Autumn Lake Healthcare At Bridgepark
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 4017 Liberty Heights Avenue, Baltimore, Maryland 21207
- CMS Provider Number
- 215195
- Inspections on file
- 17
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Bridgepark during CMS and state inspections, most recent first.
Nursing staff failed to document a resident's heart rate and did not hold a cardiovascular medication as ordered when the pulse was below a specified threshold. Additionally, staff did not accurately record the route of administration for the medication, continuing to indicate oral administration despite the resident receiving care via a feeding tube. The DON was unaware of these issues until identified during the survey.
Nursing staff failed to keep medication carts locked and secure on multiple nursing units. Several medication carts were observed unlocked and unattended, with one cart also having a medicine cup containing tablets left on top. These lapses were identified during a complaint survey across three different units.
Staff did not provide adequate supervision for a resident with a history of inappropriate sexual behavior, leading to actual harm to another nonverbal, cognitively impaired resident. Additionally, staff failed to follow a care plan requiring two-person assistance for bed mobility, resulting in a resident falling from bed and sustaining a laceration.
Surveyors found that the facility did not have documentation of required nursing competencies for several staff, including an agency RN and two nurses who provided care to a resident with a tracheostomy. The DON and administrator confirmed the absence of competency records and acknowledged concerns about staff education.
Surveyors identified that two GNAs did not receive the required 12 hours of annual in-service training, as confirmed by both record review and interviews with facility leadership. The DON acknowledged the lack of staff education as a concern.
A resident who requested care only from female staff, following an alleged incident, continued to receive care from male staff on multiple occasions. Despite documentation of the resident's preference and staff awareness, the care plan was not updated to reflect this request, and the preference was not consistently honored.
Facility staff did not notify a resident's designated representative of a change in medical condition and hospital transfer, despite documentation listing the representative and the resident's history of aphasia. The DON stated staff are expected to notify representatives, but no evidence was found that notification occurred.
A cognitively impaired resident was found by a GNA touching the genital area of another cognitively impaired resident, with the incontinence brief pulled aside. The incident was immediately reported and later substantiated as sexual abuse, indicating a failure to protect a resident from abuse.
The facility did not report an allegation of abuse within the required timeframe after a resident was suspected of being choked by a GNA, due to a staff member's failure to notify a supervisor. Additionally, an injury of unknown origin involving a non-verbal, fully dependent resident with severe contractures was not reported to the state agency, as the facility determined it was a pathological fracture two days after the injury was discovered.
The facility did not thoroughly investigate an abuse allegation due to missing documentation for an agency GNA and failed to provide required psychological and physician assessments to two residents following a substantiated incident of resident-to-resident sexual abuse.
A resident who developed swelling and redness in the lower extremity was diagnosed with ankle fractures and transferred to the hospital, but staff did not document or provide the required transfer information to the receiving provider. The section of the Change in Condition form for hospital transfer details was left blank, and both the Administrator and DON confirmed that the necessary information was not sent.
Surveyors found that the facility did not develop or implement complete care plans for several residents. One resident with a history of substance abuse lacked a care plan for this issue, another dependent resident received only one-person assistance despite a two-person assist care plan, and a third resident with a tracheostomy was not care planned for tracheostomy care. These deficiencies were confirmed through record reviews and staff interviews.
The facility did not update care plans for several residents after significant incidents, including inappropriate exposure, a fall, and substantiated sexual abuse. In each case, care plans were not revised to include necessary interventions such as supervision, monitoring, or fall prevention, despite documented needs and investigation findings. Leadership interviews confirmed that these care plan updates were not completed.
Staff failed to label a tube feeding container and water flush for a resident receiving enteral nutrition, and did not document a nursing assessment after a resident experienced a change in condition and was found unresponsive by family. The lack of labeling and incomplete documentation did not meet professional standards of care.
A resident with a tracheostomy who was dependent on staff did not receive oral care as required. The care plan lacked interventions for both tracheostomy and oral care, and documentation by respiratory therapists was inconsistent. The facility's tracheostomy care policy also did not address oral care, resulting in a failure to provide necessary assistance.
A resident who enjoyed music did not consistently receive planned one-on-one activities, as required by their care plan. Activity logs were incomplete, with missing documentation from admission and only a few recorded visits in recent months. The Activities Director cited lack of support staff and lost records as reasons for the inconsistency, resulting in the facility's failure to demonstrate an ongoing activities program tailored to the resident's preferences.
A resident did not receive the ordered frequency of physical therapy sessions, as documentation showed fewer sessions were provided than prescribed during the review period. This deficiency was confirmed through record review and staff interviews following a complaint.
Facility staff did not maintain complete and accurate medical records for multiple residents, including missing physician documentation for a resident's pathological fracture and the absence of a death certificate in another resident's file. The DON confirmed these omissions during interviews.
Surveyors found that staff failed to keep floors, bathrooms, and shower rooms clean, with trash, soiled linens, and personal items left out, as well as mobility equipment and janitor carts stored inappropriately. Additionally, a shared bathroom between male and female rooms was left open, compromising resident privacy. These issues were confirmed by staff interviews and direct observation.
Two residents with orders for splints or positioning devices to address contractures were repeatedly observed without the required devices in place, despite clear physician orders and care plan interventions. Staff and the DON confirmed the orders, but there was no documentation or explanation for the lack of application, resulting in a failure to provide care as directed to maintain or improve range of motion.
Staff failed to ensure a treatment order was in place for a resident with a suprapubic catheter after hospital readmission, and also did not provide timely incontinence care for another resident, resulting in extended periods without being changed. The DON confirmed that required orders were missing and that incontinence care was not consistently provided as expected.
A resident receiving oxygen therapy was found with an undated nasal cannula and a humidifier bottle that had not been changed for over a month. An LPN confirmed the lack of date labeling and was unsure of the required frequency for changing humidifier water, while the DON acknowledged the last change date was unknown due to missing documentation.
A review of employee files revealed that several nursing staff did not receive the state-mandated minimum of 2 hours of annual training on cognitive impairment. The DON confirmed the absence of this required training, which has the potential to impact all residents.
Failure to Follow Physician Orders and Document Medication Administration
Penalty
Summary
Nursing staff failed to follow physician orders regarding the administration of a cardiovascular medication for a resident who was totally dependent on staff for care, ventilator dependent, had a tracheostomy, and received nutrition and hydration via a feeding tube. The physician's order specified that Propranolol Hydrochloride, 10 mg, should be administered every 8 hours by mouth for tachycardia, but to hold the medication if the resident's heart rate was less than 100 beats per minute. However, review of the medication administration records for September and October showed that staff documented administration of the medication without recording the resident's heart rate or confirming whether the heart rate was below the threshold specified in the order. Additionally, the nursing staff did not accurately document the route of administration for the medication. Although the resident was receiving nutrition and hydration through a gastrostomy tube, the medical record continued to indicate that the medication was being given by mouth, rather than through the feeding tube. The Director of Nursing was unaware of these documentation and administration errors until the time of the survey.
Medication Carts Found Unlocked and Unattended
Penalty
Summary
Facility nursing staff failed to maintain medication carts in a locked and secure manner, as required for the storage of drugs and biologicals. During the initial tour, one medication cart on the second-floor nursing unit was found unlocked and unattended, with a medicine cup containing two cherry-colored oval tablets left on top of the cart. Additionally, on the fourth-floor nursing unit, two medication carts were observed unlocked and unattended, and on the third-floor nursing unit, two more medication carts were found in the same unsecured and unattended state. These observations were made during a complaint survey and involved three of four nursing units in the facility. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Provide Adequate Supervision and Required Assistance Resulting in Resident Harm
Penalty
Summary
Facility staff failed to provide adequate supervision for a resident with a known history of inappropriate sexual behavior, resulting in actual harm to another resident. Despite multiple incidents and psychiatric evaluations documenting ongoing inappropriate behaviors, the care plan for the resident exhibiting these behaviors was not updated to include increased supervision. On one occasion, a staff member witnessed the resident inappropriately touching another severely cognitively impaired, nonverbal resident, who was found tearful and distressed. The care plan interventions focused on medication management and behavioral monitoring but did not address the need for enhanced supervision to protect other residents. Additionally, the facility did not ensure that two-person assistance was provided during bed mobility care for a resident as required by the care plan. Documentation revealed that, out of 52 bed mobility tasks, 30 were performed with only one staff member, contrary to the resident's designation for two-person physical assistance. This failure led to an incident where the resident rolled out of bed during care by a single staff member, resulting in a laceration above the right eyebrow. Both deficiencies were identified through record reviews, incident reports, and staff interviews. The lack of appropriate supervision and failure to follow care plan requirements directly contributed to harm and injury to the residents involved.
Failure to Ensure Nursing Staff Competency and Skills Documentation
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to provide appropriate care for residents, as evidenced by the review of employee files and interviews. Specifically, the Director of Nursing (DON) was unable to provide documentation of nursing competencies for a contracted/agency Registered Nurse, despite requests to the staffing agency. The DON confirmed that the agency could not supply the required competency or skill test records for this nurse and acknowledged concerns regarding staff education. Additionally, a review of a confidential complaint and subsequent interviews revealed that nurses assigned to care for a resident with a tracheostomy did not have documented competencies in tracheostomy care. The facility administrator confirmed that the two staff members who worked with the resident on the date in question lacked tracheostomy care competencies. This lack of documented skills and competencies among nursing staff was identified during the survey and discussed with facility leadership.
Failure to Provide Required In-Service Training to Nurse Aides
Penalty
Summary
The facility failed to provide the required 12 hours of annual in-service training to two Geriatric Nursing Assistants (GNAs) for the year 2024. During a review of employee files, surveyors found no documentation indicating that these GNAs had completed the mandated in-service education. When asked, the facility administrator was unable to provide evidence of the training, and the Director of Nursing (DON) confirmed that the two GNAs had not received the required hours of in-service training. The DON also acknowledged that the lack of staff education was a known concern within the facility. This deficiency was identified through record review and staff interviews conducted as part of the recertification survey, specifically focusing on the sufficiency and competency of nurse staffing.
Failure to Honor Resident's Request for Female-Only Caregivers
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident's expressed preference to receive care only from female caregivers. After an alleged incident involving a male caregiver, the resident clearly communicated to the Nursing Home Administrator that they did not want any males to work with them. The facility's own investigation documentation and self-report form indicated that the resident was to receive ADL care from females only. However, review of the resident's care plan showed that it was not updated to reflect this preference. Further review of the treatment administration record (TAR) revealed that, on multiple occasions following the resident's request, care was provided by two male staff members. Nursing notes also indicated that staff were made aware of the resident's preference, yet the care plan was not revised accordingly, and the preference was not consistently honored. The Nursing Home Administrator confirmed that the male staff members performed care on the resident and acknowledged that the care plan should have been updated.
Failure to Notify Resident Representative of Change in Condition and Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's designated representative of a change in the resident's medical condition and subsequent transfer to the hospital. The resident, who had a history of aphasia, experienced shortness of breath and was evaluated by a Certified Registered Nurse Practitioner, who recommended immediate diagnostic testing and medication. Documentation showed that the resident was notified of the change, but staff incorrectly recorded that the resident was their own representative, despite the baseline care plan and admission record listing another individual as the resident's representative. The resident's representative was not informed of the change in condition or the hospital transfer, and only learned of the hospitalization the following day. During an interview, the DON stated that staff are expected to notify representatives, but also indicated that if a resident can make their own decisions, staff do not notify the representative. There was no documentation to support that the representative was notified as required.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident in which a cognitively impaired resident was found touching the genital area of another cognitively impaired resident. The event was witnessed by a Geriatric Nursing Assistant (GNA) during her initial shift rounding, who observed one resident on their knees next to another resident's bed with the incontinence brief pulled to the side. The GNA immediately intervened and reported the incident to the floor nurse. The investigation file confirmed that the incident was substantiated as sexual abuse based on the witness account. At the time of the incident, the resident who was abused did not appear to have any injuries, but the inappropriate contact was clearly documented. The Director of Nursing and the Administrator were notified shortly after the event, and the incident was reported to both the police and the state agency. The report specifically identifies a failure to ensure that the resident remained free from abuse.
Failure to Timely Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner and did not report an injury of unknown origin as required. In the first instance, a resident reported to the administrator that another resident might have been choked by a Geriatric Nursing Assistant during the evening shift. Documentation showed that a Certified Medicine Aide was informed by a resident and received a note from a roommate about the alleged abuse, but failed to notify a supervisor, resulting in a delay in reporting the incident to the state agency. The administrator acknowledged that the incident was not reported within the required two-hour timeframe due to this failure in communication. In the second instance, a non-verbal, fully dependent resident with severe contractures was found to have a swollen, red, and warm left ankle, and subsequent imaging revealed fractures of the left tibia and fibula. There was no documentation of any accident or trauma associated with the injury, and the resident was incapable of moving independently. The facility did not report this injury of unknown origin to the state agency, as the medical director determined it was a pathological fracture two days after the injury was identified. The DON confirmed that the injury was not reported because of this determination, despite the initial lack of explanation for the injury.
Failure to Investigate Abuse Allegation and Provide Post-Abuse Assessments
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation and did not maintain required documentation for agency staff. Specifically, when a resident reported that another resident might have been choked by a Geriatric Nursing Assistant (GNA) from an agency, the facility was unable to provide the employee file or training records for the GNA in question. The Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged that they did not have the contract with the agency or any documentation of the GNA's training, and the agency was no longer in existence. This lack of documentation and inability to verify training was identified as a concern during the survey. Additionally, the facility failed to provide psychological evaluations and physician assessments for residents following a substantiated incident of resident-to-resident sexual abuse. Although the facility claimed in its investigation documentation that both residents involved had been seen by psychiatric services and the facility physician, medical record reviews revealed that neither resident had received these assessments. The DON confirmed that it was standard practice for such evaluations to occur, but acknowledged that in this case, neither resident had been seen by psychiatric services or the physician regarding the incident.
Failure to Provide Required Transfer Information During Hospital Transfer
Penalty
Summary
Facility staff failed to provide the required minimum information to the receiving provider when a resident was transferred to the hospital. Medical record review showed that after a resident developed swelling, redness, and warmth in the left lower extremity, a physician ordered diagnostic tests, which later confirmed ankle fractures. The Change in Condition form, which includes a section for documenting specific information for hospital transfers, was left blank at the time of transfer. Nursing notes indicated that the resident was sent to the hospital following physician orders, but there was no documentation that the necessary transfer information was communicated to the receiving facility. Both the Administrator and DON confirmed during interviews that the required hospital transfer information was not documented or sent with the resident.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for multiple residents, as evidenced by record reviews and staff interviews. For one resident with a history of substance abuse and a diagnosis of osteomyelitis, there was no care plan addressing substance abuse, and staff confirmed that such a plan was not created. The resident's death certificate listed septic shock and necrotizing fasciitis as causes of death, with a history of IV drug and polysubstance abuse also noted. The Nursing Home Administrator acknowledged that a care plan for substance abuse should have been in place to identify potential for illicit substance use and guide interventions. Additionally, another resident who was dependent on staff for personal hygiene and toileting was care planned for two-person assistance, but records showed that care was routinely provided by only one person. This discrepancy was confirmed by the DON. A third resident, admitted with a tracheostomy, did not have tracheostomy care included in their care plan, and the DON confirmed this omission during a review of the care plan. These findings demonstrate a pattern of failure to ensure that care plans addressed all assessed needs and were implemented as written.
Failure to Revise Care Plans After Incidents and Changes in Condition
Penalty
Summary
The facility failed to revise and update care plans for multiple residents following significant incidents and changes in condition. In one case, after a resident was found naked with another resident, the facility's investigation concluded that the care plan should be updated to reflect the resident's desire for companionship and require staff supervision to prevent sexual interactions due to cognitive deficits. However, review of the electronic health record showed that the care plan was not updated to include these specific interventions or goals. In another instance, a resident experienced a fall, but the care plan and physician orders were not revised to address the new risk or to implement additional fall prevention interventions after the incident. Additionally, the facility substantiated an incident of sexual abuse involving a resident, with the corrective action indicating that the care plan should be updated to monitor and supervise inappropriate sexual behaviors and assess the effects of medication changes. Despite this, the care plan for the resident was not revised to include interventions for monitoring or supervision of the inappropriate behaviors. Interviews with facility leadership confirmed that these care plan updates and interventions were not implemented as required.
Failure to Label Enteral Feedings and Incomplete Assessment After Change in Condition
Penalty
Summary
Facility staff failed to ensure that a tube feeding container and water flush for a resident receiving enteral nutrition were properly labeled with the resident's name and date. During an initial tour, a resident was observed with an enteral feed and water flush running, neither of which were labeled as required. A registered nurse confirmed that the containers should have been labeled with the appropriate information, but this was not done at the time of observation. Additionally, staff did not follow professional standards when caring for a resident who experienced a change in condition. A family member found the resident unresponsive and called 911 after being told by staff that the resident had been in that state all day. Medical record review showed that the resident was previously documented as alert and responsive, but there was no nursing assessment documented for the day shift when the change in condition occurred. The physician later noted the resident was confused and disoriented, and hospital records confirmed the resident was admitted with altered mental status, a urinary tract infection, and a positive COVID test.
Failure to Provide Oral Care for Dependent Resident with Tracheostomy
Penalty
Summary
Facility staff failed to provide oral care to a resident who was dependent and had a tracheostomy. The resident was admitted with a tracheostomy and required assistance with activities of daily living, including oral care. A review of the resident's care plan showed no interventions for tracheostomy or oral care. Interviews with the Director of Respiratory Therapy revealed that respiratory therapists were responsible for providing and documenting oral care for dependent residents, but documentation was inconsistent among staff. Further review of the facility's tracheostomy care policy indicated that it only addressed tracheostomy care and did not include oral care procedures. The lack of documentation and absence of oral care interventions in the care plan led to the deficiency, as the resident did not receive the required oral care during their stay.
Failure to Provide and Document Resident Activities According to Care Plan
Penalty
Summary
The facility failed to provide documented evidence of an ongoing activities program that supported residents' choices, specifically for one resident reviewed during the Medicare/Medicaid recertification survey. Interviews revealed that the resident enjoyed listening to music, but the responsible party reported that no activities were being offered. The resident's care plan indicated a goal for participation in one-on-one visits at least twice per week, with interventions including gospel music, daily bread, and television. However, activity logs showed only five visits in May and two in June, with no documentation available from admission until May. The Activities Director attributed the lack of documentation to a former assistant discarding soiled logs and cited insufficient support staff as a reason for inconsistent activity provision. Observations and interviews confirmed that activities for residents unable to leave their rooms were supposed to be provided according to care plans, but the actual frequency and documentation did not align with these plans. The Activities Director stated that music was played for the resident two to three times a week for about 15 minutes per session, but this was not consistently documented. The lack of complete activity logs and inconsistent delivery of planned activities led to the deficiency, as the facility could not demonstrate that it met the resident's activity needs as outlined in the care plan.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide adequate physical therapy services to a resident as required by physician orders. A review of the resident's medical record showed that the resident was ordered to receive physical therapy 5 to 7 times per week during a specified recertification period. However, documentation revealed that the resident only received 3 sessions in one week, 4 sessions the following week, and just 1 session in the final week of the period reviewed. These findings were confirmed through review of therapy notes and interviews with facility staff, including the DON and a physical therapist. The deficiency was identified after a confidential complaint was reported to the state agency, alleging that the resident did not receive physical therapy as ordered and needed. The facility was unable to provide documentation showing that the ordered frequency of therapy was met during the review period.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for several residents, as evidenced by multiple deficiencies identified during record review and interviews. For one resident who sustained a left ankle fracture, the medical record did not contain any physician documentation regarding the injury, despite confirmation of the fracture by x-ray and hospital evaluation. The Medical Director's review and conclusion that the fracture was pathological due to underlying osteopenia and disuse atrophy were not documented in the resident's record. Additionally, the facility was unable to provide documentation of the Medical Director's findings or report in the resident's medical record. In another instance, the facility did not maintain a copy of a resident's death certificate in the medical record following the resident's death. The DON acknowledged that the death certificate should have been included in the resident's record and indicated that it had to be requested from the funeral home. These findings demonstrate that the facility did not ensure that resident medical records were complete and accurately documented in accordance with accepted professional standards.
Failure to Maintain Cleanliness and Resident Privacy
Penalty
Summary
Facility staff failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple observations of unclean floors, bathrooms, and shower rooms. Surveyors observed trash, toilet paper, cigarette ashes, and brown substances scattered on floors in various areas, including the resident smoking exit, stairwells, and elevators. The elevator floor was so sticky that a surveyor's shoes stuck to it, and trash such as a paper straw wrapper adhered to their footwear. The stairwell contained trash, leaves, a used glove, and a brown substance on the wall. Resident bathrooms and shower rooms were found with trash, soiled linens, personal hygiene items left out, and visibly soiled floors. Janitor carts with dirty mop water and mobility equipment such as wheelchairs and geri-chairs were stored in shower rooms, sometimes blocking access to shower stalls. In addition to cleanliness issues, the facility failed to ensure privacy for residents using shared bathrooms. On the third floor, a bathroom connected a room housing four male residents to a room with two female residents. Both bathroom doors were left open, allowing unsupervised access between the male and female rooms. This lack of privacy was confirmed during the surveyor's walkthrough and acknowledged by facility leadership. The open access between rooms compromised the privacy and dignity of residents, particularly as the female residents were unable to access the bathroom independently. Interviews with staff, including the Environmental Services (EVS) Director and the Nursing Home Administrator (NHA), confirmed the observations of uncleanliness and privacy concerns. The EVS Director described the cleaning schedule and staff responsibilities, but acknowledged the surveyor's findings when shown images of the facility's condition. The NHA also acknowledged concerns about the state of the shower rooms, which were observed to have soiled floors, trash, and improperly stored equipment. These deficiencies were corroborated by multiple staff interviews and direct observations by the survey team.
Failure to Apply Physician-Ordered Splints for Residents with Contractures
Penalty
Summary
Facility staff failed to ensure that residents with physician orders for splints or positioning devices received care as directed. One resident with bilateral upper extremity contractures was observed multiple times without the ordered right arm splint, which was to be worn daily for six hours according to the Treatment Administration Record. There was no documentation in the medical record explaining why the splint was not applied, and the splint was not observed in the resident's room during any of the surveyor's visits. The DON confirmed the existence of the order and stated that staff are expected to follow physician instructions. Another resident, who had an order to wear a rolled cloth on the left hand for ten hours daily after morning care and a care plan intervention for splint use to prevent contractures, was also observed on several occasions without the required splint. Staff confirmed that the resident should have been wearing the splint at the time of observation. The DON was notified of these findings, which demonstrated a failure to provide care as ordered to maintain or improve range of motion and prevent further contractures.
Failure to Maintain Catheter Orders and Timely Incontinence Care
Penalty
Summary
Facility staff failed to ensure that a treatment order was in place for a resident with a suprapubic catheter following the resident's return from a hospital stay. The resident was discharged to the hospital and returned with a suprapubic catheter, as noted in the hospital discharge summary, which recommended the catheter be changed in one month. However, upon readmission, no physician orders were entered for the catheter, and the previous order to change the catheter every 28 days had been discontinued. The Director of Nursing confirmed that it was the responsibility of the admitting nurse to ensure all necessary orders were entered at the time of admission, but acknowledged that no current orders for the catheter were present in the resident's medical record. Additionally, staff failed to provide timely incontinence care for another resident, who reported being left unchanged for extended periods following episodes of incontinence. Review of the resident's bladder continence Kardex revealed multiple instances where the resident was not changed for several hours after an incontinent episode, with specific dates identified where care was delayed. The Director of Nursing stated that incontinence care should be provided every two hours and before shift changes, but acknowledged that on the dates reviewed, the resident was not changed in a timely manner.
Failure to Properly Maintain and Label Oxygen Equipment
Penalty
Summary
Facility staff failed to provide respiratory care consistent with professional standards for one resident receiving oxygen therapy. During an initial tour, a resident was observed in bed with a nasal cannula and oxygen running at approximately 2 liters per minute. The oxygen humidifier bottle in use was dated over a month prior, and the nasal cannula tubing had no date label indicating when it was last changed. Upon dual observation, an LPN confirmed that the nasal tubing was not dated and the humidifier bottle had not been changed since the date marked. The LPN was unable to state how often the humidifier water should be changed and acknowledged that the water should not have remained unchanged for such an extended period. The DON was later informed and confirmed that the last change date for the tubing was unknown due to the lack of labeling.
Failure to Provide Required Cognitive Impairment Training to Nursing Staff
Penalty
Summary
The facility failed to comply with Maryland state regulations requiring nursing staff to receive a minimum of 2 hours of annual training on cognitive impairment. During a survey, the Director of Nursing (DON) was asked to provide employee files for five randomly selected nursing staff members. Upon review, it was found that none of these staff members had documentation showing completion of the required cognitive impairment training. The DON confirmed in an interview that these staff members did not receive the mandated training hours. This deficiency was identified through record review and staff interviews, and it has the potential to affect all residents in the facility.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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