Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Baltimore Washington during CMS and state inspections, most recent first.
Surveyors found that the facility failed to develop and implement complete, accurate care plans for several residents, including one with IV antibiotics and surgical and skin issues without corresponding goals and interventions, another with a care plan for anticoagulant‑related bleeding despite no anticoagulant orders, a resident with a fall history and Eliquis for atrial fibrillation without fall or anticoagulant care plans, and a resident with longstanding rheumatoid arthritis and multiple scheduled and PRN pain medications who had no pain management care plan and whose initial care plan meeting lacked medical or nursing staff participation.
Unsafe and Unclean Physical Environment: Surveyors observed multiple resident rooms and common areas with overflowing trash, missing toilet paper rods, stained commode and shower items, dust, cobwebs, marred walls and doors, cracked fixtures, and damaged windows and baseboards. The dining area also had leftover meal items, wrappers, and residue on tables, while shower rooms contained soiled and uncovered linens, a non-working light, and other poor housekeeping conditions.
Care plans were not updated and resident care plan meetings were not consistently held for several residents. Two residents said they were not aware of care plan meetings, and the DON confirmed missing attendance sheets in the chart. Two other residents had antibiotic therapy care plans that remained active even though current physician orders no longer showed the related antibiotic treatment, including one for Cipro and one for pneumonia-related antibiotics.
A resident with a PEG tube had tube feedings administered without the ordered tubing and the MAR did not document all scheduled bolus feedings. Another resident had a healed stage 2 pressure ulcer, yet the active treatment order remained in place and staff documented daily wound treatment on the MAR/TAR. In addition, one resident had a behavior-monitoring order tied to an antipsychotic even though the resident was actually prescribed zolpidem, and another resident’s insulin orders did not include a dose for blood sugar readings above 400.
Multiple residents experienced inaccurate MDS assessments and documentation. One resident who was lowered to the floor during a transfer had a witnessed fall documented in the medical record, but the fall was not coded on the Discharge MDS. Another resident admitted to Hospice with an active Hospice care plan was not coded for Hospice services on a Quarterly MDS. Two residents had discrepancies between their immunization records and MDS Section O coding for influenza vaccination, including one who received the vaccine in the facility and another whose historical data showed vaccination despite MDS coding of refusal. A resident with longstanding rheumatoid arthritis and constant pain had inconsistent and sometimes missing pain scores on the MAR and PDPM charting that documented no pain, despite the resident’s report of ongoing pain and frequent requests for pain medication.
Failure to cover a resident’s Foley catheter drainage bag with a dignity/privacy bag was observed in the resident’s room. The bag was hanging from the side of the bed in plain view, and both the Unit Manager and an LPN confirmed that no privacy cover was in place.
Staff failed to obtain consent from the established RP or representative for flu vaccination decisions for two residents. One resident had documented lack of decision-making capacity and an active HC POA, yet the resident’s refusal was recorded as self-RP. Another resident with autism spectrum, MR, and hearing loss had a contact person listed, but the vaccine was documented as refused after the resident was asked to consent rather than the RP.
Failure to maintain resident privacy during meal delivery. A surveyor observed an employee enter a resident's room without knocking while delivering meal trays on the unit. The resident stated that staff do not always knock before entering and that the resident and roommate prefer the door open.
A resident’s paper chart contained two MOLST forms with contradictory CPR orders. One MOLST indicated CPR based on advance directives, while a later MOLST reflected the surrogate’s decision for no CPR in cardiac arrest with DNI selected. The DON confirmed both forms were in the record and stated only one active MOLST should have been present.
Staff failed to label a tube feeding container and failed to administer enteral feeding per manufacturer instructions for two residents. One resident’s Jevity 1.5 bolus feeding was given by an LPN using a syringe without tubing, despite orders for gravity feeding and tubing changes, and the DON confirmed feeding should follow the manufacturer and resident orders. Another resident had a full tube feeding bottle connected to a pump that was not dated or timed.
Inadequate Oxygen Administration and Care Planning: A resident receiving O2 via nasal cannula was observed on a concentrator delivering 3 L/min even though the order was for 4 L/min. The care plan listed oxygen therapy but did not specify the ordered flow rate, and the UM confirmed the concentrator could not be increased to the prescribed setting.
Failure to Administer Ordered Pain Medication: A resident with a long history of rheumatoid arthritis reported constant pain and said pain meds were not being given correctly. Record review showed an ordered hydrocodone-acetaminophen dose was not signed for on the MAR, was not signed out on the controlled substance record, and the count remained accurate, indicating the dose was not administered. The ADON was notified of the med error.
A resident’s code status changed from full code to DNI, but the primary provider did not document review of the total plan of care or the informed discussion with the resident’s surrogate. The chart contained MOLST forms and progress notes from the provider, but the notes did not show the rationale for the change or that the order was discussed and entered as part of the care plan; the DON and the resident’s representative could not confirm documentation of the conversation.
Failure to Address Pharmacist MRR Recommendations: The facility did not act on consulting pharmacist MRR findings for two residents. One resident’s PRN albuterol recommendation was acknowledged but not implemented, and another resident continued receiving Midodrine at 2100 despite repeated pharmacist guidance to avoid evening dosing. The same resident also had missing iron study documentation while receiving ferrous sulfate, and the pharmacist’s recommendations for ferritin, TIBC, and TSAT monitoring were not addressed.
A resident's drug regimen was not adequately monitored, resulting in duplicate orders for trazodone and ondansetron/Zofran. The resident received trazodone twice in one day because of overlapping orders, and the chart also showed two active PRN orders for the same antiemetic with the same dose and directions. The ADON acknowledged the duplicate orders during interview.
Improper bedside storage of a resident's albuterol inhaler was observed when a surveyor found the inhaler next to the resident on two occasions. The resident said he/she had used a dose overnight for tight breathing, but the UM stated there was no order or assessment to show the resident was approved for self-administration. Facility policy required a multidisciplinary self-administration assessment to be completed and documented before a resident could self-administer meds.
A resident with no teeth or dentures reported discomfort from chewing on their gums, and the surveyor observed the resident eating breakfast without teeth. Record review showed multiple dental/oral evaluations that did not mention a pending consult, while the resident’s last dental appointment was for extractions and an earlier dental consult recommended scheduling dental surgery and then starting the denture process.
Kitchen staff failed to follow required infection control procedures when an employee with facial hair handled food without a beard net. The employee entered the kitchen, washed hands, removed lettuce, tomatoes, and ham, and began cutting the food while wearing gloves but no beard net. The Kitchen Director later confirmed beard nets were required and acknowledged the employee should have been wearing one before food handling.
Inaccurate Resident Records and Care Plans: Two residents had medical records that did not match their actual care. One resident’s chart listed Clopidogrel as an anticoagulant and included a care plan for anticoagulant-related bleeding monitoring, even though the medication was an antiplatelet and the resident was not on an anticoagulant. Another resident had an ostomy care plan and ostomy-site monitoring intervention, but the MDS showed no ostomy, the resident was bowel incontinent, and there was no physician order for ostomy care.
Infection prevention and control practices were not maintained when a clean linen cart was observed uncovered on the nursing unit while staff removed linen from it, despite a cover being attached. The facility also lacked a clear process to identify which resident in a shared room was on transmission-based precautions; staff relied on the door sign, shift report, or asking the nurse, and an LPN and the IP were uncertain whether the resident should be on Contact Precautions or EBP.
A resident was observed using oxygen through a concentrator that was only delivering 3 L/min even though the order was for 4 L/min, and the UM confirmed the machine could not be increased to the ordered setting. In another room, a resident had a chair pressed against a wall-mounted heating unit because it was not working and was blowing cool air; the NHA and DOR were unaware of the issue, and the DOR confirmed the unit was not working.
Call Bell Not Accessible and Shower Area Lacked Call Device: A resident's soft touch call bell was observed on the floor on multiple occasions during care, and a GNA and LPN noted it had likely fallen out of reach. During an environmental tour, the shower facility on Station 1 was also found without a call device system.
Unsafe and Poorly Maintained Physical Environment: Surveyors found multiple wall hand sanitizer dispensers that would not dispense in resident rooms, with staff confirming the issue had been reported and that housekeeping and maintenance shared responsibility for them. Surveyors also observed a drafty window in a resident room with dust blowing from the blinds and watermarks present, and a stained ceiling tile in a public bathroom used by residents, staff, and the public.
Pest Control Program Failure: A resident reported seeing roaches in the room all of the time. Surveyors observed a dusty pest trap, cobwebs, a dead spider in the room, and a bug crawling near Station 1. An LPN stated there had been roach sightings throughout the facility, and the Administrator acknowledged the pest control concerns.
A resident with a PEG tube was admitted without timely orders for tube flushing or site monitoring. Staff interviews confirmed that maintenance care, including water flushes and site inspection, was not initiated until several days after admission, resulting in a lapse in appropriate PEG tube maintenance.
A resident with multiple complex medical conditions, including malnutrition and a sacral wound, had an incorrect weight documented in their record, which was referenced by the physician as evidence of weight gain. The DON later corrected the error but did not notify the physician, resulting in the physician being unaware of the resident's actual weight loss over several weeks.
A resident's room was found to have a privacy curtain in disrepair that did not provide adequate privacy during wound care, along with a broken bedside table and closet door, resulting in a failure to maintain a sanitary and comfortable environment.
A resident complained of pain and alleged being hurt by staff during a transfer with a mechanical lift. The physical therapy assistant documented the complaint and informed the Director of Therapy, but the allegation was not immediately reported to administrative staff or authorities as required. The resident continued to report pain and was later admitted to the hospital with diagnoses including neglect.
A resident reported being physically injured by staff during a transfer with a mechanical lift and later expressed ongoing pain and concerns to therapy staff. The allegation was not thoroughly investigated, as the report was not escalated to administrative staff and the resident was not asked for further details. Documentation of staff education or follow-up was lacking, and the resident was later admitted to the hospital with diagnoses including neglect.
Staff did not follow or document required care plan interventions for two residents, including failing to check and record feeding tube placement and residuals for a resident with a gastrostomy tube, and not notifying a nurse when another resident at nutritional risk consumed less than half of their meals on multiple occasions.
A resident with a gastrostomy tube, quadriplegia, malnutrition, and a sacral pressure ulcer experienced significant weight loss over several weeks despite a care plan aimed at weight gain. Facility staff failed to accurately document weights and did not notify the physician or dietician of the weight loss, resulting in a deficiency related to maintaining the resident's nutritional status.
The facility did not ensure accurate and complete documentation of controlled medication administration for two residents. Multiple doses of Oxycodone were signed out by licensed staff but were not recorded in the medication administration records, as confirmed by the DON. This resulted in discrepancies between the controlled substance records and the MARs.
A resident with quadriplegia, contractures, and bilateral foot drop was observed with both feet hanging over the end of the bed, as the bed was too short to accommodate the resident's height and the use of foot drop boots. The resident communicated to the DON that the bed was too small, and this was confirmed during a surveyor's observation.
The facility was found deficient in ensuring qualified staff for food and nutrition services. The food service manager's Certified Dietary Manager (CDM) certificate had expired, and the Registered Dietician (RD) worked only part-time. This lack of qualified staff has the potential to affect all residents.
The facility failed to maintain an effective pest control program, with multiple reports and observations of flies, gnats, and bed bugs affecting residents. Staff interviews revealed a lack of awareness and use of pest log books, and the facility's process for reporting pest issues was inadequate. Pest issues, including bed bugs and mice, remained unresolved for extended periods, highlighting the facility's failure to manage and address pest concerns effectively.
The facility failed to thoroughly investigate multiple allegations of abuse and missing belongings. In one case, a resident reported sexual assault, but the investigation lacked critical details. Another incident involved abuse allegations with missing documentation and follow-up. Additionally, a complaint about missing belongings was not adequately addressed, lacking necessary documentation and statements.
The facility was found to have numerous deficiencies in maintaining a clean and safe environment, with observations of cluttered and unclean resident rooms, exposed sharp metal screws, and widespread environmental issues such as peeling paint and stained ceiling tiles. Residents expressed concerns about the uncleanliness, and staff acknowledged the issues but failed to address them promptly, as evidenced by ongoing complaints in the facility's grievance logs.
The facility failed to provide timely care and follow-up for several residents, leading to significant deficiencies. One resident experienced a fall resulting in facial injuries, and the facility delayed hospital transfer until family intervention. Another resident with mouth sores did not receive prescribed medication for three weeks. A resident with a change in mental status did not receive timely intervention, and a diabetic resident's blood sugar levels were inconsistently monitored. Additionally, a resident did not receive scheduled IV antibiotics on time due to staff shortages, with no documentation explaining the missed doses.
A resident was mistakenly given another resident's medication upon discharge, breaching medical privacy. The error was confirmed by the DON, who acknowledged the possibility of such mistakes during discharge.
The facility failed to report allegations of abuse, neglect, and incidents in a timely manner to the OHCQ. A resident reported a nurse bending their finger, and another resident's daughter alleged neglect after rough handling by a CNA. Injuries of unknown origin were not reported, and missing medications and verbal abuse allegations lacked timely initial reports. These deficiencies were identified during a survey.
A facility failed to provide written notification to a resident and their representative regarding hospital transfers. The resident was transferred twice due to a change in medical condition, but no documentation of the transfer notice was found in the medical record. The DON stated that notifications should be given at the time of transfer, with copies sent to the hospital and family members, but these were missing.
A resident with a Stage II pressure ulcer did not receive appropriate care due to a missed wound treatment order upon admission. The family noticed the outdated dressing, prompting staff to address the oversight. The facility's process for reviewing new admissions failed to ensure the necessary wound care orders were in place.
A facility failed to provide a resident and their representative with a baseline care plan summary, as required by federal regulations. The deficiency was identified during a survey, revealing that the resident was admitted without receiving a summary of the care plan, which should include initial goals, medications, dietary instructions, and services. Interviews with staff showed a lack of awareness about the requirement to provide this summary.
A facility failed to follow professional standards in medication administration, including not verifying orders before administering medications, not documenting controlled medications accurately, and mishandling an insulin pen. An RN administered medications without verifying orders against the MAR, leading to documentation discrepancies. Audits revealed multiple instances where controlled medications were not properly documented in the MAR. Additionally, the RN improperly drew insulin from a pen using a syringe, contrary to recommended practices.
A facility failed to provide appropriate treatment for a resident receiving tube feeding. The resident's Osmolite feeding was observed not running, and the water flush bag was dated incorrectly, indicating it had not been changed for several days. The tube feeding administration record lacked signatures for multiple shifts, except for one. The RD's note indicated the resident's energy needs were to be met via enteral nutrition, but the administration record showed a lack of documentation. The DON and staff acknowledged the issues, noting an incorrect order by the RD.
The facility failed to provide timely and appropriate pain management for two residents. One resident, post-knee replacement, did not receive prescribed Oxycodone in a timely manner despite its availability. Another resident with chronic pain had PRN medications without specific parameters and did not receive non-pharmacological interventions as ordered. Interviews confirmed delays and omissions in pain management.
A registered nurse improperly administered insulin by drawing it from an insulin pen using a syringe instead of the pen's specified needle and dial, believing it ensured an exact dose. This was observed during a survey, and the nurse also failed to use a computer for medication administration and did not sign off medications promptly.
The facility failed to conduct annual performance reviews for GNAs, as required. During a survey, it was found that a GNA hired in early 2022 did not have a record of an annual performance review. The DON stated that evaluations are done yearly or every 90 days by department heads, with HR tracking them. However, the DON could not provide the missing evaluation record, acknowledging the issue.
The facility failed to maintain accurate records for controlled medications, with discrepancies found between the Controlled Medication Utilization Record and the MAR for three residents. The audit revealed that several doses of Oxycodone and Percocet were not properly documented, indicating a lapse in the facility's process for administering and recording controlled medications.
A facility failed to follow up on a pharmacist's recommendation to add Divalproex to a resident's medical records. The recommendation, made in January, was not addressed by the attending physician until June. The DON and attending physician cited communication issues, with the DON acknowledging the oversight.
Failure to Develop and Implement Comprehensive, Accurate Care Plans for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, individualized care plans with measurable goals and interventions for multiple residents. For one resident who returned from the hospital on 1/24/2026, the surveyor observed an IV antibiotic mini bag at the bedside, but record review showed there was no comprehensive care plan addressing the IV antibiotic therapy or care of the IV access site. The same resident had an incomplete care plan for a mid‑back surgical site and dermatitis that lacked goals and interventions. The DON stated that the care plan had not been reactivated when the resident returned from the hospital. Another resident had an active care plan that included interventions for monitoring signs and symptoms of abnormal bleeding and bruising related to anticoagulant use, but record review showed there were no active or discontinued physician orders for any anticoagulant medication during the resident’s stay. The hospital discharge summary indicated a history of DVT and that the resident was not anticoagulated. The DON acknowledged that the clinical team was responsible for implementing and updating care plans, yet the care plan still contained anticoagulant‑related interventions that did not match the resident’s actual medication regimen. A further resident with a documented fall on 11/10/2024 and a diagnosis of history of falling did not have any problem, goal, or interventions in the comprehensive care plan for an actual fall or risk for falls. This same resident had a physician order for Eliquis 5 mg twice daily for atrial fibrillation, but there was no comprehensive care plan addressing the anticoagulant medication or the cardiac arrhythmia. In addition, another resident with a primary diagnosis of rheumatoid arthritis, constant pain, and multiple standing and PRN pain medications (including Hydrocodone‑Acetaminophen, Lyrica, Lidocaine patch, Capsaicin, and Extra Strength Tylenol) had no pain management care plan. The initial care plan update completed 72 hours after admission did not mention pain or pain relief measures, and a progress note indicated no medical or nursing staff attended that care plan meeting. When questioned, an employee stated they did not know why pain management was not included in the care plan.
Unsafe and Unclean Physical Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, homelike environment in multiple resident rooms and common areas observed during the survey. Surveyors found overflowing trash cans with trash on the floor, accumulated dust in windows and blinds, deeply scuffed flooring, and a partially detached door panel hanging loose in one room. In another room, a commode seat was stained with a brown substance, the toilet rod was missing, and wrapped toilet paper was not within reach. Additional observations included a dead spider, cobwebs, and dust on and around a window, along with marred walls, marred bathroom doors, cracked faucets, and trash cans without liners or with cracks. Common areas and other resident care spaces were also observed in poor condition. In the dining room, napkins and wrappers were around the garbage can, used meal items remained on a table, several tables had crumpled napkins underneath, and one tabletop had paint residue that could be wiped off. In shower areas, surveyors observed a non-working ceiling light, a shower chair with a brown stain, a missing shower lever, a bag of resident gowns on the shower floor, a visibly soiled chair cushion, a linen cart for soiled linens, uncovered folded linens and gowns on shelves, and a brown stain on a shower curtain. Additional room observations included a cracked window covered with dark gray tape, a blanket on a windowsill, a draft felt from the window, and a severely damaged heated baseboard pulled away from the wall.
Care plans were not updated and resident care plan meetings were missed
Penalty
Summary
The facility failed to update and revise resident care plans and failed to conduct resident care plan meetings for 4 of 7 residents reviewed for care plan timing and revision. Resident #5 stated he/she was not aware of a care plan meeting, and the medical record contained care plan meeting attendance reports for 10/10/2024, 1/17/2025, and 9/18/2025, with the DON confirming those were the only attendance reports in the chart and that there were no attendance sheets for April 2025 and July 2025. Resident #2 also stated he/she was not aware of a care plan meeting, and the record contained attendance reports for 12/19/2024, 6/12/2025, 9/11/2025, 11/4/2025, 11/14/2025, and 12/5/2025, with the DON confirming there was no attendance sheet for March 2025. Record review also showed that Resident #126 had a care plan for antibiotic therapy with Cipro for a back infection, but the active physician orders did not show a current Cipro order; the care plan had been initiated on 11/3/2025, while the discontinued orders showed Nitrofurantoin in November 2025 for 7 days and no Cipro order. Resident #75 had a care plan for antibiotic therapy related to infection/pneumonia, but the active physician orders did not show a current antibiotic order for pneumonia; the care plan had been initiated on 8/6/2025, and the discontinued orders showed Zithromax Z-pak (Azithromycin) in August 2025 for 5 days for pneumonia. The DON acknowledged that updating care plans was the responsibility of the clinical team.
Failure to Follow Standards for Tube Feeding, Wound Treatment, and Medication Orders
Penalty
Summary
Professional standards were not followed during tube feeding administration for a resident with a PEG tube and orders for Jevity 1.5 bolus feedings. The resident was observed with a labeled container of tube feed and a syringe at the bedside, but no tubing was present. The resident’s order required enteral feeding tubing and syringe changes every night shift and ordered bolus feedings via gravity at midnight, 6 a.m., noon, and 6 p.m. During interview, an LPN stated he administered the feeding by pouring formula into a cup and then into a syringe, and the surveyor confirmed that no tubing was used for the gravity feeding. The MAR also did not document the midnight and 6 a.m. feedings even though the nurse stated the feeding had been given. Professional standards were also not followed for a resident with a healed stage 2 pressure ulcer to the left buttock. The resident’s wound assessment showed the pressure ulcer was resolved and no treatment was indicated, yet the physician orders remained active for treatment of the left buttock wound during January and February 2026. The MAR/TAR showed nursing staff documenting that the treatment was performed daily despite the wound being documented as resolved. A resident’s medication-related monitoring order also did not match the resident’s actual medication regimen. The record showed an order to monitor for behaviors because the resident was on an antipsychotic medication, but the resident was not prescribed an antipsychotic. Instead, the resident had an order for zolpidem 5 mg at bedtime for insomnia, which is a hypnotic medication. In a separate record review, another resident receiving insulin for diabetes mellitus had orders for insulin before meals and at bedtime based on blood sugar results, but there was no physician order addressing what insulin dose to give when the blood sugar was above 400.
Inaccurate MDS Coding and Pain Assessment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves inaccurate completion of Minimum Data Set (MDS) assessments for multiple residents. One resident experienced a change in condition when two GNAs were transferring the resident from bed to wheelchair, the resident’s knees buckled, and the resident was lowered to the floor. A change in condition evaluation documented this witnessed fall, but the subsequent Discharge – Return Anticipated MDS assessment did not code the fall in Section J. Another resident had a physician order for admission to Hospice and an active Hospice care plan, yet the Quarterly MDS assessment did not code the resident as receiving Hospice services in Section O. Additional inaccuracies were identified in MDS coding related to influenza vaccination status. One resident’s medical record showed that the resident received the influenza vaccine in the facility, but the MDS assessment documented that the resident had not received the vaccine and that it was “not offered.” Another resident’s immunization record documented that the resident had refused the influenza vaccine on admission, with education provided on risks and benefits, and also showed in historical data that the resident had already received the influenza vaccine for the current season. However, the MDS assessment coded that the resident had not received the vaccine and that it was “offered and declined,” failing to reflect the documented administration in historical data. A further deficiency was identified in the assessment and documentation of pain for a resident with a long-standing diagnosis of rheumatoid arthritis who reported being in constant pain and stated that they had informed staff of their pain intensity. The resident had a standing order for Hydrocodone-Acetaminophen every eight hours with a requirement to record pain level on the MAR using a 0–9 scale, but the MAR showed inconsistent pain level entries, numerous “0” pain scores despite the resident’s report of never being without pain, and instances where pain level was not recorded at all. Skilled Nursing Charting PDPM entries also indicated that the resident reported no pain, which conflicted with the resident’s statements. The resident additionally had a PRN order for Extra Strength Tylenol for chronic pain, which was administered only once during the first two weeks of the month, despite the resident’s report of requesting pain medication almost daily.
Failure to Cover Foley Catheter Drainage Bag for Resident Dignity
Penalty
Summary
The facility failed to provide an environment that promotes resident respect and dignity for one resident who had a Foley catheter. On 2/08/2026 at 8:45 AM, surveyor observation of the resident revealed a Foley catheter drainage bag hanging from the right side of the bed with no dignity bag covering it. On 2/09/2026 at 9:30 AM, the surveyor brought the Unit Manager into the room and asked her to identify the condition of the catheter collection bag, and the Unit Manager acknowledged that there was no dignity bag over the collection bag. Later, on 2/09/2026 at 1:00 PM, a tour of the resident's room with an LPN again revealed that there was no privacy cover on the Foley catheter drainage bag, and the LPN confirmed that he/she or another nurse would retrieve and place a privacy cover on the drainage bag immediately.
Failure to Obtain RP Consent for Flu Vaccinations
Penalty
Summary
Facility staff failed to obtain consent from residents’ responsible parties or representatives related to influenza vaccinations for 2 of 5 residents reviewed. For Resident #3, the record showed the resident refused the flu vaccine and was educated on the risks and benefits, and an RN documented that the resident, listed as self-RP, declined the seasonal flu vaccination. However, the record also contained two certifications dated 3/25/25 stating the resident lacked adequate decision-making capacity, and the resident’s family member was listed as the active POA for health care. For Resident #10, the record showed the resident refused the influenza vaccine and was educated on the risks and benefits, with the refusal documented in the immunization record. Hospital discharge records noted the resident had a recent fall, difficulty walking prior to the fall per the aide, and a past medical history including autism spectrum, mental retardation, and hearing loss. The records also identified a contact person for the resident. During interview, the ADON stated the vaccine was offered on admission and documented as refused, but historical data showed the vaccine had already been administered for the 2025-2026 flu season, and the resident was asked to consent rather than the established RP.
Failure to Maintain Resident Privacy During Meal Delivery
Penalty
Summary
The facility failed to maintain privacy for Resident #75 during meal delivery on the nursing unit. At 8:52 AM on 2/8/2026, a surveyor observed employee #22 enter Resident #75's room without knocking before entering while delivering meal trays to residents on the unit. During an interview on 2/8/2026, Resident #75 stated that staff do not always knock when entering the room and that the resident and roommate prefer the door open. The concern with resident privacy was then brought to the administrative team during survey exit on 2/13/2026 at 2:30 PM.
Duplicate MOLST Forms in Resident Record
Penalty
Summary
The facility failed to ensure that only one Maryland Order for Life-Sustaining Treatment (MOLST) form was present in a resident’s paper medical record. During record review, the surveyor found one MOLST dated [DATE] that indicated the resident wanted CPR based on instructions in the resident’s advance directives. Later, when the surveyor requested the resident’s advance directives and MOLST, the Director of Nursing (DON) provided a different MOLST dated [DATE] that reflected the surrogate decision maker’s choice to not have CPR performed in the event of cardiac arrest, with DNI selected. The DON also provided surrogate decision-making documentation and certifications from two providers stating the resident was incapable of making medical decisions, all dated April 2024. During interview, the DON stated the first MOLST had been found in the resident’s paper medical record and acknowledged that both MOLST forms were in the chart. The DON stated only one active MOLST should have been in the record and explained that when two MOLSTs contain contradictory orders, staff review the dates and use the most recent one. The DON then removed the older MOLST dated [DATE].
Tube Feeding Container Not Labeled and Feeding Not Given Per Manufacturer Instructions
Penalty
Summary
Staff failed to ensure that a tube feeding container was labeled and failed to administer enteral tube feeding according to the manufacturer’s instructions for two residents receiving tube feeding. For one resident, the surveyor observed a tube feeding container on the bedside table with a syringe present and no tubing noted. The resident had orders for Jevity 1.5 bolus tube feeding four times daily and for the enteral feeding tubing and syringe to be changed each night shift. During interview, an LPN stated he administered the feeding by pouring formula into a cup and then into a syringe and feeding via gravity, and the surveyor confirmed that no tubing was used for the gravity feeding. The DON stated tube feeding should be administered per the manufacturer guidelines and the resident’s orders. The surveyor reviewed the Jevity 1.5 instructions, which stated that the ready-to-hang container should be used according to the directions and that failure to follow the instructions for use increases the potential for microbial contamination and may reduce hang times. For the second resident, the surveyor observed a full bottle of tube feeding formula that was not dated or timed, although the tubing was attached and connected to the pump. The resident had an order for tube feeding via pump to run over 12 hours from 6 p.m. to 6 a.m.
Inadequate Oxygen Administration and Care Planning
Penalty
Summary
Failure to provide respiratory care consistent with professional standards for oxygen administration was identified for one resident receiving oxygen therapy. Resident #8 was observed using oxygen via nasal cannula connected to an oxygen concentrator delivering 3 liters per minute, while the resident stated the ordered amount was 4 liters per minute and that the machine could not be turned higher than 3. The resident’s record showed an order written on 11/5/25 for 4 liters per minute of oxygen via nasal cannula. The care plan initiated on 12/31/25 stated that the resident had oxygen therapy related to respiratory illness, but the intervention listed the oxygen setting as "(X) liters continuously" rather than a specific flow rate. During interview, the Unit Manager reviewed the concentrator, confirmed the ordered dose should be 4 liters per minute, and stated the machine could not be increased to that level and would need to be replaced. The facility’s oxygen administration policy stated that oxygen should be administered under physician orders and that the care plan should identify the type of oxygen delivery system, continuous or intermittent use, when to discontinue, flow rates, and SpO2 levels as ordered; these elements were not all present in the resident’s respiratory care plan.
Failure to Administer Ordered Pain Medication
Penalty
Summary
Safe, appropriate pain management was not provided for Resident #31, who reported a history of rheumatoid arthritis diagnosed დაახლოებით 20 years earlier and stated they had been in constant pain since. The resident told the surveyor they were not receiving pain medication correctly. Record review showed a standing order for Hydrocodone-Acetaminophen 7.5-325 mg every 8 hours, but the Medication Administration Record did not show the 6:00 AM dose on 2/11/2026 as signed for, indicating it was not administered. The controlled substance record also did not show a tablet signed out at that time, and the count for Hydrocodone-Acetaminophen 7.5-325 mg remained accurate, further indicating the dose had not been given. The ADON was notified of the medication error.
Failure to Document Provider Review of Code Status Change
Penalty
Summary
The primary medical provider failed to review the resident’s total program of care when the resident’s code status changed. Record review showed an earlier MOLST indicating the resident wanted CPR based on advanced directives, followed by a newer MOLST indicating the resident’s surrogate decision maker elected no CPR in the event of cardiac arrest, with DNI noted. The surveyor reviewed the resident’s paper medical record, progress notes, and MOLST forms, and found no documentation in the provider notes explaining the rationale or informed decision discussion for the code status change. During interview, the DON stated the resident had been transferred to the hospital in February 2025 and suggested the code status change may have occurred there, noting the primary care provider also provides care at that hospital. The resident’s progress notes included a readmission evaluation visit and a later follow-up visit by Provider #27, but neither note documented any conversation with the resident’s representative about changing code status, and the plan of care notes did not state that the change was ordered. When interviewed by phone, the primary care physician stated he had discussed the risks and benefits of the code status change with the resident’s representative but said he would need to review his notes. The resident’s representative stated she agreed with the current MOLST order but could not recall the provider speaking with her about the MOLST on the February 2025 admission.
Failure to Address Pharmacist MRR Recommendations
Penalty
Summary
The facility failed to address medication regimen review (MRR) recommendations made by the consulting pharmacist for 2 residents reviewed during the recertification survey. For Resident #35, the pharmacist’s MRR dated 05/28/2025 recommended initiating albuterol MDI 2 puffs every 6 hours as needed for shortness of breath, with 1 minute between puffs. Although the recommendation was acknowledged on 06/18/2025, it was not implemented, and the DON stated she was unable to find follow-up documentation for the recommendation and acknowledged it was not addressed. For Resident #75, the record showed multiple pharmacist recommendations that were not acted on by the physician or DON. The resident had an order for Midodrine 5 mg by mouth twice daily for hypotension, but the pharmacist recommended on 4/23/2025, 5/29/2025, and 7/30/2025 that Midodrine should not be given after 6 pm, after the evening meal, or less than 4 hours before bedtime; the resident continued receiving it at 2100 until 8/5/2025. The pharmacist also noted on 8/28/2025 and 10/29/2025 that ferritin, TIBC, and TSAT were not documented in the medical record for the resident, who had an order for ferrous sulfate 325 mg daily, and recommended monitoring these iron studies every 3 months.
Duplicate Medication Orders Not Adequately Monitored
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen, allowing unnecessary duplicate medication orders. For Resident #8, trazodone 50 mg at bedtime for depression was ordered and later discontinued, but an additional trazodone order was written for 150 mg nightly for insomnia, and the resident received trazodone twice on 8/6/25 because of the duplicate order. The record also showed duplicate active orders for ondansetron/Zofran, with one order written for 4 mg by mouth every 8 hours as needed for nausea/vomiting and another later order written for the same medication and dose with the same instructions. During interview, the ADON acknowledged the duplicate medication orders and stated she would remove the current duplicate order.
Improper Bedside Storage of a Resident's Albuterol Inhaler
Penalty
Summary
The facility failed to properly store a resident's medication by leaving the resident's albuterol inhaler at the bedside without documentation that the resident was approved for self-administration. On 2/8/26, a surveyor observed Resident #8 with an inhaler next to him/her, and the resident stated he/she had used a dose during the night when breathing felt tight. On 2/12/26 at 11:28 AM, the surveyor and Unit Manager #10 again observed Resident #8 with the albuterol inhaler next to the resident. When asked whether the resident was supposed to have medication at the bedside, the Unit Manager stated there was no order or assessment completed to determine whether self-administration of the inhaler was appropriate. The surveyor also reviewed the facility policy, which stated that a resident may only self-administer medications after the multidisciplinary team determines which medications may be self-administered safely and that the assessment must be recorded in the medical record.
Failure to Follow Up on Dental Care Recommendations
Penalty
Summary
The facility failed to follow up on dental care recommendations for Resident #131. During interview and observation, the resident stated they had no teeth or dentures and reported discomfort from chewing on their gums, and the surveyor observed the resident eating breakfast without teeth. Record review showed dental/oral evaluations on 10/19/25, 01/23/26, and 01/26/26, but those notes did not mention a pending consult. The resident’s last dental appointment was on 08/19/24 for dental extractions. A dental consultation recommendation from 03/18/2024 stated to call the listed number to schedule dental surgery and noted that the process to start making dentures, requiring five appointments total, could begin 1 to 2 months after surgery.
Kitchen Staff Failed to Wear Required Beard Net
Penalty
Summary
The facility failed to maintain proper infection control procedures in the kitchen regarding staff use of beard nets. During a follow-up tour of the kitchen on 2/11/2026 at 12:32 PM, Staff #16 entered the kitchen wearing a hair net, washed their hands, removed lettuce, tomatoes, and ham from the walk-in refrigerator, and began cutting the tomatoes, lettuce, and ham while wearing gloves but without a beard net. At 12:41 PM, Staff #15, the Kitchen Director in Training, assisted Staff #16 with putting on a beard net. Later that day, at 2:00 PM, the Kitchen Director confirmed that hair and beard nets were required in the kitchen and acknowledged that Staff #16 should have had a beard net on before handling food. Record review at 2:15 PM showed the facility policy required kitchen staff to have hair confined in a hair net or cap and facial hair properly restrained.
Inaccurate Resident Records and Care Plans
Penalty
Summary
Resident #19’s medical record was not maintained in a way that was accurate and reflective of the resident’s care. The record showed an active physician order for Clopidogrel 75 mg by mouth daily, entered on 11/22/2025, but it was documented as an anticoagulant even though Clopidogrel is an antiplatelet medication. The resident also had a care plan addressing monitoring for signs and symptoms of complications, abnormal bleeding, and bruising related to anticoagulant use. During the surveyor’s review, the DON was informed that the resident was not currently on an anticoagulant, and the DON stated that the clinical team was responsible for implementing and revising care plans. Resident #126’s record also contained inaccurate care planning information. The care plan included bowel incontinence/ostomy and an intervention to observe and report redness, inflammation, and drainage at the ostomy site. However, review of the MDS Section H showed that the resident did not have an ostomy and was incontinent of bowel, and there was no physician order for ostomy care. The DON confirmed during interview that the resident did not have an ostomy.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility failed to maintain infection prevention and control practices for the storage of clean linen. During a random observation of the nursing unit, the clean linen cart outside of a resident room was uncovered, with folded linen visible on three shelves. An employee was administering medications nearby, and two GNAs were observed removing linen from the cart without covering it with the attached pink plastic cover. When questioned, an employee stated the linen cart should be covered and then covered it with the attached cover. The facility also failed to have a clear process to identify residents who required transmission-based precautions. A Contact Precautions sign was observed on a resident room door, but RN staff and other staff could not clearly identify which resident in the room was on precautions. One GNA stated they would talk to the nurse, and an LPN initially could not identify the resident on precautions and then stated the room should probably be on EBP before returning and changing the precaution status to EBP. Record review of the facility matrix did not show any residents on transmission-based precautions, while the IP stated one room should probably have EBP and another room was on Contact Precautions for a wound, and that the facility did not identify which bed required precautions to protect resident privacy.
Nonworking oxygen concentrator and heating unit in resident rooms
Penalty
Summary
The facility failed to assure that essential equipment was fully operational while in use in resident care areas. Resident #8 was observed using oxygen via nasal cannula connected to an oxygen concentrator that was delivering 3 liters per minute, although the resident stated the ordered oxygen dose was 4 liters per minute and the machine could not be turned higher than 3. Review of the resident’s orders showed an order written on 11/5/25 for 4 liters per minute of oxygen via nasal cannula. During interview, the Unit Manager confirmed the ordered dose should be 4 liters per minute but was unable to increase the concentrator to that level and stated the machine would need to be replaced. The facility also failed to assure that a wall-mounted heating unit in Resident #122’s room was working. The surveyor observed a chair pushed against the heating unit, which was not on and was blowing cool air. The resident stated the chair had been placed there to block the cool air because the heating unit had stopped working a few days earlier and the assistant maintenance worker was aware. During interview, the Nursing Home Administrator and Director of Maintenance stated they were unaware the heating unit was not working, and the Director of Maintenance confirmed the unit was not working.
Call Bell Not Accessible and Shower Area Lacked Call Device
Penalty
Summary
The facility failed to ensure a resident had access to the call bell and failed to ensure a call device was accessible in the shower area. On 2/8/26 at 8:25 AM, the surveyor observed Resident #1's soft touch call bell on the floor next to the bed, and during interview GNA #5 stated the call bell may have fallen out of bed when the previous shift repositioned the resident. When asked whether it was expected to check that the call bell was in reach before leaving, GNA #5 stated that was her practice. On 2/12/26 at 6:22 AM, the surveyor again observed GNA #29 providing care to Resident #1 and saw the call bell on the ground. At 6:57 AM, the surveyor returned with LPN #25 and the call bell was still on the floor; LPN #25 stated it must have fallen out when the GNA was providing care earlier and returned it to the resident. During an environmental tour on 2/10/26 at 10:10 AM with the Maintenance Director, the shower facility on Station 1 was observed without a call device system.
Unsafe and Poorly Maintained Physical Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During observation, the surveyor found that the hand sanitizer in one resident room would not dispense at 8:16 AM and again at 8:20 AM, and later observed that the hand sanitizer in room 16 also was not dispensing. During interview, a GNA confirmed the hand sanitizer in the room was not working and stated that housekeeping had been told about it on Friday. The NHA and Director of Maintenance later confirmed that both maintenance and housekeeping were responsible for wall hand sanitizers, with maintenance reviewing batteries and housekeeping monitoring levels, and the NHA stated housekeeping should refill them weekly. The surveyor also observed environmental concerns in a resident room and a public bathroom. In room 36, the surveyor noted a draft coming from the window next to the resident’s bed, dust on the blinds blowing from the draft, and watermarks on the blinds. The resident stated that when it was windy outside a draft could be felt and that when it rains water comes through the window; the NHA and Director of Maintenance confirmed the draft, and maintenance stated a window repair contractor would be called to evaluate the window. In the public bathroom used by residents, staff, and the public, the surveyor observed a ceiling tile stained with a large brown color, which was seen throughout the survey.
Pest Control Program Failure
Penalty
Summary
The facility failed to keep the premises free of pests and did not maintain an effective pest control program to prevent or address mice, insects, or other pests. During interview, Resident #131 stated that roaches were seen in the room all of the time. Surveyors observed a dusty pest trap under the wall-mounted ventilation unit, cobwebs, and a dead spider on the window in the resident room. Surveyors also observed a bug crawling on the floor near Station 1. An LPN stated there had been roach sightings throughout the facility, and the Administrator acknowledged the pest control concerns.
Failure to Provide Timely Maintenance Care for PEG Tube
Penalty
Summary
Facility staff failed to provide appropriate maintenance care for a resident's percutaneous endoscopic gastrostomy (PEG) tube. Upon admission, the resident had a PEG tube in place, but there were no orders for monitoring or flushing the tube until several days after admission. The medical record review revealed that orders for flushing the PEG tube with water, inspecting the site for signs of infection, and completing tube site care were not entered until nearly a week after the resident's admission. There was no documentation of the tube being flushed or monitored prior to these orders being added to the Medication Administration Record. Interviews with facility staff, including the unit manager and the DON, confirmed that they would have expected PEG tube care orders, including maintenance flushing and site monitoring, to be in place upon admission. The resident was able to eat and drink by mouth, and the PEG tube was not being used for feeding, but staff acknowledged that maintenance flushes should still have been performed. The lack of timely orders and documentation resulted in a failure to ensure proper maintenance care for the resident's PEG tube.
Failure to Notify Physician of Incorrect Weight Documentation
Penalty
Summary
The facility failed to notify a resident's physician regarding an incorrect weight documentation, which led to a misinterpretation of the resident's clinical status. The resident, who had diagnoses including quadriplegia, a recent gastrostomy tube placement, a sacral pressure ulcer, malnutrition, and contractures, was identified as being at nutritional risk with a care plan targeting safe weight gain. On 02/26/25, nursing staff documented a weight of 119.4 pounds for the resident, which was later found to be an error and intended for another resident's record. This incorrect weight was referenced by the physician in a subsequent assessment, leading to the belief that the resident was gaining weight. On 03/11/25, the DON corrected the error by striking out the incorrect weight entry but did not notify the resident's physician of this change. Subsequent weights showed a significant weight loss of 6.6 pounds (5.5%) over a three-week period. The failure to communicate the documentation error and the resident's actual weight trajectory to the physician resulted in a lack of timely physician awareness regarding the resident's nutritional status and weight loss.
Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
Facility staff failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment for a resident. During a wound care dressing change observation, the privacy curtain in the resident's room was found to be in disrepair, hanging on the floor, and unable to provide complete privacy. Additionally, the bedside table had two out of three drawers that would not close, and the closet door was also in disrepair and could not close completely. These deficiencies were directly observed during the provision of care and were confirmed by staff interview.
Failure to Timely Report Suspected Abuse Allegation
Penalty
Summary
Facility staff failed to immediately report an allegation of suspected resident abuse to the administrator and State Survey Agency within the required 2-hour timeframe. A resident complained of soreness in the right hip after an incident involving a Hoyer lift, stating that staff had hurt them. The physical therapy assistant (PTA) documented these complaints in progress notes and informed the Director of Therapy, but did not notify other facility administrative staff. The resident continued to express pain and reluctance to participate in therapy, and later submitted a concern form to a nursing unit manager. The unit manager addressed the concerns several days after the initial complaint, but there was no documentation of staff education or immediate reporting of the abuse allegation as required. Review of the resident's medical record showed ongoing complaints of pain and a request to go to the emergency room, which was eventually granted. The hospital record indicated diagnoses including atypical chest pain, ambulatory dysfunction, and neglect of an adult. The facility's failure to promptly report the suspected abuse and the results of the investigation to the proper authorities constituted a deficiency in meeting regulatory requirements for timely reporting of abuse allegations.
Failure to Investigate Resident's Allegation of Injury During Transfer
Penalty
Summary
The facility failed to thoroughly investigate an allegation made by a resident who reported being physically injured by staff during a transfer with a Hoyer lift. The resident complained of soreness in the right hip following the incident and later reported to a physical therapy assistant that aides had hurt them. The physical therapy assistant informed the Director of Therapy but did not notify other administrative staff, and the resident was not asked to elaborate on the allegation. Documentation shows that the concern was not escalated or formally investigated as required for abuse allegations. Further review revealed that a nursing unit manager addressed some of the resident's concerns days later, including instructing staff to be more gentle and educating the resident on safety procedures, but there was no documentation of staff education or follow-up regarding the abuse allegation. The resident subsequently requested to go to the emergency room, where they were admitted with diagnoses including atypical chest pain, ambulatory dysfunction, and neglect of an adult. The facility's records did not show that the required investigation or documentation of the alleged abuse was completed.
Failure to Implement and Document Care Plan Interventions for Two Residents
Penalty
Summary
Facility staff failed to implement parts of comprehensive care plans for two residents, as identified during a complaint survey. For one resident with quadriplegia, a recent gastrostomy tube placement, and contractures, the care plan included specific nursing interventions such as checking the feeding tube for placement and gastric residuals and recording the results. However, a review of medication and treatment administration records over several months showed that nursing staff did not document these required checks and recordings, indicating that this aspect of the care plan was not followed. For another resident with dementia, congestive heart failure, COPD, diabetes, and nutritional risk, the care plan required staff to notify the nurse if the resident consumed less than 50% of a meal. Meal intake records revealed that the resident ate less than half of their meals on 34 occasions over nearly a month, but there was no documentation that the nurse was notified as required by the care plan. These findings demonstrate that staff did not consistently implement or document key interventions outlined in the residents' individualized care plans.
Failure to Maintain Nutritional Status After Feeding Tube Placement
Penalty
Summary
A deficiency was identified when the facility failed to maintain or improve a resident's nutritional status following the placement of a gastrostomy tube. The resident, who had diagnoses including quadriplegia, malnutrition, a sacral pressure ulcer, and contractures, was admitted with a care plan to address nutritional risk and weight gain. The care plan included interventions such as administering the prescribed diet, providing tube feeding if meal intake was less than 50%, monitoring weights and labs, notifying the physician and dietician of significant weight loss, and administering supplements as ordered. Despite these interventions, the resident experienced a significant weight loss over a three-week period, dropping from 113.8 pounds to 112.8 pounds, with a mistaken entry of 119.4 pounds later corrected by the DON. The DON acknowledged that the incorrect weight entry was not communicated to the resident's physician at the time it was discovered. The resident's weights were inconsistently documented, and the significant weight loss was not promptly addressed according to the care plan's requirements. The failure to notify the physician and dietician of the weight loss and to ensure accurate and timely documentation contributed to the deficiency in maintaining the resident's nutritional status.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for residents, specifically regarding the administration and documentation of controlled medications. For one resident, a review of the controlled medication utilization record showed that two doses of Oxycodone were signed out by licensed nursing staff, but only one dose was documented as administered in the medication administration record (MAR). The Director of Nursing confirmed that there was no nursing documentation for the remaining dose that was signed out. For another resident, the controlled medication utilization record indicated that ten doses of Oxycodone were signed out, but only three doses were documented as administered in the MAR. The Director of Nursing confirmed that there was no nursing documentation for the seven remaining doses that were signed out. These findings demonstrate a lack of a system to ensure that clinical records accurately reflect medication administration, as required by facility policy and professional standards.
Resident's Bed Inadequate for Physical Needs
Penalty
Summary
Facility staff failed to ensure that a resident's bed adequately met the resident's needs. During a complaint survey, it was observed that the resident, who has quadriplegia, a gastrostomy tube, and contractures of both ankles, had both feet hanging over the bottom of the bed and foot board. The resident also suffers from bilateral ankle foot drop and wears foot drop prevention boots daily, which further extend the length of the legs. The resident was able to communicate to the DON that the bed was too small. These findings were based on complaint, observation, review of clinical records, and resident interview.
Deficiency in Qualified Food and Nutrition Staff
Penalty
Summary
The facility failed to ensure that it had qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services, which has the potential to affect all residents. During an interview, the food service manager, identified as staff #51, revealed that although they possess a Serve Safe certificate, their Certified Dietary Manager (CDM) certificate had expired due to not maintaining the required continuing education units (CEUs). The manager has initiated steps to renew the certification by sending transcripts to the program to start taking classes. Additionally, the Registered Dietician (RD), identified as staff #12, works part-time for 16 hours, and a Consultant Registered Dietician, identified as staff #53, works 8 hours. The surveyor noted that the lack of an active CDM certificate does not meet the facility's requirement for having qualified staff to carry out food and nutrition services.
Inadequate Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple reports and observations of pest issues, including flies, gnats, and bed bugs, affecting various residents and areas within the facility. Residents reported the presence of pests in their rooms and bathrooms, with some experiencing discomfort such as itching. The surveyor observed gnats and flies in several rooms and common areas, confirming the residents' complaints. Despite these issues, the facility's pest control measures were inadequate, with no effective process in place to report and manage pest issues timely. Interviews with staff revealed a lack of awareness and utilization of pest log books, which were intended to document pest sightings and concerns. The Unit Manager was unaware of the purpose of the pest log book, and the Director of Maintenance confirmed that the maintenance department did not check any paper logs on the nursing units. The facility's process for reporting pest issues relied on an electronic system, but there was no evidence of consistent use or follow-up on reported concerns. The pest control company's contract indicated that pest monitoring logs were to be checked during each visit, but the surveyor found no staff reporting of pest issues in the log books. The facility's records showed multiple incidents of pest issues, including bed bugs and mice, with some concerns remaining unresolved for extended periods. The surveyor noted that the first bed bug treatment for a reported issue did not occur until 14 days after the concern was raised. Additionally, mice issues continued to be reported over several months. The surveyor's observations and interviews with staff and residents highlighted the facility's failure to effectively manage and address pest issues, resulting in an environment that was not free from pests.
Inadequate Investigation of Abuse Allegations and Missing Belongings
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and missing belongings, as evidenced by multiple incidents involving residents. In one case, a resident reported being sexually assaulted by an employee, but the investigation lacked critical details such as the identity of the interviewer and signatures on interview notes. The Director of Nursing (DON) was unable to provide information on who conducted the interviews, and the investigation was deemed incomplete by the surveyor. Another incident involved a resident alleging abuse by staff, but the investigation file was missing key documentation, including statements from involved staff and residents. The investigation lacked time stamps, interviewer identities, and follow-up on claims made by the resident. The DON acknowledged the concerns raised by the surveyor, indicating a lack of thoroughness in the investigation process. Additionally, a complaint about missing personal belongings was not adequately addressed. The facility failed to maintain an inventory sheet or obtain statements from staff who witnessed the resident's belongings at the time of transfer. The DON confirmed the absence of necessary documentation, and the Nursing Home Administrator acknowledged the issue but did not provide evidence of a thorough investigation.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, homelike environment, as evidenced by numerous observations of unclean and unsafe conditions throughout the facility. During the initial tour, surveyors observed resident rooms with cluttered belongings, splattered food, debris, and sticky floors. Resident #31 expressed concerns about the uncleanliness of their room, which was confirmed by the facility Administrator. Additionally, the surveyor noted a lack of bed linens on several mattresses and exposed sharp metal screws in Resident #7's room, posing a safety hazard. Further observations revealed widespread environmental issues, including peeling paint, broken cove molding, stained ceiling tiles, and mismatched lighting in various rooms. The surveyor documented numerous instances of visibly dirty floors, walls, and baseboard heating units, as well as broken furniture and fixtures. Residents reported having to clean their own areas due to the facility's inadequate housekeeping, and staff acknowledged the concerns but failed to address them promptly. The facility's grievance logs indicated ongoing complaints about cleanliness and maintenance issues, dating back several months. Despite these documented concerns, the facility did not take effective action to resolve the problems, resulting in continued deficiencies. The surveyor's observations highlighted a pattern of neglect in maintaining a safe and comfortable environment for residents, with multiple staff members acknowledging the issues but not implementing corrective measures.
Multiple Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide timely care and follow-up for several residents, leading to significant deficiencies. One resident experienced a fall resulting in facial injuries, including a left orbital and jaw fracture. Despite the fall occurring in the morning, the facility did not transfer the resident to the hospital until the family intervened hours later. The Director of Nursing admitted that the staff was unaware of the fall until later, and there was a lack of documentation on the care provided immediately after the incident. Another resident with mouth sores did not receive the prescribed medication for three weeks, despite a nurse practitioner's order for treatment. The medication was ordered but never administered, and the Director of Nursing confirmed this oversight. Additionally, a resident with a change in mental status, later diagnosed with a urinary tract infection, did not receive timely intervention. The staff failed to document the change in condition or administer the prescribed anti-anxiety medication until the following day, after the family called 911. Further deficiencies included a diabetic resident whose blood sugar levels were not consistently monitored as ordered, and the facility failed to implement a physician's order for pressure relief. The resident's heels were not elevated as required, and staff signed off on the task without verifying its completion. Another resident did not receive their scheduled IV antibiotics on time due to staff shortages, and there was no documentation explaining the missed doses. These incidents highlight significant lapses in care and documentation within the facility.
Medication Privacy Breach
Penalty
Summary
The facility staff failed to protect the privacy of residents' medical information by mistakenly giving a discharged resident the medication of another resident. This incident involved Resident #161, who was discharged from the facility and received a bottle of Metoprolol with another resident's name, Resident #200, on it. The error was reported by a complainant who received the medication upon Resident #161's discharge and noticed the incorrect labeling. The surveyor's investigation confirmed that Resident #200 had been in the facility and was prescribed Metoprolol during their stay. The Director of Nursing acknowledged the possibility of such an error occurring when residents are discharged with their medications. The incident was validated by the DON, highlighting a breach in maintaining the confidentiality of residents' medical records.
Failure to Timely Report Abuse and Incidents
Penalty
Summary
The facility staff failed to report allegations of abuse and neglect within the required timeframe to the Office of Health Care Quality (OHCQ). In one instance, a resident reported that a nurse bent their finger back while administering medication, but the initial report to the state agency was not sent within the mandated two-hour window. Another case involved a resident's daughter alleging that a CNA was rough with her parent, leading to neglect. The facility administration was aware of the complaint but delayed reporting it to the state and local law enforcement by two days. Additionally, the facility did not report injuries of unknown origin to the OHCQ. A resident was found with a bruise on their chest after a fall, but there was no documentation of the incident being reported to the state agency. The facility's investigation suggested the bruise could be due to Senile Purpura, but the lack of timely reporting and documentation was noted as a deficiency. The facility also failed to submit initial reports for incidents involving missing medications and allegations of verbal abuse. Oxycodone delivered to the facility for two residents was reported missing, but there was no evidence of an initial report to the OHCQ. In another case, a resident reported being cursed at by a staff member, but the initial investigation report was not submitted promptly. These failures to report in a timely manner were identified as deficiencies during the survey.
Failure to Notify Resident of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding the resident's transfer to a hospital. This deficiency was identified during a recertification/complaint survey for one of the four residents reviewed for hospitalization. Specifically, the medical record of a resident revealed that they were transferred to the hospital on two occasions due to a change in medical condition, but there was no documentation of a transfer notice being given to the resident or their representative. The Director of Nursing (DON) stated that the facility's protocol requires that a notification of transfer be given to the resident at the time of transfer, with cognitively intact residents signing the notice and a copy being sent with them to the hospital. For residents unable to sign, a copy is sent to their family members for signature, and the facility retains a copy in the resident's medical chart. However, in this case, the notification documents for the resident's hospital transfers were missing from the medical chart, and the administrator confirmed that they could not be found.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a pressure ulcer, as identified during a recertification/complaint survey. The deficiency involved a resident who was admitted with a Stage II pressure ulcer on the left lateral malleolus. Upon admission, there were no orders for wound treatment, despite the hospital discharge summary indicating the need for specific wound care. The resident's family member noticed that the wound dressing was outdated and brought it to the attention of the nursing staff, who confirmed there was no order for dressing changes. The nursing staff, including a registered nurse, explained the process for planning care for new admissions, which involves reviewing discharge summaries and reconciling orders with the physician. However, in this case, the wound treatment order was missed during the admission process, and the Director of Nursing was informed of this oversight. The lack of a wound care order resulted in the resident's pressure ulcer not being appropriately managed until the family member intervened.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a resident and their representative with a summary of the baseline care plan, as required by federal regulations. This deficiency was identified during a recertification/complaint survey for one resident. The medical record review revealed that the resident was admitted to the facility, but there was no evidence that a copy of the baseline care plan summary was offered to the resident or their representative during the care conference. The baseline care plan summary should include initial goals, a list of current medications and dietary instructions, and services and treatments to be administered by the facility. Interviews with facility staff highlighted a lack of awareness and understanding regarding the requirement to provide a baseline care plan summary. An LPN staff member indicated that while the nursing staff initiates the baseline care plan and other departments are involved in its completion, they were not aware of the need to provide a summary. The Director of Nursing stated that the baseline care plan is created and discussed during the care plan meeting, but the surveyor noted that the facility did not offer a copy of the baseline care plan summary to the resident or their representative.
Medication Administration Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of nursing practice during medication administration, as observed in several instances. A registered nurse (RN) was seen preparing medications for a resident without verifying the current orders against the Medication Administration Record (MAR), relying instead on a binder and medication pack information. The nurse admitted to not using the facility-provided laptop to verify orders due to being in a hurry and familiarity with the resident's medications. This resulted in discrepancies in the documentation, as the controlled medication utilization record was signed, but the MAR was not updated accordingly. Further audits revealed significant discrepancies between the Controlled Medication Utilization Record and the MAR for multiple residents. For one resident, nine entries of as-needed Oxycodone did not match the MAR, while another resident had 16 entries of as-needed Percocet that were not signed in the MAR. A third resident had 21 entries of as-needed Oxycodone that were not documented in the MAR. These discrepancies indicate a failure to properly document the administration of controlled medications, as required by professional standards. Additionally, the RN was observed mishandling an insulin pen by drawing insulin into a syringe, which is not an endorsed practice by insulin manufacturers. The nurse justified this action by expressing concerns about the accuracy of the dose delivered by the pen. This improper handling of the insulin pen was contrary to the recommended use, which involves attaching a specified needle to the pen and dialing the ordered dose. These actions demonstrate a lack of adherence to established protocols for medication administration, contributing to the deficiencies identified during the survey.
Failure in Tube Feeding Administration and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident receiving tube feeding, as observed during a recertification/complaint survey. The deficiency was identified for one resident who was on both an oral diet and enteral nutrition via a PEG tube. The surveyor observed that the resident's Osmolite tube feeding was not running on multiple occasions, and the water flush bag was dated incorrectly, indicating it had not been changed since 8/20/24. Additionally, the tube feeding administration record was not signed from 8/12/24 to 8/23/24, except for one signature on 8/13/24. The surveyor confirmed with RN #9 that the dates on the Osmolite bottle and water flush bag were inconsistent, and the tube feeding machine was not properly monitored. The Registered Dietitian's note indicated that the resident's energy needs were to be met via enteral nutrition, but the administration record showed a lack of documentation. The Director of Nursing and Staff #10 acknowledged the issues, with Staff #10 noting that the order was written incorrectly by the RD. The deficiency highlights a failure in maintaining accurate records and ensuring proper administration of tube feeding and water flushes for the resident.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents during a recertification/complaint survey. Resident #161, who was admitted after a right knee replacement, was prescribed Oxycodone for pain management. Despite the availability of the medication in the facility's Omnicell system, the resident did not receive the medication until the following day, resulting in unmanaged pain. The Director of Nursing confirmed the delay in administering the pain medication. Resident #10, who suffers from chronic pain, had orders for three different PRN pain medications without specific parameters and no routine pain medication to manage the pain consistently. The resident also had an order for non-pharmacological interventions prior to PRN medication, which were not administered as required. Interviews with the resident and staff confirmed that the resident experienced delays in receiving pain medication and did not receive non-pharmacological interventions before medication administration.
Improper Insulin Administration by RN
Penalty
Summary
The facility staff failed to ensure that a registered nurse possessed the necessary skills to administer insulin correctly, as observed during a recertification/complaint survey. Specifically, RN #9 was seen drawing insulin from an insulin pen using a one cubic centimeter (cc) syringe instead of using the pen's specified needle and dial to set the dose. This action was taken because RN #9 believed that the resident would not receive the exact dose if the pen was used. The insulin was then administered to Resident #8 using the one cc syringe on the right arm, as per the resident's request. During an interview, the Director of Nursing (DON) and the corporate nurse confirmed that the correct procedure for insulin administration involved using the pen's specified needle and dial. They were informed of RN #9's incorrect method of drawing insulin. The report also noted that RN #9 was passing medications from memory without using a computer and not signing off medications in a timely manner, which contributed to the deficiency identified by the surveyors.
Failure to Conduct Annual Performance Reviews for GNAs
Penalty
Summary
The facility staff failed to conduct performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months, as required. This deficiency was identified during a recertification/complaint survey when the records of three randomly selected GNAs were reviewed for annual training requirements. Specifically, the personal file of one GNA, hired on February 15, 2022, did not contain a record of an annual performance review. During an interview, the Director of Nursing (DON) stated that performance evaluations are conducted yearly or every 90 days by department heads, and the Human Resources department is responsible for tracking and alerting staff about due evaluations. However, the DON was unable to provide the missing evaluation record for the GNA in question, acknowledging the concern.
Discrepancies in Controlled Medication Records
Penalty
Summary
The facility failed to maintain accurate drug records for controlled medications, specifically Oxycodone and Percocet, for three residents during a recertification/complaint survey. The Controlled Medication Utilization Record did not match the Medication Administration Record (MAR) for several entries, indicating discrepancies in the documentation of administered doses. For Resident #66, nine out of 23 recorded doses of Oxycodone did not match the MAR. Similarly, for Resident #21, 16 out of 27 recorded doses of Percocet were not signed in the MAR. Resident #86 had 21 out of 53 recorded doses of Oxycodone that did not match the MAR. During an interview, the Director of Nursing and a corporate nurse confirmed that nurses are required to sign and date the controlled sheet when removing medication and to sign the MAR after administration. However, an audit revealed that the administered narcotics did not match the records, indicating a failure in the facility's process for documenting controlled medication administration. This deficiency highlights a significant lapse in the facility's pharmaceutical services, potentially affecting the safety and well-being of the residents involved.
Failure to Address Pharmacy Recommendation for Medication
Penalty
Summary
The facility failed to follow up on a pharmacy recommendation for a resident during a recertification/complaint survey. The issue was identified for one of the five residents reviewed for unnecessary medication. Specifically, the pharmacist recommended on January 2, 2024, that an order for Divalproex, a medication used to treat bipolar disorder and epileptic seizures, be added to the electronic medical records (PCC) if the resident was receiving it. However, this recommendation was not addressed by the attending physician, and the medication was only started on June 4, 2024. Interviews with the Director of Nursing (DON) and the attending physician revealed a breakdown in communication and responsibility. The DON stated that pharmacy recommendations are passed to nursing staff, who then communicate them to the attending physician. The attending physician confirmed that he relies on the nursing staff to present pharmacy recommendations to him for review and action. The DON acknowledged the concern when made aware of the oversight, indicating that the recommendation was not followed up as required.
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What surveyors actually found near you
We read the 2,041 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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Nursing homes near Glen Burnie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Glen Burnie | 2.2 mi | ★★★★★ | 4 | 0 |
| Marley Neck Rehabilitation And Wellness Center | 2.3 mi | ★★★★★ | 9 | 0 |
| Complete Care At Severna Park Llc | 5 mi | ★★★★★ | 6 | 0 |
| Hammonds Lane Center | 5.1 mi | ★★★★★ | 34 | 0 |
| Autumn Lake Healthcare At Waugh Chapel | 7.4 mi | ★★★★★ | 1 | 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.