Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Careone At Wellington during CMS and state inspections, most recent first.
Controlled substance records were not consistently reconciled, with multiple narcotic entries showing wasted or removed doses that did not match the eMAR or lacked proper documentation. In addition, an LPN applied lidocaine patches to sites that did not match the physician’s orders for a resident with osteoarthritis and dementia, and the resident had severe cognitive impairment.
Missing and Delayed Employee Background Checks: The facility failed to ensure criminal background checks were completed before hire for 2 staff members. One PT had no background check on file, and one CNA had a background check dated well before employment. During survey review, the DON and LNHA were shown the record issues, and background checks were later provided after surveyor inquiry.
A resident’s MDS was inaccurately coded across multiple assessments, with SSN, ethnicity, preferred language, and interpreter use left blank in section A. The resident was documented as Spanish-speaking, needed an interpreter or media translator for more detailed communication, and had a BIMS score of 4/15, while the MDSC/RN said the SSN was left blank because she wanted to verify it and did not explain the missing language-related entries.
A resident’s care plan was not updated after a fall in which the resident slipped while attempting a self-transfer and forgot to lock the wheelchair. The IDT agreed to add assistance with transfers and ambulation as needed, but the active fall care plan reviewed by the DON did not include that intervention. An LPN acknowledged the intervention was missing from the care plan.
A resident with cellulitis, CHF, and severe cognitive impairment had bilateral lower extremity wounds, but the initial skin assessment only noted wounds without documenting wound type, size, depth, tissue characteristics, or surrounding skin. A wound consultant later documented chronic vascular wounds with measurements and drainage, and physician wound care orders were entered after that assessment. An LPN stated wound findings should be fully documented on admission, and the DON acknowledged the wounds were present but not adequately described in the record.
Inaccurate Hemodialysis Access Assessment: An LPN failed to consistently assess a resident's hemodialysis permacath correctly. The resident had ESRD and received HD three times weekly, with the care plan directing staff to check the inguinal permacath for infection, swelling, or bleeding. While one LPN documented the site as intact with no bleeding or infection, another documented bruit and thrill, which are AV fistula findings, and stated she checked for those signs. Facility policies did not clearly address assessment of a central venous catheter or distinguish it from an AV fistula.
Surveyors found an opened, undated bottle of Latanoprost eye drops on a medication cart. An LPN confirmed the bottle should have been dated after opening to calculate the expiration date, but did not know when or by whom it had been opened. The facility policy required medication labels to include an expiration date when applicable, and the manufacturer states the bottle may be stored at room temperature for 6 weeks after opening.
A resident with active wounds, leukocytosis, anemia, and a midline IV access device was observed receiving IV therapy without EBP signage or a PPE bin at the room entrance. The LPN unit manager, IP, and DON all acknowledged the resident should have been on EBP because of the wounds, IV access, and IV antibiotic therapy, but the required signage and PPE setup were not in place.
Failure to document antibiotic stewardship for a resident on IV antibiotics. A resident with leukocytosis, vascular wounds, and anemia was receiving IV Zosyn via a midline, but the resident was not included on the infection surveillance report and the EHR infection screening tool was not completed. The IP and DON acknowledged that no cultures or testing had been done since the antibiotic started and that stewardship documentation was not completed as required by policy.
A cognitively impaired resident with a known history of elopement was allowed to leave their unit unescorted after an LPN deactivated the elevator's wander guard system. Upon reaching the lobby, the resident exited the facility through a rear door after a receptionist disengaged the wander guard alarm, enabling the resident to leave unsupervised. The absence was not discovered until hours later during rounds, and the resident was eventually found in a nearby town and returned to the facility.
The facility failed to maintain proper sanitation and labeling practices in the kitchen and nutrition refrigerators. Observations included soiled and wet pans, an unlabeled oatmeal cup, and unlabeled food items in refrigerators. The CSD and nursing staff acknowledged these issues, which were not in compliance with facility policies.
The facility exhibited deficiencies in infection control practices, including improper use of PPE and inadequate hand hygiene. An LPN entered a COVID-19 positive resident's room without full PPE, and housekeeping staff failed to remove PPE inside rooms. A Unit Secretary wore her mask improperly, and CNAs did not perform hand hygiene during meal service. These actions occurred despite prior staff education on proper procedures.
The facility failed to properly document the receipt and administration of controlled substances, as evidenced by incomplete DEA 222 Forms and discrepancies in Controlled Drug Administration Records (CDAR). An LPN admitted to not signing the CDAR immediately after administering medication, and the facility's policies lacked guidance on DEA 222 forms and CDAR documentation.
The facility failed to maintain a medication error rate below 5%, with a surveyor observing three errors out of twenty-six opportunities. Errors included administering Docusate Sodium in tablet form instead of capsules and preparing to open Phenytoin Sodium Extended Capsules, which should not be crushed or opened. The nurse did not follow medication orders or cautionary instructions, and the DON confirmed that medications should be administered as ordered.
The facility failed to properly store medications on two medication carts, as observed by a surveyor. On Cart 2, a foil package of budesonide inhalant suspension and a foil package of DuoNeb were found without dates indicating when they were opened. Similarly, on Cart 1, a DuoNeb solution was also undated. Both the UM/LPN and the LPN confirmed that these medications should have been dated. The facility's policy did not include information on dating opened nebulizer solutions, leading to the deficiency.
The facility failed to maintain resident dignity during a meal service, as CNAs left trays and garbage on tables and one CNA stood while feeding a resident, which was acknowledged as inappropriate.
A facility failed to accurately document and review a resident's advance directives, as the EMR did not reflect the DNH status indicated on the resident's POLST form. Despite the resident's severe cognitive impairment and multiple diagnoses, there was no care plan related to advance directives, and staff interviews revealed lapses in the process for updating and ensuring the accuracy of these directives.
A facility failed to accurately code the MDS for two residents, resulting in incorrect gender identification. One male resident was coded as female, and one female resident was coded as male, contrary to their Admission Records. The RN MDS coordinator acknowledged the errors, which were identified during a surveyor's review.
A facility failed to follow infection control standards for a resident's respiratory care. The nasal cannula tubing was not changed as per policy and was found on the floor instead of being stored in a plastic bag. The resident, with a history of congestive heart failure and other conditions, was receiving oxygen therapy. Staff acknowledged the lapses in protocol, which were confirmed by the DON.
A resident was administered Tamsulosin, a medication not approved for use in women, without proper documentation or justification. Despite the resident's cognitive intactness and the presence of a urinary catheter, the facility failed to provide a rationale for the off-label use of the medication, leading to a deficiency in medication management practices.
A resident returned from hemodialysis with syringes still attached to their catheter, which should have been removed at the clinic. The oversight was discovered by the resident's family, and the facility failed to conduct a proper post-treatment assessment. Documentation and communication lapses were identified, as the dialysis communication report was not consistently returned, and the nurse did not thoroughly check the catheter site.
A resident was inadvertently given Dakin's solution, a wound cleanser, instead of water to take with oral medication after an RN prepared the solution in a drinking cup and mistakenly handed it to the resident. The resident experienced a burning sensation upon ingestion and reported it immediately. The incident occurred due to failure to follow facility procedures for wound care preparation and medication administration, as confirmed by staff interviews and policy review.
Controlled Substance Documentation Errors and Incorrect Lidocaine Patch Application
Penalty
Summary
The facility failed to consistently ensure accountability and reconciliation of controlled dangerous substances and failed to provide pharmaceutical services in accordance with professional standards during medication administration. During inspection of a medication cart narcotic box, the surveyor reviewed controlled drug records and shift-to-shift logs for multiple residents and found discrepancies between documented removals, waste entries, and the corresponding electronic medication administration records. For one resident, the controlled drug administration record showed repeated removals of Tramadol that were documented as wasted because the medication allegedly fell on the floor, but no succeeding removal for administration was documented on several occasions. For another resident, Lorazepam was documented as removed and wasted twice on the same date, with one entry marked as accidentally punched and dropped and another marked as dropped, while the resident’s eMAR did not show an order for Lorazepam during the months reviewed. The record for a third resident showed Alprazolam removed and wasted twice on the same date, with one entry documented as wasted because it fell on the floor and another as dropped, and the eMAR showed a one-time administration that was not documented on the controlled drug record. A fourth resident’s Lorazepam record showed a removal without the nurse’s signature, while the eMAR did not show an administration on that date. The surveyor also observed an LPN administer lidocaine patches to a resident with osteoarthritis and dementia, whose cognitive testing showed severe impairment. The physician’s orders directed application of lidocaine patches to the left hip and lumbar region, but the LPN applied the patches to the left flank and upper-mid back instead. The LPN stated the patches should have been removed the prior night and acknowledged that the application sites did not match the ordered locations, explaining that the resident complained of pain in those areas and that the resident should have been asked to confirm pain locations at the bedside.
Missing and Delayed Employee Background Checks
Penalty
Summary
The facility failed to ensure that newly hired staff underwent a criminal background investigation prior to their date of hire for 2 of 118 employees hired after 1/7/25. Employee #11, a physical therapist hired on 4/17/26, had no background check on file. Employee #67, a CNA hired on 8/22/25, had a background check on file dated 12/20/23, which was 1 year and 8 months prior to employment. During the 6/15/26 survey, the surveyor and survey team met with the DON and LNHA to review the background check records. After surveyor inquiry, the facility provided a background check dated 6/10/26 for Employee #11 and a background check dated 6/12/26 for Employee #67, and no further information was provided regarding the discrepancy for Employee #67; both employees' hire dates were confirmed as 8/22/25 for Employee #67 and 4/17/26 for Employee #11. The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program stated that the facility would conduct employee background checks and not knowingly employ or otherwise engage any individual found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.
MDS Coding Inaccurately Documented for Resident Language and Identification Information
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident who was reviewed for MDS accuracy. The resident was observed awake, alert, and oriented, and was able to answer the surveyor in simple English. During the interview, the resident stated they were Spanish and Italian and wanted an interpreter if possible so they could understand better and answer questions appropriately. The resident’s record showed an admission diagnosis that included hypertensive heart disease without heart failure, and the recent quarterly MDS assigned a BIMS score of 4 out of 15, indicating severely impaired cognition. Review of the MDS assessments showed that section A did not code the resident’s SSN, ethnicity, preferred language, or whether an interpreter was used on multiple assessments, including the entry, admission, quarterly, and annual MDSs. The monthly summary reports for March, April, and May 2026 identified the resident’s preferred language as Spanish, and the care plan included providing a Spanish communication booklet to help staff understand the resident’s needs. Staff interviews confirmed that the resident could answer simple questions, needed an interpreter or media translator for more detailed communication, and did not speak much English. The MDS Coordinator stated the SSN was left blank because she wanted to verify it and said the assessment would still be accepted without it, but she did not provide further information about the resident’s ethnicity, preferred language, or interpreter use.
Care Plan Not Updated After Fall
Penalty
Summary
The facility failed to update and revise the care plan for Resident #9 after a fall on 4/28/26. The investigation of the fall found that the resident slipped and fell after forgetting to lock the wheelchair while attempting to transfer self, and the Interdisciplinary Team agreed to add an intervention to provide assistance to transfer and ambulate as needed. When the surveyor reviewed the resident’s active care plans with the DON, the fall care plan included interventions from prior falls but did not include the newly identified intervention from this fall. During interview on 6/11/26, the LPN stated that she created care plans with other staff and acknowledged that the intervention for this fall was not included in the care plan. The surveyor also reviewed the facility’s care plan policy, which stated that the comprehensive, person-centered care plan should include measurable objectives and timeframes.
Incomplete Wound Assessment and Delayed Documentation of Treatment
Penalty
Summary
The facility failed to ensure that Resident #135 received treatment and care in accordance with professional standards of practice for wound care. The resident had diagnoses including cellulitis of the right lower limb, cellulitis of an unspecified part of a limb, and congestive heart failure, and had severe cognitive impairment with a BIMS score of 6 out of 15. On observation, the resident was seated in a wheelchair at bedside with bilateral lower extremity dressings and reported no concerns. The resident’s initial skin assessment documented right and left lower leg skin conditions as wounds, but the record did not include wound descriptions such as wound type, size, depth, tissue characteristics, or surrounding skin condition. A wound consultant later assessed chronic vascular wounds on the left posterior lower leg, right posterior lower leg, and left anterior lower leg, documenting measurements, tissue characteristics, and drainage. Physician orders for wound care were entered after the consultant’s assessment, including cleansing and dressing instructions for the lower leg wounds. During interview, an LPN stated that on admission a skin assessment should be completed with an RN within the first 8 hours and that wound findings, including descriptions and measurements, should be documented. The DON acknowledged that at the time of admission the resident’s bilateral lower extremities were dry scabbed areas with edema, but there was no additional documentation describing the wounds. The record review and staff interview showed that the initial nursing assessment did not adequately describe the wounds and there was no documentation of treatment for the bilateral lower extremity wounds prior to the wound consultant’s examination.
Inaccurate Hemodialysis Access Assessment
Penalty
Summary
Facility nurses failed to consistently perform an accurate assessment of a resident's hemodialysis vascular access site. The resident was admitted with end stage renal disease and was dependent on hemodialysis, with an order for dialysis on Mondays, Wednesdays, and Fridays and a care plan directing nurses to assess the inguinal permacath for signs and symptoms of infection, swelling, or excessive bleeding. Nursing notes showed the resident left the facility for the dialysis clinic in the early morning hours on dialysis days and returned later that morning. During the review period, one LPN consistently documented the permacath as intact with no bleeding or infection noted, while another LPN documented the access site as having a bruit and thrill, which are assessment findings used for an AV fistula rather than a permacath. When questioned, that LPN stated she checked for a bruit and thrill. The facility's policies on hemodialysis catheter care and pre/post care did not clearly address how to assess a central venous catheter and did not differentiate between AV fistula and central venous catheter access sites, except to state that central venous catheters are not to be used for blood draws or medication administration.
Opened Latanoprost Bottle Was Left Undated
Penalty
Summary
A medication storage deficiency was identified when surveyors observed an opened and undated bottle of Latanoprost eye drops on the third-floor cart 2 during the medication and storage inspection. The LPN confirmed the observation and stated that the eye drops should have been dated after opening so the expiration date could be calculated, but she did not know when the bottle had been opened or who had opened it. The survey team discussed the concern with the LNHA and DON, and no further information was provided about the opened and undated eye drop container. The manufacturer’s instructions for Latanoprost state that once opened, the bottle may be stored at room temperature for 6 weeks, and the facility policy required medication labels to include an expiration date when applicable.
Missing EBP Signage and PPE Setup for Resident Receiving IV Therapy
Penalty
Summary
The facility failed to follow infection control practices for a resident who had active wounds of the left dorsal foot and left heel, leukocytosis, anemia, and a left upper arm midline vascular access device inserted on 6/6/26. On 6/10/26 at 11:10 AM, the resident was observed receiving IV therapy from an electronic pump at the bedside, but there was no enhanced barrier precaution (EBP) signage or indicators at the room entrance. A review of the resident’s record showed orders for IV Ferrlecit for anemia and IV Zosyn for leukocytosis, both active during the observation period. At 12:12 PM, the surveyor again observed no EBP signage at the room entrance. The LPN Unit Manager acknowledged the resident had active left foot wounds and was receiving IV therapy through an IV access in the upper left arm and should have been on EBP, but there was no signage or PPE bin at the doorway. The Infection Preventionist later acknowledged the resident had an active IV antibiotic and should have been on EBP with signage and a PPE bin at the doorway. The DON also acknowledged the resident should have been on EBP for the wounds and IV access and antibiotic therapy, and that signage and additional PPE should have been in place at the entrance to the room.
Failure to Document Antibiotic Stewardship for a Resident on IV Antibiotics
Penalty
Summary
The facility failed to apply the principles of antibiotic stewardship during the treatment of one resident who was receiving IV antibiotics for leukocytosis. During the initial tour, the resident was observed receiving IV therapy from an electronic pump at the bedside. Review of the electronic health record showed diagnoses including leukocytosis, vascular wounds of the left dorsal foot and left heel, and anemia, and progress notes documented a left upper arm midline vascular access device inserted on 6/6/26. Physician orders showed Zosyn 3.375 grams in 100 milliliters of dextrose to be administered every 8 hours by IV from 6/4/26 through 6/11/26 to treat leukocytosis. The Infection Preventionist stated she was responsible for oversight of antibiotic stewardship and used EMR surveillance tools, direct nursing reports, and antibiotic reports to monitor residents receiving antibiotics. However, the resident was not on the current Infection Surveillance Report dated 6/11/26 even though antibiotics had started on 6/4/26, and the Infection Screening Tool in the EHR was not completed for this resident. The IP and DON acknowledged that no cultures or testing had occurred since 6/4/26 to identify the organism or recommended antibiotic, and they confirmed that antibiotic stewardship documentation was not completed for this resident as required by facility policy.
Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A cognitively impaired resident with a history of elopement and a severely impaired BIMS score was identified as being at risk for wandering and elopement. The resident's care plan included interventions requiring staff to accompany them to meals and scheduled activities. Despite these interventions, the resident was allowed to leave the unit unescorted in their wheelchair after an LPN deactivated the elevator's wander guard system, permitting the resident to travel alone to the lobby. Upon arrival in the lobby, the resident approached the rear exit door, which was equipped with a wander guard alarm. The receptionist at the desk disengaged the alarm, allowing the resident to exit the facility through the rear door. Video footage confirmed that the resident left the building unaccompanied and was last seen on camera propelling their wheelchair through the parking lot and out of view. Staff did not notice the resident's absence until a dinner tray was found untouched during rounds several hours later. The facility's failure to provide adequate supervision and to follow the care plan interventions for a resident at high risk for elopement resulted in the resident leaving the premises unsupervised. The resident was not located until several hours later, when they were found in a nearby town and returned to the facility. The incident occurred despite the wander guard system being operational and no equipment malfunctions being reported.
Sanitation and Labeling Deficiencies in Kitchen and Refrigerators
Penalty
Summary
The facility failed to maintain proper sanitation practices in the kitchen and nutrition refrigerators, leading to potential foodborne illness risks. During a kitchen tour, the surveyor observed that some half sheet pans were soiled with white debris and others were wet when they should have been dry before stacking. Additionally, an undated and unlabeled paper cup containing oatmeal was found on a countertop, which the Culinary Service Director (CSD) acknowledged should not have been there and removed it. In the nutrition refrigerators on the second and third floors, several items were found unlabeled, including tubs of sea salt caramel ice cream, a jar with an unknown food item wrapped in foil, and a carton of eggnog. The Registered Nurse Unit Manager (RN/UM) and Licensed Practical Nurse (LPN) acknowledged that these items should have been labeled with the resident's name and date. The CSD confirmed that these were not facility-stocked items and stated that they would follow up to identify the owners or dispose of the items if necessary. The facility's policies on sanitization and food brought by family/visitors were reviewed, revealing that equipment and utensils should be cleaned and sanitized, and food items should be labeled and stored properly. However, the policies did not address specific drying protocols for dishware and cookware. The Licensed Nursing Home Administrator (LNHA) acknowledged the expectation for personal food items to be labeled and stored correctly, indicating a team effort was needed to ensure compliance with these standards.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to appropriate infection control practices, particularly in the use of Personal Protective Equipment (PPE) and hand hygiene. An LPN entered the room of a COVID-19 positive resident without wearing the required PPE, which included an N-95 respirator mask, gown, and gloves. Despite being aware of the facility's policy, the LPN only wore a surgical mask and gloves, failing to don a gown. Additionally, housekeeping staff were observed exiting rooms of residents on Transmission-Based Precautions (TBP) without removing their PPE, which included gowns and gloves, inside the room as required. Further observations revealed that a Unit Secretary was wearing her surgical mask improperly below her nose and mouth while in the hallway. This was attributed to her not being re-inserviced after returning from vacation. Similarly, during a meal service, four Certified Nursing Assistants (CNAs) did not perform hand hygiene before distributing lunch trays or assisting residents with meal setup, which is a critical step in preventing the spread of infection. The report also highlighted multiple instances where housekeeping staff did not follow proper PPE doffing procedures, such as removing soiled PPE in the hallway instead of inside the resident's room. These actions were observed despite the staff having been previously educated on the correct procedures. The Infection Preventionist and Director of Housekeeping confirmed that staff had been in-serviced on these protocols, yet compliance was not consistently observed during the surveyor's visit.
Deficient Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, specifically in the documentation and handling of controlled substances. The deficiency was identified through a review of DEA 222 Forms and Controlled Drug Administration Records (CDAR). The DEA 222 Form used to order controlled substances was not properly filled out, as the section for recording the number received and the date received was left blank. This form was associated with an order for Schedule II controlled substances, including oxycodone tablets, intended for emergency backup supply. Additionally, discrepancies were found in the CDAR forms for two controlled substances on a medication cart, where the documented available doses did not match the physical quantity present. During the survey, a Licensed Practical Nurse (LPN) admitted to not signing the CDAR immediately after administering medication, citing being in a rush as the reason. The facility's Director of Nursing (DON) confirmed that the staff should document on the CDAR when the medication is removed from the packaging. The surveyor also noted that the facility's policies on medication labeling and storage, as well as administering medications, did not include pertinent information regarding DEA 222 forms or CDAR documentation. This lack of proper documentation and adherence to procedures led to the identified deficiencies.
Medication Administration Errors Exceeding 5% Error Rate
Penalty
Summary
The facility failed to ensure that medications were administered with an error rate of less than 5%, resulting in a medication error rate of 15.38% during an observation. The surveyor observed three nurses administering medications to six residents, with three errors occurring out of twenty-six opportunities. The errors involved two residents, one of whom was unsampled, and were administered by one nurse. The errors included administering Docusate Sodium in tablet form instead of the prescribed capsule form and preparing to open Phenytoin Sodium Extended Capsules, which should not be crushed or opened, for a resident with difficulty swallowing. The surveyor noted that the nurse did not adhere to the medication orders and failed to follow cautionary instructions, such as separating Phenytoin from calcium by at least two hours. Additionally, the nurse left a vial of Budesonide on top of a medication cart while searching for other medications, indicating a lack of proper medication management. The Director of Nursing confirmed that medications should be administered as ordered and that staff should follow medication cautions or warnings, contacting the physician or pharmacy if there are any issues or questions.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications on two of the three medication carts inspected, as observed by the surveyor. During the inspection of Cart 2 on the 2nd floor, the surveyor, accompanied by the Unit Manager/Licensed Practical Nurse (UM/LPN), found a foil package of budesonide inhalant suspension and a foil package of albuterol/ipratropium inhalant solution (DuoNeb) without dates indicating when they were originally opened. The UM/LPN confirmed that these medications should have been dated upon opening. Similarly, on Cart 1, the surveyor, in the presence of the LPN on duty, found a foil package of DuoNeb solution also lacking an opening date. The LPN acknowledged that the vial should have been dated. The surveyor reviewed the facility's policy on Medication Labeling and Storage, which did not include information on dating opened packaging of nebulizer solutions. Additionally, the manufacturer packaging information for both DuoNeb and budesonide specified the time frames within which the medications should be used once opened. The facility's failure to adhere to these guidelines and properly label the medications led to the deficiency noted in the report.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain the dignity of residents during a dining observation on the third floor, involving four Certified Nursing Aides (CNAs). During a lunch meal, the CNAs distributed trays to residents and left them on the table underneath each resident's plate. Additionally, three insulated lids were left in the middle of the tables, and the CNAs placed wrappers and garbage inside those lids, which remained on the tables throughout the entire meal. Furthermore, one CNA was observed standing while feeding an unsampled resident, which was acknowledged by the CNA as inappropriate, as she should have been seated while feeding the resident.
Failure to Accurately Document and Review Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation and review of a resident's advance directives, specifically for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, heart failure, and atrial fibrillation. The resident's paper chart included a POLST form indicating DNR, DNI, and DNH directives, signed by the resident's representative and an advance practice provider. However, the electronic medical record (EMR) did not reflect the DNH status, and there was no care plan related to advance directives. Interviews with facility staff revealed that the process for updating and ensuring the accuracy of advance directives was not followed. The LPN/UM confirmed the discrepancy in the EMR and stated that nursing staff should have ensured the EMR was updated. The Assistant Director of Social Services indicated that social services assess residents for advance directives, but the responsibility for ensuring the POLST directives are carried out lies with the nursing staff. The facility's policy requires that information about advance directives be prominently displayed and communicated to direct care staff, which was not adhered to in this case.
Inaccurate MDS Gender Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to discrepancies in their gender identification. Resident #67, who is male according to the Admission Record, was incorrectly coded as female in both the entry and comprehensive MDS assessments. Similarly, Resident #70, identified as female in the Admission Record, was inaccurately coded as male in the MDS assessments. These errors were identified through a review of the electronic medical records and the MDS assessments by the surveyor. The Registered Nurse (RN) MDS coordinator, responsible for ensuring the accuracy of MDS assessments, acknowledged the inaccuracies upon review with the surveyor. The MDS coordinator stated that the guidance from the MDS 3.0 Manual was followed, yet the errors persisted. The surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about these concerns, highlighting the facility's failure to adhere to federal guidelines requiring that resident gender on the MDS match the information in the Social Security system.
Failure to Adhere to Infection Control Standards in Respiratory Care
Penalty
Summary
The facility failed to adhere to infection control standards in the management of respiratory care for a resident. Specifically, the nasal cannula (NC) tubing used for oxygen delivery was not changed according to the facility's policy, which required a change every Tuesday on the night shift. The NC tubing was observed to be dated 12/18/24, indicating it had not been changed by 12/24/24 as required. Additionally, the NC tubing was found on the floor and not stored in a plastic bag, which is against infection control measures. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) acknowledged these lapses in protocol. The resident involved had a medical history that included congestive heart failure, schizophrenia, and major depressive disorder, and was receiving oxygen therapy as part of their care plan. The resident's cognitive status was intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The facility's Director of Nursing (DON) confirmed that the policy required NC tubing to be changed every 7 days and stored properly when not in use. The surveyor's observations and interviews with staff highlighted the failure to follow these established procedures, leading to the deficiency noted in the report.
Unnecessary Medication Administration in Female Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically involving the administration of Tamsulosin (Flomax) to a female resident. The resident was admitted with diagnoses including COVID-19, heart disease, and a urinary tract infection, and was cognitively intact with a BIMS score of 15 out of 15. The resident had a urinary catheter inserted, and Tamsulosin was prescribed for urinary retention management after the catheter was placed. However, the use of Tamsulosin, which is indicated for benign prostatic hyperplasia in men and not approved for use in women, was not supported by documentation in the resident's medical record regarding its off-label use or a benefit versus risk assessment. The Nurse Practitioner acknowledged the off-label use of Tamsulosin in the female resident but did not document the rationale or any potential benefits in the medical record, considering it a common practice. The surveyor's interview with the Director of Nursing and the Licensed Nursing Home Administrator revealed that the facility did not provide further pertinent information to justify the use of Tamsulosin in this case. The lack of documentation and justification for the off-label use of Tamsulosin in a female resident constitutes a deficiency in the facility's medication management practices.
Failure to Ensure Proper Post-Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis (HD) received services consistent with professional standards of practice. The deficiency was identified when a resident returned from an HD clinic with two empty syringes still connected to their dialysis access site, a permanent intravenous catheter in the upper chest. These syringes, used to flush the catheter with saline post-treatment, should have been removed at the clinic. The oversight was discovered by the resident's family member the following day, who alerted facility staff. The resident, admitted with conditions including end-stage renal disease and dependence on HD, had moderate cognitive impairment. Facility records indicated that the resident's dialysis site was to be assessed for infection or bleeding every shift. However, documentation revealed that the post-treatment assessment was not properly conducted or recorded. The nurse who received the resident back from HD did not perform a thorough check of the catheter site and failed to notice the syringes. Additionally, the dialysis communication report, which should accompany the resident to and from the clinic, was not consistently returned to the facility nurse. Interviews with the Director of Nursing (DON) and the Licensed Practical Nurse (LPN) involved highlighted discrepancies in the documentation and communication processes. The facility's policies required documentation of dialysis treatment and post-treatment observations, but these were not adhered to in this instance. The DON acknowledged the need for proper assessment and documentation upon the resident's return from HD, which was not adequately performed, leading to the deficiency.
Resident Given Wound Cleanser Instead of Water with Oral Medication
Penalty
Summary
A deficiency occurred when a resident was given a clear liquid by mouth to take with their medication, which was later identified as Dakin's solution (Sodium Hypochlorite 0.25%), a wound cleanser, instead of water. The registered nurse responsible for the incident had prepared the Dakin's solution in a drinking cup at the treatment cart and, after being interrupted by the resident requesting pain medication, inadvertently handed the cup containing the wound cleanser to the resident along with their oral medication. The resident immediately reported a burning sensation upon swallowing the liquid, and the incident was reported to the nurse practitioner, primary care physician, and poison control. The resident involved had a history of right femur fracture, hypertensive heart disease, bacteremia, repeated falls, and was cognitively intact according to the most recent assessment. The resident required supervision or assistance with activities of daily living. Facility records and interviews confirmed that the nurse did not follow established procedures for wound care preparation, which require pouring liquid solutions directly onto gauze and not into drinking cups, and also failed to adhere to medication administration protocols that prohibit keeping treatment supplies on medication carts and using inappropriate containers for wound solutions. Observations and interviews with staff revealed that medication carts were to be used exclusively for medications, while treatment carts were designated for wound care supplies. The director of nursing and unit manager both confirmed that the nurse's actions were not in line with facility policy or professional standards. The nurse involved was terminated following the incident and did not respond to follow-up inquiries from facility leadership.
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We read the 1,749 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hackensack
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Prospect Heights Llc | 0.7 mi | ★★★★★ | 21 | 0 |
| Complete Care At Regent Llc | 0.9 mi | ★★★★★ | 2 | 0 |
| Atlas Rehabilitation And Healthcare At Maywood | 1.5 mi | ★★★★★ | 0 | 0 |
| Alaris Health At The Chateau | 1.8 mi | ★★★★★ | 26 | 0 |
| Careone At Teaneck | 1.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.