Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Calvert Manor during CMS and state inspections, most recent first.
A resident’s family filed a grievance about care provided by an RN, and the resolution stated the RN was not to provide care to the resident. However, MAR/TAR documentation and staffing assignments showed the RN continued to provide care and was assigned to the resident multiple times afterward, and the care plan did not document the restriction.
A resident with Alzheimer's disease, identified as high risk for wandering, made several attempts to leave the unit and had a Wander Guard placed on their ankle. Facility staff did not notify the responsible party of the resident's wandering behavior or the placement of the Wander Guard, and there was no documentation of such notification in the medical record.
Staff failed to provide timely administration of medications, supplements, and wound care for two residents. One resident with dementia did not receive a prescribed medication despite its availability, while another with malnutrition experienced delays in receiving a recommended nutritional supplement and missed several ordered wound treatments. The DON confirmed these lapses in care and documentation.
The facility did not report multiple allegations of abuse, neglect, or mistreatment to the state agency within the required two-hour timeframe. In several cases, residents reported being physically or verbally mistreated, threatened, or sexually assaulted, and these reports were not promptly communicated to the Office of Health Care Quality as mandated. Documentation and staff interviews confirmed that the delays in reporting were due to lapses in following established protocols.
The facility failed to implement care plan interventions for a resident with repeated falls, did not arrange a timely orthopedic follow-up for a resident with a fractured arm, and administered medications late to two residents, including those with respiratory conditions. Additionally, a resident with diarrhea continued to receive a laxative and experienced a delay in treatment for C. difficile due to late physician notification of positive lab results.
Multiple residents and family members reported delays in care, unmet needs, and long wait times due to insufficient nursing staff, especially on weekends and night shifts. Staff interviews confirmed frequent call-outs, high resident-to-staff ratios, and challenges completing daily care tasks, with inconsistent use of agency staff contributing to the deficiency.
Surveyors found that medication carts were left unattended and unlocked, with one instance of keys left in the lock, and a computer screen displaying resident information was also left unlocked. An expired nutritional supplement was discovered in a medication room refrigerator. Staff and leadership confirmed that protocols for securing medications and information were not consistently followed.
The facility did not consistently serve meals according to the posted menu or residents' documented preferences, resulting in several residents receiving food items they did not request or wish to have. Staff substituted menu items due to supply and cost issues without updating meal tickets or informing residents, and some residents continued to receive items they had specifically declined. Staff acknowledged that menu changes and resident preferences were not always communicated or reflected in the meals served.
Surveyors found that food items, including dry pasta and trays of Tater Tots, were stored without required labels or dates in both the storage area and walk-in refrigerator. Staff were unable to provide information on when these items were received or prepared, confirming that proper labeling procedures were not followed.
Two residents did not consistently receive two showers per week as per their preferences, with records and interviews confirming missed scheduled showers and no evidence of make-up showers. Staff and DON acknowledged ongoing issues with shower scheduling and delivery.
A medication cart was observed unattended with an unlocked computer screen displaying confidential resident information, including names, medical record numbers, room numbers, and photos. The nurse responsible left the area to respond to a call light for a resident who nearly fell, leaving the cart and screen unsecured. Facility leadership confirmed that staff are expected to lock carts and blank computer screens when unattended.
A resident reported a significant amount of cash missing from their bedside, with only a portion later returned and no clear resolution or follow-up provided. Staff interviews revealed that the required inventory list documenting the resident's possessions was missing, and there was no documentation of the investigation into the missing money. The process for handling and investigating missing property was inconsistently followed, and discrepancies existed in the reported amounts and handling of the resident's cash.
A resident alleged that a GNA handled her roughly and pinched her during care, resulting in pain. Multiple staff were informed, and a skin assessment was performed, but no injuries were found and no further investigation or reporting occurred. The incident was not documented or communicated to the DON or Administrator as required.
A resident with a physician's order for a right elbow extension splint did not have this intervention or related contracture management included in their care plan. Although the splint order and occupational therapy recommendations were documented, staff confirmed that the care plan was not updated due to an entry error, resulting in the omission of essential care information.
A resident who was dependent on staff for ADLs due to significant self-care deficits did not receive scheduled showers for a month after admission and only received sporadic showers in subsequent months, despite facility policy and staff schedules requiring twice-weekly showers. Staff and DON confirmed the missed care and lack of documentation for refusals.
Staff initiated CPR on a resident with documented DNR and DNI orders, as indicated on the MOLST form, and continued resuscitation efforts until EMS arrived and identified the resident as deceased. Review of records and staff interviews revealed confusion and inconsistent interpretation of the MOLST directives, leading to the failure to honor the resident's end-of-life wishes.
A resident returned from hospitalization with a Foley catheter, but the facility failed to ensure a complete and current medical order specifying the catheter size and balloon information upon re-insertion. Nursing staff reinserted the catheter under a PRN order without verifying or obtaining a new, detailed order, resulting in a gap in proper documentation until a new order was established.
A resident receiving continuous oxygen therapy for COPD did not have their oxygen tubing and humidifier bottle changed or labeled as required, and staff failed to document these actions as ordered by the physician. Additionally, the resident's care plan did not address oxygen therapy with specific goals and interventions, resulting in a lack of comprehensive, person-centered respiratory care.
Facility staff failed to ensure safe and effective pain management for several residents, including delays and omissions in pain medication administration, lack of documentation of non-pharmacological interventions, and failure to assess and document pain levels as required by facility policy and physician orders.
Staff performed CPR on a resident with a documented DNR/DNI order due to a lack of understanding of the MOLST form and failure to check code status before initiating resuscitation. EMS found staff performing CPR despite clear documentation and signs of death. Interviews revealed that LPNs did not routinely verify MOLST forms prior to starting CPR, and staff misunderstood facility policy regarding resuscitation.
A review of staff records found that an annual performance evaluation was not completed for a GNA who worked PRN. The DON confirmed that the evaluation was overlooked and no documentation was available.
A resident with diabetes had a physician order for insulin to be held if blood sugar was below 150. Despite this, an RN administered insulin when the resident's blood sugar was 134, while the previous day an LPN had correctly held the dose for a similar reading. The discrepancy was confirmed by the unit manager and ADON, and the RN later claimed the administration was a documentation error, though the record included an injection site.
Required members of the QAA committee, including the medical director, NHA, DON, and ADON, did not consistently attend scheduled meetings as evidenced by review of attendance records and staff confirmation.
Grievance resolution not enforced for RN assignment
Penalty
Summary
The facility failed to ensure a grievance resolution was carried out for a resident after a family grievance about care provided by RN #23. The resident’s family member reported that a grievance filed in December 2025 resulted in a resolution that RN #23 was not to provide care to the resident in any capacity. The grievance record reviewed by surveyors showed the facility initiated the grievance on 12/31/2025, and the corrective action stated that the nurse named in the complaint was aware he was not to treat the resident per the daughter’s request for routine care. The decision on the grievance was dated 1/5/2026 and signed by the facility SW. Despite that resolution, the resident’s MAR and TAR showed RN #23 documented medication administration and/or assessments on 1/9/2026, 1/19/2026, 2/8/2026, 2/12/2026, 4/23/2026, and 5/20/2026. Staffing assignment sheets also showed RN #23 was assigned to care for the resident on those same dates. Review of the care plan did not show documentation that RN #23 was not to provide care to the resident. When surveyors reviewed the concern with the DON and SW #22, both confirmed the grievance resolution was that RN #23 was not to provide care to the resident, and stated they believed RN #23 had been verbally made aware of that restriction.
Failure to Notify Responsible Party of Change in Resident Condition
Penalty
Summary
Facility staff failed to notify a resident's responsible party of a significant change in condition. The resident, who was admitted with Alzheimer's disease and assessed as high risk for wandering and elopement, was observed on the day of admission making several attempts to leave the unit. In response, staff placed a Wander Guard device on the resident's right ankle. However, there was no documentation in the medical record indicating that the responsible party was informed of the resident's wandering behavior or the placement of the Wander Guard. During interviews, the responsible party confirmed not being notified, and the Director of Nursing verified the absence of documentation regarding this notification.
Failure to Administer Medications, Supplements, and Treatments as Ordered
Penalty
Summary
Facility staff failed to administer medications, treatments, and supplements as ordered for two residents. For one resident with dementia, Donepezil 5 mg was not administered as ordered on the evening of 9/11/25, despite the medication being available in the Omnicell system. The Director of Nursing confirmed that the medication was not given as prescribed by the physician. Another resident, admitted with malnutrition, did not receive a recommended house supplement shake in a timely manner. Although the Registered Dietitian recommended the supplement and the Nurse Practitioner agreed, the supplement was not ordered until three days later and not administered until four days after the recommendation. Additionally, this resident did not receive ordered wound treatments for a left foot wound on several documented shifts, with no evidence of administration in the treatment record. The Director of Nursing confirmed the lack of documentation for these missed treatments.
Failure to Timely Report Alleged Abuse and Mistreatment
Penalty
Summary
The facility failed to timely report multiple incidents of alleged abuse, neglect, or mistreatment to the Office of Health Care Quality (OHCQ) as required by regulation. In several cases, residents reported being physically mistreated, threatened, or sexually assaulted by staff or unidentified individuals. These allegations were communicated to facility staff, including nurse aides, charge nurses, and unit managers, who then relayed the information to the Director of Nursing (DON) or the facility administrator. However, the initial reports to the state agency were not made within the mandated two-hour window, with delays ranging from several minutes to several hours. Specific incidents included a resident reporting being lifted and dropped by a staff member, another resident alleging rough handling and verbal abuse, and multiple reports of sexual assault or inappropriate touching. In each case, the timeline of internal reporting and subsequent notification to OHCQ exceeded the required timeframe. Documentation and interviews confirmed that the DON and other staff were aware of the two-hour reporting requirement but failed to meet it consistently. In one instance, a resident's complaint of being pinched and roughly handled was not escalated to the DON or reported to OHCQ at all until brought to attention by a surveyor. The facility's investigation files and staff interviews corroborated the late reporting, with the DON acknowledging the delays and confirming the accuracy of the timelines. The failure to promptly report these allegations as required by regulation was evident for six of ten residents reviewed for abuse during the survey.
Failure to Implement Care Plans, Arrange Follow-Up, Timely Medication Administration, and Prompt Lab Reporting
Penalty
Summary
The facility failed to implement and monitor care plan interventions, arrange necessary follow-up appointments, administer medications in a timely manner, and promptly report and act on laboratory results for multiple residents. One resident experienced repeated falls, with documentation indicating that interventions such as hipsters and soft helmets were included in the care plan but were not ordered by a physician, resulting in staff not implementing or monitoring these safety measures. Another resident who suffered a fractured arm did not have a timely orthopedic follow-up appointment arranged as ordered by the physician, and when the family could not keep the scheduled appointment, the recommended emergency room visit was not carried out. Medication administration was also deficient for two residents. One resident's morning medications were consistently administered 2-3 hours late, outside the facility's policy window of one hour before or after the scheduled time. Another resident, who required timely administration of inhaled medications for respiratory conditions, received these medications several hours late on multiple occasions, with staff acknowledging that both residents and staff had raised concerns about the timeliness of medication passes. Additionally, the facility failed to hold a prescribed laxative for a resident experiencing diarrhea and delayed notifying the physician of a positive C. difficile laboratory result. The resident continued to receive the laxative for several days while having diarrhea, and the positive lab result was not communicated to the physician for six days, resulting in a delay in starting appropriate treatment. Staff interviews confirmed that the laxative should have been held and the physician notified promptly, and that the delay in treatment initiation was not in accordance with facility policy.
Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by interviews, clinical record reviews, and complaint investigations involving multiple residents. Residents and family members reported frequent staffing shortages, particularly on weekends and night shifts, resulting in delayed assistance with activities of daily living such as toileting, dressing, and hygiene. One resident with a BIMS score of 14 reported being left in the same nightgown from the previous day and sometimes lying in body waste before being cleaned. Another resident described waiting up to an hour for call bell responses, and family members noted that staff were unable to assist with getting residents out of bed or providing timely meals due to insufficient staffing. Several complaints documented similar concerns, including instances where only two staff members were available to care for multiple halls of residents, leading to high resident-to-staff ratios. Staff interviews corroborated these findings, with GNAs and the staffing coordinator acknowledging frequent call-outs, reliance on agency staff, and occasions where a single GNA was responsible for up to 30 residents. Staff reported difficulty completing daily care tasks when staffing was inadequate, and the use of agency staff was described as inconsistent, with some agency personnel unwilling to perform all required duties. The DON was made aware of these ongoing staffing concerns during the survey.
Medication Storage and Expired Supplement Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the secure storage and management of medications and nutritional supplements. During facility tours, three medication carts were observed to be left unattended and unlocked, with one instance where the keys were left in the lock. In another case, a medication cart was left unlocked in a hallway across from the nursing station, and a staff member locked it only after being observed. Additionally, a medication cart was found unattended and unlocked outside a resident's room, with the computer screen displaying resident information also left unlocked and unattended. Upon inspection, the drawers containing medications were accessible. Surveyors also found an expired container of Nutren 2.0 nutritional supplement in a medication room refrigerator on the East Nursing Unit. The expired supplement was observed during a dual inspection with a unit manager, who acknowledged the finding and removed the item. Interviews with nursing staff and facility leadership confirmed that the expectation is for medication carts and computer screens to be locked and secured when unattended, but these protocols were not consistently followed during the survey.
Failure to Serve Meals According to Menu and Resident Preferences
Penalty
Summary
The facility failed to ensure that residents were served meals according to predetermined menus that incorporated their preferences. Multiple residents received meal trays that did not match their meal tickets or the posted menu. For example, residents expecting scrambled eggs, breakfast ham, and orange juice were instead served French toast, egg patties, and cranberry juice without having requested these substitutions. Staff interviews revealed that changes were made to the menu due to supply issues, such as running out of orange juice or substituting egg patties for scrambled eggs due to cost, without updating meal tickets or informing residents. Additionally, some residents continued to receive items they had specifically requested not to be served, and meal tickets sometimes contained errors or were not updated to reflect actual substitutions. Staff acknowledged that menu changes were not consistently communicated to residents and that meal tickets were not always updated to match what was actually served. In several instances, residents expressed disappointment or confusion about receiving meals that did not align with their preferences or dietary restrictions as indicated on their meal tickets. The surveyor's observations and interviews with both residents and staff confirmed that the facility did not consistently follow or update menus, nor did it ensure that residents' dietary preferences and needs were met as required.
Failure to Label and Date Food Items in Storage and Refrigeration
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and dating of food items in both dry storage and the walk-in refrigerator. During the initial kitchen tour, two bags of dry pasta were found on a storage shelf without any labels or dates indicating when they were received, opened, or their expiration. Staff confirmed that the origin and expiration of these items were unknown, leading to their removal from storage. Additionally, six trays of Tater Tots were found in the walk-in refrigerator without any indication of their preparation date. Staff present at the time were unable to provide information on when the Tater Tots were prepared and acknowledged that the trays should have been labeled. The lack of labeling made it impossible to determine how long the food had been stored, and these findings were confirmed by staff during the survey process.
Failure to Provide Showers According to Resident Preference
Penalty
Summary
Facility staff failed to ensure that residents received two showers per week according to their preferences. One resident reported typically receiving only one shower per week despite expressing a desire for two, and review of shower records confirmed that the resident did not consistently receive the scheduled showers, with no documentation of refusals. The resident's shower sheets for three months showed fewer than the expected number of showers, and there was no evidence that missed showers were made up on weekends as required. Staff interviews confirmed that showers were not provided on several assigned days, and the unit manager acknowledged ongoing issues with residents not receiving scheduled showers. Another resident stated that they were supposed to receive a weekly shower but had not received one for two consecutive weeks, with the possibility of a third missed week. Clinical records indicated that the resident was offered four showers in one month, received two, and refused one, but there was no evidence of make-up showers for the missed weeks. The DON was informed of these inconsistencies and acknowledged that showers were not being provided consistently, with no documentation of make-up showers for the affected residents.
Resident Information Left Exposed on Unattended Computer Screen
Penalty
Summary
A deficiency was identified when a surveyor observed a medication cart outside a resident room with an unattended, unlocked computer screen displaying confidential resident information. The exposed information included resident names, medical record numbers, room numbers, and photos for multiple residents. The computer screen was left open and visible to the public, and the cart was not secured at the time of observation. The concern was immediately acknowledged by the unit manager present during the observation. Further inquiry with a registered nurse revealed that the nurse had left the cart and computer screen unattended to respond to a resident's call light due to a fall incident. The nurse confirmed that facility policy requires nurses to lock the cart and computer screen when leaving them unattended and demonstrated the locking mechanism to the surveyor. Both the Director of Nursing and Assistant Director of Nursing later confirmed that the expectation is for medication carts to be locked, all items covered, and computer screens to be blanked when unattended.
Failure to Protect Resident Property and Maintain Inventory Documentation
Penalty
Summary
The facility failed to exercise reasonable care for the protection of a resident's property from loss or theft. A resident reported that $840 in cash, which was stored in wallets at the bedside, was stolen. The resident stated that $135 was later returned, but the remaining balance was unaccounted for. The resident reported the incident to the unit manager, but did not receive follow-up information regarding the outcome of the investigation. The resident was provided with a locked drawer, but expressed concerns about its security, stating that it could be easily opened with a small tool. Interviews with staff revealed inconsistencies and gaps in the facility's process for documenting and investigating missing property. A GNA stated that missing items are typically reported to a nurse and documented on an inventory list, but the inventory list for this resident could not be located. An LPN confirmed the absence of the inventory list in the resident's chart and described a process for investigating missing money that included notifying social work and other departments. The social worker acknowledged awareness of the missing money but was not involved in the investigation and stated that there was no documentation of the investigation. A review of the grievance form showed discrepancies in the reported amounts of missing money and no supporting documentation to clarify the resident's possessions upon admission.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
A resident reported to a surveyor that a GNA had pulled her by the feet and legs, causing ongoing pain, and had pinched her thighs while assisting with personal care. The resident also stated that the GNA appeared irritated during the interaction and that her thigh made contact with the bedrail. The resident informed the Unit Manager of these concerns, and the Unit Manager, along with a Nurse Practitioner, performed a skin assessment but found no visible injuries. The Unit Manager asked the resident to demonstrate how she was pinched, but the resident declined, and no further action was taken. There was no documentation in the medical record regarding a change in condition or the incident. Multiple staff members, including a Physical Therapist Aide and a Social Worker, were made aware of the resident's allegations and communicated them to the Unit Manager. The incident was not reported to the Director of Nursing or the Administrator, and the accused GNA was not informed of the allegations. The Director of Nursing later acknowledged that the incident should have been investigated and reported as alleged abuse, but this was not done at the time.
Failure to Include Splint Care in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was comprehensive and person-centered, specifically regarding the management of a right elbow contracture with a prescribed splint. Medical records showed that a physician's order for a right elbow extension splint, including specific instructions for use, hygiene, and monitoring, was initiated. However, upon review, it was found that the resident's care plan did not include any information about the splint use or contracture management, despite the order being in place and relevant discharge recommendations from occupational therapy. Interviews with facility staff, including an LPN and a unit manager, confirmed that care interventions are discussed in meetings and that unit managers are responsible for updating care plans. The unit manager acknowledged that the splint order should have been reflected in the care plan. The DON later confirmed that the splint and associated care had been entered on the kardex but not on the care plan due to an entry error, and this information was not available on the care plan at the time of the survey.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for activities of daily living (ADL) due to self-care performance deficits related to activity intolerance, fatigue, and musculoskeletal issues, did not receive regular showers as required. The resident was admitted for rehabilitation and had a care plan in place that included staff assistance with personal hygiene, such as bathing and grooming. Despite this, documentation showed that the resident did not receive a shower for an entire month after admission and only received sporadic showers in the following months. Staff interviews confirmed that residents are scheduled to receive showers twice a week, with documentation of both completed showers and refusals in the electronic medical record. However, review of the shower schedule and records indicated that the resident did not receive showers according to the established schedule, and there was no documentation of refusals for the missed showers. The DON verified that the resident did not receive the scheduled showers and acknowledged awareness of the issue.
Failure to Honor DNR/DNI Orders Resulting in Unwarranted CPR
Penalty
Summary
Facility staff failed to accurately interpret and follow a resident's Maryland Orders for Life Sustaining Treatment (MOLST) form, resulting in the initiation of cardiopulmonary resuscitation (CPR) on a resident who had a documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) order. When emergency medical services (EMS) arrived in response to a call, they found multiple staff members performing CPR and providing supplemental ventilation to the resident, despite the presence of rigor mortis and a MOLST form indicating No CPR and DNI. The EMS officials confirmed the resident's status and discontinued resuscitation efforts upon review of the MOLST form. Record review revealed two MOLST forms in the resident's closed records, both indicating No CPR and DNI, with one marked as void per protocol. Staff interviews demonstrated inconsistent understanding of the MOLST form directives, with both a registered nurse and the Assistant Director of Nursing stating that no CPR or intubation should be performed for residents with such orders. The facility's policy on residents' rights and advanced directives did not specify that CPR must be attempted on all residents regardless of MOLST status.
Failure to Ensure Complete Medical Orders for Foley Catheter Upon Re-Insertion
Penalty
Summary
The facility failed to ensure that a complete and current medical order for a Foley catheter was in place for a resident upon their return from hospitalization and after the re-insertion of the catheter. Medical record review showed a gap in active Foley catheter orders between 12/4/24 and 2/17/25, despite documentation that the resident had a Foley catheter both upon arrival to and discharge from the hospital. Upon the resident's return, there was no medical order specifying the catheter size and balloon information, and a progress note indicated that the catheter was reinserted without a standing order detailing these specifics. Interviews with nursing staff confirmed that the facility's expectation is for every resident with a Foley catheter to have a medical order specifying the catheter size and balloon information. However, the nurse who reinserted the catheter did so under a PRN order and assumed the same type was used, without verifying or obtaining a new, complete order. The lack of a complete and current medical order for the Foley catheter persisted until a new order was written on 2/17/25.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not properly labeling and changing oxygen tubing and humidifier bottles as required, not following physician's orders for oxygen administration, and not developing a comprehensive, person-centered care plan for oxygen therapy. During observation, a resident with COPD was found using a nasal cannula connected to an oxygen concentrator set at 2LPM, with a humidifier bottle that was almost empty and dated more than a week prior. The oxygen tubing was not labeled with the date it was last changed, and the resident could not recall when it had been replaced. Staff confirmed that both the humidifier bottle and oxygen tubing should be changed weekly and labeled, but this was not done. Review of the resident's medical record revealed active physician orders for continuous oxygen therapy and weekly changes of the humidifier bottle and oxygen tubing, but there was no documentation on the MAR or TAR that these changes had been performed as ordered. Additionally, the resident's care plan did not address oxygen therapy with specific goals and interventions, indicating a lack of a comprehensive, resident-centered approach to respiratory care. The DON verified the absence of documentation and acknowledged that oxygen therapy should be included in the care plan.
Failure to Provide Safe and Effective Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for multiple residents, as evidenced by delayed, missed, or improperly documented pain medication administration. One resident, following hip surgery, experienced severe pain and reported waiting several hours for pain medication upon admission, with no pain medication administered for over five hours despite a pain score of 5/10 escalating to 8/10. The resident also reported that non-pharmacological interventions, such as an ice pack, were not provided as requested, and there was no documentation that such interventions were attempted prior to administering PRN pain medication, as required by physician orders. Additionally, pain medication was administered late on another occasion, and there were no active orders for mild to moderate pain prior to a new order being placed after surveyor observation. Another resident with a history of severe leg pain was given PRN acetaminophen and morphine sulfate outside of the ordered pain score parameters on multiple occasions. Documentation was lacking for non-pharmacological interventions prior to PRN pain medication administration, as required by the physician's orders. Staff interviews confirmed that pain medications were administered outside of the prescribed parameters and that documentation of non-pharmacological interventions was inconsistent or missing after a certain date. The expectation for staff to document both the interventions and any deviations from the ordered parameters was not met. A third resident, who reported shoulder pain, had an active order for topical lidocaine cream for pain, but there was no documentation that the medication was ever administered. Furthermore, there was no evidence of pain level assessment or use of a pain scale in the resident's records, despite facility policy requiring consistent pain assessment. Staff were unable to demonstrate or provide documentation of pain assessments, and it was revealed that the order for pain assessment was not renewed after a hospital stay, resulting in a lack of ongoing pain assessment and management for this resident.
Failure to Honor MOLST/DNR Orders Due to Staff Misunderstanding
Penalty
Summary
Facility staff lacked the necessary knowledge to correctly interpret and follow the Maryland Orders for Life Sustaining Treatment (MOLST) form, resulting in the initiation of cardiopulmonary resuscitation (CPR) on a resident who had a documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) order. When Emergency Medical Services (EMS) arrived, they found several staff members performing CPR and providing supplemental ventilation to the resident, despite the presence of rigor mortis and clear documentation on the MOLST form indicating that no resuscitative efforts were to be made. Staff later admitted to misunderstanding the MOLST form, believing that the DNI option only meant not to intubate, not that all resuscitative efforts, including CPR, were to be withheld. Additionally, staff reported that it was facility policy to attempt resuscitation regardless of any valid MOLST or DNR paperwork, which was not supported by the written policy reviewed. Interviews with nursing staff revealed that they did not routinely check the MOLST form before initiating CPR on unresponsive residents. Both interviewed LPNs described their process for responding to an unresponsive resident, which included starting CPR without first verifying the resident's code status or reviewing the MOLST form. The Assistant Director of Nursing was made aware of these concerns and expressed surprise at the staff's lack of knowledge regarding the proper protocol for honoring MOLST and DNR orders.
Missed Annual Performance Evaluation for GNA
Penalty
Summary
A review of staff records revealed that the facility failed to conduct an annual performance evaluation for one Geriatric Nursing Assistant (GNA) in 2023. Specifically, during a review of three randomly selected GNA employee files, it was found that there was no performance evaluation on file for one staff member who worked on an as-needed (PRN) basis. In an interview, the Director of Nursing (DON) confirmed that the responsibility for ensuring annual performance evaluations lies with the DON and unit managers, and acknowledged that the evaluation for this staff member was overlooked. No additional documentation of the required evaluation was provided.
Failure to Follow Insulin Administration Parameters
Penalty
Summary
A deficiency was identified when a resident with diabetes mellitus had an active medical order for Lyumjev KwikPen insulin, specifying administration of 15 units subcutaneously with meals and to hold the dose if blood sugar (BS) was less than 150. On review of the medical record, it was found that on one occasion, a registered nurse (RN) administered the insulin despite the resident's blood sugar being documented at 134, which was below the ordered threshold. The previous day, a licensed practical nurse (LPN) had correctly held the insulin when the resident's blood sugar was 138, in accordance with the order parameters. Interviews with the unit manager and assistant director of nursing (ADON) confirmed the discrepancy between the medication order and the administration record. The RN who documented the administration later stated that it was a typo, but the record also included documentation of the injection site, further supporting that the medication may have been given. This failure to follow the prescribed parameters resulted in the resident not being free from unnecessary medication, as required.
Failure to Ensure Required QAA Committee Member Attendance
Penalty
Summary
The facility failed to ensure that the required members consistently participated in the Quality Assessment and Assurance (QAA) committee meetings. Review of attendance sheets from January 2024 through February 2025 revealed that the medical director did not attend the February 2024 meeting, the Nursing Home Administrator (NHA) missed the meetings in April, September, and October 2024, and both the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were absent from the August 2024 meeting. These findings were confirmed by the QAPI representative upon review of the records, and the NHA acknowledged her absences during the survey exit conference, citing health reasons.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 372 citations issued within 25 miles in the last 12 months — including the 6 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rising Sun
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oxford Health Center | 5.6 mi | ★★★★★ | 3 | 0 |
| Laurelwood Healthcare Center | 9.8 mi | ★★★★★ | 16 | 0 |
| Preston Residence | 9.9 mi | ★★★★★ | 0 | 0 |
| Elkton Nursing And Rehabilitation Center | 11.4 mi | ★★★★★ | 48 | 0 |
| Newark Manor Nursing Home | 11.7 mi | ★★★★★ | 7 | 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.