Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Princess Anne Health & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to notify the physician of missed medication administrations for three residents, including a resident with a PICC line for sepsis treatment and another with diabetes mellitus. Despite the facility's policy requiring physician notification of medication errors, there was no documentation of such notifications, as confirmed by staff interviews.
A resident with multiple health conditions received medications late from the facility's administrator instead of a licensed nurse, due to staff shortages. The medications were administered under the supervision of the DON, who was unable to stand for long periods. This action did not adhere to the facility's policy for safe and effective medication administration.
The facility failed to document incontinence care for two residents, one with severe cognitive impairment and another with stress incontinence. Despite care plans requiring frequent toileting and hygiene assistance, documentation was missing on several dates. CNAs cited staffing issues as a barrier to providing care every two hours, as per the facility's policy.
A facility failed to provide sufficient staffing, resulting in delayed medication administration and inadequate care for residents. A resident with complex medical needs did not receive timely medications, while another experienced hyperglycemia due to delayed insulin administration. Staffing shortages were confirmed through interviews and records, with frequent call-outs and early departures by nurses.
The facility failed to administer medications safely, leading to significant errors for four residents. Medications were either administered late or not at all, and physicians were not notified of these discrepancies, contrary to the facility's policy. This affected residents with various conditions, including diabetes and chronic kidney disease, highlighting a systemic issue in medication administration and communication.
Two residents in an LTC facility did not receive care as per their comprehensive care plans. One resident's medications were administered at incorrect times, while another resident did not receive consistent incontinence care due to staffing issues. These deficiencies were acknowledged by the facility's administrative staff.
A resident with diabetes and osteoarthritis, requiring maximum assistance for personal care, did not have documented pressure ulcer care on two occasions as per the facility's policy. An LPN confirmed the absence of evidence for the treatments, which was communicated to the facility's leadership.
Failure to Notify Physician of Missed Medications
Penalty
Summary
The facility failed to notify the physician of a change in condition for three residents, leading to deficiencies in medication administration. Resident #1, who was cognitively intact and required moderate assistance for daily activities, did not receive medications as ordered, including Clopidogrel and Aspirin, which were administered late. The facility's Medication Error policy requires physician notification of such errors, but there was no documentation of this notification. Resident #4, also cognitively intact, was at risk for complications due to diabetes mellitus. The resident did not receive the prescribed Mounjaro injection on two occasions due to a drug shortage, yet the physician was not notified. The facility's policy mandates notifying the physician of medication errors, but this was not documented. Resident #6, who had a PICC line for intravenous medication, missed several doses of Cefazolin for sepsis. Despite the facility's policy requiring physician notification of medication errors, there was no documentation of such notification. Interviews with facility staff confirmed that the physician was not informed of these missed medications, highlighting a systemic issue in communication and adherence to policy.
Medication Administration by Non-Licensed Staff
Penalty
Summary
The facility staff failed to meet professional standards by not administering medications as ordered to a resident. The resident, who was admitted with conditions including hemiplegia, diabetes mellitus, cerebrovascular accident, and chronic kidney disease, was cognitively intact and required moderate assistance for certain activities. The comprehensive care plan highlighted the risk of bleeding due to antiplatelet use, and the physician's orders specified a regimen of medications to be administered at specific times. However, the medication administration record showed that the medications were given late, at 1:14 PM instead of the scheduled 8:00 or 9:00 AM. The deficiency occurred when the facility's administrator, not a licensed nurse, administered the medications to the resident. This was done under the supervision of the Director of Nursing (DON), who was unable to stand for long periods and was on the medication cart in the hallway. The administrator took the medications from the DON, delivered them to the resident, and ensured they were taken with water. The resident confirmed receiving the medications late due to staff shortages on a Sunday. The facility's policy requires medications to be administered safely and effectively, reviewing the five rights of medication administration, which was not adhered to in this instance.
Failure to Document Incontinence Care for Two Residents
Penalty
Summary
The facility staff failed to provide evidence of activities of daily living (ADL) care, specifically incontinence care, for two residents. Resident #2, who was admitted with diagnoses including dementia, COVID, and a fractured right femur, was severely cognitively impaired and required maximum assistance for various ADLs. The comprehensive care plan indicated the resident was incontinent and required toileting hygiene with brief changes. However, documentation of incontinence care was missing on several dates across different shifts in December 2023 and January 2024. Interviews with CNAs revealed that incontinence care was intended to be provided every two hours, but staffing issues sometimes prevented this from occurring. The facility's urinary elimination policy required frequent care and documentation of voiding, but this was not consistently evidenced. Similarly, Resident #3, who was cognitively intact but dependent on assistance for most ADLs, was occasionally incontinent due to stress incontinence, reduced mobility, and weakness. The care plan required assistance with toileting and hygiene as needed. However, documentation of incontinence care was also missing on multiple dates in April and May 2024. Interviews with CNAs confirmed that while the goal was to provide care every two hours, staffing shortages sometimes hindered this. The facility's policy emphasized the need for frequent care and documentation, which was not adequately maintained for Resident #3 either.
Inadequate Staffing Leads to Delayed Care and Medication Errors
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by multiple instances of inadequate nurse coverage across various units. On several occasions, there were no nurses present during shifts, and in some cases, only one CNA was available to cover an entire unit. This lack of staffing led to delays in medication administration and inadequate care for residents. For example, on Unit 200, a resident did not receive their scheduled medications on time due to the absence of a nurse, which was confirmed by the medication administration record. Resident #1, who was cognitively intact and required moderate assistance for daily activities, did not receive their medications at the scheduled time on April 14, 2024. The medications were administered several hours late, which could have impacted the resident's health, given their complex medical history, including hemiplegia, diabetes mellitus, and chronic kidney disease. Interviews with staff and residents confirmed that staffing issues were ongoing, with frequent call-outs and nurses leaving shifts early without proper handover. Resident #4, who was also cognitively intact and required maximum assistance for certain activities, experienced a significant delay in receiving insulin for diabetes management. This delay resulted in hyperglycemia, with a blood sugar level of 341, necessitating consultation with a health provider. Additionally, Resident #5, who was severely cognitively impaired, did not receive their prescribed medications on two separate occasions due to staffing shortages. These incidents highlight the facility's failure to maintain adequate staffing levels to ensure timely and appropriate care for residents.
Significant Medication Errors Due to Missed Doses and Lack of Physician Notification
Penalty
Summary
The facility staff failed to administer medications safely, resulting in significant medication errors for four residents. Resident #1, who was cognitively intact and required moderate assistance for daily activities, did not receive their prescribed medications, including Clopidogrel, Aspirin, and others, at the scheduled time. The medications were administered several hours late, and there was no documentation of physician notification regarding the delay, which is against the facility's medication error policy. Resident #4, also cognitively intact, was at risk for complications due to diabetes mellitus. The resident's medication, Mounjaro, was not administered on two scheduled dates, and there was no documentation of physician notification. The facility's drug shortage report indicated an alternative medication, but the physician was not informed of the need to order an alternative, highlighting a communication breakdown. Resident #5, who was severely cognitively impaired, did not receive Levothyroxine and Omeprazole on two occasions, with no physician notification documented. Similarly, Resident #6, who was cognitively intact and had a PICC line for medication administration, missed doses of Cefazolin Sodium Injection on three occasions. In all cases, the physician was not notified of the missed medications, contrary to the facility's policy, indicating a systemic issue in medication administration and communication.
Failure to Implement Care Plans for Medication and Incontinence Care
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for administering medications as ordered for a resident. This resident was admitted with multiple diagnoses, including hemiplegia, diabetes mellitus, cerebrovascular accident, and chronic kidney disease. Despite being cognitively intact and requiring moderate assistance for certain activities, the resident's care plan included administering antiplatelet medications to prevent deep vein thrombosis. However, a review of the medication administration record revealed that medications were administered at an incorrect time, significantly later than scheduled. An LPN confirmed that the care plan was not implemented as medications were not administered as ordered. Another deficiency was identified in the care plan implementation for incontinence care for a second resident. This resident, who was severely cognitively impaired and required maximum assistance for most activities, had a care plan that included providing toileting hygiene with brief changes. However, documentation for incontinence care was missing on several shifts and dates, as noted in the activities of daily living records. Interviews with CNAs revealed that incontinence care was not consistently provided every two hours as required, often due to staffing issues, and there was no evidence of care being documented in the system. Both deficiencies were brought to the attention of the facility's administrative staff, including the administrator, assistant director of nursing, regional director of clinical services, and vice president of operations. The facility's care planning policy emphasizes the development and implementation of individualized care plans to provide effective, person-centered care, but these deficiencies indicate a failure to adhere to this policy for the residents involved.
Failure to Document Pressure Ulcer Care for a Resident
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, identified as Resident #6, who was part of the survey sample. Resident #6 was admitted with diagnoses including diabetes mellitus and osteoarthritis and was assessed as cognitively intact but requiring maximum assistance for hygiene, dressing, and bathing. The resident's care plan highlighted the risk of complications due to diabetes and included specific interventions for wound care. However, a review of the treatment administration record (TAR) for May 2024 revealed missing documentation of wound care treatments on two specific dates, 5/5 and 5/6, for an abscess in the right pubic area. During an interview, an LPN confirmed that the absence of documentation on the TAR indicated that there was no evidence the wound care treatments were provided on those dates. The facility's policy mandates routine assessment and treatment of wounds as ordered, but the lack of documentation suggests a failure to adhere to this policy. The findings were communicated to the facility's administrative and clinical leadership, including the administrator, assistant director of nursing, regional director of clinical services, and vice president of operations. No further information was provided before the survey exit.
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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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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Jones & Cabacoy Veterans Care Center | 1.7 mi | — | 0 | 0 |
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| Birchwood Park Rehabilitation | 4.8 mi | ★★★★★ | 0 | 0 |
| Thalia Gardens Rehabilitation And Nursing | 4.9 mi | ★★★★★ | 31 | 0 |
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