Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenspring Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, impaired mobility, and incontinence developed a facility-acquired stage 3 pressure ulcer after staff failed to implement or update preventative interventions following the healing of a previous wound. The resident was often observed in bed without evidence of regular repositioning, and documentation of skin assessments and wound care was incomplete, leading to harm.
Five residents were not aware of how to file a complaint with the state licensure office or state survey agency, despite required postings being present on nursing units. The facility's admission packet did not include the necessary contact information, and staff were unaware of this omission until it was pointed out during the survey.
Five residents were not informed about how to file grievances, where to find grievance forms, or who the grievance officer was. During a council meeting, these individuals stated they had never received this information, and review of the admission packet confirmed the absence of grievance education materials. Facility leadership initially believed the information was provided but could not locate it upon review.
The facility allowed multiple staff members, including CNAs, LPNs, and therapists, to work and provide direct care without timely verification of criminal background checks or active, unencumbered licenses and certifications, as required by facility policy. In some cases, staff worked for extended periods without proper screening or with expired credentials.
Facility staff did not review or respond to pharmacy medication regimen reviews in a timely manner for three residents, including those with psychiatric and cognitive disorders. Pharmacy recommendations for medication adjustments and monitoring were not addressed within required timeframes, and when declined, lacked documented rationale. Staff interviews and record reviews confirmed delays and incomplete documentation, in violation of facility policy.
Surveyors found that a scoop was stored directly in bulk flour and serving pans were nested while still wet, contrary to facility policy requiring separate scoop storage and air drying of dishware. Facility leadership confirmed these practices did not meet established sanitary standards.
The facility failed to implement and sustain corrective actions for previously identified deficiencies, resulting in ongoing issues such as incomplete care plans, delayed medication reviews, improper food storage, and errors in COVID-19 vaccine administration. The quality assurance committee did not effectively monitor or address these persistent problems, and audits failed to identify or resolve ongoing non-compliance.
Staff did not maintain the walk-in freezer in safe working order, as the door seal was in disrepair for over seven months, resulting in ongoing condensation and ice accumulation. Despite repeated work orders and an outside vendor's recommendation for door replacement, the issue remained unresolved, and the freezer door continued to be difficult to latch.
A resident with severe cognitive impairment and multiple medical conditions was physically and verbally mistreated by a private duty aide, who was witnessed shoving the resident into a wheelchair and calling the resident 'crazy.' The aide, hired by the family as a companion and not authorized to provide direct care, failed to report the incident or seek staff assistance as required by facility policy. The incident was immediately reported by a housekeeper, and the resident was found to have no injuries or behavioral changes following the event.
A resident was not provided a gradual dose reduction (GDR) for one of their prescribed antidepressants, Trazodone, despite a pharmacy recommendation to reduce both Trazodone and Lexapro. The provider only reduced the Lexapro dose and did not document a reason for not addressing the Trazodone recommendation. Staff interviews and record reviews confirmed that the facility did not fully follow its policy for GDR of psychotropic medications.
Facility staff did not develop or implement a timely and adequate baseline care plan for a resident admitted with a fractured ankle and multiple comorbidities, resulting in a lack of clear guidance for staff on the use and care of an orthotic boot. The care plan was not completed within the required timeframe, lacked individualized interventions, and did not provide the resident or their representative with a copy or summary, contrary to facility policy.
A resident with a left lower extremity fracture and orthotic boot did not have a comprehensive, person-centered care plan that included measurable objectives, timeframes, or specific guidance for the use and application of the boot. Staff and the resident's significant other noted inconsistencies in care, and the care plan was not updated to reflect changes in condition, falls, or new physician orders. The care plan also failed to address cognitive impairment, medication changes, and acute health concerns, contrary to facility policy.
Facility staff did not update or revise care plans for three residents, resulting in care plans that failed to reflect current needs such as activity programming for a non-verbal resident, the use of an electronic monitoring device, and the application and care of an orthotic boot with changes in weight-bearing status. Staff and management interviews, as well as documentation reviews, confirmed that these omissions led to incomplete and inaccurate care plans.
A resident was unable to receive a prescribed PRN cough medication due to it being out of stock, and the LPN did not notify the physician as required by facility policy. The nurse was unaware of the stat box for emergency medications, and the resident ultimately contacted her pulmonologist and was transferred to the hospital without receiving the medication.
A resident with respiratory concerns was not properly assessed by staff before being sent to the ER, and staff failed to communicate with the provider prior to the resident calling 911. Upon the resident's return, the ER report with new medication orders was not promptly reviewed or implemented, and the nurse practitioner did not perform a physical assessment within 24 hours. Documentation was incomplete, and staff did not follow expected protocols for assessment and provider notification.
A resident with confusion and a history of falls experienced multiple incidents while attempting to transfer without assistance. Staff repeatedly documented reeducation and reminders, but did not implement new or modified interventions after each fall, despite facility policy requiring such updates. Leadership confirmed that interventions were duplicated and not adjusted to address the ongoing risk.
A resident with significant weight loss did not consistently receive prescribed nutritional interventions, such as fortified foods and supplements, as outlined in the care plan. Observations and staff interviews confirmed that required items like super soup, super mashed potatoes, and a magic cup were not reliably provided, and meal tickets did not reflect these interventions. Documentation showed ongoing concerns about the resident's nutritional status, but the facility failed to ensure the interventions were implemented as ordered.
Facility staff did not develop or document resident-specific interventions or identify target behaviors for a resident with dementia who was prescribed antipsychotic medication. Although the resident exhibited some behaviors such as wandering and occasional anxiety during care, these were not consistently documented or addressed in the care plan, and the facility failed to provide its dementia care policy when requested.
A resident was unable to receive a prescribed PRN cough medication because it was out of stock, and staff did not promptly notify the provider or utilize available emergency medication resources. The medication was ordered from the pharmacy but was not received in time, and the resident was ultimately transferred to the hospital without having received the needed medication.
Staff failed to maintain a medication error rate below 5%, with three errors in 29 opportunities. Incidents included a resident receiving extended-release morphine instead of immediate-release as ordered, and two residents receiving Vitron-C tablets inappropriately—one tablet was crushed against label instructions and both were not administered on an empty stomach as required. LPNs involved did not consistently follow physician orders or pharmacy labeling, and the facility's policy on the five rights of medication administration was not adhered to.
Staff failed to maintain complete and accurate clinical records for two residents: one resident's POLST form was left incomplete, omitting documentation of CPR and treatment wishes, while another resident's record lacked the required hospice plan of care. These omissions were confirmed through staff interviews and record reviews.
Staff failed to follow infection control protocols by not wearing required PPE when entering a resident's room under contact precautions and by an LPN contaminating gloves during medication administration by touching multiple surfaces before handling medications. These actions were observed and confirmed through staff interviews and policy review.
A resident with multiple chronic conditions and severe cognitive impairment was not offered a pneumococcal conjugate vaccine (PCV20 or PCV21) at least one year after receiving PCV13, as required by CDC guidelines. Facility records and staff interviews confirmed the omission, and no documentation was found to show the vaccine was offered, despite facility policy aligning with CDC recommendations.
Facility staff did not offer an updated COVID-19 vaccine to a resident with multiple chronic conditions and moderate cognitive impairment, despite facility policy and CDC guidelines requiring vaccination offers and documentation. The resident's record showed no evidence of being offered the 2023-2024 or 2024-2025 COVID-19 vaccines after receiving a previous dose in 2022.
Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
Facility staff failed to implement appropriate interventions to prevent the development of a pressure ulcer for a resident with significant risk factors, including severe cognitive impairment, impaired mobility, incontinence, and dependence for turning and repositioning. The resident was admitted with multiple diagnoses and was assessed as high risk for skin breakdown. Despite the healing of a previous stage 2 sacral wound, no new preventative measures were documented or implemented after the wound healed, even though the resident remained at high risk. The care plan included an alternating pressure mattress and gel cushion, but there was no evidence of updated interventions or changes in treatment following the identification of a new wound. Observations and interviews revealed that the resident was frequently found reclining on her back in bed, with limited evidence of regular repositioning or efforts to get her out of bed, despite her dependence on staff for mobility. The resident reported staying in bed too much and not being assisted out of bed as promised. Staff interviews indicated that the resident sometimes refused transfers, but there was no documentation of refusals or of staff attempts to address these issues. Clinical records showed a gap in skin assessments and inconsistent documentation regarding the presence and treatment of wounds, including a lack of information about a new stage 3 coccyx wound and a stage 2 wound on the left buttock. The facility's documentation and skin assessments were incomplete and did not reflect the resident's changing condition or the development of new wounds. There was a lack of timely and appropriate response to the emergence of a stage 3 coccyx wound, with no evidence of revised interventions or updated care planning. The facility's own policy emphasized the importance of prevention and management of pressure injuries, but the actions taken did not align with these standards, resulting in the resident acquiring a facility-acquired stage 3 pressure ulcer.
Failure to Inform Residents of Complaint Filing Procedures
Penalty
Summary
Facility staff failed to ensure that five residents were aware of how to file a complaint with the state licensure office and state survey agency. During a resident council meeting, these residents stated they did not know where the postings with this information were located. Although the surveyor observed that the required postings were present on each nursing unit, the residents remained unaware of their location and content. Further investigation revealed that the facility's admission packet, which was supposed to contain information on how to contact the state licensure and surveyor agencies, did not include this information. The assistant administrator initially stated that the complaint education was provided in the admission packet, but upon review, acknowledged that the information was missing. This lack of accessible and clear information resulted in residents not being properly informed of their rights and the process for filing complaints.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
Facility staff failed to ensure that five residents were informed about the process for filing grievances, the location of grievance forms, and the identity of the grievance officer. During a resident council meeting, these residents stated they were unaware of what a grievance form was or how to file a grievance, and none could identify the grievance officer. The surveyor provided copies of the grievance form to the residents, who confirmed they had never previously received this information. One resident noted the absence of a social worker on their floor, which they felt contributed to the lack of information. Interviews with facility leadership revealed that staff believed grievance education was included in the admission packet, specifically in the "Residence and Care Agreement." However, upon review, neither the surveyor nor the assistant administrator could locate any grievance education materials in the admission packet. These findings were discussed with facility administration and unit managers, who acknowledged the concerns raised.
Failure to Pre-Screen Staff for Background Checks and License Verification
Penalty
Summary
Facility staff failed to implement their abuse prevention policy regarding pre-screening of employees, as evidenced by the review of 12 out of 25 staff records. Specifically, one certified nursing assistant (CNA) was allowed to work for 20 months without confirmation of a completed criminal background check. Interviews with human resources personnel revealed that while background checks were requested, there was no documentation confirming receipt of the results for this employee. The facility's abuse prevention policy requires criminal background checks and verification of licensing or certification for all employees, but this was not consistently followed. Additionally, the facility permitted ten employees, including LPNs, CNAs, occupational therapists, and a speech language pathologist, to provide direct resident care without verifying that they held active and unencumbered licenses or certifications at the time of hire. In several cases, verification was delayed by months or even a year after the employee began working. The facility's own policy mandates that licenses and certifications be verified and tracked upon hire and that employees without active credentials be removed from the schedule, but these procedures were not adhered to. Furthermore, one CNA was allowed to work with an expired certification, as the facility did not verify renewal of the license before permitting continued employment. These findings were confirmed through staff interviews and review of facility documentation, which showed a lack of evidence for timely background checks and license verifications as required by facility policy.
Failure to Timely Review and Respond to Pharmacy Medication Regimen Reviews
Penalty
Summary
Facility staff failed to review and respond to pharmacy medication regimen reviews (MRRs) in a timely manner for three residents. For one resident with diagnoses including psychosis, bipolar disorder, and anxiety disorder, multiple pharmacy consultations recommending gradual dose reductions and monitoring for medication side effects were not addressed or signed by the physician or DON within the expected timeframes. In some cases, recommendations were not addressed for several months, and when eventually reviewed, no rationale was provided for declining the pharmacist's suggestions. Another resident with severe cognitive impairment and diagnoses such as dementia and major depressive disorder also experienced delays in the review and response to pharmacy recommendations. Recommendations for gradual dose reductions and medication tapers were not addressed promptly, and when declined, lacked documented rationale. Facility policy required that the attending physician review and sign the MRRs and document their review of identified irregularities within 30 days, but this was not consistently followed. For a third resident, the facility staff did not respond to a pharmacist's recommendation regarding the concomitant use of Tramadol and Quetiapine in a timely manner, and the physician's rationale for declining the recommendation was left blank. Additional MRRs were not present in the resident's clinical record as required, and there were inconsistencies in provider signatures and documentation. Interviews with nursing staff and providers confirmed delays and lapses in the process of reviewing and acting upon pharmacy recommendations, contrary to facility policy and regulatory expectations.
Improper Food Storage and Dish Handling in Kitchen
Penalty
Summary
During an inspection of the facility's main kitchen, surveyors observed that a scoop was stored inside a bulk flour bin, resting directly in the flour. The executive chef confirmed that this was not the correct procedure and stated that the scoop should be removed and cleaned after each use, rather than being left in the flour. Additionally, a rack containing ready-to-use stainless serving pans was inspected, and eight large pans were found nested together with visible water droplets along their rims. The certified dietary manager acknowledged that the pans should have been air dried before stacking or nesting, and a dry rack was available for proper storage. Facility policies reviewed during the inspection specified that scoops for bulk dry foods must be stored separately in a holder and that all dishware and utensils must be air dried to prevent wet nesting or contamination. The observed practices were not in compliance with these policies or with applicable federal, state, and local regulations regarding sanitary food storage and preparation. These findings were discussed with facility leadership, and no additional information was provided prior to the conclusion of the survey.
Failure to Sustain Correction of Quality Deficiencies Across Multiple Areas
Penalty
Summary
The facility's quality assessment and assurance program failed to implement appropriate plans of action to correct previously identified quality deficiencies, resulting in continued non-compliance across multiple areas. Despite having submitted an approved plan of correction after an earlier survey, the facility did not sustain compliance, as evidenced by repeated deficiencies during a revisit survey. These deficiencies included failures in the development and implementation of comprehensive, resident-centered care plans, timely review and revision of care plans, completion of drug regimen reviews, management of unnecessary psychotropic medications, proper food storage practices, and accurate documentation and administration of COVID-19 immunizations. Specific incidents included staff not implementing nutritional interventions for a resident who experienced significant weight loss, and failing to update care plans to reflect changes in residents' conditions, such as the need for oxygen therapy or interventions to prevent falls. Additionally, recommendations from a pharmacist for gradual dose reductions of psychotropic medications were not addressed in a timely manner, resulting in a resident continuing to receive unnecessary medications. The facility also failed to correct improper food storage practices, as the same issues observed in a previous survey were found again during the revisit. Furthermore, the facility did not properly document or respect a resident's declination of the COVID-19 vaccine, resulting in the vaccine being administered despite the resident's refusal. The quality assurance committee did not effectively monitor or identify ongoing non-compliance, as audits and reviews were either not conducted as planned or failed to detect persistent issues. Meetings and discussions about deficiencies often occurred outside of the formal QAPI process, and there was a lack of evidence that audit findings were reviewed or acted upon in a timely manner.
Failure to Maintain Walk-In Freezer in Safe Working Order
Penalty
Summary
Facility staff failed to maintain the walk-in freezer in proper working order, as evidenced by a door seal that had been in disrepair for over seven months. During an inspection, heavy frozen condensation was observed across the ceiling and on the fan grates of the freezer, with fine ice shavings noted on the floor. The certified dietary manager and executive chef confirmed that the condensation issue had been ongoing for months, requiring staff to scrape and remove condensation at least weekly. Despite work orders being written and maintenance efforts, the problem persisted, and the freezer door remained difficult to latch due to the faulty seal. Interviews with maintenance staff revealed that an outside vendor had assessed the issue and determined that the freezer door needed replacement, providing a quote months prior. However, the door had not yet been replaced, and the maintenance supervisor indicated that the repair was pending approval beyond their authority. Documentation confirmed that the need for door replacement was identified during a vendor visit several months earlier, but no corrective action had been completed at the time of the survey.
Failure to Protect Resident from Physical and Verbal Abuse by Private Duty Aide
Penalty
Summary
A resident with multiple diagnoses, including Parkinson's disease, dementia with behavioral disturbance, and severely impaired cognitive skills, was involved in an incident where a private duty aide, hired by the resident's family, was witnessed shoving the resident back into a wheelchair and referring to the resident as 'crazy.' The incident was observed by a housekeeper who was present in the room at the time. The private duty aide was classified as a companion and was not authorized to provide direct care to residents, according to facility policy. The housekeeper immediately reported the incident to facility staff, and subsequent interviews confirmed that the private duty aide had physically and verbally mistreated the resident. The aide denied calling the resident 'crazy' and claimed to be preventing a fall, but the housekeeper's account was consistent across multiple interviews. The aide had previously cared for the resident in other settings and was familiar to the resident and family, who reported no prior issues. Facility records indicated that the resident was assessed following the incident and showed no physical injuries or changes in behavior. The private duty aide had not provided care to any other residents in the facility. The facility's policies clearly stated that private duty aides were not permitted to provide direct care and were required to report significant events to facility staff, which did not occur in this case.
Failure to Complete Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary psychotropic medications and did not perform a required gradual dose reduction (GDR) for one of the resident's antidepressant medications. Clinical record review showed that while a GDR was completed for Lexapro, no GDR was attempted for Trazodone, despite a pharmacy recommendation to consider dose reductions for both medications. The provider accepted the pharmacy's recommendation but only implemented a dose reduction for Lexapro, leaving the Trazodone dose unchanged without providing a documented reason for not reducing it. The provider's note and the clinical record did not address the pharmacy's recommendation regarding Trazodone. Interviews with staff, including an LPN and regional clinical operations, confirmed that pharmacy recommendations are to be reviewed and acted upon by the physician, with floor nurses and the clinical manager responsible for ensuring recommendations are addressed. Facility policy requires a structured approach to gradual dose reduction for psychoactive medications to avoid unnecessary chemical restraint. However, documentation and staff statements indicated that the process was not fully followed for the resident's Trazodone prescription, resulting in the deficiency.
Failure to Develop and Implement Timely Baseline Care Plan for Resident with Orthotic Boot
Penalty
Summary
Facility staff failed to develop and implement a timely and adequate baseline care plan for a resident who was admitted with multiple complex medical conditions, including a fractured left ankle requiring an orthotic boot, Parkinson's Disease, muscle weakness, history of falls, dementia with severe agitation, and other diagnoses. Upon admission, the resident was non-weight bearing and required the boot at all times, but this status and the specific care instructions for the orthotic boot were not documented in the baseline or interim care plan. The care plan lacked individualized interventions, start dates, review dates, and did not provide staff with clear guidance on how to properly apply or manage the orthotic boot. Observations and interviews revealed that staff and the resident's significant other were aware of the need for the boot and the changes in its use, but there was no consistent or accessible documentation to guide staff on the correct application or care of the boot. The only available signage in the resident's room indicated when the boot should be worn, but not how to secure it, and staff relied on informal communication or memory rather than written instructions. The care plan in the resident's room and the electronic health record were inconsistent, and neither contained adequate or timely updates regarding the resident's changing needs or equipment use. The facility's own policy required an interim care plan to be generated within 8 hours of admission, reflecting the resident's goals and current needs in a format understandable to the resident and/or representative, and to provide a copy to them. However, the baseline care plan for this resident was not completed within the required timeframe, did not address the use or care of the orthotic boot, and there was no evidence that the resident or their representative had been provided with a copy or summary of the care plan.
Failure to Develop and Implement Comprehensive, Measurable Care Plan
Penalty
Summary
Facility staff failed to develop and implement an accurate, comprehensive, person-centered care plan for a resident with a left lower extremity fracture requiring an orthotic boot. The care plan did not include measurable objectives, timeframes, or specific guidance for the use and application of the orthotic boot, despite changes in the resident's weight-bearing status and ongoing use of the device. Observations and interviews revealed that staff and the resident's significant other were aware of inconsistencies in how the boot was applied, and that instructions for proper application were not documented in the care plan. The only reference to the boot was a handwritten entry added after the fact, and there was no detailed guidance for staff on care considerations or changes in the resident's condition. Further review of the care plan and clinical records showed that updates were not made to reflect the resident's evolving needs, including changes in weight-bearing status, fall incidents, and new or changed physician orders. The care plan lacked individualized interventions following multiple falls, and did not address the resident's cognitive impairment, medication changes, or acute health concerns such as hospitalizations and infections. Staff interviews confirmed that care plan updates were not consistently documented, and that there was confusion regarding which version of the care plan was most accurate and how to ensure interventions were measurable and effective. Facility policy required comprehensive, person-centered care plans to be developed within 72 hours of admission, to include measurable objectives and to be updated with any change in condition. However, the care plan for this resident was not completed within the required timeframe, and failed to address the resident's medical, nursing, mental, and psychosocial needs as identified in assessments. The lack of timely and accurate care plan updates resulted in staff not having clear, consistent guidance to meet the resident's needs.
Failure to Review and Revise Care Plans for Multiple Residents
Penalty
Summary
Facility staff failed to review and revise care plans for three residents, resulting in care plans that did not accurately reflect the residents' current needs and conditions. For one resident who was non-verbal and fully dependent on staff for all activities of daily living, the care plan inaccurately stated that the resident preferred to engage independently, despite observations and staff interviews confirming the resident was unable to initiate or pursue leisure or stimulation programs without assistance. The care plan also did not reflect the resident's need for encouragement and escort to group activities, nor did it address the resident's preferences for sensory stimulation as indicated in the Minimum Data Set (MDS) assessments. Another resident had an electronic monitoring device installed in the room by the family, with both video and auditory capabilities. Although the facility administration and staff were aware of the device and had communicated with the family regarding its use and privacy considerations, the resident's care plan did not include any mention of the electronic monitoring device. Interviews with staff and review of facility documentation confirmed that the presence and use of the camera were not reflected in the care plan, despite the expectation that such information should be included to ensure privacy and proper care. A third resident was observed wearing an orthotic boot for a left lower extremity fracture, with changes in weight-bearing status documented in physician and therapy records. However, the care plan did not include any reference to the orthotic boot, specific guidance on its application, or updates reflecting changes in the resident's weight-bearing status. Staff interviews revealed that care directives for the boot were communicated verbally or through signs in the room, but not documented in the care plan. The lack of timely and accurate updates to the care plan resulted in omissions of essential care information, as confirmed by staff and management interviews and review of facility policy.
Failure to Notify Physician of Unavailable PRN Medication
Penalty
Summary
Facility staff failed to follow professional standards of nursing practice by not notifying the physician when a prescribed PRN cough medication was unavailable for a resident. The resident, who had a physician's order for dextromethorphan-guaifenesin oral liquid to be given as needed every six hours for cough, reported that after receiving a dose during the night, she was told in the morning that the medication was out of stock and would need to be ordered. The nurse did not check the stat box for an emergency supply and was reportedly unaware of its existence. The resident was informed that the medication would arrive by 8:00 a.m., then noon, but by 2:30 p.m. it was still not available. The LPN on duty confirmed that the medication was out of stock and had been ordered, but stated that the physician was not notified because it was a PRN medication. Facility policy requires that if a medication is unavailable, the provider should be notified and the conversation documented in the electronic medical record, with possible consideration for alternative medications. The resident, unable to receive her prescribed medication, contacted her pulmonologist and was subsequently transferred to the hospital. Documentation confirmed that no PRN cough medication was administered prior to the resident's transfer.
Failure to Assess, Communicate, and Review Orders for Resident Sent to ER
Penalty
Summary
Facility staff failed to properly assess a resident prior to her being sent to the emergency room, did not communicate with the provider before the resident called 911, and did not review the emergency room report for new orders upon her return. The resident, who had a history of respiratory issues and was under the care of a pulmonologist, reported that her vital signs were not checked and that she had to request oxygen level checks. She independently contacted her pulmonologist and subsequently called 911 herself to be sent to the emergency room for evaluation and treatment of a cough, as she felt the facility could not address her needs. Interviews with staff revealed that the LPN was aware of the resident's actions but did not notify the physician or intervene according to standard procedures. The nurse practitioner did not physically assess the resident within 24 hours of her return from the emergency room, and the emergency room report containing new medication orders was not promptly reviewed or acted upon by the staff. Clinical documentation showed a lack of assessment upon the resident's return and incomplete recording of vital signs. The facility's regional director of clinical operations confirmed that staff did not follow expectations for assessment, provider notification, and timely review of new orders.
Failure to Update Fall Prevention Interventions After Repeated Resident Falls
Penalty
Summary
Facility staff failed to implement effective interventions to prevent falls for a resident with a history of confusion and repeated falls. The resident experienced a fall while attempting to transfer from a wheelchair to bed without assistance, despite existing care plan interventions instructing the resident to call for help. After a subsequent fall under similar circumstances, staff again documented reeducation and reminders, but these interventions were already in place from previous incidents. There was no evidence that new or modified interventions were added to address the ongoing risk, as required by facility policy. Interviews with facility leadership confirmed that the interventions following both falls were duplicative and not updated to reflect the resident's changing needs. The care plan presented by the ADON included interventions not found in the original care plan, and the regional director of clinical operations acknowledged that no new interventions were implemented at the time of the falls. Facility documentation and policy require review and modification of care plans after such incidents, but this was not done, resulting in a failure to adequately address the resident's fall risk.
Failure to Implement Prescribed Nutritional Interventions for Resident with Weight Loss
Penalty
Summary
Facility staff failed to implement prescribed nutritional interventions for a resident who experienced significant weight loss. The resident's care plan included specific interventions such as providing super soup in a mug, super mashed potatoes at lunch and dinner, and a magic cup at dinner. However, during observation, the resident's meal did not include these items as ordered; the soup was served in a bowl rather than a mug, there were no potatoes, and the magic cup was absent. The meal ticket also did not reflect the required interventions, and the resident's spouse confirmed that the correct items were inconsistently provided. Clinical record review showed the resident had notable weight fluctuations, with a 7.58% weight loss over a period of less than two months. The care plan and dietary preferences were documented, but staff interviews revealed a lack of clarity and consistency in implementing these interventions. The certified nursing assistant was unable to confirm if the soup provided was the fortified 'super soup,' and the dietary manager acknowledged that the required supplements were not always listed or prepared as needed. The dietary manager also could not confirm if the correct soup was served on the observed date. Documentation from the registered dietician indicated ongoing concerns about the resident's nutritional intake and weight loss, with recommendations for fortified foods and supplements. Despite these recommendations, the interventions were not reliably provided as ordered. The facility's policy required care plan review and intervention updates in response to significant weight changes, but the observed failure to deliver the prescribed nutritional support contributed to the resident's continued weight loss.
Failure to Develop Resident-Specific Dementia Care Interventions
Penalty
Summary
Facility staff failed to ensure appropriate dementia care was in place for a resident diagnosed with dementia. The care plan for the resident did not include resident-specific interventions or identify target behaviors, despite the resident having a diagnosis of dementia with behavioral disturbances and being prescribed antipsychotic medication. The only mention of behaviors in the care plan was related to medication use, with general approaches such as providing calm, quiet surroundings, but without specifying which behaviors to monitor or how staff should respond when those behaviors occurred. Observations and clinical record reviews showed that the resident was generally calm and engaged during group activities and meals, with no behaviors noted during those times. However, documentation revealed that the resident had exhibited wandering and had one instance of refusing a shower, which was managed with a bed bath. Nursing notes and psychiatric provider notes did not document any significant behavioral changes or target behaviors for staff to monitor. The only behaviors documented by certified nursing assistants were four occurrences that interfered with care, but there were no associated nursing progress notes providing details about these incidents. Interviews with facility staff, including the unit manager and the DON, confirmed that the resident sometimes yelled out or became anxious during care, but these behaviors were not consistently documented or addressed in the care plan. The facility's policy on psychoactive medications required documentation of specific target behaviors and treatment goals, but this was not reflected in the resident's records. Additionally, the facility was unable to provide its dementia care policy during the survey.
Failure to Provide Timely PRN Medication Due to Out-of-Stock and Communication Lapses
Penalty
Summary
Facility staff failed to ensure that a prescribed PRN cough medication was available for a resident who required it. The resident reported that after receiving a dose of the cough medicine during the night, she was unable to receive another dose in the morning because the medication was out of stock. The nurse on duty was unaware of the availability of a stat box for immediate medication needs and did not notify the physician about the unavailability of the PRN medication. The resident was told the medication would arrive by specific times, but it was still not available several hours later. Review of the clinical record confirmed a PRN order for dextromethorphan-guaifenesin, and documentation showed that the medication was out of stock and had been ordered from the pharmacy, but not received in time. The medication administration record indicated that no PRN cough medicine was administered prior to the resident being transferred to the hospital. Facility policy required prompt ordering and provider notification when medications were unavailable, but these steps were not fully followed in this instance.
Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5 percent, with three errors identified out of 29 opportunities, resulting in a 10.3 percent error rate. One incident involved a resident who was administered an extended-release morphine tablet when the physician's order specified immediate-release morphine. The LPN responsible for the medication pass acknowledged the discrepancy after reviewing the resident's clinical record and medication supply, stating uncertainty about why the incorrect formulation was given. The assistant director of nursing confirmed that the nurse should have recognized and clarified the order before administration. Another deficiency involved a resident with documented swallowing difficulties who required medications to be crushed. During medication administration, the LPN crushed and administered a Vitron-C tablet despite the pharmacy label indicating 'Do not crush' and instructions to give the medication on an empty stomach. The LPN stated the resident had not eaten yet, but breakfast was being served at the time, and the medication was not administered as directed by the label and physician's order. A third incident involved a resident who was to receive Vitron-C on an empty stomach. The LPN initially withheld the medication when the resident was eating breakfast but later administered it as lunch was being served, again not adhering to the requirement to give the medication on an empty stomach. The facility's consultant pharmacist confirmed that Vitron-C should not be crushed and should be administered on an empty stomach, as per manufacturer recommendations and physician orders. Facility policy requires staff to verify the five rights of medication administration, which was not consistently followed in these cases.
Incomplete Clinical Records for Advance Directives and Hospice Care
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for two residents. For one resident, the medical provider did not complete or accurately document the resident's CPR wishes on the POLST form, leaving critical sections regarding cardiopulmonary resuscitation orders, initial treatment orders, additional instructions, and medically assisted nutrition blank. This omission was confirmed during interviews with both an LPN and a medical doctor, who acknowledged that the form was incomplete and did not reflect the resident's wishes. The facility's own policies require that such forms be fully completed to guide care, but this was not followed in this instance. For another resident, staff did not maintain a complete clinical record by failing to include the hospice plan of care. Although there was a physician order to admit the resident to hospice, there was no documentation or care plan in the clinical record indicating what care and services hospice would provide. When requested, facility administration was unable to immediately provide the hospice care plan and had to request it from the hospice provider.
Failure to Follow Infection Control Standards During Medication Administration and Contact Precautions
Penalty
Summary
Facility staff failed to adhere to infection control standards in two key areas. On one unit, a physical therapist aide was observed entering and exiting a resident's room under contact precautions without donning the required personal protective equipment (PPE), such as gowns and gloves, as indicated by signage and facility policy. The aide was seen retrieving a gown from the PPE cart outside the room after already entering without any PPE, and then re-entered the room still without donning the necessary protective gear. Interviews with staff and the director of nursing confirmed that the correct procedure was not followed, as PPE should be worn upon entry and removed before exiting the room. Additionally, during medication administration, an LPN was observed wearing gloves while preparing and administering medications, but touched multiple surfaces—including keys, a medication cabinet, the medication cart, and computer equipment—with the same gloved hands before handling medications directly. The LPN then placed the medications into a cup for resident administration. The facility's medication administration policy referenced adherence to nursing standards but did not specifically address glove use during medication administration. The LPN acknowledged the breach in infection control practices when questioned by the surveyor.
Failure to Offer Recommended Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
Facility staff failed to offer a pneumococcal conjugate vaccine (PCV20 or PCV21) to a resident in accordance with CDC guidelines. The resident, who had a history of muscle weakness, dementia, hypertensive heart disease, anxiety disorder, occlusion and stenosis of bilateral carotid arteries, and stage 2 chronic kidney disease, was over the age of 65 and had received a PCV13 vaccine. However, there was no evidence that the resident was offered a subsequent PCV20 or PCV21 vaccine at least one year after the PCV13, as recommended by the CDC for adults in this age group with prior PCV13 vaccination. The deficiency was identified through staff interviews, clinical record review, and facility document review. The resident's medical record and immunization history confirmed the administration of PCV13 but lacked documentation of any offer or administration of PCV20 or PCV21. The Infection Preventionist was unable to provide evidence that the additional pneumococcal vaccine was offered, and the facility's policy required vaccines to be offered per CDC guidelines. No further information was provided to the survey team before the survey exit.
Failure to Offer Updated COVID-19 Vaccine to Resident
Penalty
Summary
Facility staff failed to offer an updated COVID-19 vaccine to one of five sampled residents reviewed for immunizations. Specifically, a resident with multiple diagnoses, including Parkinson's Disease with Dyskinesia, muscle weakness, repeated falls, cognitive communication deficit, glaucoma, hypertension, type 2 diabetes, dementia, and atrial fibrillation, had not been offered the 2023-2024 or 2024-2025 formula COVID-19 vaccines. The resident's most recent assessment indicated moderate cognitive impairment, with a BIMS score of 9 out of 15. A review of the resident's vaccination record showed the last COVID-19 vaccine was administered in October 2022, with no documentation of being offered subsequent updated vaccines. During the survey, the Infection Preventionist confirmed that there was no evidence the resident had been offered the updated vaccines, despite facility policy requiring COVID-19 vaccination history to be obtained, documented, and vaccines offered per CDC guidelines.
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.
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What surveyors actually found near you
We read the 990 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| August Healthcare At Leewood | 3.1 mi | ★★★★★ | 3 | 1 |
| Belvoir Woods Health Care Center At The Fairfax | 4.1 mi | ★★★★★ | 14 | 0 |
| Burke Health & Rehabilitation Center | 4.3 mi | ★★★★★ | 0 | 0 |
| Annandale Healthcare Center | 5 mi | ★★★★★ | 0 | 0 |
| Goodwin House Alexandria | 6.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.