Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase during CMS and state inspections, most recent first.
Kitchen Food Storage and Hairnet Compliance Deficiencies: During the kitchen tour, staff and a vendor were observed in the kitchen without proper hair covering, and no hairnets were available at the entrance. The surveyor also found uncovered and undated food items in freezers and expired items in a refrigerator, including tuna filets, soy sauce, and artichokes. The DCS stated that expired food should be removed and disposed of and that employees must wear hairnets before entering the kitchen.
Call bells were not kept within reach for two residents. One resident with hemiplegia, dependent mobility, and unclear speech had the call button placed about 4 feet from the bed, while another resident with impaired cognition and dependent mobility had a call bell pad on the floor under the bed despite care plan directions to keep the call light within reach.
Failure to maintain an effective grievance program. A resident reported repeated loss of labeled clothing in the laundry process and said staff gave no follow-up after saying they would investigate. Surveyors found no posted grievance officer, no accessible grievance forms, and inconsistent staff understanding of the grievance process; the DON and administrator also confirmed there had been no documented grievances since 2022. A separate complaint about alleged inappropriate care during a bed bath was reported to activity staff but was not documented as a grievance or incident.
Failure to Immediately Report Abuse Allegations: Staff failed to promptly report two abuse allegations. One resident’s spouse was overheard making a threat to shoot the resident and himself, but the former DON did not report it to the State agency right away and reportedly told staff not to document or worry about it. In a separate incident, a resident said staff handled them roughly while getting dressed, but the allegation was not immediately escalated to the Administrator by the Activities Director.
Failure to Thoroughly Investigate Alleged Abuse/Injury of Unknown Origin: A resident was tearful and stated, "He hit me," while RN observed a raised hematoma with blue/green bruising on the forehead. The facility's investigation did not include an evaluation of the resident's statement, a psych assessment, or interviews with other residents about the possible abuse allegation, and the DON confirmed no other residents were interviewed and no clinical evaluation was completed.
Unattended medication was left in a cup on a resident’s bedside table, creating an accident hazard. The resident had dementia and a BIMS score of 5, indicating severe cognitive impairment, with no documented evidence supporting self-administration of meds. An RN said leaving the medication at the bedside was the only way to get the resident to take it, while another RN and the DON stated that self-medication required assessment, an updated care plan, and that it would not be appropriate to leave meds unattended.
Failure to Document Non-Pharmacological Pain Interventions: A resident had PRN orders for oxycodone and acetaminophen, but MAR and progress note review showed repeated instances where non-pharmacological interventions were not documented with pain med administrations. The DON stated that pain management includes pain scale assessment and that non-pharmacological interventions must be documented on the MAR, and later confirmed none were evident.
Hospice Documentation and Communication Not Maintained: A resident receiving hospice services had incomplete coordination between the hospice agency and facility. The DON was unsure of the resident’s treatment goal and where hospice communication was documented, and the resident’s EHR showed the last hospice service document was outdated. Although hospice staff reportedly visited weekly and verbally communicated with nursing staff, the required hospice documentation was not consistently available in the resident’s record.
The facility failed to protect residents from abuse, with incidents involving physical assault by a GNA and inadequate investigations into allegations of abuse. Staff did not report incidents immediately, and the facility did not ensure all staff had required abuse training. Additionally, the administration dismissed allegations without thorough investigation, contributing to the facility's inability to protect residents.
A facility failed to conduct a root cause analysis for a resident with Alzheimer's Dementia who experienced multiple falls, one resulting in a hip fracture. Despite being identified as a high fall risk, the resident's care plan lacked updated interventions to prevent further falls. The facility's Fall Reduction and Management Policy was not fully adhered to, as confirmed by the DON, who noted that only monitoring was listed as an intervention and the Root Cause of Fall section was not completed.
The facility did not conduct annual performance reviews for GNAs, as required, since 2011. The DON, who joined in 2020, confirmed that evaluations were not performed for GNAs, only for the ADON. This oversight affects the facility's ability to provide targeted in-service education.
The facility failed to consistently monitor and document meal temperatures before serving, as required by policy. The Dietary Manager, new to the position, had not reviewed temperature logs until recently and was unaware that staff were not temping all food items. This oversight potentially affected all residents consuming food from the kitchen, except one resident who was NPO.
The QA committee at the facility failed to conduct a thorough Performance Improvement Project (PIP) as required by their QAPI program. The DON admitted that the PIP for increasing pressure ulcers was limited to collecting information and filling out a form, without tracking outcomes or conducting a root cause analysis. The Administrator acknowledged the lack of proper documentation, which hindered the ability to demonstrate the facility's efforts.
The facility administration failed to ensure effective oversight, resulting in incomplete investigations of injuries and abuse. The DON provided inadequate reports for residents with unwitnessed falls, lacking assessments and care plan updates. An abuse allegation was mishandled, with the alleged perpetrator not suspended and police not notified. Additionally, an LPN did not report an abuse incident immediately, and the facility could not verify required abuse training for agency staff.
The facility failed to ensure all nursing staff, including agency staff, received training on abuse reporting procedures. An LPN witnessed a GNA physically abusing a resident but delayed reporting the incident, allowing the GNA to continue working. The facility did not verify the LPN's abuse training, relying on the agency for documentation.
The facility failed to report several incidents of alleged abuse, neglect, or injuries of unknown origin to the OHCQ within the required timeframe. This included cases of unwitnessed falls, bruises, and abuse allegations that were not reported to local law enforcement or the state agency promptly. The facility's policy requires immediate reporting of such incidents, but this was not adhered to, and investigations were not conducted thoroughly.
The facility failed to thoroughly investigate multiple allegations of abuse and injuries of unknown origin, and did not protect residents from further harm. Incidents included unwitnessed falls resulting in fractures, unreported physical abuse, and dismissed verbal abuse allegations. Investigations were incomplete, lacking interviews with all relevant staff and residents, and failed to implement preventive measures.
The facility failed to administer and document pain medication for two residents with reported pain. One resident with severe cognitive impairment was found with hip pain, but the MAR did not reflect the administration of Tylenol as documented. Another resident with dementia and gait abnormalities experienced arm pain after a fall, but further doses of Tylenol were not recorded despite ongoing pain complaints and a physician's order. These issues were discussed with the facility's DON and NHA.
A facility failed to maintain accurate medical records for a resident who alleged abuse by an employee. The incident was reported, but the resident's medical records lacked documentation of the abuse allegation, assessment of injury, mental status, physician notification, or measures taken. Despite 17 nursing progress notes during the relevant period, none addressed the abuse incident.
A resident with a history of a left femur fracture and neuropathy did not have their lidocaine patches removed as per physician's orders, despite documentation indicating otherwise. The patches were found still on the resident during an observation, and the discrepancy was confirmed by the DON. The facility's policy on medication administration was not followed.
Kitchen Food Storage and Hairnet Compliance Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards during the initial kitchen tour for the recertification/complaint survey. At the kitchen entrance on 03/23/2026 at 8:14 AM, there were no hairnets available, and when the surveyor asked for one, Dietary Receiver Staff #4 had to go to the middle of the kitchen to get it. During continued observation at 8:20 AM, Dietary Staff #2 was at the dishwashing station without a hairnet, Dietary Staff #3 was walking throughout the kitchen wearing a baseball cap with shoulder-length hair hanging out and not covered by a hairnet, a vendor entered the kitchen with uncovered hair to drop off boxes, and the Director of Culinary Services also entered without a hairnet and went to the middle of the kitchen to retrieve one. At 8:25 AM, the walk-in freezer contained nine uncovered, undated loaves of bread on top of a box, another freezer held an undated canister of fruit, and a refrigerator contained two tuna filets plus a clear container and a larger container of soy sauce that were expired on 03/21/2026, along with a clear container of artichokes expired on 03/22/2026. During an interview at 8:57 AM, the Director of Culinary Services stated that expired food should be removed and disposed of and that employees must wear hairnets before entering the kitchen. The concern was then shared with the DON on 03/24/2026 at approximately 1:15 PM.
Call Bells Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure that call bells were kept within residents’ reach for 2 residents observed during the recertification survey. During the initial tour, one resident was observed in bed with the call button located on top of a recliner approximately 4 feet away from the left side of the bed. At the same time, another resident was observed with a call bell pad on the floor under the bed. A GNA was notified and confirmed that call bells should be placed within residents’ reach. Record review showed that the first resident had a diagnosis of hemiplegia and hemiparesis affecting the right dominant side, with MDS coding indicating impairment on one side, dependent bed mobility, dependent chair/bed transfers, and unclear speech. The resident’s care plan directed staff to keep the call bell within reach at all times. The second resident had a BIMS score of 4.0 indicating impaired cognition, with MDS coding showing dependent bed mobility and dependent chair/bed transfers. That resident’s care plan included interventions to anticipate and meet needs, keep the call light within reach, provide a call bell pad to aid in alerting staff, check frequently, and maintain a safe environment with a working and reachable call light.
Failure to Maintain an Effective Grievance Program
Penalty
Summary
The facility failed to maintain an effective grievance program and did not ensure resident concerns were consistently treated as grievances, documented, or made accessible to residents. During interview, a resident reported significant loss of clothing, especially shirts, during the facility laundry process despite the items being labeled with the resident’s name. The resident said staff were notified and said they would investigate, but no follow-up information was provided. The resident also reported that the head of laundry said the facility could not control incoming laundry personnel and that new hires allegedly failed to check clothing labels. Survey observations and staff interviews showed that the grievance officer’s identity was not properly posted, and information on how residents could express grievances and accessible grievance forms were absent from the facility. Staff gave inconsistent explanations about the grievance process, with one nurse stating concerns were verbally relayed to the relevant department, the social worker stating concerns were addressed immediately without written documentation and that no grievance postings or forms were available, and the DON identifying the administrator as the grievance officer. The administrator confirmed that grievance information was in the admission packet and resident council, but also confirmed there was no posting of the grievance officer, no accessible grievance forms, and no documented grievances since 2022. In addition, a complaint involving alleged inappropriate care by nursing staff during a bed bath was reported to activity staff, but no documentation was found in the resident’s record, and the DON verified that no self-reported incident or grievance had been filed. Staff later stated the matter was not formally reported because the resident denied abuse during an internal interview and the issue had been addressed immediately.
Failure to Immediately Report Abuse Allegations
Penalty
Summary
Facility staff failed to report allegations of abuse immediately in two incidents reviewed during the survey. In one case, Resident #72’s spouse was overheard by RN #11 and Nursing Aide #19 saying, “I will shoot you and I will shoot myself,” on 11/05/25, but the incident was not reported to the State agency until 11/10/25. RN #11 stated she immediately informed the former DON, Staff #12, after hearing the threat, and a former NHA statement indicated Staff #12 dismissed the concern and said not to document it or worry about it. Staff #12 was later terminated for failing to report the spouse’s threat. In another case, Resident #18 told the Activities Director that staff had handled them roughly while getting dressed. The Administrator did not learn of the allegation until reviewing resident council meeting notes the next day, and the report states the allegation was not immediately brought to the Administrator’s attention by the Activities Director. The facility’s investigation began after the Administrator identified the concern, and the DON later stated the Activities Director should have reported it immediately.
Failure to Thoroughly Investigate Allegation of Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of injury of unknown origin involving one resident who was found tearful and reported, "He hit me." RN #22 observed a raised hematoma with blue/green bruising on the left side of the forehead at the hairline, but the facility's investigation did not include an evaluation of the resident's statement, a psychological assessment, or interviews or statements from other residents regarding the possible abuse allegation. During interview, the DON stated that staff should interview employees and residents when investigating an injury of unknown origin and confirmed that no other residents were interviewed and no clinical evaluation was performed regarding the resident's specific statement.
Unattended Medication Left at Bedside of Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that the resident’s environment remained free from potential accident hazards when three unattended white pills were observed in a small medication cup on the bedside table of a resident with dementia. During the initial tour, the surveyor found the medication left at the bedside, and an RN stated that leaving the medication there was the only way he could get the resident to take it. The RN was unsure whether the resident’s care plan authorized independent medication administration and acknowledged that the resident was confused at times. A review of the resident’s care plan showed a diagnosis of dementia with no documented evidence that the resident was able to self-administer medications. The resident’s most recent MDS showed a BIMS score of 5, indicating severe cognitive impairment. An RN explained that the facility’s self-medication process required a resident assessment, including being alert and oriented, and an updated care plan, and stated that it would not be appropriate to leave medication at the bedside. The facility’s medication policy required staff to avoid leaving medication unattended and to observe the resident’s consumption of medications. The DON confirmed that the resident was not a candidate for self-administration because of cognitive impairment.
Failure to Document Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to provide appropriate pain management for Resident #57, who had standing physician orders for oxycodone HCl 5 mg every 6 hours as needed for severe pain and acetaminophen 325 mg, 2 tablets every 6 hours as needed for mild pain or temperature over 101. Review of the resident’s MARs and progress notes for February and March 2026 showed that non-pharmacological interventions were not documented with multiple pain medication administrations. In February, this documentation was missing for 5 oxycodone administrations and 3 Tylenol administrations, and in March it was missing for 2 Tylenol administrations and 2 oxycodone administrations. During interview, the DON stated that pain management involves assessing the pain scale and following the physician’s order, and that non-pharmacological interventions must be documented on the MAR under supplement documentation before medication is administered. The DON later confirmed that no non-pharmaceutical interventions were evident.
Hospice Documentation and Communication Not Maintained
Penalty
Summary
The facility failed to maintain an effective collaborative communication process for a resident receiving hospice services. Resident #30 was confirmed to be receiving hospice care during the care plan review, but the Director of Nursing was unsure of the resident’s treatment goal and uncertain where hospice communication was documented in the record. The hospice agency typically documented care notes in its own system and provided documentation for upload to the facility’s electronic medical record, but the DON acknowledged that the facility did not receive documentation from the hospice agency after each visit. A review of Resident #30’s electronic medical record showed that the last updated hospice care service document was dated 02/18/2026, and the DON admitted that hospice staff saw the resident at least weekly and verbally communicated with facility nursing staff during visits, but documentation was not always available in the resident’s medical record after each visit. The hospice agency contract stated that the hospice agency was required to update the resident’s comprehensive assessment and evaluate progress and response to care no less than every 15 days.
Failure to Protect Residents from Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving staff and residents. In one case, a Geriatric Nursing Assistant (GNA) physically assaulted a resident by choking and punching them, which was witnessed by other staff members. Despite the severity of the incident, the abuse was not reported immediately, allowing the GNA to continue working for an additional 12 hours before being suspended. The facility also failed to ensure that all staff had the required abuse training, particularly agency staff, and did not conduct a Root Cause Analysis or involve the Quality Assessment Performance Improvement (QAPI) committee in addressing the incident. In another incident, a resident alleged that they were slapped by a staff member after a verbal altercation. The facility's investigation was inadequate, as it did not include statements from all staff who worked during the time of the alleged incident, and the police were not notified. Additionally, a staff member failed to report an allegation of abuse immediately, and the facility did not act on this information when it was brought to their attention. A third incident involved a resident alleging verbal and mental abuse by a GNA, who was not suspended during the investigation. The facility's administration dismissed the allegations without conducting a thorough investigation, relying on assumptions rather than interviewing the resident or staff. This lack of immediate action and failure to follow proper procedures contributed to the facility's inability to protect residents from abuse and neglect.
Removal Plan
- Resident #45 was interviewed by the social worker regarding his/her abuse claim. The facility reported the incident to the state. A 5-day investigation was completed and submitted. The conclusion was that alleged abuse could not be substantiated. GNA #1 was removed from resident #45's care. All residents in GNA #1's group were interviewed by the social worker with no concerns identified.
- All other residents in WillowBrooke Court will be interviewed by nursing and the social worker to ensure there is no suspected abuse or neglect.
- Training on Abuse, Neglect, Reporting & Investigation was conducted by the Regional Clinical Director to the Director of Nursing (DON) & Assistant Director of Nursing (ADON). All team members currently working were educated on Abuse & Neglect Policy and protocol focusing on report abuse as soon as possible, obtaining witness statements, suspension pending investigation, Acts policy and state regulations on Abuse & Neglect, & who the abuse coordinator of the community is by nursing management (DON/ADON). The rest of the team members working in WillowBrooke Court will complete training by nursing management (DON/ADON). For those team members not on the schedule to work the training will be conducted by the DON and ADON by phone.
- The management team (NHA, DON, & ADON) will round twice a week to randomly interview 5% of the current residents on different shifts and different times regarding the quality of their care and monitor team members' interaction with residents. Any issues identified will be corrected immediately. Any concern from the resident will be reported per regulation requirement. Any alleged team member will be suspended immediately pending investigation.
- Random interviews by the NHA, DON, & ADON will be audited until 100% compliance is achieved and findings will be discussed in monthly QAPI.
Failure to Conduct Root Cause Analysis for Resident Falls
Penalty
Summary
The facility failed to conduct a root cause analysis and thorough investigation for a resident who experienced multiple falls, one of which resulted in a left hip fracture requiring surgery. The resident, diagnosed with Alzheimer's Dementia, had severe cognitive impairment and was identified as a high fall risk. Despite this, the facility did not implement new interventions to prevent further falls between September 2023 and July 2024, even after the resident experienced 11 falls. The resident's care plan identified them as a fall risk due to deconditioning, gait/balance problems, incontinence, and unawareness of safety needs. However, the interventions listed in the care plan were not updated with new strategies to address the ongoing fall risk. The facility's Fall Reduction and Management Policy aimed to identify and mitigate fall risks, but the lack of new interventions and failure to complete the Root Cause of Fall section in the Fall Incident Reports indicated a gap in adherence to this policy. The Director of Nursing confirmed that the Fall Intervention Form only included monitoring as an intervention and acknowledged that the Root Cause of Fall section was not completed. This oversight potentially limited the facility's ability to develop effective fall prevention strategies, as no new interventions were identified or implemented following the resident's falls.
Failure to Conduct Regular Performance Reviews for GNAs
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received a performance review at least once every 12 months, which has the potential to affect all residents. This deficiency was identified during a review of staff records and interviews with facility staff. Specifically, the employee file of one GNA was reviewed, revealing no performance reviews since 2011. The Director of Nursing (DON), who joined the facility in 2020, admitted to not conducting evaluations for GNAs, only for the Assistant Director of Nursing (ADON). The lack of performance reviews prevents the facility from providing regular in-service education based on these evaluations.
Failure to Monitor and Document Meal Temperatures
Penalty
Summary
The facility failed to ensure that meal temperatures were consistently taken and documented before each meal was served, which is a critical step in maintaining food safety standards. The Dietary Manager (DM) reviewed the food temperature logs and found that from January 1 to January 9, temperatures were not documented for all three meals or all hot food items prepared for each meal. The DM, who had been in the position for four months, admitted to not reviewing the temperature logs until the week of the survey and was unaware that staff were not temping all food items prepared for each meal. During interviews, both the DM and the Director of Nursing (DON) expressed their expectations that food should be served at the correct temperature and that staff should ensure this is done in a timely manner. The facility's policy on food temperatures, revised in January 2013, states that food temperatures should be obtained and recorded prior to meal service, and any inappropriate temperatures should be corrected. However, the lack of consistent documentation and monitoring of food temperatures indicates a failure to adhere to this policy, potentially affecting all residents consuming food from the kitchen, except for one resident who was nothing by mouth (NPO).
Inadequate Performance Improvement Project Documentation
Penalty
Summary
The Quality Assurance (QA) committee at the facility failed to conduct a comprehensive Performance Improvement Project (PIP) that included continuous improvement of processes, measured outcomes, developed and implemented action plans, and conducted a root cause analysis. This deficiency was identified through interviews and a review of facility documentation. The facility's Quality Assurance, Performance Improvement (QAPI) and Compliance Program document, dated October 2022, outlined the purpose of QAPI as a proactive, systematic, interdisciplinary, comprehensive, and data-driven approach to improve the quality of life, care, and services for residents. However, the QA committee did not adhere to these guidelines, as evidenced by the lack of thorough documentation and analysis in their PIP efforts. During an interview, the Director of Nursing (DON) revealed that each department could fill out a form to report areas of concern or improvement, and residents could report concerns through the Resident Council or to any nurse or employee. The Infection Preventionist (IP) identified an issue with increasing pressure ulcers, prompting a PIP. However, the DON admitted that the PIP consisted merely of collecting information from the IP and filling out a form, without tracking outcomes, developing and implementing action plans, conducting a root cause analysis, or measuring the success of actions. The Administrator acknowledged that while work was being done, it was not being documented properly, resulting in a lack of proof to demonstrate the facility's efforts.
Facility Fails to Investigate and Address Abuse and Injuries
Penalty
Summary
The facility administration failed to provide effective oversight to ensure resources were used effectively to meet the health and safety needs of residents. This was evidenced by the lack of a system to complete investigations related to injuries of unknown origin, failure to address abuse, and failure to ensure all staff received required training for abuse. The Director of Nursing (DON) provided incomplete investigation reports for incidents involving residents with unwitnessed falls resulting in fractures. These reports lacked essential information such as resident assessments, witness statements, and care plan updates. The DON admitted to not conducting root cause analyses for incidents and only discussing them without proper documentation. The facility did not report or investigate several incidents involving residents with falls and injuries of unknown origin. Additionally, a staff member identified in an abuse allegation was not suspended upon notification, and the facility failed to conduct thorough investigations into these incidents. The DON and Nursing Home Administrator (NHA) were unable to identify who was responsible for the final review of investigations prior to submission. An abuse allegation against a GNA was not handled appropriately, as the alleged perpetrator was not suspended and continued working on the same unit. The facility also failed to notify the police of a previous abuse allegation and did not expand the investigation to include all potential witnesses. Furthermore, an LPN witnessed an abuse incident but did not report it immediately, and the facility could not verify the required abuse training for this agency staff member.
Failure to Ensure Abuse Training for Agency Staff
Penalty
Summary
The facility failed to ensure that all nursing staff received training on abuse, including procedures for reporting incidents of abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified during the review of a facility-reported incident involving a resident who was physically abused by a Geriatric Nursing Assistant (GNA). The incident was witnessed by an LPN, who did not report it until nearly 19 hours later, allowing the GNA to continue providing care to residents during that time. The Director of Nursing confirmed that the LPN, who was an agency staff member, had not received the required abuse training from the facility, as the facility relied on the agency to provide necessary documentation, excluding abuse training verification.
Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility administration failed to report several incidents of alleged abuse, neglect, or injuries of unknown origin to the Office of Health Care Quality (OHCQ) within the required timeframe. This deficiency was evident in multiple cases, including a resident with Alzheimer's and osteoporosis who experienced an unwitnessed fall resulting in a fracture, which was reported to the OHCQ approximately 10 hours after the incident. Another resident with breast cancer, dysphagia, and dementia had multiple documented injuries of unknown origin that were not reported to the OHCQ, including bruises and an unwitnessed fall. In another case, a resident with dementia and Parkinson's disease was found on the floor with a fracture, but the incident was not reported to the OHCQ. Additionally, an allegation of abuse involving a resident being slapped by an employee was not reported to local law enforcement, and the facility's investigation revealed that staff failed to report the incident immediately. Furthermore, a resident reported being physically abused by a Geriatric Nursing Assistant, but the incident was not reported to the OHCQ or local law enforcement in a timely manner. The facility's policy requires immediate reporting of suspected abuse, neglect, or crimes to the appropriate authorities, but this was not adhered to in several instances. The Director of Nursing and the Administrator were aware of the allegations but failed to report them to the state agency or conduct thorough investigations. In one case, the Administrator concluded there was no validity to an allegation without interviewing the resident or staff involved. These failures to report and investigate incidents in a timely manner highlight significant deficiencies in the facility's handling of abuse and neglect allegations.
Inadequate Investigations and Resident Protection Failures
Penalty
Summary
The facility staff failed to thoroughly investigate allegations of abuse and injuries of unknown origin, and failed to protect residents from further abuse. This was evident in several cases, including Resident #902, who experienced an unwitnessed fall resulting in a nondisplaced elbow fracture. The investigation into this incident was inadequate, as it only included an interview with the GNA assigned to the resident and lacked new interventions to prevent future falls. Resident #903 also suffered from an unwitnessed fall, resulting in a hip fracture. The investigation was limited to interviews with the nurse and GNA caring for the resident, and there was no documentation of corrective actions regarding a faulty bed alarm that may have contributed to the fall. Similarly, Resident #904 experienced multiple unwitnessed falls, with one resulting in a subdural hematoma and facial fractures. The investigation did not include interviews with staff or residents, and assumptions were made about the cause of the falls without thorough investigation. In another case, Resident #901 reported being slapped by an employee, but the facility's investigation was insufficient, as it did not expand to include all potential witnesses. Additionally, GNA#7 was not immediately removed from duty after being accused of physically abusing Resident #905, and the facility failed to conduct a comprehensive investigation into the incident. Furthermore, the facility did not adequately investigate an injury of unknown origin for R24, and R45's allegations of verbal abuse by a GNA were dismissed without proper investigation or reporting to the state.
Failure to Administer and Document Pain Management
Penalty
Summary
The facility failed to administer and document pain medication for residents with reported pain, as evidenced by the cases of two residents. Resident #903, who had severe cognitive impairment and was diagnosed with unspecified dementia and abnormalities of gait, was found on the bathroom floor with complaints of left hip pain. Although nursing staff documented that Tylenol was administered for the pain, the medication administration record (MAR) did not reflect this, despite the resident's pain being documented as a '6' prior to hospital transfer. Similarly, Resident #902, also diagnosed with unspecified dementia and abnormalities of gait, was found with a swollen arm and pain after a fall. Although the MAR indicated that Tylenol was administered initially, no further doses were recorded despite ongoing complaints of pain and a physician's order for medication every six hours as needed. Additionally, on a separate occasion, Resident #902 complained of leg pain and had a bruise, but no pain medication was documented as administered until several hours later. These deficiencies were discussed with the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA).
Failure to Document Abuse Allegation and Assessment
Penalty
Summary
The facility staff failed to maintain complete and accurate medical records for a resident involved in an abuse allegation. The incident involved a resident who reported to their daughter that an employee had physically assaulted them after being called a derogatory name. The Director of Nursing (DON) reported the incident to the state agency and initiated an investigation. However, a review of the resident's medical records revealed that there was no documentation of the abuse allegation, no assessment specific to the allegation, and no record of any evidence of injury, the resident's mental status, physician notification, or measures implemented in response to the incident. This lack of documentation was evident despite the presence of 17 nursing progress notes within the relevant timeframe, none of which addressed the abuse allegation or related assessments.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders for a resident's medication were followed, specifically regarding the removal of lidocaine patches. The resident, who was cognitively intact and had a history of a left femur fracture and neuropathy, was prescribed two lidocaine patches to be applied in the morning and removed at bedtime. However, during an observation, it was found that the patches had not been removed as per the physician's orders, despite documentation indicating otherwise. The incident involved a registered nurse who documented the removal of the patches without actually performing the task. This was confirmed during interviews with the nurse and the Director of Nursing, who acknowledged the discrepancy between the documentation and the actual practice. The facility's policy on medication administration and management, which requires accurate documentation of medication administration, was not adhered to in this instance.
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Illustrative
What surveyors actually found near you
We read the 124 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
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Nursing homes near Easton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pines Nursing And Rehab | 0.3 mi | — | 13 | 0 |
| Mallard Bay Nursing And Rehab | 13 mi | ★★★★★ | 30 | 0 |
| Autumn Lake Healthcare At Chesapeake Woods | 13 mi | ★★★★★ | 26 | 1 |
| Caroline Nursing And Rehab | 15.4 mi | ★★★★★ | 5 | 0 |
| Denton Nursing And Rehab | 16.7 mi | ★★★★★ | 29 | 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 October 2026) and official state health department websites.