Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Preakness Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities, including muscle weakness and rheumatoid arthritis, had physician orders and CNA documentation requiring a 2-person assist at all times and mechanical lift transfers with 2-person assistance. Assignment sheets and caregiver forms reflected these requirements, and staff acknowledged awareness that the resident was total care and needed two-person assistance for care and transfers. Despite this, a CNA provided care alone, with another CNA only assisting during the mechanical lift transfer. Following this care, the resident was found with a skin tear and finger laceration on the right hand and was later treated in the ER, returning with stitches and a splinted hand for a laceration and finger fracture.
The facility failed to maintain proper kitchen sanitation practices, including improper storage of dented cans and unlabeled opened items, inadequate cleaning of cooking equipment, and improper storage of boxes. Staff violated dress code by wearing large earrings, and a Chef failed to sanitize a thermometer before use. These actions were contrary to the facility's policies, leading to noted deficiencies.
The facility failed to conduct reference checks for 10 newly hired staff members, including RAs, LPNs, and a Registered Dietician, among others. The HR department did not follow the facility's policy requiring at least one employment reference, as confirmed by the Executive Director and HR Secretary.
The facility failed to transmit MDS assessments for 17 residents within the federally mandated 14-day period. Despite attempts to submit weekly, the assessments were delayed by over 120 days. The MDS Coordinator acknowledged the issue, and the facility's policy did not address MDS data transmission.
The facility was found to have a medication administration error rate of 8%, exceeding the acceptable threshold of 5%. An LPN incorrectly crushed Divalproex capsules for a resident with dementia, misunderstanding the MAR instructions. Additionally, an RN prepared the wrong medication for a resident with constipation, realizing the error before administration. These errors were discussed with the LNHA and DON.
A resident with severe cognitive impairment and a preference for Spanish communication was not provided with a communication board or Spanish TV channels, as required by their plan of care. Staff, including an LPN and CNA, were unable to communicate effectively with the resident, highlighting a failure to adhere to the facility's communication protocols.
The facility failed to follow physician's orders for two residents regarding heel booties and for another resident regarding weekly vital signs monitoring. A resident with Parkinson's and a femur fracture was observed without heel booties, despite orders for them to be worn at all times. Another resident with hypertension had no documented weekly vital signs, contrary to physician's orders. Additionally, a resident with severe cognitive impairment was found without heel booties, as required by their physician's order.
A facility failed to develop a comprehensive care plan for a resident with end-stage renal disease who refused dialysis, medication, and meals. Despite the resident's intact cognition and expressed preferences, the care plan did not address these refusals. Nursing staff confirmed the non-compliance and lack of documentation, violating the facility's policy requiring updates to the care plan.
A resident's urinary catheter drainage bag was improperly stored, hanging from the bed's side rail and not in a privacy bag, with tubing above the bed. The resident had a history of paraplegia and neuromuscular dysfunction of the bladder. The RN noted the improper placement and attributed it to the night shift CNA. The facility's policy requires the bag to be below the bladder level, which was not followed.
A facility failed to maintain proper infection control during tracheostomy care for a resident in a persistent vegetative state. The RT did not adhere to hand hygiene protocols, using the same gauze for both sides of the neck and failing to change gloves between tasks. Interviews confirmed the RT's non-compliance with established procedures, compromising infection control and patient safety.
A facility failed to provide appropriate dialysis care for a resident, as the Hemodialysis Communication Record (HCR) was not signed by a nurse for 14 days, and vital signs and dialysis site assessments were not documented. A medication change recommendation was not followed, and the resident's Physician Order Form lacked a diet order. Staff acknowledged these deficiencies, which were contrary to the facility's policy.
Due to staff shortages, a resident did not receive a scheduled shower, and two residents experienced delays in morning care, affecting their daily activities. Staffing reports showed high CNA-to-resident ratios, and missing documentation indicated lapses in care. Interviews with staff confirmed the impact of insufficient staffing on care delivery.
The facility failed to accurately document the receipt of Schedule II controlled substances, as required by DEA 222 Forms. The forms were incomplete, lacking the number received and date received, despite supplier packing slips indicating delivery. The Consultant Pharmacist and DON acknowledged the oversight, which was contrary to the facility's policy and procedure manual.
A resident was prescribed two medications for nausea or vomiting, which had not been used in over 60 days. The facility's Consultant Pharmacist recommended discontinuation, but the physician disagreed without explanation. The lack of specific instructions for these medications could lead to treatment delays if unfamiliar staff were on duty. The facility's policy on medication sequencing was not followed.
A survey revealed deficiencies in medication labeling and storage at a facility. An RN and an LPN acknowledged that opened vials of Novolog insulin and blood glucose test strips were not dated as required. Another LPN found an undated Arformoterol inhalation solution and loose, unidentifiable tablets in a medication cart. The facility's policies on medication storage were not adhered to, leading to these deficiencies.
The facility did not maintain and post the most recent Federal and State inspection results in an accessible area. Instead, outdated results from 2021 were observed at the reception desk. The DON confirmed the 2023 results should have been available and acknowledged the absence of a policy for posting survey results.
Two residents receiving psychoactive medications for behavioral symptoms, such as hallucinations and anxiety, did not have care plans addressing these behaviors, despite ongoing psychiatric assessments and documented episodes. Facility leadership confirmed the absence of care plan focus on these issues, contrary to facility policy requiring behavioral care planning for residents on such medications.
A facility failed to follow its Medical Emergency Response policy for a resident with respiratory distress, leading to a delay in emergency care. The resident, with a history of COPD and heart failure, was found lethargic and using accessory muscles for breathing. Despite these symptoms, the facility used a non-emergency transport service instead of calling 911, delaying the resident's transfer to the hospital. Staff interviews revealed confusion about when to use emergency versus non-emergency transport services.
Failure to Provide Required Two-Person Assistance Resulting in Resident Hand Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required two-person assistance for all care and transfers was provided that level of assistance, resulting in injury. The resident had multiple diagnoses including rheumatoid arthritis, fibromyalgia, muscle weakness, neurocognitive disorder, and hypertension, and an MDS BIMS score of 99 indicating severe cognitive impairment. Physician orders in the record specified “2 Person Assist at all Times for Safety” and “Mechanical Lift Transfers with 2 Person Assist for Safety using a Large Sling Pad.” These requirements were reflected on the CNA Direct Caregiver Form and on the CNA assignment sheet, which coded the resident as needing a mechanical lift with large sling and assistance of two staff. On the date of the incident, CNA assignment records for the 7:00 AM–3:00 PM shift listed the resident under a specific CNA’s assignment with codes indicating mechanical lift and assist of two. The CNA Direct Caregiver Form also documented the two-person assist requirement and included an FYI notation, but the box for that shift was not initialed. Interviews with the regular unit LPN and the resident’s regular CNA confirmed that the resident was total care, required two-person assistance for care and mechanical lift transfers, and that this information was communicated through the assignment sheets and caregiver forms. Staff also reported receiving regular education on care and transfers, including mechanical lifts. Despite these documented requirements and staff awareness, the investigation found that CNA #1 provided care to the resident alone, with CNA #2 only assisting with the mechanical lift transfer. CNA #1 acknowledged knowing that the resident required two-person assistance for care but proceeded to provide care independently. Subsequently, CNA #1 reported to the nurse that the resident had a skin tear on the right hand. Assessment by the RN identified a 2 cm x 0.5 cm skin tear on the right hand and a 1.4 cm x 0.5 cm laceration on the right pinky finger. The resident was later evaluated in the ER and returned with four stitches and a splinted hand, with documentation of a laceration and a fracture of indeterminate age to the fourth finger, establishing that the facility did not ensure the resident’s environment and supervision were free from accident hazards as required.
Kitchen Sanitation and Policy Compliance Deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, as observed during a survey. In the dry storage room, a dented can of sliced potatoes was found among non-dented goods, and several opened items lacked open/use by labels. Additionally, boxes were stored above the 18-inch ceiling clearance in multiple storage areas, and the cooking equipment had a sticky brown substance on it, indicating inadequate cleaning. The Dietary Supervisor and Registered Dietitian were unable to provide explanations for these issues. Further observations revealed that staff members, including the Dietary Supervisor and Chef, wore large hooped earrings, which violated the kitchen dress code. The Chef also failed to sanitize a thermometer before use, acknowledging that it should have been sanitized after being set down. The facility's policies, which were reviewed, outlined proper procedures for handling dented cans, labeling opened items, storing food, cleaning equipment, and maintaining dress code and thermometer sanitization, but these were not followed, leading to the deficiencies noted.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that reference checks were completed for 10 out of 10 newly hired staff members prior to their employment start dates. This deficiency was identified through a review of 10 randomly selected new employee files, which revealed that none of the files contained documentation of reference checks. The staff members included a Recreation Activity Aide, Licensed Practical Nurses, a Registered Dietician, an Occupational Therapist, a Maintenance staff, a Food Service Worker, a Registered Nurse, and a Physical Therapist, all hired between October 2023 and December 2024. During interviews, the Executive Director, Director of Nursing, and Assistant Director of Nursing acknowledged the absence of reference checks, attributing the oversight to the Human Resources department, which is located off-campus. The HR Secretary confirmed that reference checks were not conducted, as the responsibility had temporarily shifted within the department. The facility's policy, as outlined in their Abuse Policy, requires at least one employment reference to be obtained for prospective employees, which was not adhered to in these cases.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) assessments in accordance with federal guidelines for 17 residents. The MDS is a federally mandated tool for clinical assessment of residents, which must be transmitted to the Quality Measure System within 14 days of completion. However, the facility did not transmit the MDS for these residents within the required timeframe, with delays extending over 120 days. The MDS Coordinator, a Registered Nurse, acknowledged the late submissions and stated that attempts were made to submit the assessments weekly, but they were still not transmitted on time. The surveyor reviewed the MDS assessments for the 17 residents and found that all were completed but not transmitted until nearly a month later. The facility's MDS 3.0 Policy, reviewed in June 2023, did not address the transmission of MDS data, contributing to the deficiency. The survey team discussed the issue with the Licensed Nursing Home Administrator, Director of Nursing, and Assistant DON, but no further information was provided to address the concern.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility was found to have a medication administration error rate of 8%, exceeding the acceptable threshold of 5%. This deficiency was observed during a medication pass involving four nurses and five residents, with two errors noted. One error involved a Licensed Practical Nurse (LPN) administering Divalproex to a resident with dementia and behavior disturbance. The LPN incorrectly crushed the contents of the Divalproex capsules, despite the medication administration record (MAR) cautioning against crushing or chewing the contents. The LPN misunderstood the instructions, believing it was acceptable to crush the contents once removed from the capsule. Another error involved a Registered Nurse (RN) preparing medication for a resident with constipation. The RN incorrectly prepared Senna 8.6 mg instead of the prescribed Senna-Plus 8.6-50 mg. The RN realized the mistake after comparing the medication bottles with the MAR, acknowledging the error before administering the medication. These errors were discussed with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), but no further pertinent information was provided by the facility.
Failure to Ensure Communication in Resident's Preferred Language
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring communication in the resident's preferred language, Spanish, as outlined in the plan of care. This deficiency was observed when a surveyor noted that the resident, who spoke Spanish, did not have a communication board in their room, and the television was set to an English channel. During an interaction, both the LPN and CNA were unable to communicate effectively with the resident in Spanish, which hindered the resident's ability to comply with repositioning requests and change the TV channel to Spanish. The LPN acknowledged the absence of a communication board and the need for assistance from the Maintenance department to adjust the TV settings. Further investigation revealed that the resident's medical records indicated a preference for Spanish communication and a need for an interpreter, as documented in the Minimum Data Set and the plan of care. The resident had severe cognitive impairment and was admitted with diagnoses including type 2 diabetes mellitus and essential hypertension. Despite the facility's policy to protect residents' rights to dignified existence and communication, the Registered Nurse Supervisor also struggled to communicate with the resident and was unaware of the Spanish channel settings. The Director of Nursing confirmed the requirement for a communication board, highlighting a lapse in adhering to the facility's communication protocols.
Failure to Follow Physician's Orders for Heel Booties and Vital Signs Monitoring
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice by not following physician's orders for two residents regarding the use of heel booties. Resident #72, who was admitted with conditions including Parkinson's disease and a femur fracture, was observed without the prescribed heel float booties, despite a physician's order for them to be worn at all times. The Treatment Administration Record indicated that the booties were documented as being worn, which was contradicted by the surveyor's observation and the Licensed Practical Nurse's acknowledgment. Additionally, the facility did not comply with a physician's order to document weekly vital signs for Resident #88, who had diagnoses such as hypertension and a history of transient ischemic attack. The Medication Administration Record for December 2024 and January 2025 lacked entries for the weekly monitoring of vital signs, and there was no indication of the scheduled day or frequency. Interviews with nursing staff revealed a lack of clarity and documentation regarding the order, which was not addressed until the surveyor's inquiry. Furthermore, Resident #158, who had severe cognitive impairment and was admitted with type 2 diabetes and hypertension, was also found without the required heel booties. The surveyor's observation and subsequent interviews with nursing staff confirmed the absence of the booties, which were supposed to be in use according to the physician's order. The facility's policies did not adequately address the adherence to physician's orders, contributing to these deficiencies.
Failure to Implement Comprehensive Care Plan for Resident Refusal
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice by not developing and implementing a comprehensive person-centered care plan that included the resident's refusal of care. This deficiency was identified for a resident with end-stage renal disease who was non-compliant with dialysis, medication, and dietary preferences. The resident, who was alert and oriented with intact cognition, expressed a preference for ordering food from outside the facility and refused to attend scheduled dialysis sessions multiple times. The medical records review revealed that the resident had refused dialysis four times and meals five times, and there was no care plan addressing these refusals and non-compliance. Interviews with nursing staff confirmed the resident's non-compliance and the lack of documentation in the care plan. The facility's policy required changes in the resident's status to be reflected in the interdisciplinary care plan, but this was not done, leading to the identified deficiency.
Improper Storage of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure proper storage of a urinary catheter drainage bag for a resident, which could lead to an increased risk of urinary tract infections. During an observation, the surveyor noted that the resident's urinary catheter drainage bag was improperly hung from the bed's side rail in an elevated position and not placed in a privacy bag. The tubing leading to the drainage bag was also positioned above the bed, contrary to best practices for catheter care. The resident involved had a history of paraplegia, neuromuscular dysfunction of the bladder, and hyperlipidemia, and was admitted with an indwelling catheter. The RN acknowledged the improper placement of the drainage bag and attributed it to the night shift CNA's actions. The facility's policy on indwelling catheters, last reviewed in 2019, specifies that the catheter should be secured to facilitate urine flow and that the bag should be below the level of the bladder, which was not adhered to in this instance.
Inadequate Infection Control During Tracheostomy Care
Penalty
Summary
The facility failed to maintain proper infection control practices during tracheostomy care for a resident. The resident, who was in a persistent vegetative state and dependent on all activities of daily living, had a tracheostomy and was attached to a ventilation system. The respiratory therapist (RT) responsible for the resident's care did not adhere to proper hand hygiene and infection control protocols during the tracheostomy care process. The RT was observed performing tracheostomy care without using a paper towel to turn off the water after washing hands, and did not change gloves between different stages of the procedure, such as after cleansing the overbed table with disinfectant wipes and before handling sterile equipment. Additionally, the RT used the same piece of gauze to clean both sides of the resident's neck and tracheostomy area, which is against standard infection control practices. These actions were contrary to the facility's hand hygiene policy and the RT Practice Resource Guide. Interviews with the RT, Vent Program Manager, and Registered Nurse Infection Preventionist revealed acknowledgment of the improper practices and a lack of adherence to established protocols. The RT admitted to not using a paper towel to shut off the water and not changing gloves as required. The Vent Program Manager and RN/IP confirmed that the RT did not perform tracheostomy care correctly, which was essential for infection control and patient safety.
Deficiencies in Dialysis Care Documentation and Medication Management
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, as evidenced by several deficiencies in the documentation and follow-up of dialysis treatment. The Hemodialysis Communication Record (HCR) was not signed by a facility nurse to acknowledge review for 14 consecutive days. Additionally, there was no section on the HCR for documenting vital signs and the condition of the dialysis access site post-treatment, which was not recorded in the medical record for several days. The facility also did not follow a recommendation for a medication change from Epogen to Mircera, as noted in the HCRs. Despite the recommendation, the Physician Order Form and Medication Administration Record continued to reflect an order for Epogen, and there was no evidence of the new medication being administered. Furthermore, the resident's Physician Order Form lacked a diet order, which was confirmed by the Registered Dietician. The Registered Nurse Supervisor and other staff members acknowledged the deficiencies during interviews with the surveyor. The facility's policy required nurses to review the HCR, document vital signs, and assess the dialysis site post-treatment, but these procedures were not consistently followed, leading to the identified deficiencies.
Staff Shortages Lead to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide adequate staffing, resulting in unmet care needs for residents. Specifically, one resident did not receive a scheduled shower due to staff shortages, as reported by the resident during a group meeting with the surveyor. The resident also experienced delays in morning care, which affected their ability to attend a Christmas lunch meal on time. Another resident reported that morning care was delayed over a weekend due to insufficient CNA staffing on their floor. The facility's records corroborated these claims, showing missing signatures on the Weekly Body Inspection forms for certain weeks, indicating a lack of documentation for provided or refused showers. The surveyor's review of staffing reports revealed that the CNA-to-resident ratios on specific dates were higher than optimal, contributing to the care delays. Interviews with facility staff, including a CNA and the Director of Nursing, confirmed that the staffing shortages impacted the ability to provide timely showers and morning care. The facility's policy required weekly showers and skin assessments, but the lack of documentation and staff availability led to deficiencies in meeting these care standards.
Incomplete Documentation of Controlled Substance Receipts
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, specifically in the accurate documentation of the receipt of controlled substances. This deficiency was identified during a review of DEA 222 Forms, which are used to order controlled substances. The forms for four Schedule II controlled substance medications ordered and received by the facility were incomplete, as the section requiring the purchaser to record the number received and the date received was not filled in. This issue was noted on three separate DEA 222 Forms, despite the presence of supplier packing slips indicating delivery. During interviews, the Consultant Pharmacist acknowledged the oversight, stating that the facility must have missed completing those sections, although they were aware of the correct procedure. The Director of Nursing also acknowledged the incomplete forms and agreed that they should have been completed upon receipt of the items. The facility's policy and procedure manual, revised in February 2023, outlines the requirement for completing DEA 222 Forms in accordance with state and federal regulations, yet this was not adhered to in practice.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically involving two medications prescribed for nausea or vomiting. The resident, who was cognitively intact, had been prescribed Ondansetron and Tigan, both as needed for nausea or vomiting. The facility's Consultant Pharmacist had recommended discontinuing these medications as they had not been used in over 60 days, but the physician disagreed without providing a reason. Additionally, the Consultant Pharmacist had previously requested clarification on the administration sequence of these medications, but no response was recorded from the physician. The deficiency was further highlighted during an interview with a Registered Nurse, who admitted that if unfamiliar staff were on duty, they would need to call the physician for clarification, potentially delaying treatment. The facility's policy required specific instructions for medications with the same indication, which was not followed in this case. The issue was discussed with the facility's administration, and the Ondansetron order was eventually discontinued after the surveyor's inquiry.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility was found to have deficiencies in the labeling, disposal, and storage of medications during a survey. On one occasion, a surveyor observed an opened and undated vial of Novolog insulin and a bottle of blood glucose test strips in a medication cart, which were not labeled with the date they were opened. The Registered Nurse present acknowledged that these items should have been dated upon opening. Similarly, another medication cart was found to contain an opened and undated bottle of blood glucose test strips, which the Licensed Practical Nurse confirmed should have been dated. The manufacturer's specifications indicated that these items have specific expiration periods once opened, which were not adhered to. In another instance, a surveyor inspecting a medication cart found a box of Arformoterol inhalation solution without a date indicating when it was opened. The Licensed Practical Nurse confirmed that nebulizer solutions are typically dated, and without a date, it was unclear how long the medication had been stored. Additionally, the surveyor discovered loose tablets and capsules in the cart's drawer, which the nurse could not identify and acknowledged should not be stored in such a manner. These loose medications were subsequently disposed of in the drug disposal device. The facility's policies on medication storage, which require medications to be stored in an orderly and organized manner, were not followed. The policies also stipulate that medications should be stored in their original labeled containers and at appropriate temperatures as per pharmacy or manufacturer guidelines. Despite these policies, the facility failed to ensure proper labeling and storage of medications, as evidenced by the surveyor's findings.
Failure to Post Current Survey Results
Penalty
Summary
The facility failed to maintain and post the most recent Federal and State inspection results in an area that was readily accessible to residents, families, and the public. On January 16, 2025, a surveyor observed that the survey results available at the reception desk were from August 12, 2021, instead of the most recent results from 2023. The Security Staff confirmed the outdated survey results, and the Director of Nursing (DON) acknowledged that the 2023 survey results should have been available. The DON was unaware of why the outdated results were posted and later confirmed that the facility had no policy regarding the posting of survey results, although they followed the regulation to post the most recent results. Despite discussions with the survey team, no additional information was provided by the facility.
Failure to Develop and Implement Behavioral Care Plans for Residents on Psychoactive Medications
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing behavioral issues for residents prescribed psychoactive medications. For one resident with multiple chronic conditions, including dementia with hallucinations and delusions, documentation showed ongoing administration of antipsychotic medication (Olanzapine) for target behaviors such as hallucinations and paranoia. Despite psychiatric assessments and behavioral monitoring indicating the presence of these behaviors, the resident's care plan did not include a focus area, goals, or interventions related to these target behaviors. Another resident, diagnosed with end stage renal disease and anxiety related to hemodialysis, was prescribed an antianxiety medication (Alprazolam) to be administered before dialysis sessions. Progress notes documented episodes of anxiety, including screaming, crying, and expressions of distress, which were managed by staff through redirection and monitoring. However, the care plan for this resident did not address the behavioral issues or include interventions for managing anxiety during dialysis, as identified in psychiatric evaluations and nursing notes. Interviews with facility leadership confirmed that while psychotropic medication monitoring and psychiatric follow-up occurred, there was no corresponding care plan focus on the residents' behavioral issues. Review of facility policy indicated that care plans should be initiated and updated for residents receiving psychoactive medications, but this was not done for the residents in question, resulting in a deficiency under the cited regulation.
Failure to Follow Medical Emergency Response Policy for Resident in Respiratory Distress
Penalty
Summary
The facility failed to follow its Medical Emergency Response policy for a resident in respiratory distress, leading to a deficiency. Resident #2, who had a history of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory issues, and heart failure, was found lethargic and using accessory muscles for breathing. Despite these symptoms, the facility did not call 911 immediately but instead waited for a non-emergency transport service, which delayed the resident's transfer to the hospital. The resident's condition was assessed by the RN/ANS, who determined that the resident was stable and did not require immediate emergency transport. The resident was placed back on a BiPAP machine, and the nurse called the doctor, who ordered the resident to be sent to the emergency room for evaluation of acute respiratory distress. However, the facility used a non-emergency transport service, which took over an hour to arrive, during which time the resident's condition did not improve. Interviews with staff revealed confusion about when to use emergency versus non-emergency transport services. The RN/ANS and other staff members believed the resident was stable and did not require 911, despite the resident's altered mental status and respiratory distress. The facility lacked a clear policy for determining the appropriate type of transport based on residents' symptoms, contributing to the delay in emergency care for Resident #2.
Removal Plan
- Educating all staff on the Non-Emergent Medical Transportation Policy
- Educating all staff on the revised Emergency Medical Response Policy
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Excel Care At Wayne | 0.9 mi | ★★★★★ | 3 | 1 |
| Doctors Subacute Healthcare, Llc | 1.8 mi | ★★★★★ | 6 | 0 |
| Atrium Post Acute Care Of Wayne | 2.3 mi | ★★★★★ | 0 | 0 |
| Windmere | 2.5 mi | ★★★★★ | 7 | 0 |
| Barnert Subacute Rehabilitation Center, Llc | 3 mi | ★★★★★ | 0 | 0 |
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