Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodlawn Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to protect confidential health information when a med cart was left unattended with an open laptop displaying a resident's eMAR, including name, photo, DOB, vital signs, and medication orders, along with a face-up paper listing several residents' names and medications. On the same unit, a clipboard was left face-up on the nurse's station counter with no staff present, showing multiple residents' names, room numbers, meal intakes, bathing information, and vital signs, leaving this PHI visible and accessible to residents and visitors.
Staff failed to promptly clean a spilled liquid on the floor in an ambulatory, legally blind resident’s room after being notified, leaving the resident to transfer and ambulate with a walker in the presence of the spill. In addition, a metal threshold plate at a main entrance used by residents was not properly secured, with loose edges and gaps causing it to shift under weight, following a complaint that the broken threshold impeded wheelchair exit.
Surveyors found an unattended med cart on a unit with a med cup containing red liquid (identified by a CNA-M as Robitussin prepared for a resident) and a cup holding used crushing sleeves with med residue on top of the cart, while a resident was nearby in the hallway. The CNA-M stated she had left the cart and acknowledged she should have secured the medication in a locked drawer. This situation did not follow the facility’s policy requiring all meds and biologicals to be stored in locked compartments and prohibiting unattended med carts when meds are potentially accessible.
A resident who was cognitively intact went approximately two weeks without a bowel movement despite the facility having standing bowel management orders and a bowel protocol that should begin after three days without a BM. Documentation showed the resident had escalating pain over multiple shifts, and staff interviews confirmed that the protocol called for progressive use of prune juice, Senna, Milk of Magnesia, suppositories, and Fleet enemas as needed. In this case, only limited interventions were documented over a prolonged period, the resident repeatedly reported pain and discomfort to staff, and when a suppository was finally given it was ineffective. The resident developed hypoactive bowel sounds and a firm, tender abdomen and had to be transferred to the ER, where constipation was resolved with an enema. The DON and administrator confirmed that the resident’s constipation was not appropriately managed according to the facility’s bowel protocol.
A resident returned from an ER visit for constipation with an order to have a follow-up sodium level drawn on a specific date after a moderately low sodium result. The facility did not obtain the ordered lab on that date, and there was no documentation in the clinical record of a reported subsequent conversation between the DON and the provider to reschedule the lab to the facility’s routine lab day. The DON acknowledged she could have drawn the lab herself but did not. The sodium level was not checked until several days later, when it was found to be critically low, leading to another ER transfer.
Surveyors found that emergency respiratory equipment, including an Ambu bag, resuscitation mask, and oxygen tubing, was stored in poor condition, with items being dirty, discolored, expired, or overdue for inspection. The DON confirmed that night shift staff were responsible for maintaining the emergency cart and acknowledged the deficiencies.
Laundry washers were not maintained in safe operating condition. Surveyors observed missing keypad buttons on both washer control panels and a leak from the left washer, with a bucket placed underneath and a wire hanging into it. The Laundry/Housekeeping supervisor said the control panels had been broken for months and the leak had been ongoing for months, and the Maintenance Director stated the washers had been in that condition for four or five months with no documented PM program.
Failure to inspect bed frames, mattresses, and bed rails for entrapment hazards was identified for all 37 beds. Surveyors observed exposed bedframe openings and gaps between mattresses and footboards in multiple resident rooms, including one resident sleeping in bed and another being assisted in bed. An LPN confirmed the mattress was offset from the bedframe, and the Maintenance Director stated he had never done bed assessments and did not know how to assess mattresses or bed frames.
Surveyors found that a resident's room contained multiple electrical cords and cables crossing the floor, creating trip hazards due to insufficient electrical outlets for necessary appliances. Additionally, both the East and West units and the main lobby had issues such as dirty floors, damaged surfaces, and unclean equipment, all confirmed by the Maintenance Director.
Surveyors identified multiple deficiencies in food storage and sanitation, including expired thickened water available for use, improper labeling and dating of food items, chemical hoses hanging in the pot sink, and improper storage of bread products in the freezer. These issues were confirmed by the Food Service Director and DON.
The facility failed to keep several residents’ care plans current with their actual needs. A resident had missing meal intake documentation, another had hearing aids listed in the care plan but no evidence of use, a resident with a missing dental filling had pain and bleeding but no care plan measures, an active smoker had no smoking goals or interventions, and another resident’s care plan still referenced power chair use even though the DON said it was no longer used.
Medication Storage and Labeling Deficiencies: Surveyors found expired meds and improperly labeled insulin available for use in medication storage areas. In one area, insulin products were kept in an unlocked cabinet in an unsecured location, and several open insulin vials and pens had conflicting or missing open dates. An LPN confirmed insulin should be discarded 28 days after opening, but one vial was undated and could not be timed for expiration.
Laundry Room Equipment and Flooring Hazards: Surveyors observed a heavily soiled laundry room with cracked and broken floor tiles, exposed cement flooring, missing washer control panel buttons, a leaking washer, and a frayed power supply wire with exposed internal wires. The Laundry/Housekeeping supervisor and Maintenance Director confirmed the washers had been broken for months and that staff used their fingers or a wooden rod to operate the machines through the damaged control panels.
Failure to obtain representative consent for bed rail use. A resident with severe cognitive impairment had an advance directive naming a medical decision-maker, but the record showed side rail consent was obtained from the resident rather than the representative. The DON stated the resident's son/daughter was responsible for the resident, and the chart lacked evidence that the representative received education on the risks of side rail use or gave informed consent.
A resident's care plan was not reviewed and revised by the IDT with resident and/or representative participation after a Quarterly MDS assessment. The clinical record lacked evidence of any care plan meeting after the assessment, and the Social Services Director confirmed the absence of documentation.
A resident’s advance directive/code status was documented inconsistently in the chart, with the electronic record showing DNR/DNI while a POLST in both the electronic and paper chart indicated Attempt Resuscitation/CPR. During review with the DON, the conflicting information was confirmed.
A resident’s IDT care plan meeting was not held within 7 days of MDS completion and was instead held 17 days late. The SSD stated the meeting had been scheduled earlier but was rescheduled because the family could not make it, and she also confirmed she had not been offering residents or families copies of the care plan after IDT meetings.
Failure to ensure a resident’s hearing aids were in use. Observations showed no evidence of hearing aid use over multiple days, even though the care plan directed staff to place them appropriately and the admission inventory documented both left and right hearing aids. The resident said the aids were in a box in the room, batteries had been mailed, and help was needed to put them in. An LPN and two CNAs were unaware the resident had hearing aids, and the DON confirmed they should be used.
A resident’s oxygen equipment was observed with tubing changes and humidification added, but the concentrator filter remained heavily soiled with dust and debris. An LPN stated the filter should be washed with tubing changes, yet the surveyor confirmed it had not been cleaned and was still dirty.
Unsanitary garbage storage area: two surveyors observed two of three large trash receptacles outside by a dumpster with swing lids open and exposed trash hanging out during an initial kitchen tour. The FSD confirmed the finding during interview.
Incomplete Nutrition Documentation in Clinical Record: A resident with paraplegia, CKD, and DM had a care plan directing staff to monitor and document intake and output per facility policy, but the nutrition record lacked documented amounts eaten for multiple breakfast, lunch, and dinner meals. The missing entries were reviewed with the DON during an interview.
The facility did not ensure sufficient direct care staff were scheduled and on duty to meet resident needs, particularly on weekends. A review of the Payroll Based Journal staffing report revealed low weekend staffing during the second quarter of 2024. The Administrator confirmed the lack of adequate staffing, potentially affecting all residents needing assistance with ADLs.
A facility failed to monitor and document behaviors to support the use of psychotropic medications for a resident with depression. The resident was prescribed Escitalopram oxalate, but there was no evidence of monitoring for side effects. A nurse confirmed the lack of monitoring, and the DON stated that documentation is only done by exception.
The facility failed to maintain an effective infection control program, as evidenced by a COVID-19 positive resident moving unmasked through the facility and the absence of Enhanced Barrier Precautions (EBP) for residents with MDRO and Foley catheters. The LPN responsible for infection prevention was unaware of tracking procedures, and necessary signage and PPE were missing until noted by surveyors.
The facility did not effectively implement its Antibiotic Stewardship Program, as evidenced by an increase in antibiotic prescriptions and a lack of monitoring and discussion in QAPI meetings. The LPN responsible for infection prevention was not fully trained and did not track infections or manage antibiotic orders. The QIM could not provide evidence of antibiotic stewardship practices, and the Administrator confirmed the absence of such discussions in QAPI meetings.
The facility appointed an LPN as the Infection Preventionist in October 2023 without ensuring the completion of necessary specialized training. The LPN began the IP training course in February 2024 and was only halfway through it at the time of the survey, with no prior training or guidance provided. This was confirmed by the Senior DON and the Regional Quality Improvement Manager.
The facility failed to provide two residents with written information about their rights to accept or refuse treatment and to formulate an advance directive upon admission. A Social Worker confirmed that advance directive information was not offered to these residents, highlighting a lapse in the facility's admission process.
A resident with dementia was found with a bruise of unknown origin, which was not investigated or reported to the state agency in a timely manner. The injury was initially noted as a small spot and later developed into a larger bruise. A nurse assumed the incident had been reported by others and did not inform the DON, leading to a delay in reporting to the DLC.
A facility failed to update a care plan for a resident diagnosed with COVID-19, resulting in the resident leaving their room unmasked and passing others in the hallway. A CNA reported a lack of guidance on handling the resident's noncompliance with isolation precautions. The care plan lacked goals and interventions for managing the infection and noncompliance, contrary to the expectations of the Senior DON.
The facility failed to update care plans for a resident who tested positive for COVID-19, as there were no precaution signs or PPE outside the room, and the care plan was not updated after the resident was off precautions. Additionally, another resident's care plan lacked goals and interventions for a cardiac pacemaker, as the necessary details were not on file.
A resident received incorrect insulin doses due to the facility's failure to follow physician's orders. Insulin was administered despite blood sugar levels being below the threshold, and variable doses were not adjusted according to blood sugar readings, leading to multiple discrepancies.
A facility failed to administer tube feedings according to provider orders for a resident with cognitive impairment and a diagnosis of failure to thrive. The resident's nutritional supplement was not administered continuously as ordered, and the feeding bag was unlabeled and undated. A nurse confirmed the resident did not receive the full nutritional support.
A facility failed to maintain a sanitary environment for respiratory care for a resident with COPD and COVID-19. Observations revealed an oxygen concentrator and nebulizer with tubing not properly bagged or dated, despite not being used since mid-July. The facility administrator was unaware of the equipment's presence, highlighting a deficiency in maintaining a sanitary environment.
The facility did not post nurse staffing information in a prominent and visible location for residents and visitors. This was confirmed by the Administrator during an interview.
The facility failed to ensure a CNA received the required 12 hours of annual in-service education, specifically lacking training on abuse and resident rights. This was confirmed during a review of the CNA's education records and an interview with the Administrator.
A facility failed to ensure a resident's safety during a Hoyer lift transfer, leading to a fall and head injury. A CNA transferred the resident alone, against the policy requiring two CNAs, resulting in the resident slipping and hitting their head.
Failure to Protect Confidential Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' protected health information on the West Unit when staff left electronic and written records unattended and visible. A surveyor observed an unattended medication cart outside a resident room with an open laptop displaying the electronic Medication Administration Record (eMAR) for Resident #4, including the resident's name, photograph, date of birth, vital signs, and medication orders. A white sheet of paper on top of the same cart, left face-up, listed three residents' names along with a medication name and strength under each name. The cart and information were unattended until a CNA-M returned, at which time she acknowledged she should have closed the laptop and turned the resident information sheet upside down before leaving the cart. On the same unit, a surveyor later observed a clipboard left face-up on the nurse's station countertop with no staff nearby. The assignment sheet on the clipboard contained the names of 17 residents, their room numbers, meal intakes, and bathing information. A smaller attached sheet listed the names and vital signs of two residents. This information remained visible and accessible to residents and visitors. During interviews, the DON acknowledged the observations and stated that she had previously educated nursing staff not to leave the clipboard on the countertop.
Failure to Maintain Safe Resident Environment and Secure Entrance Threshold
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards when staff did not promptly clean a liquid spill in an ambulatory resident’s room. A resident with recent admission diagnoses including legal blindness and syncope and collapse reported spilling coffee on the floor next to the bed and stated that a staff member had been notified and said she would return to clean it up but had not done so. During an initial observation, the resident was lying in bed with liquid visible on the floor. A subsequent observation showed the resident had transferred independently and ambulated with a walker from the bed to a chair positioned next to the bed while the coffee spill remained on the floor. The facility also failed to ensure that a metal threshold plate at the main front entrance used by residents was properly secured, resulting in a tripping hazard. A complaint had been received stating that the threshold at the first entrance was broken and that a client could not exit with a wheelchair in an emergency situation. Upon observation with the Maintenance Director, the metal transition plate at the entrance threshold had outer edges that were not properly secured, creating gaps between the plate and the floor or ground and causing the plate to shift when weight was applied. The Maintenance Director confirmed that residents use this entrance to exit and enter the building with family or staff.
Unattended Medication Cart With Accessible Medications on Resident Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were stored properly and in accordance with its own Medication Labeling and Storage policy on the West unit. On 2/25/26 at 9:43 a.m., a surveyor observed an unattended medication cart located outside a resident room on the named unit. On top of the cart, there was a medication cup containing an unknown red liquid and a clear plastic cup containing plastic sleeves used for crushing medications, with visible medication residue inside the sleeves. The medication cart was unattended during this time. During the observation, Resident #3 was seen foot-propelling in his/her wheelchair in the hallway near the unattended medication cart. At 9:50 a.m., CNA-M #1 returned to the cart and, during an interview, stated that the plastic sleeves were trash containing residue from medications she had crushed for a resident and that the red liquid in the medication cup was Robitussin she had poured for a resident. CNA-M #1 acknowledged she should have placed the medication in a locked drawer before leaving the cart unattended. The facility’s written policy, revised 3/2025, requires all medications and biologicals to be stored in locked compartments and specifies that carts used to transport medications are not to be left unattended if open or otherwise potentially available to others.
Failure to Follow Bowel Management Protocol Leading to Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow its standing bowel management orders for a cognitively intact resident, resulting in unmanaged constipation over an extended period. The facility’s standing orders and bowel protocol allowed nursing staff to administer multiple PRN bowel medications, including Bisacodyl suppositories, MiraLAX, Senna, Milk of Magnesia, and Fleet enemas, beginning after three days without a bowel movement and progressing from least to more invasive interventions. Record review showed the resident had a bowel movement on 1/9/26, then went seven days without a bowel movement before receiving Senna on 1/16/26, and ultimately went 15 days without a bowel movement before a Bisacodyl suppository was given on 1/24/26. The suppository was documented as ineffective, and nursing notes on 1/24/26 described hypoactive bowel sounds and a firm, tender abdomen, at which point an order was obtained to transfer the resident to the ER. The resident reported remembering going two weeks without a bowel movement and experiencing severe pain, stating they had informed multiple staff members of their pain and discomfort. Review of the medication and treatment administration records for the period 1/10/26 through 1/24/26 showed documented pain on multiple shifts, with two occurrences on day shift and six on evening shift under pain monitoring. Interviews with an LPN, a medication tech, the DON, and the administrator confirmed that the facility’s bowel protocol was to start after three days without a bowel movement and to escalate from prune juice to Senna, Milk of Magnesia, suppository, and then Fleet enema as needed. The DON and administrator acknowledged that the resident’s constipation was not appropriately managed according to this protocol, and the resident ultimately required transfer to the ER, where the constipation was resolved with an enema before the resident returned to the facility.
Failure to Obtain Timely Sodium Lab Draw After ER Discharge
Penalty
Summary
The facility failed to obtain timely laboratory services for a resident who required follow-up sodium testing after an emergency room (ER) visit for constipation. During the ER visit, the resident’s sodium level was found to be moderately low at 125, and the ER discharge summary directed that the sodium level be redrawn on 1/26/26. Review of the resident’s medical record showed no evidence that this lab draw occurred on the specified date. Instead, a nursing progress note dated 1/29/26 documented that the resident had a critical sodium level of 121, the on-call provider was notified, and the resident was transferred back to the ER. In an interview, the DON and Administrator reported that the DON spoke with the facility provider on 1/27/26 and that the sodium level was ordered to be drawn on 1/29/26, the facility’s regular lab day, but this conversation was not documented in the clinical record. The DON acknowledged that she could have drawn the lab herself when she became aware of the order but did not, and confirmed that the lab should have been drawn on 1/26/26 as directed by the ER provider. This sequence of events shows that the facility did not follow the ER provider’s order for a sodium redraw on the specified date, did not document the reported provider communication regarding rescheduling the lab, and did not take available steps to obtain the lab in a timely manner, resulting in the resident’s sodium level not being reassessed until it was critically low and necessitated another ER transfer.
Emergency Cart Respiratory Equipment Not Maintained in Clean, Ready-to-Use Condition
Penalty
Summary
During an observation of the facility's emergency cart with the DON, several deficiencies were identified regarding the maintenance and cleanliness of emergency respiratory equipment. The adult manual resuscitator (Ambu bag) was found stored in a torn, cloudy plastic bag, with its attached reservoir bag appearing worn, discolored, and consistent with prior use. The plastic resuscitation mask and oxygen tubing were discolored, yellow, and visibly dirty. Additionally, a package of oxygen tubing was found to be expired. The suction machine on the cart was dusty, and its inspection sticker showed that the last inspection was overdue. In an interview, the DON confirmed that night shift staff were responsible for maintaining the emergency cart and acknowledged the issues with the overdue inspection and the condition of the equipment.
Laundry washers not maintained in safe operating condition
Penalty
Summary
The facility failed to ensure that the laundry room equipment was maintained according to the manufacturer’s instructions and kept in a correct and safe operating condition for 4 of 4 days of survey. The manufacturer’s instructions stated not to tamper with controls, to keep the washer in good condition, not to operate the washer with missing or broken parts, not to bypass safety devices, and to maintain the washer according to the instructions. The maintenance instructions also required weekly checks for leaks. On 7/30/25, a surveyor observed the laundry room and found that the left washing machine control panel keypad was missing 4 buttons and the right washing machine control panel keypad was missing 1 button. A bucket was placed under a leak from the left washing machine, and a wire was observed running from the washing machine, hanging down into the bucket, and then running out a wall attached to other wires. The Laundry/Housekeeping supervisor confirmed that the control panels had been broken with holes in them for many months and that the left washer had leaked for many months, with the bucket overflowing every night and flooding the laundry room floor by morning. The Maintenance Director stated that the two washers had been in their current broken state for four or five months, that there was no documented preventive maintenance program for the washers, and that the company servicing the washers said parts could not be obtained to repair them. Survey observations on 7/29/25, 7/30/25, and 7/31/25 also documented the missing keypad buttons and the leak from under the left washing machine.
Failure to Inspect Beds for Entrapment Hazards
Penalty
Summary
The facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a maintenance program to identify areas of possible entrapment for 37 of 37 beds. On 7/28/25, a surveyor observed in one resident’s room that the exposed bedframe at the head of the bed had a 4.83-inch wide by 4-inch long opening, and the foot of the bed had a 4-inch gap between the mattress and the footboard. The resident was not in bed at the time of the observation. During an interview shortly afterward, the LPN confirmed the mattress was offset from the bedframe and the exposed bedframe created the potential for entrapment of body parts, and stated the bed should have a bumper for the foot of the bed to prevent injuries. On 7/29/25, surveyors observed one resident sleeping in bed with a 5-inch space between the mattress and footboard, and later observed another resident being assisted in bed with a 5.5-inch space between the mattress and footboard, partially filled with a 2-inch mattress extender. On 7/30/25, the Maintenance Director stated he had never done bed assessments, that the facility had a Bionix System but only used it for handrails, and that he did not know how to assess bed mattresses or bed frames or whether there were specific measurements to know. Surveyors confirmed there was not a maintenance program to identify areas of possible entrapment through regular inspection of all bed frames, mattresses, and bed rails.
Unsafe Environment Due to Trip Hazards and Poor Maintenance
Penalty
Summary
Surveyors observed that the facility failed to provide a safe and comfortable environment for a resident by allowing multiple electrical cords and cables to cross the floor in the resident's room, creating trip hazards. The bed cord, television cable, bed remote cable, and power cord for the bed were all found running along the floor at the foot of the bed. The resident, who ambulates in the room, unplugged the bed to use a fan due to insufficient electrical outlets for their appliances, which included a nebulizer, cell phone charger, oxygen concentrator, and fan. The LPN and Maintenance Director confirmed the lack of outlets and the presence of trip hazards, with the Maintenance Director stating that management declined to install additional outlets. During an environmental tour, surveyors found further deficiencies in housekeeping and maintenance on both the East and West units and in the main lobby. Observations included dirty floors around toilets, cracked and stained ceilings, chipped and gouged wooden windowsills and lobby walls with missing sealant exposing untreated wood, a sit-to-stand lift with dirt and food debris, a ceiling vent in disrepair, and a door with torn laminate creating an uncleanable surface. The Maintenance Director confirmed these findings during the tour.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies related to food storage and sanitation during two tours of the facility's kitchen and food service areas. On the first tour, a maintenance worker was seen in the kitchen without appropriate hair or face protection. The three-bay pot sink had two chemical hoses hanging into the sinks, and in the dry storage room, two containers of thickened water were found with best use dates that had already passed. In the walk-in refrigerator, a package of whipped topping was present without a thaw date, despite manufacturer instructions requiring use within two weeks of thawing. Additionally, in the walk-in freezer, a large open box of hamburger buns was stored directly on the floor, and a package of bread sticks was stored under the freezer compressor with visible ice buildup. On the following day, an open container of thickened water with an expired best use date was found on a beverage cart in a hallway, available for use. These findings were confirmed by the Food Service Director and the DON during interviews. The facility's own Food Storage policy required all foods to be covered, labeled, dated, and monitored for use by their expiration dates, which was not followed in these instances.
Failure to Update Comprehensive Care Plans for Nutrition, Hearing Aids, Dental Needs, Smoking, and Mobility
Penalty
Summary
The facility failed to update and implement comprehensive care plans for multiple residents based on their current needs and conditions. For one resident with nutritional monitoring needs, the care plan directed staff to monitor and document intake and output, but the nutrition record lacked documented meal intake for multiple breakfasts, lunches, and dinners in July 2025. The Director of Nursing was interviewed about the missing documentation. For another resident, the care plan stated that hearing aids should be placed appropriately, but observations on three consecutive days lacked evidence of hearing aid use, and the DON confirmed the resident had hearing aids that should be used. The facility also failed to address a resident’s dental issue in the care plan after a provider note stated the resident had lost a filling in the right lower molar and needed a dental referral. The resident reported tooth pain when eating and brushing, along with bleeding gums, but the care plan did not include measures for the missing filling while awaiting the dental appointment. In addition, a resident who was an active cigarette smoker was observed smoking outside on multiple days after admission, yet the care plan lacked goals and interventions for smoking. Another resident’s care plan continued to identify risk related to use of a power chair even though the DON stated the resident had not used one for many months and the care plan had not been updated to reflect that change.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles and stored in locked compartments, including separately locked compartments for controlled drugs. During an observation in the East Medication Storage room, surveyors and an LPN found medications available for use that included an open box of acetaminophen suppositories with an expiration date of 12/2024, a tube of Vagicaine Anti-itch Cream with an expiration date of 6/30/24, and a box of Miconazole Vaginal Antifungal 7 day treatment with an expiration date of 5/24/25. Also observed was a pre-filled insulin pen labeled Lantus Solostar with conflicting open dates, with one date on the cap and a different date on the pen base; the LPN stated insulin should be discarded 28 days after opening. Surveyors also found insulin medications, including vials, quick pens, needles, and lancets, stored in an unlocked cabinet in an unsecured area behind the East Wing nurse station. In the East Wing Medication Storage area, surveyors observed an open vial of insulin lispro with an open date of 6/24/25 and a tube of Halobetasol Propionate cream 0.05% with an expiration date of 4/2025. In addition, two open vials of insulin aspart and three open vials of insulin glargine were found in the East Medication Storage room, including vials that were dated and one that was open but undated, and the LPN was unable to determine when the undated vial had been opened or when it would expire.
Laundry Room Equipment and Flooring Hazards
Penalty
Summary
The facility's laundry room and equipment were observed to have multiple safety hazards affecting staff. Surveyors found the tiled floor heavily soiled with dirt, approximately 16 cracked, broken, and loose floor tiles, and exposed untreated cement flooring in front of, beside, and behind the two washing machines. The control panel on the left washing machine was missing 4 buttons, and the control panel on the right washing machine was missing 1 button. A bucket was placed under a leak from the left washing machine, and a wire from the machine was hanging down into the bucket and running out a wall attached to other wires. The power supply wire for the equipment was observed with a broken protective sheath and exposed internal wires at the point of connection to the wall. The surrounding area was heavily soiled with dryer lint. The Laundry/Housekeeping supervisor confirmed that the control panels had been broken for many months and that the left washer had leaked for many months. She stated that staff used their fingers or a wooden dowel to reach into the control panel holes to activate the washing machines and demonstrated this to the surveyor. She also stated that the bucket under the leak overflowed every night and flooded the laundry room floor by morning, requiring staff to mop water from the area in front of the washing machines. The Maintenance Director stated that the washers had been in their current broken state for 4 or 5 months and confirmed that staff used their fingers or a wooden rod to access the computer board behind the broken control panel to operate the machines, acknowledging that this was not safe.
Failure to Obtain Representative Consent for Bed Rail Use
Penalty
Summary
The facility failed to provide education and/or obtain informed consent from a resident's representative regarding the use of bed rails for one resident reviewed for accidents. The resident had an advanced directive identifying a representative to make medical decisions on his/her behalf and had a BIMS score of 5, indicating severe cognitive impairment. The clinical record showed that informed consent regarding side rail usage was provided for the resident to sign, stating that the resident had considered the risks of side rail use and consented to rails, but the record lacked evidence that education was provided to the resident's representative or that informed consent was obtained from the representative. During interview, the DON stated the resident's son/daughter was responsible for the resident and that the bed rail consent should have been completed with the resident representative; the surveyor confirmed the record lacked evidence of representative education and informed consent.
Failure to Hold Care Plan Meeting After Quarterly Assessment
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team that included the resident and, to the extent possible, the resident's representative after a Quarterly MDS assessment for one resident. Resident #2 was admitted in 2021, and the latest Quarterly MDS assessment was completed on 5/16/25. A review of the clinical record found no evidence that a care plan meeting was held by the IDT at any point as of 7/31/25 to review the care plan with the resident and/or the resident's representative. On 7/31/25 at 9:15 a.m., the Social Services Director confirmed that the clinical record lacked evidence of a care plan meeting after the last Quarterly assessment was completed.
Conflicting Code Status Documentation
Penalty
Summary
The facility failed to ensure that Resident #24’s right to formulate an advance directive regarding code status was accurately reflected in the resident’s electronic clinical record. On review of the medical record, the electronic record showed a code status of DNR/DNI, while both the electronic record and the paper chart also contained a POLST dated [DATE] indicating a code status of Attempt Resuscitation/CPR. During an interview with a surveyor and the DON on [DATE] at 8:50 a.m., the medical record was reviewed for the resident’s advance directive regarding code status, and the conflicting information was confirmed.
Late IDT Care Plan Meeting
Penalty
Summary
The facility failed to ensure an Interdisciplinary Care Plan Meeting (IDT) was held within 7 days after completion of the Minimum Data Set (MDS) for Resident R17. Review of the clinical record showed an MDS dated [DATE], and the IDT meeting was not held until 7/28/25, which was 17 days late. During an interview on 7/29/25, the Social Services Director stated she is supposed to schedule IDT meetings within 7 days of MDS completion and confirmed R17’s meeting had been held the day before. She stated she had originally scheduled the meeting for 7/24/25 but believed the family could not make it, so it was rescheduled to 7/29/25, and confirmed the original meeting date would not have been within 7 days of MDS completion. She also confirmed she had not been offering residents or families copies of the care plan after each IDT meeting.
Failure to Ensure Hearing Aids Were Used
Penalty
Summary
The facility failed to ensure hearing aids were in use for one resident reviewed for communication. Observations of the resident on 7/28/25, 7/29/25, and 7/30/25 showed no evidence of hearing aid use. The resident’s care plan, updated 7/17/25, directed staff to ensure hearing aids were placed appropriately, and the new admission personal item inventory dated 10/13/24 documented admission with both left and right hearing aids. During interviews, an LPN and two CNAs stated they were unaware the resident had hearing aids. The resident stated the hearing aids were in a box in the room, that batteries had been mailed by the resident’s sister, and that the resident could not get them in and was waiting for help. The resident also stated hearing was difficult during activities and the Activity Director had to repeat what was being said. The DON later confirmed the resident wore hearing aids and they should be used.
Soiled Oxygen Concentrator Filter and Tubing
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for Resident #24, whose oxygen tubing was observed connected to an oxygen concentrator with the tubing labeled 7/28/25. The concentrator filter was observed to be heavily soiled with dust and debris. The next day, during an interview with two surveyors and an LPN, the resident’s oxygen concentrator was observed with new tubing related to the addition of humidification dated 7/29/25, while the nasal cannula tubing remained dated 7/28/25. The concentrator filter was again observed to be heavily soiled with dust and debris, and the LPN stated the filter should be washed with tubing changes. The surveyor confirmed the filter had not been cleaned with the tubing change and remained heavily soiled.
Unsanitary Garbage Storage Area
Penalty
Summary
The facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests. During an initial kitchen tour, two surveyors observed two of three approximately 30 to 40 gallon trash receptacles outside by a dumpster with swing lids open and exposed trash hanging out. The Food Service Director later confirmed the findings during interview.
Incomplete Nutrition Documentation in Clinical Record
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for 1 of 1 records reviewed, Resident #1, who had diagnoses including paraplegia, chronic kidney disease (CKD), and diabetes mellitus (DM). The resident’s care plan, updated 7/10/25, directed staff to monitor and document intake and output according to facility policy. Review of the resident’s nutrition records showed missing documentation of amount eaten for multiple meals, including breakfast on 7/1/25, 7/6/25, 7/19/25, 7/20/25, 7/22/25, 7/23/25, 7/24/25, and 7/30/25; lunch on 7/1/25, 7/3/25, 7/6/25, 7/9/25, 7/14/25, 7/17/25, and 7/23/25; and dinner on 7/11/25, 7/13/25, 7/27/25, and 7/30/25. During an interview on 7/30/25 at 4:15 p.m., this was discussed with the DON.
Insufficient Weekend Staffing
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was identified through a review of the Payroll Based Journal staffing report, which revealed low weekend staffing during the second quarter of 2024. On August 28, 2024, at 6:15 p.m., the facility's Administrator confirmed the lack of adequate staffing to meet resident needs on weekends, which has the potential to affect all residents requiring assistance with Activities of Daily Living (ADLs).
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor and document targeted behaviors to support the use of psychotropic medications for a resident diagnosed with depression. The resident was prescribed Escitalopram oxalate 10 mg daily for depressed mood, starting on March 12, 2024. However, the clinical record lacked evidence of monitoring for side effects of this medication. During interviews, a registered nurse confirmed that the facility does not monitor for side effects of psychotropic medication, and the Senior Director of Nursing indicated that documentation for side effects is only done by exception in nursing notes.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. The first deficiency involved the management of a COVID-19 outbreak, where a resident who tested positive for COVID-19 was observed unmasked and moving through the facility, potentially exposing other residents. The Certified Nursing Assistant (CNA) did not offer the resident a mask, and the Licensed Practical Nurse (LPN) responsible for infection prevention was unaware of how to track or trace the source of the infection. Despite acknowledging the need for improvement, the Quality Improvement Manager downplayed the issue by stating the facility had a low infection rate. The second deficiency was related to the lack of Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDRO) and those with Foley catheters. Over two days, surveyors noted the absence of signage and personal protective equipment (PPE) for residents requiring EBP. Documentation regarding the use of EBP was also missing. It was only after the surveyor's observation that EBP signage and PPE were placed outside the rooms of the affected residents, confirming the facility's failure to implement necessary precautions for infection control.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) effectively, which includes protocols for antibiotic use and a system to monitor such use. During the months of April to July 2024, there was a noticeable increase in the number of antibiotics prescribed, yet the facility's RX Quality Pharmacy Reports lacked evidence of antibiotic use or discussion. Interviews revealed that the Licensed Practical Nurse (LPN) responsible for infection prevention was not fully trained and did not know how to track infections or manage antibiotic orders. The LPN also did not receive or review quarterly antibiotic use reports from the pharmacy during Quality Assurance and Performance Improvement (QAPI) meetings. The facility's Quality Improvement Manager (QIM) claimed that McGuire's criteria for antibiotic stewardship were consistently used but could not provide supporting documentation or evidence of review during QAPI meetings. The QIM acknowledged the need for improvement in infection control but believed the facility had a low infection rate. The Administrator confirmed that the RX Quality Assurance Reports discussed in QAPI meetings did not include antibiotic stewardship, indicating a lack of focus on this critical aspect of infection control.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that their designated Infection Preventionist (IP) had completed the necessary specialized training before assuming the role. An LPN was appointed as the IP in October 2023 but did not begin the required IP training until February 2024. As of the time of the survey, the LPN was only halfway through the course and had not received any prior training or guidance on the responsibilities of the IP role. This lack of training and preparation was confirmed by both the Senior Director of Nursing Services and the Regional Quality Improvement Manager during interviews with surveyors.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written information to residents or their representatives regarding the right to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for two residents during a review of their clinical records. Resident #20 was admitted on April 18, 2023, and Resident #31 was admitted on July 24, 2024. In both cases, there was no evidence in their clinical records that they were offered or refused the opportunity to formulate an advance directive upon admission. During an interview with a surveyor, the Social Worker confirmed that she had not asked or offered advance directive information to these residents upon their admission. This oversight indicates a failure in the facility's process to ensure residents are informed of their rights regarding advance directives.
Failure to Timely Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and report an injury of unknown origin for a resident with dementia in a timely manner. The incident involved a resident who was found with a bruise on the left temple area, initially noted as a small spot and later developing into a larger bruise. The resident, due to dementia, was unable to recall how the injury occurred. The initial report to the Division of Licensing and Certification (DLC) was made four days after the incident was first noted, indicating a delay in reporting. The nursing notes indicated that the bruising was observed on the resident's face, but the origins were unknown. A registered nurse mentioned that she was informed by certified nursing assistants that the bruising had occurred days before her notes, but she did not report it, assuming it had already been reported. The Director of Nursing was not informed of the incident until the report was made to the DLC. The lack of timely investigation and reporting of the injury was confirmed by the facility's administrator during an interview with a surveyor.
Failure to Update Care Plan for COVID-19 Positive Resident
Penalty
Summary
The facility failed to update and implement a care plan for a resident diagnosed with COVID-19, leading to a deficiency. The resident, admitted on an unspecified date, tested positive for COVID-19 and required quarantine isolation precautions. However, on a subsequent observation, the resident was seen self-propelling down a unit hallway without a mask, passing other residents and a staff member. A Certified Nursing Assistant reported that the resident frequently left their room and that no guidance had been provided on managing the resident's noncompliance with isolation precautions. A review of the resident's care plan, last updated before the positive COVID-19 test, showed no goals or interventions for managing the infection or the resident's noncompliance with isolation measures. The Senior Director of Nursing expressed that care plans should have been updated to reflect these needs.
Failure to Update Care Plans for Isolation Precautions and Pacemaker Management
Penalty
Summary
The facility failed to update and implement care plans for isolation precautions for a resident who tested positive for COVID-19. The resident was admitted and placed on isolation precautions after testing positive. However, observations revealed that there were no precaution signs or personal protective equipment outside the resident's room. Interviews with staff confirmed that the resident had been off quarantine precautions for some time, yet the care plan was not updated to reflect this change. The Senior Director of Nursing acknowledged that the care plan should have been updated once the resident was no longer on precautions. Additionally, the facility did not update or implement goals and interventions for a resident with a cardiac pacemaker. The resident was admitted with a pacemaker, but the care plan lacked necessary details such as the serial number or expiration date of the pacemaker. The Minimum Data Set Coordinator confirmed that they were unaware of the need to have this information on file, as the resident sees a cardiologist regularly. This oversight resulted in the absence of a comprehensive care plan for the resident's pacemaker management.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician's orders for administering insulin to a resident, leading to multiple instances of incorrect insulin administration. The resident, who was receiving insulin coverage, had specific orders to hold insulin if blood sugar levels were below 170. However, on several occasions, the resident received insulin despite blood sugar readings being below the threshold. For example, on three separate mornings, the resident's blood sugar was below 170, yet insulin was administered contrary to the physician's instructions. Additionally, there were discrepancies in the administration of variable doses of insulin based on blood sugar levels. The resident's blood sugar readings indicated a need for specific insulin dosages, but the administered doses did not align with the physician's orders. On one occasion, the resident received no insulin when 6 units were required, and on another, the resident received fewer units than prescribed. These errors were confirmed during an interview with the Quality Improvement Manager, highlighting a failure in following the prescribed treatment plan.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer tube feedings according to provider orders for a resident who was observed for tube feeding. The resident, who was admitted with a diagnosis of failure to thrive, had a Basic Interview for Mental Status (BIMS) score indicating cognitive impairment. The resident's active orders included a specific nutritional supplement to be administered via enteral tube at a continuous rate for 16 hours, with scheduled water flushes before, during, and after feeding. However, during an observation, it was noted that the feeding machine was off, and the bag containing the nutritional supplement was unlabeled and undated. A registered nurse confirmed that the bag had been hung the previous day and that the resident did not receive the entire nutritional support as ordered.
Failure to Maintain Sanitary Respiratory Care Environment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, as observed in the case of a resident diagnosed with chronic obstructive pulmonary disease and who tested positive for COVID-19. The resident's room contained an oxygen concentrator and a nebulizer machine with tubing that was not properly bagged or dated, despite the equipment not being used since July 13, 2024. This lack of proper storage and sanitation was noted during multiple observations on August 19, 20, and 21, 2024. The resident's clinical records indicated labored breathing and the use of oxygen to maintain adequate oxygen saturation levels. However, the registered nurse confirmed that the resident had not used the oxygen or nebulizer since mid-July. The facility administrator was unaware of why the equipment remained in the room, especially since the resident's COVID-19 case was mild and did not necessitate the use of such equipment. This oversight in maintaining a sanitary environment for respiratory care was identified as a deficiency by the surveyors.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post the nurse staffing information in a prominent place that was readily accessible and visible to all residents and visitors. This deficiency was observed on one of the three days of the survey, specifically on 8/26/24. During an interview on 8/27/24, the Administrator confirmed that the nurse staffing information was not posted in an area visible to residents and visitors on the previous day.
Deficiency in CNA In-Service Education
Penalty
Summary
The facility failed to ensure that a Certified Nurse's Aide (CNA) received the required 12 hours of annual in-service education. Specifically, CNA2, who was hired on April 11, 2023, did not receive in-service training on abuse or resident rights for the period from April 11, 2023, through April 11, 2024. This deficiency was identified during a review of CNA2's education records and confirmed in an interview with the Administrator on August 28, 2024, at 6:24 p.m. with two surveyors.
Failure to Follow Hoyer Lift Policy Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a resident's safety during a Hoyer lift transfer, resulting in harm to the resident. On 4/9/24, a Certified Nursing Assistant (CNA) attempted to transfer a resident alone using a Hoyer lift, contrary to the facility's policy requiring two CNAs for such transfers. During the transfer, the resident became restless and slipped out of the Hoyer pad, falling to the floor and hitting their head. The resident sustained a closed head injury and was diagnosed with swelling at the back of the head. The resident's care plan, dated 3/2/24, indicated the need for extensive assistance with transfers using a mechanical lift and two people, which was not followed in this instance. The facility's internal investigation and the Incident Report confirmed that the CNA was aware of the policy but proceeded without assistance due to the unavailability of another CNA. The Root Cause Analysis identified the failure to follow the lift policy as a contributing factor. Interviews with the CNA and the facility administrator corroborated these findings, highlighting the lapse in adhering to established safety protocols during the transfer process.
Removal Plan
- One on One training with CNA #1 on the Lifting Machine policy and procedure that indicates At least two nursing assistants are needed to safely move a resident with a mechanical lift.
- Mandatory re-education on Hoyer Safety with all nursing staff.
- Newly hired CNAs will demonstrate competency with Hoyer lift transfers.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Skowhegan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Ridge Center | 1.8 mi | ★★★★★ | 12 | 0 |
| Maplecrest Rehab & Living Center | 8 mi | ★★★★★ | 0 | 0 |
| Waterville Center For Health And Rehab | 14.1 mi | ★★★★★ | 22 | 0 |
| Oak Grove Center | 15.2 mi | ★★★★★ | 1 | 0 |
| Lakewood A Continuing Care Center | 15.3 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.