Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wynwood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident's shower documentation was inconsistent between the MAR and the POC system, with nurses and CNAs recording different information about when showers were given or refused. Staff interviews confirmed that both groups are responsible for ensuring accurate documentation, and facility policy requires records to be complete and accurate. This resulted in a failure to maintain accurate and complete medical records.
A facility failed to maintain a safe, clean, and comfortable environment in resident rooms and utility areas. Surveyors observed linens and debris left on the floor in a resident room, filled trash bags left on the floor in a soiled utility room, a linen cart with a purse and other personal bags stored among clean linens and incontinence briefs, and a trash can without a liner in another room. The LNHA stated housekeeping is expected to clean rooms daily and perform deep cleans, and the facility policy required housekeeping surfaces to be cleaned regularly and when visibly soiled.
Late completion of annual MDS assessments was identified for two residents. The regional MDS coordinator acknowledged that the annual MDSs were completed beyond the required ARD timeframe, and the facility policy stated assessments must be completed and submitted according to federal and state timeframes.
A resident's QMDS was completed after the required ARD window. During survey, the regional MDS coordinator acknowledged the quarterly assessment was late, and facility policy stated the MDS completion date must be no later than 14 days after the ARD.
Two residents had inaccurate MDS coding. One resident with schizophrenia, depression, and a positive PASRR for mental illness was incorrectly coded as not having serious mental illness or intellectual disability on the Significant Change MDS. Another resident with dementia and hospice services was coded as not receiving hospice on quarterly MDSs, even though the ICCP included hospice-related care and the facility’s MDS coordinator acknowledged the mismatch.
A surveyor found a medication card for Gabapentin 100 mg capsules behind the bottom drawer of a medication cart, with 16 capsules remaining, even though the medication belonged to a resident who had already been discharged. An LPN stated discharged residents' medications should be returned to the pharmacy, and the facility did not provide a medication storage policy.
Bed Size and Positioning Did Not Meet Resident Needs: A resident was observed in bed with the feet hanging off the end and the ankles resting on the foot board, and the resident stated he/she could not sleep because the bed was too small. The resident had intact cognition and a height of 72 inches. The ADON and RDCS stated residents should be assessed for a larger bed or extender based on fit, comfort, height, weight, or preference, and the facility policy required ongoing evaluation of individual needs and preferences.
Missing Handrails in Corridor: A surveyor observed a six foot-nine inch section of wall in the South wing near the PT area with no handrail for residents to use on both sides of the corridor. The MA confirmed the finding, and the Administrator was informed of the Life Safety Code deficiency during survey exit. The deficient practice had the potential to affect all 104 residents.
The facility failed to ensure safe smoking practices for residents, leading to inadequate supervision and improper handling of smoking materials. Residents were found with lighters, lighting each other's cigarettes, and resting lit cigarettes on smoking aprons, causing burn marks. Staff did not enforce the smoking policy, resulting in a deficiency identified by surveyors.
A facility failed to protect residents from abuse and did not adequately supervise a cognitively impaired resident with a history of wandering. This resident entered other residents' rooms, leading to physical altercations and inappropriate sexual behavior. Despite awareness of these issues, the facility did not implement effective interventions, resulting in an Immediate Jeopardy situation.
The facility failed to thoroughly investigate injuries and abuse allegations for three residents. One resident with cognitive impairment had an infected wound that worsened, leading to hospitalization and amputation, without proper documentation or physician communication. Another resident's sexual abuse allegation was delayed in investigation, lacking documentation and immediate reporting. A third resident's hip fracture was not thoroughly investigated, with missing documentation and insufficient staff interviews. The facility did not adhere to its policies on unexplained injuries and abuse reporting.
A resident with moderate cognitive impairment and total dependence on staff developed a stage IV pressure injury due to the facility's failure to implement and document necessary interventions. Despite being at risk, the resident's wound progressed to necrotic exposed bone, leading to a hospital transfer and right above-the-knee amputation. The facility did not adequately monitor or report the wound's condition, contributing to the resident's severe health decline.
The facility failed to provide timely incontinence and nail care for residents, as observed by surveyors. A resident reported staff refusal to assist with incontinence care, while another had untrimmed, dirty nails. Several residents were found soaked in urine, and a CNA confirmed that staff shortages led to residents being left soiled. Double incontinence briefs were used improperly, and residents reported being left soiled for extended periods. The facility's policy on daily living activities was not followed.
The facility failed to provide adequate staffing, resulting in residents being left soiled and without proper nail care. Staff shortages led to neglect in incontinence care, with residents found in unsanitary conditions. Additionally, the facility did not ensure staff competency in handling allegations of sexual abuse, as a resident's report of inappropriate touching was not properly documented or addressed.
The facility failed to provide adequate supervision and care for residents, leading to incidents of injury, inappropriate behavior, and insufficient incontinence care. A resident with wandering behaviors was not properly monitored, resulting in injury and inappropriate contact with another resident. The facility also failed to investigate adverse events thoroughly, such as a severe wound requiring amputation and a fracture. Inadequate staffing led to poor incontinence care, and the QAPI program did not address significant concerns, contributing to the facility's deficiencies.
The facility failed to implement effective QAPI systems, leading to deficiencies in managing a wandering resident who committed sexual abuse, inadequate supervision of smoking residents, and neglect in providing incontinence care. Additionally, adverse events like fractures were not properly documented or reviewed.
The facility failed to provide proper pharmaceutical services, as observed during a survey. Issues included an undated and unlabeled prescription medication in a medication room, expired supplies, and undated blood glucose test strip bottles on medication carts. Additionally, discrepancies were found in the administration log for Zolpidem 5mg, which was removed without a physician's order for a resident. The facility's policy on reporting and resolving discrepancies was not followed, raising concerns about accountability and reconciliation of controlled substances.
A resident with a history of confusion and exit-seeking behavior managed to break a window latch and exit the facility, despite having a wanderguard in place. The incident was witnessed by staff and reported internally but was not reported to the DOH as required. The Maintenance Director confirmed the resident exerted enough force to dislodge the window brackets. The LNHA considered the incident an anomaly and did not report it.
A facility failed to complete a Significant Change in Status Assessment (SCSA) within the required 14-day period for a resident who elected hospice services. The resident, diagnosed with cancer and hypertension, began hospice care, but the SCSA was completed 20 days late, as confirmed by the MDS Coordinator.
A resident with hemiplegia reported that their resting hand splint had not been applied for months, despite a physician's order. Observations confirmed the splint was not in use, and staff inaccurately documented its application. The care plan and facility policy on range of motion were not followed, as the splint was found unused in the resident's dresser.
A resident receiving tube feeding expressed a desire for oral feeding, having passed a feeding test. However, the facility failed to document or follow up on this request, maintaining an NPO status without consulting the physician or reviewing swallowing studies. The RD confirmed the resident's history of aspiration and increased tube feeding for wound healing but did not document discussions with the interdisciplinary team or follow up on the resident's preferences, leading to a deficiency.
A resident with congestive heart failure and dementia was prescribed Seroquel for a mood disorder, despite no marked behaviors or appropriate indications for the drug. The facility failed to attempt a gradual dose reduction (GDR) annually, as required by policy, citing contraindications without clear evidence. The care plan was outdated, and staff interviews revealed reliance on psychiatric evaluations that did not document previous GDR attempts.
An LPN in a facility failed to perform hand hygiene during medication administration, risking infection spread. The LPN did not wash hands after removing PPE and before handling medications, despite facility protocols requiring hand hygiene. The facility's Infection Preventionist and policy emphasized the importance of hand hygiene, which was not followed, leading to a deficiency.
Inaccurate and Incomplete Shower Documentation for Resident
Penalty
Summary
The facility failed to ensure that resident records were accurate and complete for one resident regarding documentation of activities of daily living (ADL) care, specifically showers. A review of the medication administration record (MAR) for the resident showed that nurses documented showers on multiple dates throughout the month. However, a review of the Certified Nursing Assistants' (CNA) documentation in the point of care (POC) system indicated discrepancies, including a recorded refusal on one date and showers given on two other dates, with the remaining dates marked as not applicable. Interviews with facility staff, including the unit manager, assistant director of nursing (ADON), a CNA, and an LPN, confirmed that both nurses and CNAs are responsible for documenting showers and that the POC and MAR documentation should match. The facility's policy requires that documentation in the medical record be objective, complete, and accurate. The inconsistency between the MAR and POC documentation for the resident's showers demonstrated a failure to maintain accurate and complete records in accordance with accepted professional standards.
Unsafe and Unclean Resident Rooms and Utility Areas
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment in resident rooms and designated utility areas on 2 of 3 units. In Resident #89's room, the surveyor observed linens on the floor and a pile of debris that appeared to have been swept but was left and not discarded. In the Soiled Utility room near room [ROOM NUMBER], filled trash bags were observed left on the floor and not in the container. A linen cart outside room [ROOM NUMBER] contained personal bags, including a purse, on the top shelf among clean linens and incontinence briefs. In room [ROOM NUMBER]-1, the surveyor observed a trash can with no bag liner. During interview, the LNHA stated that housekeeping is expected to do the rooms daily and deep cleans as well. The facility policy titled, Cleaning and Disinfecting Resident's Rooms, revised August 2013, states that housekeeping surfaces such as floors and tabletops will be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled.
Late Completion of Annual MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive MDS assessments within the required time frame for 2 of 11 residents reviewed for resident assessment. Resident #30 had an annual MDS dated [DATE] that was completed on 6/9/25, which was 3 days late. Resident #40 had an annual MDS dated [DATE] that was completed on 10/22/2025, which was 6 days late. During an interview on 12/05/2025 at 10:05 AM, the regional MDS Coordinator stated that annual MDSs should be completed within 14 days of the ARD and acknowledged that the annual MDSs for Resident #30 and Resident #40 were completed late. The facility policy titled, MDS Completion and Submission Timeframes, revised October 2023, stated that resident assessments would be conducted and submitted in accordance with current federal and state submission timeframes.
Late Quarterly MDS Completion
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (QMDS) within the required time frame for Resident #4. The report states that the QMDS dated [DATE] was completed on 10/21/25, even though it was due on 10/18/25. During an interview on 12/05/2025 at 10:05 AM, the regional MDS Coordinator stated that Quarterly MDSs should be completed within 14 days of the assessment reference date (ARD) and acknowledged that Resident #4's QMDS was completed late. The facility policy titled, MDS Completion and Submission Timeframes, revised October 2023, stated that resident assessments would be conducted and submitted in accordance with current federal and state submission timeframes, and the policy titled, Quarterly Assessments, stated that the MDS completion date would be no later than 14 days after the ARD.
Inaccurate MDS Coding for Mental Illness and Hospice Status
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for two residents. One resident had diagnoses that included schizophrenia and depression, and the level II PASRR showed the resident was positive for a mental illness. However, the resident’s Significant Change MDS incorrectly coded the item asking whether the resident was currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition as 0, indicating no mental illness or intellectual disability. The Regional MDS Coordinator stated that this item should have been coded as 1 because the resident had a serious mental illness or intellectual disability. A second resident was admitted with diagnoses including a mass and lump on the neck and dementia, and the Significant Change MDS dated 5/8/25 indicated the resident was placed on hospice on 5/1/25. However, the quarterly MDS assessments dated 8/8/25 and 11/8/25 coded hospice as 0, indicating the resident was not receiving hospice services. The resident’s current ICCP, revised on 8/13/25 and 10/14/25, included a focus area for hospice services related to senile degeneration of the brain. The Regional MDS Coordinator acknowledged that the MDS did not reflect the resident’s current hospice status, and the facility’s Resident Assessment policy stated that MDS assessments must consistently reflect progress notes, plans of care, and resident observations/interviews.
Discharged Resident Medication Found in Medication Cart
Penalty
Summary
The facility failed to ensure that medications for a discharged resident were properly removed from the medication storage area. During inspection of Medication Cart 1 outside room [ROOM NUMBER], the surveyor, with LPN #1 present, found a medication card for Gabapentin 100 mg capsules behind the bottom drawer of the cart. The card contained 16 remaining capsules and belonged to a resident who had already been discharged from the facility. LPN #1 stated that discharged residents' medications should not have been in the cart because they are returned to the pharmacy. The facility did not provide a policy regarding medication storage.
Bed Size and Positioning Did Not Meet Resident Needs
Penalty
Summary
The facility failed to ensure that Resident #118’s bed and mattress were properly positioned and adjusted to meet the resident’s needs and ensure safety and comfort. During the initial tour, the surveyor observed the resident in bed with the feet extended over the mattress and the ankles resting on the foot board. The resident stated he/she could not sleep at night because the feet were always hanging off the bed and said he/she thought a nurse had been told that the bed was too small. The resident’s MDS showed a BIMS score of 14, indicating intact cognition, and a height of 72 inches. During interviews, the ADON stated residents are assessed for a larger bed if it is noticed that they do not fit or if they say they are uncomfortable, and that residents’ feet should never be hanging off the end of the bed. The RDCS stated that reasons a resident might need a different bed or an extender could include height, weight, or preference, and confirmed that Resident #118 now had a bed extender. The facility policy on Accommodation of Needs stated that the resident’s individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and on an ongoing basis.
Missing Handrails in Corridor
Penalty
Summary
The facility failed to provide handrails on both sides of the corridor. During an observation on 12/02/2025 in the presence of the facility's Maintenance Assistant, the surveyor measured and recorded a six foot-nine inch section of wall in the South wing adjacent to the Physical Therapy area with no evidence of a handrail for residents to use. The Maintenance Assistant confirmed the finding at the time of observation, and the Administrator and Maintenance Assistant were informed of the Life Safety Code deficiency during the survey exit at approximately 1:30 PM. The report states the deficient practice had the potential to affect all 104 residents in the facility.
Inadequate Supervision and Unsafe Smoking Practices
Penalty
Summary
The facility failed to ensure a consistent and safe smoking process for 17 residents identified as smokers. This deficiency was observed through inadequate supervision and monitoring of residents who required assistance while smoking. Specifically, residents were found to be in possession of lighting materials, which they used to light other residents' cigarettes, contrary to the facility's smoking policy. Additionally, residents were observed resting lit cigarettes on their smoking aprons, causing burn marks, and disposing of cigarette ashes improperly. Resident #29, who had contractures and required close supervision while smoking, was observed without adequate supervision. The resident's cigarette was lit by another resident, and the resident was seen resting the lit cigarette on a charred smoking apron. The staff failed to intervene appropriately, and the ashes from the smoking apron were improperly disposed of over the patio and into the bushes. This lack of supervision and improper handling of smoking materials posed a risk of serious injury to the residents. The facility's smoking policy was not effectively communicated or enforced among staff and residents. Staff members, including the Activity Director and CNAs, were observed allowing residents to retain lighters and light each other's cigarettes. The facility's failure to adhere to its own smoking policy and ensure proper supervision and safety measures for residents who smoke led to the identification of this deficiency by the surveyors.
Failure to Protect Residents from Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect residents from physical and sexual abuse and did not ensure adequate supervision for a severely cognitively impaired resident with a history of wandering. This resident, identified as Resident #84, had been documented as wandering into other residents' rooms since February, leading to incidents of physical altercations and inappropriate sexual behavior. On one occasion, Resident #84 was shoved by another resident, resulting in a fall and a skin tear. Additionally, Resident #84 was reported to have inappropriately touched another resident, Resident #94, in a sexual manner, which was not adequately addressed by the facility. The facility's inaction in addressing Resident #84's wandering behavior and inappropriate conduct was evident in the lack of timely interventions and documentation. Despite multiple reports and observations of Resident #84's behavior, including urinating in inappropriate places and entering other residents' rooms, the facility did not implement effective measures to prevent these incidents. The care plan for Resident #84 included interventions such as applying a wander guard and redirecting the resident, but these were not effectively executed, leading to repeated incidents. Interviews with staff and residents revealed that the facility was aware of Resident #84's behavior but failed to take appropriate action. The Director of Nursing and other staff members were not fully informed or did not act on the reports of abuse and wandering. The facility's investigation into the incidents was incomplete, lacking statements from key witnesses and failing to address the full extent of the reported abuse. This lack of action and oversight resulted in an Immediate Jeopardy situation, placing all residents at risk of harm.
Removal Plan
- Resident #84 was placed on a one to one and Resident #84 was discharged from the facility.
- The facility identified that all residents have the potential to be affected. All alert and oriented residents were interviewed by the Social Worker and all remaining cognitively impaired residents had full body skin checks completed to rule out abuse that could have occurred by a resident wandering into their rooms.
- The Director of Nursing and designee began in-servicing all facility staff in every department on the Abuse-Neglect-Exploitation Policy, implementing effective interventions to prevent all residents from abuse and neglect, implementing effective interventions to prevent residents who wander from entering other residents' rooms, protecting residents who wander from being abused, and implementing effective interventions after a resident abuse allegation. This in-servicing will continue until all staff that work in the center are in-serviced. Staff will be in-serviced prior to starting their assignment.
- The LNHA or Director of Nursing will conduct audits on all residents with wandering behaviors by direct observation, resident interviews, and staff interviews to ensure that residents who have the potential to wander into other residents' rooms have effective interventions in place to prevent them from wandering into other residents' rooms and that abuse has not occurred. These audits will be weekly for four weeks, then bi-weekly x four weeks, and then monthly x one month. The Nursing Home Administrator or Director of Nursing will interview five alert and oriented residents regarding abuse. These audits will be weekly for four weeks, then bi-weekly x four weeks, and then monthly x one month. Findings of all audits will be reviewed by the Quality Assurance Committee at the monthly QAPI meetings x three months.
Deficiencies in Investigation of Injuries and Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into injuries of unknown origin and allegations of abuse, leading to deficiencies in care for three residents. One resident, who had moderate cognitive impairment and was dependent on staff for all activities of daily living, was found with an infected wound that required hospitalization and was later diagnosed with osteomyelitis. Despite the worsening condition of the wound, there was no documentation of wound assessments or communication with the physician. The resident was later found with exposed bone and fractures, necessitating hospitalization and eventual amputation. The facility did not document or investigate the wound's progression adequately, and the Director of Nursing (DON) was unable to provide additional information or documentation. Another resident reported an allegation of sexual abuse to an LPN, but the facility delayed the investigation until several days later. The incident was not documented in the resident's medical record, and the investigation lacked a statement from the LPN who initially heard the allegation. The DON and the Social Worker were not fully aware of the details of the allegation, and the investigation did not include all necessary documentation or interviews with involved parties. The facility's policy on abuse reporting was not followed, as the allegation was not reported immediately to the appropriate authorities. A third resident, who had a history of being combative with care, reported new onset pain in the right hip/leg and was later diagnosed with a fracture. The facility's investigation into the injury was incomplete, with missing dates and insufficient documentation of staff interviews. The DON confirmed that the investigation did not go back 72 hours as required, and there was no evidence of a thorough investigation to rule out abuse or neglect. The facility's policy on unexplained injuries was not adhered to, as the investigation lacked critical information and documentation.
Failure to Prevent and Manage Pressure Ulcer Leads to Amputation
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development and worsening of a stage IV pressure injury for a resident. The resident, who had moderate cognitive impairment and was totally dependent on staff for all activities of daily living, was admitted with several diagnoses, including dementia and failure to thrive. Despite being identified as at risk for pressure injuries, the facility did not adequately monitor or document the resident's wound condition, leading to a severe deterioration of the wound. The resident initially had a skin tear on the left lower leg, which was documented but not properly managed, resulting in the wound progressing to necrotic exposed bone. The facility's records showed that skin checks and wound care were supposedly completed, but there was a lack of narrative documentation regarding the wound's condition. The wound was not reported as infected until a nurse practitioner identified it during wound rounds, and the facility failed to notify the physician or wound care team of the infection. The resident was eventually transferred to the hospital, where the wound was diagnosed as infected with osteomyelitis, leading to a right above-the-knee amputation. The facility's failure to document and report changes in the wound condition, as well as to follow their own policy on unexplained injuries, contributed to the resident's severe health decline. The Director of Nursing and Licensed Nursing Home Administrator were unable to provide additional information or rationale for the lack of documentation and intervention.
Inadequate Incontinence and Nail Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide routine and appropriate incontinence and nail care for dependent residents, as evidenced by multiple observations and interviews. A surveyor noted a strong odor of feces in a resident's room, and the resident reported that staff refused to assist with incontinence care. Another resident was observed with long, jagged fingernails coated with a black substance, despite their care plan indicating regular nail maintenance. During an incontinence care tour, several residents were found soaked in urine, and a CNA confirmed that residents were often left soiled due to staff shortages. Further investigation revealed that residents were sometimes left in double incontinence briefs, which were not changed in a timely manner. One resident was found covered in feces and urine, wearing two saturated briefs, and the CNA admitted that this was not the first occurrence. The facility had previously provided education against using double briefs, but staff shortages during certain shifts led to this practice. Interviews with CNAs confirmed that the facility was understaffed, with only two CNAs caring for 45 residents during the night shift, contributing to inadequate care. Additional interviews with residents and their representatives highlighted ongoing issues with incontinence care. One resident reported being left soiled for hours and stated that incontinence care was not provided during the night shift. Another resident's representative mentioned that the resident was left in a chair for an extended period without being changed. The facility's policy on Activities of Daily Living was reviewed, which stated that residents should receive necessary services to maintain hygiene, but the facility failed to adhere to this policy.
Inadequate Staffing and Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient and competent staff to meet the needs of residents, resulting in inadequate incontinence care and nail care. Several residents were found soiled with urine and feces, indicating a lack of timely care. For instance, one resident was observed covered with feces and urine, with saturated double incontinent briefs, bed protector, and sheets. The CNA admitted that due to staff shortages, residents were often left soiled. Another resident reported being left soiled from one night until the next evening, and despite notifying the DON and Administrator, the issue persisted. Additionally, the facility failed to provide proper nail care for a resident who was dependent on staff for ADLs. The resident was observed with overgrown, jagged fingernails with black substances underneath, indicating neglect in personal hygiene care. This further highlights the facility's inability to meet the basic care needs of its residents due to insufficient staffing. The facility also failed to ensure staff competency in handling and documenting allegations of sexual abuse. A resident reported an incident of inappropriate touching by another resident, which was not properly documented or addressed by the LPN. The resident's roommate corroborated the account, stating that the perpetrator had been wandering into their room for months, and despite reporting this to staff, no action was taken. This lack of response and documentation of serious allegations further underscores the facility's deficiencies in staff training and resident safety protocols.
Deficiencies in Resident Supervision and Care
Penalty
Summary
The administrator of the facility failed to ensure effective supervision and care for residents, leading to several deficiencies. A resident with known wandering behaviors was not adequately supervised, resulting in an incident where the resident was injured after being shoved by another resident. Additionally, this resident was involved in an inappropriate sexual incident with another resident, which was not promptly investigated, creating an Immediate Jeopardy situation. The facility also failed to thoroughly investigate adverse events, such as a resident developing a severe wound that progressed to exposed bone and required amputation, and another resident experiencing a fracture that was not promptly addressed. The facility did not maintain adequate documentation and communication regarding wound care, leading to a resident's wound worsening significantly without proper intervention. There was also a failure to report an elopement incident to the Department of Health, as required. Staffing levels were insufficient to meet the needs of residents, resulting in inadequate incontinence care for multiple residents, with some residents being left soiled for extended periods. This lack of care was exacerbated by the practice of double briefing residents, which was against facility policy. The Quality Assurance and Performance Improvement (QAPI) program was not effectively implemented, as it failed to identify and address significant concerns such as resident safety, supervision, and care deficiencies. The program did not include a review of significant or reportable events, and issues such as wandering, incontinence care, and smoking safety were not brought to the QAPI committee's attention. The administrator's lack of awareness and action regarding these issues contributed to the facility's failure to provide adequate care and supervision for its residents.
Deficiencies in Resident Care and Safety Protocols
Penalty
Summary
The facility failed to implement effective systems and procedures for feedback to identify areas for Quality Assurance and Performance Improvement (QAPI). This deficiency was evident in several areas, including the management of a resident known to wander, who had a history of being injured by another resident and subsequently sexually abused another resident. Despite repeated reports from the affected resident and their roommate, the facility did not take adequate measures to address the wandering behavior, leading to a serious incident of sexual abuse. Additionally, the facility did not ensure proper supervision and safety measures for residents who smoked. Observations revealed that residents were lighting each other's cigarettes and handling lighting materials unsupervised, which posed a significant safety risk. Staff were also observed disposing of cigarette waste inappropriately, further indicating a lack of effective supervision and safety protocols for smoking residents. The facility also failed to provide appropriate incontinence and daily living care for several residents. Surveyors noted strong odors of feces and urine in resident rooms, indicating neglect in incontinence care. Residents reported that staff refused to assist with their care needs, and observations confirmed that residents were left soiled due to staffing shortages. Furthermore, the facility did not adequately document or investigate adverse events, such as fractures requiring hospitalization, which were not reviewed or addressed in the QAPI meetings.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, as observed during a survey. In one of the medication rooms, an undated and unlabeled prescription medication, Lidocaine Prilocaine 2.5%/2.5% Cream, was found among over-the-counter medications. The Licensed Practical Nurse (LPN) acknowledged that prescription medications should be labeled, even if intended for backup use, and took steps to remove the item and inform the Unit Manager (UM). Additionally, expired supplies, including syringes and needles, were found in the medication room, which the LPN also removed and reported to the UM. Further deficiencies were noted in the medication carts. In the North wing, an opened blood glucose test strip bottle was found without a date, which is necessary to track its six-month usability period. The LPN responsible for the cart admitted to opening the bottle the previous night but forgetting to date it. Another LPN on the same wing also found an undated test strip bottle and confirmed it should have been dated. Both LPNs took action to discard the undated bottles and inform their UM. A significant issue was identified with the electronic back-up machine (EBM) for controlled substances. The surveyor found discrepancies in the administration log for Zolpidem 5mg, which was removed without a corresponding physician's order for Resident #27. The Director of Nursing (DON) acknowledged the discrepancy and noted that it was not identified until the surveyor's inspection, despite the presence of a UM or Supervisor over the weekend. The facility's policy requires immediate reporting and resolution of such discrepancies, but this was not adhered to, leading to concerns about accountability and reconciliation of controlled substances.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an incident involving a resident who was confused, wandered, and was identified as being exit-seeking. The resident, who had a history of alcohol dependence with withdrawal delirium, difficulty walking, and schizoaffective disorder, managed to break a latch on a window and exited the building. This incident was witnessed by a nurse and a certified nurse aide, who followed the resident outside and brought them back inside. Despite the incident being reported internally to the Director of Nursing (DON) and the Administrator, it was not reported to the Department of Health (DOH) as required. The resident had been assessed for confusion, wandering, and exit-seeking behaviors, and a wanderguard was in place to prevent elopement. However, the wanderguard did not prevent the resident from exiting through the window. The Maintenance Director later confirmed that the resident had exerted enough force to pull the screws out of the window brackets, allowing the window to open fully. The Licensed Nursing Home Administrator (LNHA) stated that they did not believe the incident met the reportable requirement, considering it an anomaly.
Failure to Timely Complete SCSA for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who elected hospice benefits, as required by the Center for Medicare/Medicaid Services (CMS) guidelines. The deficiency was identified for a resident with diagnoses including cancer and hypertension, who began receiving hospice services on March 26, 2024. According to the CMS Resident Assessment Instrument (RAI) 3.0 Manual, an SCSA must be performed within 14 days of a resident's election of hospice services to ensure a coordinated plan of care between the hospice and the nursing home. In this case, the Assessment Reference Date (ARD) for the SCSA was set for April 6, 2024, but the assessment was not completed until April 29, 2024, which was 20 days late. The MDS Coordinator, who confirmed the timeline, acknowledged that the SCSA should have been completed within the 14-day window following the hospice election. This oversight resulted in a failure to adhere to the required timeline for conducting the SCSA, as outlined by CMS regulations.
Failure to Apply Resting Hand Splint as Ordered
Penalty
Summary
The facility failed to follow a physician's order for the application of a resting hand splint to the right hand of a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, reported concerns about the lack of physical therapy and assistance with range of motion (ROM) exercises to prevent further contractures in the right hand. Despite the physician's order dated January 24, 2024, for the application of the resting hand splint in the morning and removal at night, the resident informed the surveyor that the splint had not been applied for months. Observations by the surveyor confirmed that the splint was not in use, and the Treatment Administration Record (TAR) was inaccurately initialed by staff, indicating the splint had been applied when it had not. The resident's care plan, which included the use of the resting hand splint as an intervention, was not adhered to, and there was no documentation in the progress notes from May to July 2024 indicating any refusal by the resident to wear the splint. The facility's policy on range of motion, which requires interventions to maintain and improve ROM, was not followed. The surveyor's review of the resident's electronic medical record and discussions with the resident revealed a lack of compliance with the prescribed care, as the splint was found in the resident's dresser, unused, during the surveyor's visit.
Failure to Address Resident's Nutritional Preferences and Follow-Up
Penalty
Summary
The facility failed to ensure comprehensive follow-up on a resident's nutritional goals and preferences, particularly for a resident receiving nutrition via a tube. The deficiency was identified during a surveyor's interview with the resident, who expressed a desire to receive food orally, stating that they had passed a feeding test conducted by the Veteran's Administration. Despite this, the resident's care plan continued to list them as NPO (nothing by mouth), and there was no documented evidence of follow-up on the resident's request for pleasure feeding. The Registered Dietitian (RD) at the facility confirmed that the resident had a history of aspiration and was agreeable to an increase in tube feeding to aid wound healing. However, the RD did not communicate with the physician regarding the resident's request for oral feeding, nor was there documentation of discussions with the interdisciplinary team about the resident's previous pleasure feedings. Additionally, the RD did not review any available swallowing studies, which were recommended by the Veteran's Administration but had not been scheduled. The facility's Nutritional Management Policy requires that nutritional recommendations be made based on the resident's preferences and clinical condition, followed up with the physician for orders. However, the facility was unable to provide documented evidence of follow-up on the resident's wishes or the scheduling of a swallowing study. This lack of documentation and follow-up led to the deficiency noted in the survey report.
Failure to Attempt Gradual Dose Reduction of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) of an antipsychotic medication, Seroquel (quetiapine), was attempted annually for a resident with congestive heart failure and dementia. The resident, who had no marked behaviors or history of schizophrenia or bipolar disorder, was receiving Seroquel for a mood disorder, which is not a manufacturer's indication for the drug. Despite the absence of behaviors warranting the medication, the facility did not attempt a GDR, citing contraindications without clear evidence of necessity. The resident's care plan, last updated in 2022, included interventions for anxiety, depression, and mood disorder, with a note that the family was not interested in a dose reduction. However, the care plan was not revised to reflect any changes or considerations for a GDR. The facility's policy required an annual GDR unless clinically contraindicated, but this was not adhered to, as the resident continued to receive the medication without a documented attempt at dose reduction. Interviews with facility staff, including the Certified Consultant Pharmacist (CCP) and the Advanced Practice Nurse-Certified (APN-C), revealed a reliance on psychiatric evaluations that deemed a GDR contraindicated. However, these evaluations did not provide specific dates or evidence of previous GDR attempts. The facility's failure to attempt a GDR and the lack of clear documentation and rationale for continued use of Seroquel without marked behaviors or appropriate indications contributed to the identified deficiency.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to minimize the potential spread of infection during medication administration, as observed by a surveyor. On the morning of June 28, 2024, a Licensed Practical Nurse (LPN) was observed preparing medications for a resident on the North Wing. The LPN donned gloves and a PPE gown before entering the resident's room to check blood sugar levels. After exiting the room, the LPN removed the gloves and gown but did not perform hand hygiene before retrieving a syringe and administering insulin to the resident. This lack of hand hygiene was repeated when the LPN prepared and administered medication to another resident, failing to wash hands after removing soiled PPE and before handling medications. The LPN was observed not performing hand hygiene at several critical points during the medication pass, including after removing PPE and before handling medications and the computer keyboard. The LPN admitted to the surveyor that she thought hand hygiene was only necessary when moving from one resident to another, acknowledging the risk of infection spread due to her actions. The Unit Manager and Director of Nursing confirmed that staff were required to perform hand hygiene before and after medication administration, and the facility's policy emphasized the importance of hand hygiene in preventing infection spread. The facility's Infection Preventionist reiterated the expectation for nursing staff to use Alcohol-Based Hand Rub (ABHR) between residents and to wash hands before donning and after doffing gloves. The facility's hand hygiene policy, last revised in May 2024, clearly stated that gloves do not replace hand hygiene and emphasized the need for proper hand hygiene procedures to prevent infection spread. The surveyor's observations and interviews with staff highlighted a failure to adhere to these protocols, resulting in a deficiency in infection prevention and control.
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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 Cinnaminson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverview Estates Rehab And Senior Living Center | 1.9 mi | ★★★★★ | 6 | 0 |
| Willowbrooke Court Skilled Care At Evergreens | 2.5 mi | ★★★★★ | 5 | 0 |
| Sterling Manor | 2.6 mi | — | 0 | 0 |
| Careone At Moorestown | 2.8 mi | ★★★★★ | 1 | 0 |
| River's Edge Rehabilitation & Healthcare Center | 3.4 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.