vent was off because it was cold in the area. In the clean laundry area, the surveyor observed holes in the ceiling with loose, exposed insulation materials, and clean folded clothes were stored directly below the affected area. The ADON stated staff are expected to wear gowns, gloves, and eye shield, and confirmed that blue disposable gowns are the one-time-use gowns provided by the facility. When shown the hospital gowns being used as PPE, the ADON stated they were not appropriate because they are cloth and not protective. During a later tour with the ADON and DON, the ADON stated dirty clothes should be bagged and acknowledged the cart of unbagged clothes. The surveyor also showed the ADON and DON the ceiling holes and exposed insulation in the clean area, and the ADON later reported maintenance had turned on the ventilation switch and would fix the ceiling holes.
Failure to Submit Final Investigation Report to OHCQ
Penalty
Summary
The facility failed to report the final investigation of an incident of alleged abuse to the Office of Health Care Quality (OHCQ) as required. On December 19, 2024, a resident was observed with discoloration on her bilateral hands and left forearm by a staff member and the resident's family member. The resident was unable to explain how the discoloration occurred. The facility submitted the initial report to OHCQ within 24 hours of the allegation, but did not submit the final investigation report within the required 5 working days. During an interview on March 10, 2025, the Assistant Director of Nursing confirmed that the staff could not locate any documentation that the 5-day conclusion was reported to the State Survey Agency for the incident.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered, leading to a significant medication error. This was identified during a complaint survey involving a resident who was prescribed the antibiotic Cefepime, 1 gram, to be administered intravenously every 24 hours for 7 days. However, the medication administration records revealed that the nursing staff administered the antibiotic twice daily on three consecutive days, contrary to the physician's order. This error was discovered during a review of the resident's closed medical record and was confirmed by both the resident's physician and the facility pharmacy manager. The resident's physician confirmed that the order was for a single daily dose, and the facility pharmacy manager corroborated that the pharmacy received the correct order. The error was brought to the physician's attention by a nurse, indicating a lapse in following the prescribed medication regimen. The report does not provide details on the resident's medical history or condition at the time of the deficiency, but it highlights a critical failure in medication administration and documentation, which could have significant implications for resident safety.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility staff failed to maintain an accurate medical record for a resident, as identified during a complaint survey. The deficiency was noted in the medical record of one resident, where a completed physician certification form related to medical condition, decision making, and treatment limitations was dated incorrectly. The form, completed and signed by the facility nurse practitioner, was found in the resident's closed medical record with a date discrepancy. During an interview, the nurse practitioner was unable to explain why the signed certification form did not have the resident's name printed on it. The issue was discussed with the Administrator and Assistant Director of Nursing.
Failure to Ensure Resident Safety During Wheelchair Transport and Fall Prevention
Penalty
Summary
The facility failed to ensure the safety of a dependent resident during transportation to activities in a wheelchair, resulting in actual harm. Resident #28, who was non-ambulatory and had a history of osteoporosis and a previous tibial fracture, was being transported without leg rests on the wheelchair. The resident's legs became too heavy to hold up, causing them to drop and get caught under the wheelchair, leading to a fracture in the lower leg. The incident highlighted a lack of adherence to the facility's protocol for using leg rests during wheelchair transport, as confirmed by staff interviews and facility documentation. Additionally, the facility did not implement new fall interventions for a resident at high risk for falls, despite multiple incidents resulting in injuries. Resident #51, who was severely cognitively impaired and had a history of falls, experienced several falls without any updates to their care plan to address the risks. Staff interviews revealed a lack of communication and documentation regarding fall interventions, and the care plan had not been updated since February 2023, despite the resident's repeated falls and injuries. Furthermore, another resident, #57, was observed being transported in a wheelchair without leg rests, requiring them to hold their legs up. This was against the facility's policy, which mandates the use of leg rests during transport to prevent injury. Staff interviews confirmed that the policy was not followed, and the leg rests were not available in the resident's room. The facility's failure to adhere to its own safety protocols for wheelchair transport and fall prevention contributed to the deficiencies identified by the surveyors.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to provide timely and adequate dental care for a resident, identified as R55, who experienced significant dental pain and weight loss. R55 was admitted with multiple diagnoses, including hip and knee contractures, congestive heart failure, and adjustment disorder with anxiety. Despite being assessed as moderately cognitively impaired and on a regular diet with no initial dental concerns, R55 began experiencing tooth pain, which was documented in the nursing progress notes. The facility's care plan did not address changes in dental pain, and interventions for weight loss due to poor food intake did not consider dental issues. R55's dental pain was first noted on 07/24/24, with a decayed and chipped tooth identified. Although a dental consult was ordered, the resident was not seen by the 360 dental group due to time constraints and insurance issues. The resident continued to experience pain, affecting their ability to eat, leading to a downgraded diet and significant weight loss. Despite being prescribed antibiotics and pain medication, the facility failed to ensure R55 received the necessary dental care, resulting in ongoing pain and discomfort. Interviews with facility staff revealed a lack of communication and coordination in addressing R55's dental needs. The Medical Records/Social Services staff and the Director of Nursing were aware of the resident's pain but did not take effective action to secure timely dental care. The facility's reliance on the 360 dental group and the misunderstanding of the resident's eligibility for services contributed to the delay in treatment. The facility did not have a policy addressing dental concerns, leading to confusion and inadequate response to R55's acute dental issue.
Failure to Update and Revise Care Plans
Penalty
Summary
The facility staff failed to update care plans when there were changes in resident needs or preferences, and did not thoroughly evaluate and revise resident plans of care after each assessment. This deficiency was identified during a complaint survey involving six residents. For instance, Resident #40's care plan was not updated to include the use of Geri-sleeves despite a physician's order, and Resident #27's care plan lacked updates after a fall, failing to include the use of fall mats and leg rests. Resident #34's care plan was not revised to include increased rounding and frequent toileting after a fall incident. Similarly, Resident #28's care plan did not reflect the need for wheelchair leg rests after sustaining an injury during transport. Resident #504's care plan was not updated with additional interventions despite multiple falls and a change in medical status, and it also lacked details on oxygen use and inhaler administration. Resident #505's care plan was not updated with new interventions following a fall that resulted in a fracture. Interviews with facility staff, including the Assistant Director of Nursing, Director of Nursing, and MDS Coordinator, revealed a lack of consistent documentation and updating of care plans. The MDS Coordinator acknowledged that while interventions were being implemented, they were not documented in the care plans. The Director of Nursing stated that care plans should be updated after incidents, but this was not consistently done, leading to the deficiencies identified in the survey.
Failure to Ensure Privacy During Resident Bed Bath
Penalty
Summary
The facility failed to provide visual privacy during a bed bath for a resident, identified as R56, who was totally dependent on staff for bathing and was cognitively intact with a BIMS score of 13 out of 15. During a facility tour, a surveyor observed R56 lying completely naked and exposed on her bed while a Geriatric Nurse Aide (GNA) was providing a bed bath. The privacy curtain was not pulled, and the resident was visible from the hallway. Additionally, the window curtain was not drawn, exposing the resident to anyone walking outside past her ground-level room. Interviews conducted with the GNA and the Director of Nursing (DON) confirmed the lack of privacy measures during the bed bath. The GNA acknowledged that the curtains were not pulled and the resident was not covered. The DON stated that the facility's expectation is to ensure privacy and dignity during care, which includes pulling both the privacy and window curtains and covering the resident during a bath. The resident expressed discomfort at the thought of being seen by a man while exposed.
Failure to Maintain Restraint-Free Environment
Penalty
Summary
The facility failed to maintain a restraint-free environment for a resident identified as R51, who was reviewed for physical restraints. The resident, who was severely cognitively impaired with a BIMS score of 99, was observed in a low bed with a fall mat and a quarter side rail. The left side of the bed was against the wall, and a wheelchair was placed against the head of the bed, effectively preventing the resident from getting out of bed. This setup was not listed as an appropriate restrictive device in the facility's policy, and the use of the wheelchair in this manner was not included in the resident's care plan for falls. During interviews, a Geriatric Nurse Aide (GNA) admitted to placing the wheelchair against the bed to prevent the resident from falling out. A Registered Nurse (RN) on duty acknowledged seeing the wheelchair against the bed but did not take action to move it or inquire about its placement. The Infection Control Nurse/Staff Development nurse confirmed that the wheelchair acted as a barrier, and the Director of Nursing verified that the wheelchair should not have been placed against the bed. These actions and inactions contributed to the deficiency, as the facility did not adhere to its policy of maintaining a restraint-free environment.
Failure to Timely Report Allegations of Abuse and Injury
Penalty
Summary
The facility failed to report allegations of an injury of unknown source within the required 2-hour timeframe to the Office of Health Care Quality (OHCQ). This was evident in the case of a resident who was found with a discoloration/bruise on the outer corner of the right eye. The incident was discovered on a Thursday morning, but the initial report was not sent until later that afternoon, exceeding the 2-hour requirement. The resident's daughter had noticed the discoloration four days earlier but did not report it, and the nursing staff also failed to report it until the day of discovery. The Director of Nursing (DON) acknowledged the delay and attributed it to the resident's frequent bruising due to combative behavior and medication use, but this did not justify the failure to report promptly. In another incident, the facility did not submit a report within the required 24-hour timeframe after a resident allegedly punched a staff member, resulting in a laceration on the resident's hand. The initial report was submitted several days after the incident, and the DON confirmed the delay. These failures to report in a timely manner were identified during a complaint survey and involved inadequate communication and documentation by the facility's staff, leading to non-compliance with regulatory requirements.
Incomplete Investigations of Resident Incidents
Penalty
Summary
The facility failed to thoroughly investigate incidents of injuries of unknown origin for two residents during a complaint survey. In the first case, a resident was noted to have a discoloration to the outer corner of the right eye, which was first noticed by the resident's daughter on a Sunday. However, the facility staff did not report the discoloration until the following Thursday. The facility's investigation included interviews with some staff members but failed to include interviews with ten additional staff members who worked during the period when the discoloration was first noticed. The Director of Nursing was unable to explain why the staff who worked with the resident during that time did not report the discoloration. In the second case, a resident sustained a fall and was found on the floor near a wheelchair with a spilled cup of coffee. The facility's investigation included an incident report, a nurse's statement, an x-ray report, hospital documentation, and the resident's medication list. However, it lacked interviews with the two GNAs who found the resident and any other staff who may have seen the resident before the fall. The Assistant Director of Nursing acknowledged that the investigation was incomplete, as it did not include expected statements from the GNAs or others who saw the resident prior to the fall.
Inaccurate MDS Coding for Resident Behaviors
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident during a complaint survey. The resident exhibited behaviors such as wandering, verbal aggression, and exit-seeking, which were documented in the medical records. However, these behaviors were not accurately reflected in the MDS assessments. For instance, the MDS with an assessment reference date of June 7, 2023, incorrectly documented that the resident did not exhibit verbal behavioral symptoms or wandering, despite multiple notes indicating otherwise. The inaccuracies in the MDS assessments were attributed to the social worker's workload, as they were working two jobs and had enlisted help from another individual. This helper documented the behaviors in progress notes but failed to code them correctly on the MDS. The social worker eventually stopped the helper from completing further MDS assessments upon realizing the errors. This oversight led to the deficiency in accurately assessing and documenting the resident's needs and behaviors.
Improper Storage of Respiratory Masks
Penalty
Summary
The facility failed to properly store CPAP and nebulizer masks for two residents, increasing the potential for respiratory infections. Resident 5, who was cognitively intact with a BIMS score of 13, had a CPAP mask left uncovered on the dresser beside their bed during multiple observations. Similarly, Resident 26, who was moderately cognitively impaired with a BIMS score of 8, had a nebulizer mask left uncovered on the dresser beside their bed during the same observation periods. These observations were confirmed by Registered Nurse 4, who acknowledged the masks should have been stored in bags for infection control. The Director of Nursing (DON) acknowledged that the facility's policy for CPAP masks had been recently updated due to issues with cleaning during the 3-11 shift. However, there was no policy regarding the storage of these masks. The DON confirmed that the masks should have been stored in plastic bags and changed weekly for infection control, but this was not being done, leading to the deficiency noted by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Salisbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Deer's Head Center | 1.1 mi | ★★★★★ | 10 | 0 |
| Anchorage Rehabilitation And Wellness Center | 1.3 mi | ★★★★★ | 28 | 0 |
| Bay Harbor Post Acute Healthcare Center | 2.3 mi | ★★★★★ | 15 | 2 |
| Delmar Nursing & Rehabilitation Center | 5.9 mi | ★★★★★ | 4 | 0 |
| Manokin Nursing And Rehab | 12.5 mi | ★★★★★ | 44 | 2 |
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