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 Spring Grove Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Unsafe and Unsanitary Environmental Conditions: Surveyors observed ripped linen cart covers, damaged linen cart shelving, and clean linens and gowns stored in carts parked in hallways near resident rooms and precaution areas. They also found grayish, whitish, blackish, and brownish-grayish substances on ceiling vents in a resident toilet room and the South unit central bath, along with chipped paint and exposed wallboard in several resident rooms. The DON, LED, LNHA, and Maintenance Director were present for some observations and acknowledged the conditions.
A nurse administered meds to a resident while the resident was seated on the toilet in the lavatory, rather than waiting until the resident was in a more appropriate setting. The resident had dementia with a BIMS score of 0, and the care plan did not address med administration in the lavatory. The DON stated this was not appropriate, and the facility’s dignity policy prohibited demeaning practices and required staff to treat cognitively impaired residents with dignity and sensitivity.
A resident with COPD, muscle weakness, difficulty walking, and need for assistance with personal care had orders for duloxetine for depression, trazodone for insomnia, and PRN clonazepam for insomnia/anxiety. The chart lacked documented behavior monitoring for the psychotropic meds, the cMDS did not identify an active diagnosis for the antianxiety and antidepressant meds, and the record did not clearly document an indication for insomnia. The LPN/UM confirmed behavior monitoring should be in the eMAR, and the DON stated the clonazepam order and behavior monitoring were clarified after the surveyor’s inquiry.
Inaccurate MDS coding affected two residents. One resident’s MDS omitted active diagnoses such as HTN, anxiety, depression, and DJD despite physician documentation and ongoing use of related meds, while another resident’s MDS failed to reflect repeated refusal of psychotropic meds documented on the eMAR. The RN/MDSC acknowledged both assessments were inaccurate.
Medication administration was documented before the meds were actually given for two residents during a med pass observation. An RN marked the eMAR as meds were prepared and checked them off as administered before entering the rooms, then gave the meds afterward. One resident had severe cognitive impairment with dementia and difficulty walking, and the other had moderate cognitive impairment with type 2 diabetes and GERD. The facility policy stated meds should be initialed on the MAR after each med is given and before moving to the next resident.
A resident with a Stage 3 sacral/coccyx pressure ulcer and multiple chronic conditions, including quadriplegia and DM2, had daily wound care that was not documented on the eTAR for one day. The surveyor also found that a wound care consultant recommended changing the treatment to collagen powder, but there was no contemporaneous documentation that nursing notified the physician or that the physician reviewed, accepted, or declined the recommendation, and the original Triad paste order remained in place.
Missing Nephrostomy Order and Outdated Catheter Care Plan: A resident returned from the hospital with a nephrostomy tube in place, but the chart had no active MD order for nephrostomy management or care at the time of review. In a separate case, another resident’s Foley had been discontinued, yet the care plan still listed an indwelling urinary catheter and UTI-related focus instead of reflecting the current incontinent status.
Surveyors found respiratory care deficiencies involving two residents. One resident receiving O2 at 2 L/min had tubing repeatedly observed on the floor and an undated humidification bottle, despite an order to date and label the equipment and change tubing weekly. Another resident’s neb/O2 tubing was hanging to the floor, with a mask stored in a drawer outside a bag and no dates on the equipment; the resident could not recall whether a neb treatment had been given that day. Facility policy required dated, labeled, and properly stored respiratory equipment.
A resident with OA and chronic pain had PRN pain meds ordered, but the facility did not consistently monitor and document pain levels or administer pain medication according to the physician’s orders. Ibuprofen was given when the resident’s pain score was 1 even though it was ordered for moderate pain of 3 or more, while other PRN pain orders lacked clear pain-scale instructions. The RNS stated the orders were confusing, and the resident said staff dispensed what was ordered by the doctor and that they were not aware of naproxen being prescribed.
Failure to Post Accurate Daily Staffing Reports: Surveyors observed that the NHRCSR was not accurately posted at the front desk before the start of the shift on 2 of 5 days reviewed. On one occasion, the report was dated the prior day and no current report was posted; on another, an incorrectly dated report was displayed and the census did not match the DON’s later staffing information. Interviews showed the SC/HR was responsible for preparing the sheets and the receptionist was expected to post them in the morning, but the reports were not posted accurately when surveyors entered the facility.
The facility failed to complete and accurately document behavioral health monitoring for two residents receiving psychotropic medications. One resident with psychosis, depression, and dementia-related behaviors had multiple missing shift entries and staff used NO and other markings instead of the required side effect codes. Another resident with major depressive disorder, dementia, psychosis, and anxiety had blank behavior-monitoring shifts and inconsistent use of the facility’s required coding system for behavior and side effect documentation.
An LPN was observed preparing meds for a resident when ordered enoxaparin could not be found. The LPN checked the eMAR, documented the med as on order and awaiting delivery, and stated they would wait two days before calling the pharmacy. The resident had an active daily order for enoxaparin for DVT prophylaxis, and the eMAR showed the dose was not administered on two occasions. The DON later stated the LPN should have notified the physician right away, checked backup supply, or arranged immediate pharmacy delivery.
A facility failed to act on CP medication regimen review recommendations for three residents. Issues included unaddressed PRN psychotropic and pain-med orders, lack of stop dates and rationale for PRN insomnia meds, failure to clarify pain scales for PRN analgesics, and an acetaminophen liquid dose that was difficult to measure. Nursing staff acknowledged some of the orders were confusing, and one resident received PRN tramadol even when the documented pain score was 0.
Medication labeling and storage deficiencies were identified in the North unit med storage room and med carts. Surveyors found expired Iodoform packing strips, an opened acetaminophen ER container with no expiration date, a clonazepam blister pack missing a resident label and name but identified by an LPN as belonging to a resident, and an OTC acetaminophen bottle with no expiration date. Staff, including the DON, confirmed the items should have been discarded.
Staff failed to verify a resident's identity before discussing medical information during a care conference, resulting in confidential health details being disclosed in the presence of the wrong resident. The error was discovered when a family member recognized the mistake, leading to a breach of privacy and noncompliance with facility policy.
A resident in a LTC facility sustained an ankle injury during rehabilitation therapy, but there was a delay in notifying nursing staff and assessing the injury. The resident experienced severe pain and swelling, but was not assessed by a nurse until two days later, leading to a delayed diagnosis of a non-displaced fracture. The incident highlighted a communication breakdown between the rehabilitation and nursing departments, as well as a failure to follow documentation policies.
Surveyors observed that the facility failed to provide timely incontinence care to residents, with multiple instances of residents wearing two saturated briefs, contrary to policy. Residents with severe cognitive impairments and those requiring assistance for personal hygiene were not checked and changed every two hours as required. Additionally, a cognitively intact resident reported not receiving incontinence care throughout the day, leading to saturated clothing and equipment.
The facility failed to ensure call bells were within reach for six residents, all with severe cognitive impairments and requiring assistance for ADLs. Observations showed call bells were often on the floor or under beds, contrary to care plans and facility policy. Staff acknowledged the oversight, confirming call bells should be accessible.
The facility failed to issue the required SNF ABN and/or NOMNC for three residents regarding insurance termination. Two residents who stayed in the facility after Medicare Part A coverage ended did not receive the SNF ABN, and a resident discharged to a lesser level of care did not receive a NOMNC. The Administrator cited a change in social service staff as a possible cause.
A facility failed to discontinue a treatment order for a healed wound and did not follow a physician's treatment order for a resident with a history of heart disease and hypertension. Despite the wound being healed, the treatment was still signed off daily. The resident reported not receiving treatments, and inspection confirmed no dressing or gauze was applied. The RN Supervisor and DON were informed of these issues.
A resident with acute respiratory failure and other conditions was not provided with continuous oxygen therapy as prescribed. On two occasions, the resident was found without the oxygen concentrator in use, and when it was used, the oxygen flow was set incorrectly. The RN acknowledged the oversight and corrected the settings, but the facility's policy on verifying physician orders was not followed.
A facility failed to identify psychoactive medication irregularities for a resident with severe cognitive impairment. Despite recommendations for gradual dose reductions of Lexapro and Seroquel by an APN-C, the Consultant Pharmacist did not identify these irregularities during monthly reviews. The physician's notes lacked rationale for not following the recommendations, and there was no documented discussion with the resident's family. The Director of Nursing confirmed the oversight, highlighting a communication breakdown between the CP, nursing staff, and physician.
A resident with Alzheimer's disease, requiring total assistance, fell from bed while being cared for by a single CNA, despite needing a two-person assist. The CNA, newly hired and oriented on safety, acted alone due to insufficient help, resulting in the resident sustaining a forehead abrasion. The CNA was later discharged for policy violation.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment during environmental tours of the North, [NAME], and South units. Surveyors observed multiple linen carts with ripped covers and damaged shelving while clean linens and gowns were stored inside them, including carts parked in hallways between resident rooms and near rooms with posted isolation or precaution signs. The DON and LED were present for some of these observations and confirmed that the items inside the carts were considered clean linens and gowns, while the LNHA later stated the linen carts were brand new. Surveyors also observed environmental cleanliness concerns in resident areas. In one resident room, the toilet room ceiling vent had grayish and whitish substances, and two residents were in their beds in the room at the time. In the South unit central bath, the LNHA accompanied the surveyor and observed ceiling air vents in multiple shower cubicles with grayish, blackish, and brownish-grayish substances. When asked about the material in the vents, the LNHA stated it was not dust and later said it was aesthetic and needed to be painted. Additional observations on the South unit found chipped paint and exposed wallboard behind the bed near the window in three resident rooms, with chipped paint also noted on windowsills in two of those rooms. The Maintenance Director acknowledged the concerns and stated that his rounds did not routinely include resident rooms, and that repairs were addressed through staff submissions in the electronic maintenance system. The facility’s Homelike Environment policy stated that residents are provided with a safe, clean, comfortable, and homelike environment, and the laundry and linen policy stated that clean linen should remain hygienically clean through measures designed to protect it from environmental contamination, such as covering clean linen carts.
Medication Administered While Resident Was on Toilet
Penalty
Summary
The facility failed to treat a resident with respect and dignity during medication administration when the Registered Nurse administered medications while the resident was seated on the toilet in the lavatory. During observation, the nurse prepared the medications, entered the resident’s room, noted the resident was receiving care in the lavatory, and then entered the lavatory to give the medications while the resident remained on the toilet before returning to the med cart. When asked if this was common practice, the nurse stated they had known the resident for a long time and that the resident liked to get medications right away. Resident #43 was admitted with diagnoses including acute embolism and thrombosis, dementia, and difficulty walking. The resident’s comprehensive MDS showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. Review of the resident’s comprehensive care plan did not include any focus, goal, or intervention for administering medications while the resident was in the lavatory or seated on a toilet. The DON later stated that it was not appropriate to administer medications to a resident while seated on a toilet, and the facility’s dignity policy prohibited demeaning practices and required staff to treat cognitively impaired residents with dignity and sensitivity.
Psychotropic Medication Monitoring and Indication Not Adequately Documented
Penalty
Summary
The facility failed to adequately monitor target behavior for psychotropic medications and failed to ensure that an antianxiety medication was ordered for an appropriate diagnosis or indication for one resident reviewed for unnecessary medications. The resident was admitted with diagnoses including COPD, muscle weakness, difficulty walking, and need for assistance with personal care. The March 2026 eMAR showed orders for duloxetine 30 mg daily for depression, trazodone 50 mg at bedtime for insomnia, and clonazepam 0.5 mg every 14 hours PRN for insomnia/anxiety. The record contained no behavior monitoring documented for duloxetine, trazodone, or clonazepam during March. The resident’s most recent cMDS showed a BIMS score of 13/15, indicating intact cognition, and reflected receipt of an antianxiety and antidepressant medication, but did not identify an active diagnosis for those medications. The care plan included focus areas for antianxiety medication use and depression/anxiety related to admission to the nursing facility, with interventions to administer medications as ordered and monitor/document side effects and effectiveness, but it did not document target behaviors for the psychotropic medications. The late entry H&P and physician progress notes documented COPD and anxiety/depression, but there was no documented indication for insomnia in the progress notes. A psychiatric DNP note listed clinical signs and target symptoms of anxiety and depression and included clonazepam, duloxetine, melatonin, and trazodone as psychotropic medications being monitored. During interview, the LPN/UM stated that diagnosis and indication should be based on physician documentation and confirmed behavior monitoring should be in the eMAR, while the DON later stated the clonazepam order was clarified and behavior monitoring was entered after the surveyor’s inquiry.
Inaccurate MDS Coding for Active Diagnoses and Medication Refusal
Penalty
Summary
The facility failed to accurately complete portions of the MDS for 2 of 23 residents reviewed, resulting in assessments that did not reflect the residents’ status as of the ARD. For one resident admitted with COPD, muscle weakness, difficulty walking, and need for assistance with personal care, the March 2026 cMDS with an ARD of 3/5/26 showed a BIMS score of 13 and indicated use of antianxiety, antidepressant, and pain medications, but did not include active diagnoses such as HTN, anxiety, depression, or DJD even though the resident was receiving medications for those conditions and physician documentation reflected those diagnoses. Survey review showed the resident’s MAR included nifedipine for HTN, duloxetine for depression, trazodone for insomnia, clonazepam PRN for insomnia, and tramadol PRN for pain, with multiple administrations documented during the assessment period. The resident’s care plan included focus areas for anxiety, depression, and pain, and the physician H&P and progress notes documented HTN, DJD, and anxiety/depression. The RN/MDSC stated she used physician H&P, physician notes, hospital records, and nursing notes to complete Section I, but acknowledged the MDS was inaccurate and that the active diagnoses should have been included. For the second resident, the quarterly MDS with an ARD of 3/5/26 reflected cognitive impairment consistent with dementia and metabolic encephalopathy, but Section N was not coded accurately to reflect medication refusal. The resident had diagnoses including dementia, major depressive disorder, psychosis, Parkinson’s disease, hemiplegia, aphasia, diabetes, atrial fibrillation, HTN, CKD, and anemia, and the care plan addressed psychosis, depression, dementia-related behaviors, and psychotropic medication use. The eMAR showed repeated refusals of mirtazapine and quetiapine over the seven days before the assessment, yet the MDS did not capture this pattern; the RN/MDSC stated the section had been completed by the SW and acknowledged the assessment was not accurate.
Medication Administration Documented Before Administration
Penalty
Summary
The facility failed to correctly document medication administration during a medication pass observation for 2 of 4 residents observed. The surveyor observed the RN preparing medications for two residents and marking the eMAR as medications were placed into a dose cup, then checking a box indicating the medications had been administered before entering the residents’ rooms. The RN then administered the medications and moved on to the next resident. When asked whether it was common practice to sign for medication administration before the medications were given, the RN stated, “not really, I just hit the button.” Resident #43 had diagnoses including acute embolism and thrombosis, dementia, and difficulty walking, and the cMDS reflected a BIMS score of 0 out of 15, indicating severe cognitive impairment. Resident #69 had diagnoses including type 2 diabetes and GERD, and the quarterly MDS reflected a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The eMARs for both residents showed scheduled medications were documented as received during the observation, and the facility policy stated the individual administering the medication initials the MAR after giving each medication and before administering the next one.
Missing Wound Care Documentation and Unfollowed Consultant Recommendation
Penalty
Summary
The facility failed to ensure that a resident with a Stage 3 pressure ulcer received care and services consistent with professional standards of practice. The resident had diagnoses including quadriplegia, type 2 diabetes mellitus, muscle wasting and atrophy, hypertension, depression, neuromuscular dysfunction of the bladder, hyperlipidemia, anemia, thyrotoxicosis with diffuse goiter, cervical disc disorder with myelopathy, and arthropathy. The resident’s quarterly MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and the care plan identified a Stage 3 sacral pressure ulcer related to immobility and incontinence with interventions that included ordered treatments, monitoring, documentation, and use of a low air loss mattress. The surveyor found that the ordered daily wound care treatment was not documented on the eTAR for one day, and there was no progress note, weekly skin assessment, or other documentation confirming that the treatment had been completed on that date. Although a weekly skin check was listed as complete, there was no documentation specific to the wound care treatment itself. The LPN told the surveyor that the resident was seen by wound care weekly and that wound care was completed daily to the sacrum, and later the DON stated that the nurse probably forgot to sign the eTAR. A typed and signed statement from the nurse, created after the surveyor’s inquiry, stated that the wound treatment had been provided before medication pass but was not signed in the eTAR. The surveyor also found that a wound care consultant evaluated the Stage 3 coccyx wound and recommended changing treatment to collagen powder because the wound was stable and showed granulation tissue with no signs of infection. However, there was no documentation that nursing notified the physician of the recommendation, and no contemporaneous documentation showed that the physician reviewed, accepted, or declined the change in treatment. The existing physician order for Triad paste with border dressing remained unchanged. Later notes entered after the surveyor’s inquiry stated that the doctor opted not to change the dressing, but no prior physician documentation or rationale was present before those late entries.
Missing Nephrostomy Order and Outdated Catheter Care Plan
Penalty
Summary
The facility failed to ensure that an active physician order was in place for the management, care, and monitoring of a nephrostomy tube when a resident returned from the hospital. The resident was observed in bed with a nephrostomy drainage bag in place and functioning, and the resident stated the tube was being used for urine drainage. Record review showed diagnoses including obstructive and reflux uropathy, renal agenesis, urinary calculus, and status involving artificial openings of the urinary tract. The resident’s MDS indicated the presence of an indwelling catheter including a nephrostomy tube, and the care plan included interventions for nephrostomy care, drainage, dressing, monitoring urine, and monitoring the insertion site for infection. The admission summary documented that the resident was readmitted from the hospital with a nephrostomy tube attached to a urine drainage bag at the left lower back, and that admission orders were verified with the physician. However, review of the physician orders and eTAR showed no active physician order for the nephrostomy tube or nephrostomy care at the time of survey review. The record showed that prior nephrostomy orders had existed before the resident’s most recent hospitalization, but no active order had been entered after the resident returned from the hospital. The facility also failed to ensure that the comprehensive care plan accurately reflected the current status of another resident’s urinary catheter after the device was discontinued. The resident had diagnoses including ESBL in urine, was frequently incontinent of bowel and bladder, and the most recent cMDS indicated no indwelling catheter. A physician progress note documented an order to remove the Foley catheter, and a nursing note documented that the Foley was removed with 400 mL output. Although the eTAR later showed catheter care and Foley maintenance orders discontinued, the care plan still reflected an indwelling urinary catheter related to neurogenic bladder and a UTI focus, and it was not revised to reflect that the catheter had been discontinued.
Respiratory Equipment Not Maintained or Labeled Properly
Penalty
Summary
The facility failed to maintain necessary respiratory care and services and failed to follow physician orders for two residents receiving oxygen and nebulizer-related respiratory support. For one resident, surveyors observed oxygen tubing connected to nasal cannula oxygen at 2 L/min laying on the floor while the resident sat in a common area. The tubing was observed on the floor again later, and the humidification bottle was undated. An LPN and later an RNS both confirmed the tubing should not be touching the floor and that the humidification bottle should be dated, but the tubing was only moved off the floor and not replaced. That resident’s record showed diagnoses including a left femur fracture, orthopedic aftercare, and unspecified dementia, with a BIMS score of 3 indicating severe cognitive impairment. The resident had an order for oxygen at 2 L/min via nasal cannula to maintain SpO2 above 90%, and an order to change oxygen tubing, humidifier, and clean the filter weekly on Wednesday night shift and as needed, with tubing and humidifier bottle to be dated and labeled. Surveyors observed the oxygen tubing on the floor again on a later date while the resident was participating in an activity, and the RNS again removed the tubing from the floor without disposing of it or replacing it. For the second resident, surveyors observed oxygen tubing connected to a nebulizer machine hanging to the floor and looped into a drawer, with a mask stored in the drawer not contained in a bag and neither the tubing nor mask labeled with a date of use. On a later observation, the same conditions remained, and the resident stated they could not recall whether they had received a nebulizer treatment that day. The resident’s record showed orders for two medications administered by nebulizer and a care plan directing respiratory treatments and inhalants as ordered and keeping respiratory equipment clean with disposable equipment changed per facility policy. The facility policy required nebulizer equipment to be stored in a plastic bag with the resident’s name and date and tubing changed every seven days or per protocol.
Pain Medication Given Without Clear Pain Scale Documentation
Penalty
Summary
Facility failed to provide safe, appropriate pain management for a resident with intact cognition and diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, malignant neoplasm of endometrium, and bilateral primary osteoarthritis of the knees. The resident’s MDS indicated occasional pain with a pain score of 2 (mild), and the care plan addressed back pain, hand and wrist pain probably due to OA, and chronic pain and/or potential for pain related to arthritis. The physician order summary included an order to monitor for pain every shift and document a pain scale every shift, along with PRN orders for acetaminophen, ibuprofen, and naproxen. During record review, the ibuprofen order was written for moderate pain of 3 or more, but the medication administration record showed ibuprofen was given when the resident’s pain level was 1. The surveyor also found that the acetaminophen and naproxen orders did not specify a pain scale for administration, and the care plan did not include an intervention stating that the resident would tell staff which pain medication to give. Nursing progress notes for the relevant dates did not document that the resident verbalized which pain medication was preferred. In interview, the RNS stated she would ask the resident what the pain was on a 1-10 scale, but also stated the orders for Tylenol and naproxen needed clarification because they did not indicate a pain scale. She further stated she could not explain why ibuprofen was given with a pain scale of 1 and said she would not give it that way. The resident stated they used Motrin for finger pain, were not aware of any other pain medications ordered, did not take naproxen because it was not prescribed, and did not tell nurses which pain medication to give.
Failure to Post Accurate Daily Staffing Reports
Penalty
Summary
The facility failed to ensure that the daily Nursing Home Resident Care Staffing Report (NHRCSR) showing licensed nurse staffing, CNA staffing, and resident census was posted before the start of the current shift on 2 of 5 days reviewed during the annual recertification survey. On 3/24/26 at 8:55 AM, surveyors observed a staffing report posted at the front desk that was dated 3/23/26 and reflected a census of 100 for the day shift, and there was no NHRCSR posted for 3/24/26. The LNHA later provided a 3/24/26 staffing report showing a census of 100 with 2 RNs, 3 LPNs, and 13 CNAs. On 3/27/26 at 8:07 AM, surveyors again observed an incorrectly dated staffing report posted at the front desk, dated 3/26/26 with a census of 100. The LNHA stated the Human Resources/Staffing Coordinator was responsible for posting, and later provided a 3/27/26 report showing a census of 100 with 3 RNs, 4 LPNs, and 14 CNAs, while the DON had earlier provided staffing with a census of 98. The LNHA later acknowledged that two discharges before midnight were not reflected on the 3/27/26 report. Interviews with the DON, Regional Human Resources, receptionist, and LNHA showed the process was for the staffing sheets to be prepared in advance and posted in the morning, but the reports observed by surveyors were not accurately posted at the front desk at the time of entry. The facility policy stated daily staffing numbers are posted for every shift, and another policy stated the number of unlicensed nursing personnel is posted within 2 hours of the beginning of each shift, while the regulation required posting at the beginning of each shift.
Incomplete behavioral health monitoring and inaccurate psychotropic documentation
Penalty
Summary
The facility failed to ensure the implementation and accurate documentation of behavioral health monitoring for 2 of 5 residents reviewed for unnecessary medications. Resident #4 was observed seated in a wheelchair in the hallway and was noted to be confused at baseline, with no behavioral concerns observed during the surveyor’s observations. The resident’s care plan included psychosis, depression, dementia-related behaviors, and psychotropic medication monitoring, with directions to administer medications as ordered and monitor and document side effects and effectiveness each shift. For Resident #4, review of the eMAR and eTAR showed incomplete behavior monitoring documentation, including nine missing night shift entries and two missing day shift entries. The record also showed that staff were not using the facility’s required side effect coding system as ordered; instead of entering code 15 for side effect not seen and code 13 for side effect noted, nurses documented NO, placed markings above initials, or entered information in the wrong column. A nurse told the surveyor that monitoring for mood, behaviors, and medication refusal was completed each shift and documented on the eTAR. Resident #9 had diagnoses including major depressive disorder, dementia, psychosis, and anxiety disorder, and was receiving Seroquel and sertraline with orders to monitor behaviors. The resident was observed self-propelling in a wheelchair and later seated in the day room, smiling but not verbally responding. The March 2026 Behavior Monitoring Record showed four blank shifts for behavior monitoring, X and O markings where monitoring was not completed, and use of markings and NO entries instead of the required codes. Two shifts were also left blank for anti-psychotic side effect monitoring, and the DON and LNHA confirmed that behavior monitoring was not fully completed and that staff were not consistently following the facility’s designated coding system for side effect documentation.
Unavailable Ordered Medication During Med Pass
Penalty
Summary
Pharmaceutical services were not provided in accordance with professional standards when a medication ordered for a resident was unavailable during medication administration. During a med pass observation, an LPN preparing medications for Resident #21 stated that enoxaparin could not be located. The LPN accessed the eMAR, saw that the medication was listed as on order from the pharmacy, and documented that it was awaiting delivery. When asked about the procedure for an ordered medication that had not arrived, the LPN stated that if it did not come within two days they would call the pharmacy, and only then might call the resident’s doctor. Resident #21 was admitted with diagnoses including displaced bicondylar fracture, essential hypertension, and difficulty walking. The resident’s cMDS showed a BIMS score of 14 out of 15, indicating intact cognition. The resident had an order for enoxaparin sodium injection 30 mg/0.3 mL subcutaneously daily for DVT prophylaxis, and the eMAR showed documentation on two dates indicating the medication was not administered. The DON later stated that the LPN should have notified the physician right away and obtained further instructions, checked the backup supply, or called the pharmacy for immediate delivery. The facility policy stated that medications are administered in accordance with prescriber orders, but it did not address missing or undelivered medications.
Failure to Act on CP Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to act on Consultant Pharmacist (CP) recommendations for 3 of 23 residents whose medication regimens were reviewed. The deficiency involved failure to follow irregularity reporting guidelines in the facility’s policies and procedures, including failure to address CP recommendations within the required timeframe and failure to document prescriber responses for identified medication irregularities. For one resident with COPD, muscle weakness, difficulty walking, and intact cognition, the CP recommended clarifying clonazepam, identifying a stop date for PRN use beyond 14 days, and clarifying the pain severity scale for PRN tramadol. The record showed PRN clonazepam, trazodone, melatonin, and tramadol orders, including tramadol being administered on days when the documented pain level was 0. The surveyor also found that the CP recommendation to identify a stop date and document rationale for PRN insomnia medications was not acted upon, and the recommendation to clarify the pain scale for tramadol was not followed. For another resident with hemiplegia/hemiparesis, intracranial hemorrhage, essential hypertension, severe cognitive impairment, and a tracheostomy with mechanical ventilation, the CP recommended changing PRN acetaminophen liquid from 650 mg to 640 mg because the ordered 20.3 mL dose was difficult to measure. The recommendation was signed by nursing staff, but the survey found no timely follow-up on the recommendation in the record. For a third resident with diabetes, chronic kidney disease, endometrial cancer, osteoarthritis, and intact cognition, the CP recommended that if more than one pain medication was used, the facility should include continuity of pain scales across each order and address all choices 1-10. The resident’s orders for acetaminophen, ibuprofen, and naproxen did not include consistent pain-scale parameters, and nursing staff acknowledged the orders were confusing. The facility policy stated that a licensed pharmacist reviews each resident’s medication regimen at least monthly and that irregularities are to be addressed within 30 days of receipt.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly store and label medications and biologicals in accordance with accepted professional principles and the facility’s medication labeling and storage policy. During inspection of the North Nursing Unit med storage room, the surveyor observed a container of Iodoform packing strips with an expiration date of 2/2026 and a container of acetaminophen ER 650 mg that had been opened but had no expiration date. The RN/UM confirmed that the expired medication and packing strips should have been discarded. During inspection of the North nursing unit med carts, the surveyor and staff identified additional labeling problems. A blister pack of clonazepam 1 mg tablets in the narcotic count was missing a medication label and did not include a resident name, although LPN #1 identified it as belonging to Resident #72 and the back of the bingo card showed clonazepam 1 mg tablets with a use-by date. The pack contained 27 tablets, matching the declining inventory sheet. In a separate med cart, a bottle of acetaminophen 325 mg OTC had no expiration date. LPN #1 and LPN #2 each confirmed the items should have been discarded, and the DON stated that all medications should be labeled with the resident’s name and that missing labels or expired medications should be discarded and the pharmacy contacted.
Failure to Safeguard Resident Medical Information During Care Conference
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information and did not follow its own Resident Rights policy. During an interdisciplinary team (IDT) meeting intended to update a resident's family member on their progress, staff mistakenly brought the wrong resident to the meeting. The Unit Manager began reading the intended resident's medication information aloud with the incorrect resident present. The error was identified when the family member on the phone noted that the resident present did not sound like their family member. Upon checking the identification band, staff confirmed that the wrong resident was present, and the meeting was stopped. The resident whose information was disclosed had diagnoses including muscle wasting and atrophy, type 2 diabetes, and chronic lymphocytic leukemia, and was cognitively intact according to assessment records. The facility's Licensed Nursing Home Administrator confirmed that staff did not verify the resident's identity before discussing medical information, which resulted in a breach of privacy and confidentiality. Facility policy and federal standards require verification of resident identity to protect sensitive health information, but this protocol was not followed in this instance.
Delayed Care and Communication Breakdown Following Resident Injury
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident who sustained an injury during rehabilitation therapy. On the day of the incident, the resident twisted their ankle while using a rollator during a physical therapy session. Although the Physical Therapy Assistant (PTA) applied ice and a bandage as a precautionary measure, there was no immediate notification to the nursing staff or physician about the injury. The resident did not initially express significant pain, and the PTA assumed the resident would inform the nursing staff, which did not occur. The following day, the resident was observed to have swelling and reported severe pain in the injured ankle during a physical therapy session. Despite this, there was no documentation in the Nursing Progress Notes regarding the resident's pain or injury on that day. The resident's pain was not assessed by a Registered Nurse until two days after the injury, at which point an x-ray was ordered, revealing a non-displaced fracture of the medial malleolus. The delay in assessment and treatment resulted in a lack of pain management and delayed diagnosis of the fracture. Interviews with facility staff revealed a breakdown in communication between the rehabilitation and nursing departments. The facility's policies required immediate notification of nursing staff following an injury, which did not occur in this case. The nursing staff was unaware of the incident until two days later, leading to a delay in the resident receiving appropriate care and pain management. The facility's documentation policies were not followed, as evidenced by the lack of entries in the Nursing Progress Notes and the Medication Administration Record, which contradicted the physical therapy notes.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to dependent residents, as observed by surveyors on two units. Multiple residents were found wearing two incontinence briefs, both saturated with urine, which is against facility policy. This practice was observed in several residents, including those with severe cognitive impairments and those requiring assistance for personal hygiene. The use of double briefs was noted to potentially cause skin breakdown, as stated by the registered nurses involved in the observations. Specific instances included residents with severe cognitive impairments, such as dementia and Parkinson's disease, who were found with saturated briefs and bedding. These residents were dependent on staff for personal hygiene and required regular incontinence care, which was not provided as per their individualized care plans. The facility's policy was to check and change residents approximately every two hours, but this was not adhered to, leading to the observed deficiencies. Additionally, a resident with intact cognition reported not receiving incontinence care after being transferred to a wheelchair in the morning, remaining in soiled briefs until the evening. This resident's request for two briefs was due to the lack of timely care, resulting in saturated clothing and equipment. The facility's policy and staff statements confirmed that incontinence care should be provided every two hours, yet this was not consistently practiced, leading to the deficiencies noted by the surveyors.
Failure to Ensure Call Bells Within Reach of Residents
Penalty
Summary
The facility failed to maintain the call bell within reach of residents, which was identified for six residents during the survey. Observations revealed that the call bells for these residents were either on the floor, under the bed, or otherwise not accessible to the residents. This deficiency was noted during multiple observations over several days, indicating a pattern of neglect in ensuring that residents could summon assistance when needed. The residents involved in this deficiency had severe cognitive impairments, as indicated by their Brief Interview for Mental Status (BIMS) scores, and required staff assistance for activities of daily living (ADLs). Their individualized care plans included interventions to ensure the call bell was within reach and to remind residents to use it for assistance. Despite these documented interventions, the call bells were consistently found out of reach, compromising the residents' ability to request help. Staff members, including CNAs and RNs, acknowledged the oversight when shown the misplaced call bells and confirmed that the call bells should have been within reach. The facility's policy on answering call lights emphasized the importance of timely responses to residents' needs, yet this policy was not adhered to, as evidenced by the surveyor's findings. The Director of Nursing confirmed the expectation that call bells should always be accessible to residents.
Failure to Provide Required Insurance Termination Notices
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and/or the Notice of Medicare Non-coverage (NOMNC) for three residents who were reviewed for facility change notifications regarding insurance termination. Specifically, the facility did not provide the SNF ABN form to two residents who elected to stay in the facility after their Medicare Part A coverage ended. Additionally, the facility failed to provide a NOMNC form to a resident who was discharged to home or a lesser level of care. The deficiency was identified during a survey when the facility presented a list of residents discharged within six months who were required to receive Beneficiary Notices. The surveyor found that the facility did not comply with the notification requirements for the three residents reviewed. The Administrator attributed the errors to a change in social service staff responsible for providing these notifications, but no further information was provided.
Failure to Discontinue Healed Wound Treatment and Follow Physician Orders
Penalty
Summary
The facility failed to discontinue a treatment order for a healed wound and did not follow a physician's treatment order for a resident. The resident, who was alert and able to communicate their needs, had a history of atherosclerotic heart disease, congestive heart failure, and hypertension. The Minimum Data Set assessment indicated no cognitive deficits. The October 2024 Order Summary Report included orders to clean the resident's toe web spaces and apply gauze daily, as well as to cleanse a deep tissue injury on the right buttock and apply a foam cover daily. However, the Wound Assessment Report from September 2024 noted that the right buttock wound had resolved. Despite the wound being healed, the Treatment Administration Record showed that the nurse continued to sign off on the treatment order for the right buttock daily. During an interview, the RN Supervisor confirmed that the treatment orders were still being signed even though the wound had healed. Additionally, the resident stated they were not receiving any wound treatments, and upon inspection, the RN Supervisor confirmed there was no dressing on the right buttock or gauze between the toes. The Director of Nursing was informed of these concerns regarding the physician treatment orders.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident with acute respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease, and dementia. On two separate occasions, the resident was observed without the prescribed continuous oxygen therapy. Initially, the oxygen concentrator was not in use, despite a sign indicating the need for continuous oxygen. The RN assigned to the resident's care acknowledged the oversight and activated the concentrator, setting it to 2.5 liters per minute (lpm), which was above the prescribed 2 lpm. The following day, the resident was again found without the oxygen concentrator in use. The RN, upon entering the room, realized the mistake and corrected it by turning on the concentrator and setting it to the correct 2 lpm. The facility's policy on oxygen administration, which requires verification of physician orders, was not adhered to, leading to these deficiencies. The RN confirmed the discrepancy between the physician's order and the actual oxygen administration, acknowledging the failure to follow the prescribed order.
Failure to Identify Psychoactive Medication Irregularities
Penalty
Summary
The facility failed to identify psychoactive medication irregularities during the monthly Medication Record Review (MRR) conducted by the Consultant Pharmacist (CP) for a resident. The resident, who was admitted with diagnoses including unspecified dementia, obsessive-compulsive disorder, anxiety, and major depressive disorder, was observed to be frequently drowsy and asleep during the survey. Despite recommendations from an Advanced Practical Nurse/Board Certified Psychiatric Nurse Practitioner (APN-C) for gradual dose reductions (GDR) of Lexapro and Seroquel, the CP did not identify these irregularities in the medication regimen. The resident's medical records showed that the APN-C recommended a decrease in Lexapro and Seroquel doses, but the physician's progress notes did not reflect any rationale for not following these recommendations. Additionally, there was no documented discussion with the resident's family regarding the risks and benefits of the dose reductions. The CP's recommendations from May to September did not address the irregularities between the APN-C's recommendations and the physician's notes. During discussions with the survey team, the Director of Nursing (DON) confirmed that the physician was aware of the GDR recommendations but did not document discussions with the family, which was cited as the reason for not implementing the GDR. The CP also failed to communicate effectively with the nursing staff and physician regarding the medication irregularities, as required by the facility's policies and the Consultant Pharmacist Provider Agreement.
Resident Fall Due to Inadequate Assistance
Penalty
Summary
The facility failed to ensure a resident with Alzheimer's disease remained free from accident hazards, leading to a fall incident. The resident, who was severely cognitively impaired and required total assistance with care, including a two-person assist and the use of a Hoyer lift, fell from the bed while being cared for by a single CNA. The incident occurred when the CNA was providing care alone, despite the resident's care plan indicating the need for two-person assistance. The CNA was lowering the bed and had turned the resident on their side when the resident rolled out of bed onto a floor mat, sustaining an abrasion on the forehead. The CNA involved in the incident was newly hired and had received orientation on resident safety. However, during the incident, the CNA proceeded to provide care without waiting for additional assistance, citing a lack of help as the reason for acting alone. The resident's spouse witnessed the fall and called for help, leading to the involvement of an LPN who assessed the resident. The CNA was subsequently suspended and discharged for violating company policy and code of conduct.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,148 citations issued within 25 miles in the last 12 months — including the 18 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 New Providence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuing Care At Lantern Hill | 1.2 mi | ★★★★★ | 4 | 1 |
| Autumn Lake Healthcare At Berkeley Heights | 2.4 mi | ★★★★★ | 8 | 0 |
| Runnells Center For Rehabilitation & Healthcare | 2.6 mi | ★★★★★ | 11 | 1 |
| Chatham Hills Subacute Care Center | 2.7 mi | ★★★★★ | 17 | 0 |
| Childrens Specialized Hospital Mountainside | 3.5 mi | ★★★★★ | 2 | 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 July 2026) and official state health department websites.