Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodland Manor Nursing Center during CMS and state inspections, most recent first.
A resident with COPD, DM, CKD, anxiety, constipation, OSA, and MASD was observed during wound care while an RN and CNA failed to protect privacy. The RN repeatedly opened the door to get supplies and left it open for several minutes, exposing the resident’s buttocks and abdomen to the hallway, and two CNAs walked by and looked in.
Failure to document informed consent for psychotropic medications: The facility did not provide documentation that residents and/or their responsible parties were informed of the risks and benefits before psychotropic medications were started for nine residents. The affected residents had diagnoses including MDD, anxiety, bipolar disorder, dementia, PTSD, suicidal ideations, and malnutrition, and were prescribed medications such as antipsychotics, antidepressants, antianxiety agents, and lamotrigine without documented consent or education. The DON and Administrator stated they would expect residents to be informed of the risks and benefits of psychotropic medications.
A resident discharged from skilled Medicare services and remained in the facility, but the SNF ABN was given to the resident's representative only one day before coverage ended instead of at least two calendar days before the end of Medicare skilled services. The DON and Administrator stated the notice should have been provided earlier.
Shower Room Not Maintained in Clean, Safe, Homelike Condition: A shower room on the 100 Hall was observed with the door propped open, missing tile trim, a torn and stained shower curtain, peeling ceiling paint, a hole in the ceiling, soiled items on the floor, a toilet with dark liquid and foul odor, stained and cracked toilet seat areas, and other clutter and personal items stored in the room. CNA E said the shower curtain had been torn for a month or two, and the DON stated shower rooms should be in good repair and shower curtains not torn.
Failure to provide written transfer notices: The facility did not document that residents and/or their representatives were notified in writing of hospital transfers and the reasons for those transfers for seven sampled residents. Records showed multiple hospital transfers and returns, but no transfer notices were found. An LPN was unaware of an official transfer form, the SSD said he/she only mailed bed-hold notices, and the DON stated nurses were responsible for completing transfer sheets at the time of transfer.
Incomplete and inaccurate MDS coding: The facility failed to accurately code MDS assessments for multiple residents. One resident with SMI had a PASRR Level II finding that was not reflected on the MDS, another resident with cancer and weekly chemo was not coded for cancer or chemo, a resident with multiple diagnoses and orders for warfarin, oxygen, and BiPAP was missing several active diagnoses and treatments, and a resident receiving IV ceftriaxone via PICC was not coded for IV meds. The MDS Coordinator said coding was based on what was found in records, orders, and staff interviews, and the Administrator expected the MDS to accurately reflect the resident’s condition.
The facility failed to develop individualized care plans that reflected the current needs of four residents. Care plans did not include key interventions for a suprapubic catheter, ileostomy, anticoagulant therapy with PT/INR monitoring, a cardiac pacemaker, dementia care, PICC line care, antibiotics, respiratory support with BiPAP and oxygen, DM management, and blood thinner therapy. The DON, Nurse Manager, and Administrator stated that care plans should accurately reflect residents’ current conditions and be revised with changes.
Oxygen Orders and Tubing Care Not Followed: The facility failed to obtain oxygen orders for two residents and failed to follow oxygen orders for three others. A resident with COPD and lung cancer was observed on oxygen at 3 LPM when the order was for 2 LPM, and two residents with COPD were receiving oxygen without current orders. Another resident with heart and lung conditions was observed on oxygen at 3 LPM despite a PRN order for 2 LPM, and a resident with COPD and chronic respiratory failure was observed at 3.5 LPM and later 3 LPM despite an order for 2 LPM continuously; tubing was also observed undated or not stored in a bag when not in use.
Incomplete Controlled Medication Count Documentation: The facility failed to maintain a system of records for the receipt and disposition of controlled medications and failed to ensure staff counted and signed narcotic count sheets at the beginning and end of shifts for four sampled medication carts. Review of the 100 Hall and 400 Hall narcotic count/reconciliation sheets showed numerous missing nurse and CMT signatures or initials, and staff interviews confirmed narcotics should be counted and signed at each shift change.
Medication storage and bedside inhaler order deficiencies were identified when the 100 Hall Nurse and CMT refrigerators had repeated missed temp logs and readings below the expected range while storing refrigerated meds and vaccines, including insulin, Tubersol, Trulicity, and influenza vaccines. In addition, a resident had an albuterol HFA inhaler at the bedside without a physician order for bedside use, without a documented self-administration assessment, and without care plan documentation addressing self-administration.
Staff failed to follow infection control practices during wound care, incontinent care, catheter care, IV medication administration, and routine medication pass. Observations showed an RN, CNAs, an LPN, and a CMT not consistently performing hand hygiene, changing gloves, or using gowns for high-contact care, and staff also handled medications with bare hands and used the same tissue for both eyes. Several staff said they did not know what EBP was, and the facility’s EBP policy did not address high-contact resident care activities.
Three residents with significant care needs did not receive scheduled bi-weekly showers over several months, with missed showers not consistently documented and some residents reporting no alternative hygiene care. Interviews and observations confirmed lapses in shower provision, documentation, and staff encouragement, resulting in residents experiencing poor hygiene and unaddressed personal care needs.
A resident with cognitive impairment and multiple chronic conditions experienced a fall, but the responsible nurse did not notify the physician or the resident's representative as required by facility policy. Staff interviews and record review confirmed the lack of notification and documentation following the incident.
A resident reported a sexual assault by an RN, and although the facility's policy required a final investigation report within five working days, the investigation was not completed and no final report was submitted to authorities after seven business days. The administrator had not obtained written statements from the involved parties and was unaware of the reporting requirement.
The facility failed to consistently document code status for four residents, leading to discrepancies between facesheets, care plans, and signed documents. Interviews revealed that staff were instructed to verify code status through electronic records, but responsibility for managing code statuses had been transferred, contributing to the inconsistencies.
The facility failed to provide written notification to residents and/or their representatives for hospital transfers, affecting 13 residents. The policy required notification during admission and at transfer, but no documentation was found. Staff interviews revealed that nurses were responsible for notifying representatives by phone, and written notifications were not provided. The facility's process involved a Resident Transfer form given to EMS, but this did not ensure representatives received timely written notice.
The facility failed to provide written notification of the bed hold policy to residents and their representatives during hospital transfers. This issue affected 12 out of 13 sampled residents, with no documentation in medical records to confirm compliance with the facility's policy. The Administrator indicated that the policy was sent with residents to the hospital, but this did not ensure direct notification to the residents or their representatives.
The facility failed to update and revise care plans for two residents, leading to inaccuracies in addressing their medical conditions and medications. One resident's care plan did not reflect critical conditions and prescribed medications, while another's care plan included outdated interventions and medication orders. Interviews confirmed these discrepancies, and the DON and Administrator acknowledged the expectation for accurate care plans.
The facility failed to monitor and implement interventions to prevent falls for two residents, and did not update care plans with new interventions. One resident experienced a fall due to delayed assistance, while another sustained a head injury from a fall that was not documented. Additionally, alcoholic beverages were left unsecured in an unlocked office, posing a risk to residents.
The facility failed to assess and document side rail use for eight residents, lacking necessary evaluations and informed consent. Observations confirmed residents using side rails without proper documentation, and interviews indicated reliance on side rails for mobility. The DON acknowledged the expectation for assessments and consent, which were not completed.
The facility failed to ensure individualized care plans for two residents diagnosed with dementia, as their care plans lacked specific interventions and goals for dementia care. Observations showed one resident frequently lying in bed, indicating a lack of engagement. Interviews with the DON and MDS Coordinator confirmed that dementia care should be individualized, revealing a gap in care planning practices.
The facility failed to maintain a medication error rate below five percent, resulting in a 6.45% error rate. Two residents were affected when RNs administered insulin without priming the pens, contrary to manufacturer instructions. Interviews revealed a lack of awareness and adherence to proper insulin administration procedures.
The facility failed to date four opened vials of Tubersol used for tuberculosis testing, as observed in the Terrace and Pavilion medication rooms. Interviews with RNs and the DON confirmed that vials should be dated upon opening and discarded after 30 days. The facility's medication storage policy did not address this requirement, despite the manufacturer's recommendations.
The facility failed to follow infection prevention protocols for a resident with a Clostridium difficile infection by not performing proper hand hygiene and glove changes during care. Additionally, enhanced barrier precautions were not implemented for two residents with indwelling medical devices, as staff did not wear gowns or display appropriate signage. The Director of Nursing confirmed the expected procedures were not followed.
The facility failed to conduct regular inspections of bed frames, mattresses, and side rails for eight residents, lacking a structured maintenance program. Observations showed residents using side rails during care, but medical records lacked inspection documentation. Interviews revealed that the Administrator was unaware of entrapment assessments, and the Maintenance Director confirmed that inspections were based on nursing work orders without entrapment assessments.
The facility failed to provide the required twelve hours of in-service education per year for CNAs, with CNA R attending only ten hours and CNA S attending eight hours without completing dementia care competency. The facility lacked a policy for tracking in-service training hours, and the DON expected CNAs to complete 12 hours annually, including abuse/neglect and dementia care training.
Resident Exposed During Wound Care
Penalty
Summary
The facility failed to ensure staff treated a resident with dignity and respect during wound care by leaving the resident exposed. Resident #134 was admitted with diagnoses including COPD, DM, CKD, anxiety disorder, constipation, and obstructive sleep apnea. The resident’s quarterly MDS showed intact cognition, dependence on staff for dressing, bed mobility, transfers, and toileting, was always incontinent of bladder and bowel, and had MASD. During observation of wound care, RN J and CNA K entered the room and began treatment. RN J closed the door initially, but repeatedly opened it to retrieve supplies and left it open for several minutes each time, exposing the resident’s buttocks and later abdomen to the hallway. Two CNAs were observed walking by and looking in while the resident remained exposed. The report also states there was no curtain available to close for privacy during the care.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties, in advance, of the risks and benefits of proposed psychotropic medications before starting treatment for nine sampled residents. The report states that the facility policy required the physician or psychiatrist to document discussion with the resident and/or responsible party regarding the risk versus benefit of the medication, including off-label use, but no such documentation was provided for any of the nine residents reviewed. Resident #2 had diagnoses of major depressive disorder, anxiety disorder, and bipolar disorder and was prescribed olanzapine, buspirone, and sertraline without documentation of consent or education about risks and benefits. Resident #6, who had cerebral infarction and moderate protein-calorie malnutrition, was prescribed mirtazapine with no documentation of consent or education. Resident #7, diagnosed with generalized anxiety disorder and MDD, had orders for bupropion, clonazepam, and escitalopram, and Resident #10, diagnosed with MDD, anxiety disorder, suicidal ideations, and PTSD, had an order for duloxetine; neither record contained documentation of consent or education for the medications. Additional records showed the same issue for Resident #24, diagnosed with MDD and prescribed sertraline and bupropion XL; Resident #37, diagnosed with anxiety and restless leg syndrome and prescribed hydroxyzine, clonazepam, and buspirone; Resident #67, diagnosed with dementia, psychophysical visual disturbances, and depression and prescribed venlafaxine; Resident #104, diagnosed with dementia, bipolar disorder, and unspecified psychosis and prescribed fluoxetine and lamotrigine; and Resident #123, diagnosed with MDD and prescribed duloxetine. During interviews, the DON and Administrator stated they would expect residents to be informed of the risks and benefits of psychotropic medications.
Failure to Provide Timely SNF ABN Before End of Medicare Coverage
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) in writing at least two calendar days before the end of skilled Medicare services for one resident. Resident #13 discharged from skilled Medicare services on 11/05/25 and remained in the facility, but the resident's representative received the SNF ABN on 11/04/25. The facility's policy required the social services designee to give at least a 72-hour notice of non-coverage and to provide a SNF ABN at least three days prior to discharge when the resident was discharging from Medicare services and staying in the facility. During interviews, the Director of Social Services and the Administrator stated the SNF ABN should have been provided at least two days prior to the last day covered by Medicare.
Shower Room Not Maintained in Clean, Safe, Homelike Condition
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in the shower room located at the end of the 100 Hall. Observation showed the shower room door propped open, a 4 inch by 12 inch piece of tile trim missing at the base of the door entry, a white plastic shower curtain that was stained, torn in half, and missing three hooks so it drooped, and areas of peeling ceiling paint with a hole in the ceiling. The room also contained a wheelchair seat cushion on the shower floor, a toilet full of dark brown liquid with a foul odor, a toilet seat with stained and cracked peeling areas, a walker beside the toilet, and wheelchair leg rests/foot pedals stored on a wire shelf above the toilet. Additional observations in the same shower room showed soiled pants on the floor, a pillow and two wheelchair seat cushions beside the toilet, a 2 inch by 3 inch area of brown splatter on the wall next to the toilet, a plugged-in hairdryer in the sink, and an opened bottle of aftershave liquid without a lid on the sink. CNA E stated the shower curtain had been torn for a month or two and that staff used both shower rooms on the 100 Hall. The Maintenance Director said staff submitted work orders for items needing repair or replacement and placed them in wall boxes, and the DON stated she would expect shower rooms to be in good repair and shower curtains not torn.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of hospital transfers and the reasons for those transfers for seven sampled residents. Review of the records for Residents #2, #4, #6, #8, #27, #68, and #73 showed multiple transfers to the hospital and returns to the facility, but no documentation that written transfer notices were provided to the resident or the resident’s representative with the reason for each transfer. The facility policy titled Discharge Procedures stated that before transfer or discharge, written notification must be sent to the resident in a manner reasonably calculated to be understood, and also to the resident’s legally authorized representative and at least one family member. During interviews, an LPN said he/she was unaware of any official transfer form. The SSD said he/she completed and mailed bed-hold notices to the responsible party but did not complete transfer notices, stating that it was the nurse’s responsibility to send the resident to the hospital. The DON said nurses were responsible for completing the transfer sheets at the time of transfer and expected them to be completed.
Incomplete and inaccurate MDS coding
Penalty
Summary
The facility failed to document complete and accurate MDS assessments for four of 25 sampled residents. Review of the facility policy stated that resident interviews must be completed, the medical record must be comprehensively reviewed, and then the MDS assessment section may be completed according to the RAI Manual. The RAI Manual guidance reviewed by surveyors stated that PASRR coding must reflect Level II findings for serious mental illness or intellectual disability, active diagnoses must include physician-documented diagnoses with a direct relationship to the resident’s current status during the look-back period, high-risk drug classes must be coded when medications in the class are taken with indications noted, and special treatments, procedures, and programs must be coded when performed within the look-back period. For one resident with major depressive disorder, anxiety disorder, and PTSD, the PASRR showed a serious mental illness, but the admission MDS stated the resident was not considered by the state Level II process to have a serious mental illness or related condition. For another resident with myelofibrosis, a port, and weekly chemotherapy, the quarterly MDS did not code cancer or chemotherapy. A third resident with thrombophilia, atrial fibrillation, heart disease, chronic kidney disease, depression, COPD, sleep apnea, a pacemaker, warfarin, furosemide, venlafaxine, oxygen, and BiPAP had an admission MDS that did not code renal failure, depression, anticoagulant use, or BiPAP/non-invasive mechanical ventilation. A fourth resident with cellulitis, left foot osteomyelitis, ceftriaxone IV, and a PICC line had an admission MDS that did not code IV medications. The MDS Coordinator stated information was gathered from records, care plans, progress notes, orders, and staff interviews, and if it was not mentioned during those reviews, it would not be coded on the MDS. The Administrator stated the MDS should accurately reflect the resident’s condition at the time of assessment.
Incomplete Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans with specific interventions for four sampled residents. The deficiency was identified through observation, interview, and record review, and involved residents with multiple ongoing conditions and ordered treatments that were not reflected in their care plans. The facility policy stated that care plans were to be individualized, based on assessment and resident choices, and revised as the resident’s status changed. For one resident with benign prostatic hyperplasia, a suprapubic catheter care order and a catheter output monitoring order were present, but the care plan did not address the suprapubic catheter, its care, or output monitoring. For another resident with Ogilvie syndrome and an ileostomy, the care plan did not address the ileostomy with goals and interventions. A third resident with thrombophilia, atrial fibrillation, heart disease, dementia, and a cardiac pacemaker had orders for warfarin and PT/INR monitoring, but the care plan did not address the anticoagulant therapy, lab monitoring for dose titration, the pacemaker, or dementia care. A fourth resident with cellulitis of the right lower limb, atrial fibrillation, DM, dementia, bipolar disorder, OSA, COPD, HF, and asthma had multiple active orders, including IV and oral antibiotics, BiPAP use, oxygen saturation monitoring, PICC line dressing changes, insulin therapy, and Eliquis, but the care plan did not address the PICC line, antibiotics, respiratory needs, DM care, blood thinner therapy, or dementia. During interviews, the DON, Pavillion Nurse Manager, and Administrator stated that care plans should accurately reflect the resident’s current condition and be revised as needed with resident changes.
Oxygen Orders and Tubing Care Not Followed
Penalty
Summary
The facility failed to ensure physician orders for oxygen use and oxygen tubing care were obtained for two residents and failed to follow physician orders for oxygen use for three residents. The facility policy stated that orders received by the physician are to be followed as prescribed, and the oxygen storage/use policy stated that oxygen tubing is to be bagged when not in use. During the survey, staff observed multiple residents receiving oxygen at settings that did not match the orders in the medical record, and some oxygen tubing was not dated or stored in a bag when not in use. Resident #8 had diagnoses of COPD and bilateral lung cancer. The March 2026 physician order sheet showed oxygen at 2 LPM via nasal cannula every shift, but the resident was observed on two occasions with oxygen running at 3 LPM via an undated nasal cannula. The resident stated the oxygen should be set at 2 LPM and said staff changed the nasal cannula, but he/she was not sure how often. The care plan also stated that tubing and mask were to be changed weekly and as needed. Resident #27 and Resident #40 both had diagnoses including COPD, and their March 2026 physician order sheets did not contain orders for oxygen administration, yet both were observed receiving oxygen at 3 LPM, and Resident #40 was later observed at 4.5 LPM and then without oxygen while the undated nasal cannula was on the floor and not in a storage bag. Resident #81 had an order for oxygen 2 LPM via nasal cannula as needed for shortness of breath, with titration to maintain saturations above 90%, but was observed receiving oxygen at 3 LPM with an undated nasal cannula wrapped around the wheelchair armrest and not stored in a bag. Resident #123 had orders for oxygen 2 LPM continuously and to change the oxygen canister and tubing every Sunday, but was observed receiving oxygen at 3.5 LPM and later 3 LPM via an undated nasal cannula, with the tubing noted in use and staff stating the tubing had not been changed in a while.
Incomplete Controlled Medication Count Documentation
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of all controlled medications in sufficient detail to allow accurate reconciliation of controlled medications. The facility also failed to ensure nursing staff counted and signed the narcotic count sheet at the beginning and end of each shift for four of four sampled medication carts. The facility did not provide a policy regarding the receipt and disposition of controlled medications or reconciliation of controlled medications. Review of the 100 Hall CMT Cart Change of Shift Narcotic Count sheet showed no signature and/or initials by the nurse or CMT for 63 of 151 opportunities. Review of the 100 Hall Nurse Cart Change of Shift Narcotic Count Sheet showed no signature and/or initials by the nurse for 86 of 157 opportunities. Review of the 400 Hall CMT Cart Narcotic Package Count Shift Reconciliation sheet showed no designated signature space for oncoming staff to sign, no signature and/or initials by the nurse or CMT for the oncoming shift for 43 of 43 opportunities, and no signature and/or initials by the nurse or CMT for the off going shift for 4 of 43 opportunities. Review of the 400 Hall Nurse Cart Narcotic Package Count Shift Reconciliation sheet showed no designated signature space for oncoming staff to sign, no signatures and/or initials by the nurse for the oncoming shift for 44 of 44 opportunities, and no signature and/or initials by the nurse for the off going shift for 14 of 44 opportunities. Staff interviews confirmed narcotics should be counted at the beginning and end of each shift and the count sheet should be signed when the count is completed.
Medication Storage and Bedside Inhaler Order Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles when refrigerator temperatures were not documented consistently for the 100 Hall Nurse refrigerator and the 100 Hall CMT refrigerator. The facility policy titled, Storage of Medications, required medications needing refrigeration to be stored in a secured location, but it did not address checking or maintaining appropriate refrigerator temperatures. Review of the 100 Hall Nurse refrigerator temperature log for 03/01/26 through 03/26/26 showed 13 missed temperature entries out of 31 opportunities, and recorded temperatures included 34°F on multiple days and 32°F on one day. Observation of the refrigerator on 03/26/26 showed a thermometer reading of 34°F and contained four unopened vials of Tubersol, one opened vial of Tubersol dated 03/24/26, 33 unopened Lantus and Novolog insulin pens, one unopened Trulicity pen, 11 unopened influenza vaccines, two unopened vials of cyanocobalamin, 63 unopened acetaminophen suppositories, and 26 unopened Bisacodyl suppositories. Review of the 100 Hall CMT refrigerator temperature log for 03/01/26 through 03/26/26 showed nine missed temperature entries out of 31 opportunities, with recorded temperatures of 34°F on multiple days. Observation of the CMT refrigerator on 03/26/26 showed a thermometer reading of 34°F. During interview, the CMT said the day shift CMT was responsible for checking refrigerator temperatures and that the logs should be updated daily. The DON stated she would expect refrigerator temperatures to be recorded daily and within the appropriate range. The facility also failed to ensure Resident #24 had a physician's order to keep an inhaler at the bedside. The resident was admitted on 10/30/25 and had an order for albuterol sulfate HFA 90 mcg aerosol inhaler, 2 inhalations four times a day as needed for shortness of breath. The medical record did not contain an order for bedside medication storage, documentation of an assessment for safe self-administration, or care plan documentation addressing self-administration. Observations showed the albuterol inhaler on the resident's bedside table on multiple occasions. The resident stated the inhaler was used about once a day as needed for difficulty breathing. Staff interviews indicated they expected a physician's order for bedside medication use, and the DON stated she would expect such an order and that the resident should be assessed for safety and tell staff when the medication was self-administered.
Failure to Follow Hand Hygiene and EBP During Resident Care
Penalty
Summary
The facility failed to follow infection control precautions during resident care, including hand hygiene, glove changes, gown use, and enhanced barrier precautions (EBP). Surveyors observed multiple instances where staff did not wash hands or change gloves when moving between dirty and clean tasks during wound care, incontinent care, catheter care, and medication administration. The facility also did not provide a hand hygiene policy, and its EBP policy did not address high-contact resident care activities. During wound care for a resident with left shin and ankle wounds, an RN performed hand hygiene at the start, put on gloves, and did not put on a gown. The RN removed soiled dressings, removed packing from the shin wound, sprayed and wiped the wounds, and at several points did not perform hand hygiene or change gloves while moving between tasks. During wound care for another resident with bilateral buttock wounds, the RN again did not wear a gown, removed soiled dressings, sprayed and wiped the wounds, changed gloves at one point, but also removed gloves without performing hand hygiene before covering the resident with a blanket. The RN stated he/she had never heard of EBP and said gowns, gloves, and masks should be worn during wound care, with hand hygiene before, after, and when going from dirty to clean tasks. Surveyors also observed medication administration and other resident care where infection control practices were not followed. A CMT did not perform hand hygiene, touched medications with bare hands while pouring tablets into a pill cup, administered multiple medications, and used the same tissue to blot both eyes after eye drop administration. An LPN administering IV ceftriaxone to a resident with an IV did not wear a gown and did not have EBP signage outside the room. Additional observations showed CNA staff providing incontinent care and catheter care without consistent hand hygiene, glove changes, or gown use, including care for residents with wounds, urinary catheters, and other conditions that the facility’s policy associated with EBP. Staff interviews showed several employees did not know what EBP was or who qualified for it, while the DON/IP stated that residents with chronic wounds or indwelling devices should have EBP during high-contact care and that staff should perform hand hygiene before, after, and when moving from dirty to clean tasks.
Failure to Provide Scheduled Showers and Document Refusals
Penalty
Summary
The facility failed to provide showers as scheduled for three residents out of six sampled, despite having a policy requiring bi-weekly showers and documentation of refusals or missed showers. Review of shower sheets and schedules revealed that these residents missed multiple scheduled showers over a three-month period, with some months showing no showers provided at all for certain residents. The facility's policy also required that refusals be documented and reported, but there was evidence that this was not consistently done. Resident #1, who had diagnoses including multiple sclerosis and COPD and was dependent on staff for showering, missed the majority of scheduled showers from October to December. Resident #2, with COPD, heart failure, and rheumatoid arthritis, also missed nearly all scheduled showers during the same period and reported not receiving bed baths in between. Resident #5, who required substantial assistance due to muscle weakness and Parkinson's disease, similarly missed several scheduled showers, with some refusals documented but others not clearly accounted for. Interviews with residents and staff confirmed the lack of regular showers, with residents expressing a desire for more frequent bathing and staff acknowledging ongoing issues with shower provision and documentation. Observations included musty odors and unkempt appearance, and staff interviews indicated a lack of encouragement for residents to take showers and inconsistent completion of required documentation.
Failure to Notify Physician and Representative After Resident Fall
Penalty
Summary
The facility failed to notify both the physician and the resident's representative following a fall involving a resident with cognitive impairment and multiple medical diagnoses, including dementia, diabetes, chronic kidney disease, and hypertension. According to facility policy, after a fall, the licensed nurse is required to assess the resident, initiate SBAR communication, and notify the physician and responsible party. However, documentation and interviews revealed that after the resident was found on the floor between the bed and the wall, there was no evidence that the physician or the resident's representative was contacted regarding the incident. Staff interviews confirmed that the charge nurse was informed of the fall, but neither the physician nor the resident's family was notified as required. The resident's care plan specifically included interventions to notify both parties in the event of a fall. The Director of Nursing acknowledged that the charge nurse did not fulfill these responsibilities, and the progress notes lacked documentation of any notifications being made.
Failure to Timely Complete and Submit Abuse Investigation Report
Penalty
Summary
The facility failed to complete and submit a final investigation report in a timely manner following an allegation of sexual abuse involving one resident. The resident reported to Emergency Medical Services that a registered nurse had sexually assaulted them, and the incident was reported to the Central Registry Unit. The facility's abuse policy requires that the person in charge of the investigation report the conclusions within five working days of the incident, including detailed documentation and a final written report to the Department of Health and Senior Services. Despite these requirements, as of seven business days after the initial report, the facility had not completed the investigation or submitted the final report. The administrator acknowledged during an interview that the investigation was incomplete, with no written statements obtained from either the accused nurse or the resident. The administrator also stated he was unaware that a final report was required since the facility had determined there was no abuse.
Inconsistent Documentation of Code Status
Penalty
Summary
The facility failed to ensure consistent documentation of code status throughout the medical records for four residents. For Resident #17, discrepancies were found between the code status documented on the facesheet, the care plan, and the signed documents, with conflicting indications of DNR and Full Code status. Similarly, Resident #33's medical record showed inconsistencies between the facesheet, signed documents, and care plan, with both DNR and Full Code statuses recorded. Resident #53's records also displayed conflicting information, with a Full Code status on the facesheet but a DNR status signed by the resident and others. Resident #92's medical record contained a DNR status on the facesheet, yet a Full Code status was signed by the resident and others, with an order for DNR status. Interviews with the Administrator and SSD revealed that staff were instructed to verify code status through scanned documents in the electronic chart, and a binder with code statuses was kept in the SSD's office. However, the responsibility for managing code statuses had been transferred to another staff member, contributing to the inconsistencies.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding facility-initiated transfers to the hospital. This deficiency was identified for 13 residents who were transferred to the hospital for medical evaluations. The facility's policy required that residents and their families or representatives be notified twice about transfers: once during the admission process and again at the time of transfer. However, there was no documentation of written notifications being provided for any of the transfers reviewed. Interviews with facility staff revealed that the responsibility for notifying the resident's representative of a transfer fell to the nurses. The Social Services Designee confirmed this during an interview. The Administrator also stated that the notification process involved a phone call to the resident's representative, but acknowledged that written notifications were not provided. Instead, a Resident Transfer form was completed by the nurse and given to emergency medical services to pass along to hospital staff, who were then expected to give it to the resident's representative. The lack of written notification was consistent across all reviewed cases, indicating a systemic issue in the facility's adherence to its own policy. The facility's census at the time was 127, and the deficiency affected all 13 sampled residents who were transferred to the hospital. The Administrator noted that mailing notifications was not practiced because they would often arrive after the resident had returned to the facility.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform residents and their legal representatives in writing of the bed hold policy at the time of transfer to the hospital. This deficiency was identified for 12 out of 13 sampled residents, indicating a systemic issue in the facility's process for communicating this important information. The facility's policy requires that residents and their representatives be notified of the bed hold policy twice: once during the admission process and again at the time of transfer. However, there was no documentation in the medical records of the sampled residents to confirm that this policy was followed. The report details multiple instances where residents were transferred to the hospital for medical evaluations and subsequently readmitted to the facility. Despite these transfers, there was no evidence that the residents or their representatives received written notification of the bed hold policy. This lack of documentation was consistent across various residents, including those who were transferred multiple times throughout the year. During an interview, the facility's Administrator stated that the bed hold policy was sent with the resident to the hospital, and it was the responsibility of the hospital staff to provide it to the resident's representative. This practice, however, does not align with the facility's policy, which mandates direct notification to the resident and their representative. The absence of written documentation in the residents' medical records highlights a significant gap in the facility's adherence to its own policies and regulatory requirements.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions tailored to meet individual needs for two residents. Resident #3's care plan did not address several critical medical conditions and medications, including anticoagulant, antiviral, nerve pain, depression, and anxiety medications, as well as heart failure. Despite having multiple diagnoses such as urinary tract infections, falls, polyneuropathy, hypothyroidism, major depressive disorder, anxiety disorder, hypertension, atrial fibrillation, heart failure, and pain, the care plan was last reviewed on 10/04/24 and did not reflect these conditions or the prescribed medications. Resident #17's care plan was outdated and did not accurately reflect the resident's current condition. The care plan included interventions for vision impairment that were not applicable, as the resident was completely blind and could only perceive light differences and shadows. The care plan also contained outdated medication orders, such as Xanax and quetiapine, and did not include current prescriptions. Interviews with the resident, an LPN, and the MDS Coordinator confirmed the inaccuracies in the care plan, and the DON and Administrator acknowledged the expectation for care plans to accurately reflect residents' current conditions.
Deficiencies in Fall Prevention and Safety Measures
Penalty
Summary
The facility failed to adequately monitor and implement interventions to prevent falls and accidents for two residents, as well as failed to update their care plans with new interventions. Resident #3, who was dependent on staff for transfers and used a wheelchair, experienced a fall that was not documented or assessed according to facility policy. The resident had been waiting for assistance for an extended period, which led to weakness and a subsequent fall when being transferred by staff. The incident was not reported as a fall by the staff involved, and the care plan was not updated to reflect this event. Resident #39, who required partial assistance with mobility and used a wheelchair or walker, fell at the nurse's station and sustained a head injury, requiring hospital evaluation. This fall, along with another observed fall in the resident's room, was not documented or addressed in the care plan. Staff noted that the resident often placed themselves on the floor, which was not considered a fall by the facility's standards, leading to a lack of appropriate intervention and documentation. Additionally, the facility failed to secure alcoholic beverages in the Activity Director's office, which was left unlocked and accessible to residents. This posed a potential risk to all residents who could freely move around the facility. The Activity Director acknowledged that confused residents had previously entered the office, and the Administrator expected liquor to be stored in a location inaccessible to residents.
Failure to Assess and Document Side Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of side rails for eight residents, leading to a deficiency in compliance with safety protocols. The report highlights that the facility did not conduct necessary assessments or obtain informed consent from residents or their representatives before installing or using side rails. This oversight was observed in all eight sampled residents, who were using side rails without documented evaluations or consents. Resident #3, with intact cognition and a history of falls, was observed using side rails for repositioning without documented informed consent. Similarly, Resident #7, who had intact cognition and multiple health conditions, was using side rails without quarterly assessments or informed consent. Resident #48, with severe cognitive impairment and a history of falls, also lacked documentation of quarterly assessments and informed consent for side rail use. Other residents, including Resident #50, #105, #111, #127, and #389, were similarly affected, with no documentation of side rail assessments or informed consent. Observations confirmed that these residents were using side rails, and interviews with some residents and family members indicated reliance on side rails for mobility and repositioning. The Director of Nursing acknowledged the expectation for quarterly assessments and informed consent, but these were not completed as required.
Failure to Provide Individualized Dementia Care Plans
Penalty
Summary
The facility failed to provide a personalized plan of care for residents diagnosed with dementia, specifically for two residents out of a sample of three. Resident #108, who was admitted with a diagnosis of unspecified dementia, had a care plan that did not address dementia-specific problems, interventions, or goals. Observations showed the resident frequently lying in bed, sometimes with eyes closed, and eating lunch in bed, indicating a lack of engagement or activity tailored to their condition. The Minimum Data Set (MDS) assessment confirmed the diagnosis of dementia, yet the care plan remained inadequate in addressing the resident's needs. Similarly, Resident #115, also diagnosed with dementia, had a care plan that failed to address dementia-specific issues. The care plan lacked interventions or goals for dementia care and activities suitable for the resident's condition. Interviews with the Director of Nursing and the MDS Coordinator revealed an expectation that dementia care should be individualized and addressed in the care plan, highlighting a gap between expected and actual care planning practices at the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration, resulting in an error rate of 6.45%. This deficiency was identified through observation, interview, and record review, affecting two residents out of a sample of two. The errors involved the administration of insulin without proper priming of the insulin pens, as required by the manufacturer's instructions. Specifically, a registered nurse (RN) administered insulin lispro to a resident without priming the pen, and another RN administered Fiasp insulin without priming the pen, both of which are necessary steps to ensure accurate dosing. The facility's policy on medication administration, revised in May 2021, mandates that medications be administered as prescribed and in accordance with manufacturers' specifications. However, interviews revealed that one RN was unaware of the need to prime insulin pens, while another RN believed priming was only necessary before the first use. The Director of Nursing confirmed that insulin pens should be primed with each use, highlighting a gap in adherence to the facility's medication administration guidelines. The facility census at the time was 127, and the expectation was for the medication error rate to be less than five percent.
Failure to Date Opened Tubersol Vials
Penalty
Summary
The facility failed to ensure that four vials of Tubersol, a solution used for tuberculosis testing, were dated when opened. This oversight was identified during observations of the medication refrigerators in both the Terrace and Pavilion medication rooms, where two opened vials of Tubersol solution in each location were found without dates. Interviews with Registered Nurses B and A, as well as the Director of Nursing, confirmed that multi-dose vials, including Tubersol, should be dated upon opening and discarded after 30 days. The facility's policy on the storage of medications did not address the requirement for dating vials when opened, although the manufacturer's recommendations for Tubersol specified that the solution should be discarded 30 days after opening.
Infection Control Deficiencies in Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices for Resident #48, who was on contact precautions due to a Clostridium difficile infection. During a wound vac dressing change, the registered nurse (RN) did not perform hand hygiene between glove changes and failed to change gloves between different procedures, such as cleaning the wound and the peri area. This lack of adherence to hand hygiene and glove-changing protocols was observed multiple times during the care process, despite the facility's policy requiring hand washing between glove changes. Additionally, the facility did not implement enhanced barrier precautions (EBP) for two residents with indwelling medical devices. Resident #71, who had a Foley catheter, and Resident #389, who had a PICC line, did not have appropriate EBP signage, and the staff did not wear gowns during care procedures. The Director of Nursing acknowledged that EBP should be used for residents with indwelling tubes and wounds, and that hand hygiene should be performed before and after glove use, as well as when changing gloves.
Failure to Conduct Regular Inspections of Bed Rails and Mattresses
Penalty
Summary
The facility staff failed to conduct regular inspections of bed frames, mattresses, side rails, and enabler bars for eight residents, as part of a regular maintenance program. The facility's census was 127, and the deficiency was identified through observation, interview, and record review. The medical records of the residents involved showed no maintenance inspections for the side rails, and observations confirmed that the residents were using side rails in various positions during care activities. The facility did not provide a policy on inspections of side rails, indicating a lack of structured maintenance procedures. Interviews with the facility's Administrator, Director of Nursing (DON), and Maintenance Director revealed gaps in the inspection process. The Administrator was unaware of entrapment assessments, and the DON stated that maintenance inspected the bed rails as needed. However, the Maintenance Director clarified that bed rails were checked monthly through work orders from nursing, which did not include measurements or assessments for entrapment. This lack of comprehensive inspection and assessment contributed to the deficiency identified by the surveyors.
Deficiency in CNA In-Service Training and Dementia Care Competency
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required twelve hours of in-service education per year, as well as the necessary annual competencies in dementia care. Specifically, two CNAs, identified as CNA R and CNA S, did not meet the annual in-service training requirements. CNA R, hired on April 11, 2022, attended only ten hours of in-service training from April 2023 to April 2024. CNA S, hired on October 28, 2022, attended only eight hours of in-service training from October 2023 to October 2024 and did not participate in the required annual competency in-service on dementia care. The facility did not have a policy in place for CNA in-service training, and the administrator acknowledged that while the required subjects were covered, the facility did not track the number of hours completed by each CNA. The Director of Nursing (DON) confirmed that in-service sessions typically lasted about 30 minutes and expressed the expectation that CNAs should complete 12 hours of in-service training annually, including training on abuse/neglect and dementia care. The facility census at the time was 127 residents.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 772 citations issued within 25 miles in the last 12 months — including the 14 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Arnold
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South County Health Care Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Delmar Gardens South | 2.9 mi | ★★★★★ | 0 | 0 |
| Bethesda Southgate | 5 mi | ★★★★★ | 0 | 0 |
| Nazareth Living Center | 5.2 mi | ★★★★★ | 4 | 0 |
| Maple Grove Wellness & Rehabilitation | 5.5 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.