Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Catonsville during CMS and state inspections, most recent first.
Food items were found in the kitchen and walk-in refrigerator without proper labels, open dates, or expiration dates, including opened hot dogs, cheese, produce, dry cereal containers, and an unlabeled frozen meat item. Staff also thawed raw chicken in the triple sinks used for sanitizing dishes instead of the designated food prep area, and the DON confirmed this was not the facility's thawing procedure.
Surveyors found widespread sanitation and maintenance issues, including vermin droppings, debris, broken tiles, and poor cleaning practices in areas such as the kitchen, laundry, conference, and rehabilitation rooms. Pest management records showed repeated recommendations to address unsealed voids and improve sanitation, but these issues persisted across the facility.
Surveyors found that the facility did not maintain an effective pest control program, with repeated observations of vermin droppings, unsanitary conditions, and unaddressed recommendations from the pest management company. Evidence included pest activity in resident rooms and common areas, as well as a complaint where a mouse remained on a trap in a resident's room for an extended period before removal.
A facility failed to provide a dignified existence when residents’ clothing was stored in clear garbage bags, a resident’s shoes were left in a wheelchair, and a bedpan was found in another resident’s wheelchair. A GNA confirmed the clothing storage issue and stated staff needed hangers for the armoire, and the Administrator was told that most residents on Unit C had clothing in garbage bags. Furniture in one resident’s room was also damaged, with laminate off a dresser drawer and missing drawer handles.
Facility staff failed to ensure multiple residents on Unit C had their call bells available. During survey observations, several residents were unable to locate their call bells, one resident was observed without a call bell, and another resident’s call bell was found on the floor near the bed. A RN confirmed one resident did not have a call bell, and GNAs stated they check for call bells during unit rounds or after assisting residents.
Dirty carpets and maintenance issues were observed in resident care areas, including stained carpeting throughout the first floor and A-wing, a clogged commode, damaged resident furniture, rusted equipment, a poorly fitting commode lid, damaged drywall and tile, and an unsecured paper towel dispenser. The DON said staff enter maintenance concerns into TELS linked to PCC.
An LPN failed to clarify polyethylene glycol mixing instructions before preparing medication for two residents and administered meds through a resident’s G-tube without checking placement. In another case, an LPN documented that a resident received Tylenol and Mylanta and had an EKG, but there was no documentation to verify the meds were given and the test was not performed.
Staff failed to keep unit staffing boards current on multiple units, with boards still showing the prior date, overnight shift, and staff from earlier shifts instead of the current assignment. The facility also posted a nurse staffing sheet that listed names, titles, and hours worked but did not include the facility name or resident census, and prior staffing sheets reviewed had the same omissions.
Improper Dumpster Waste Disposal: Surveyors observed a full dumpster with the lid open and waste scattered on the ground around it, including garbage bags, empty water bottles, COVID 19 tests, boxes, and part of the dumpster lid. The MD stated dumpster upkeep was a joint effort between EVS and the kitchen and that everyone who uses the dumpster is responsible for keeping the area clean.
The facility failed to maintain infection control practices by not providing cold running water and an available alcohol-based sanitizer dispenser in a resident room, and by allowing unlabeled used urinals to be stored in resident areas and bathrooms. Surveyors also observed a stock bottle of medication brought into a resident room for a resident on EBP and returned to the med cart without being sanitized.
Unsafe equipment and maintenance issues were observed throughout the facility, including exposed wires in walls, a damaged charging cord for a standing scale, nonfunctioning shared bathroom lights, and a resident bed alarm sounding repeatedly with a low-pressure bed control reading. The Administrator said the exposed-wire issue would be fixed right away, and the Maintenance Director stated staff are supposed to enter maintenance concerns in TELS.
A resident could not reach the call bell from a wheelchair, two room call bell lights did not illuminate when activated, and the PT bathroom lacked a functioning call bell system. Surveyors also found a missing corridor light cover and burned-out bulbs above resident room doors, while staff confirmed the rehab bathroom had no call bell system for resident use.
A resident's discharge MDS assessment was inaccurately completed, with errors including the omission of documented falls and incorrect reporting of a scheduled pain medication regimen, despite no evidence of scheduled pain medication administration.
A resident with peripheral vascular disease developed new wounds on both lower extremities, but staff failed to document wound size, characteristics, or changes in condition as required by facility policy. Despite orders for wound care and multiple assessments, documentation did not include necessary details to track wound progression or response to treatment.
A resident with significant cognitive impairment and a history of abnormal weight loss was not appropriately assessed for pain, despite having as-needed orders for Tylenol and Morphine. Staff failed to use a pain assessment tool suitable for the resident's cognitive status, and pain assessments were inconsistently documented or omitted, even when pain medication was administered. The facility's pain management policy requiring appropriate assessment and reassessment was not followed.
Two residents did not receive medications as ordered, with one resident's as-needed pain and anxiety medications not documented in the MAR despite being administered, and another resident's heart and pulmonary medications held without provider notification or documented parameters. The facility failed to ensure proper medication administration and documentation according to procedures.
Surveyors identified that the facility did not maintain accurate and complete medical records for two residents, including incomplete documentation of oxygen therapy and missing hospice visit notes after medication administration. Additionally, documentation for one resident was found misfiled in another resident's paper chart, including appointment and consultation forms. These deficiencies were confirmed through record review and staff interviews, including with the DON and RN.
A facility failed to accommodate two married residents who wanted to share a room. One resident stated that his spouse also lived in the facility but they slept separately, and the SS director acknowledged the couple had discussed rooming together when the spouse was admitted. The Administrator later said he was not aware of the request, and the surveyor noted the residents had been in the facility for about a year.
A resident’s bed was repeatedly observed placed against the wall with a floor mat beside it, and staff said the setup was used because the resident rolled out of bed and had frequent falls. The DON stated the resident had been moved to a different floor due to falls and room constraints, but no documentation was provided to support the bed placement or consent from the responsible party.
Failure to follow a resident’s care plan for toileting, urinal hygiene, and O2 monitoring. A resident with COPD, O2 dependence, anxiety, and limited mobility reported that a night GNA refused to empty and clean a full urinal, leaving it at the bedside. Surveyors later observed the urinal full on multiple occasions and found the resident calling out that the O2 tank was nearly empty; staff then replaced an almost empty tank. The care plan included room checks, assistance with urinal or commode needs, consistent routines, and monitoring for anxiety-related respiratory distress, but these interventions were not consistently carried out.
Failure to provide ADL and incontinence care to a dependent resident. A resident was observed in bed with copious oral secretions on the face and neck, and later had a strong odor of urine while an LPN administered medications. The LPN stated there were no GNA staff available, then returned to the med cart and did not provide incontinence care or seek assistance for the resident's needs.
A resident with a feeding tube had tube feeding and normal saline bags hanging on an IV pole without proper labels, and the tube feeding bag cap was not securely closed. Surveyors observed fruit flies around the resident’s area, and the DON was shown that the bags were missing labels. The bags were later found dated with black marker before a printed label matching facility policy was observed.
Medication storage and labeling deficiencies were observed in two medication carts. An LPN found ear and eye drops for three residents without open-date labels, an RN left a med cart unlocked, and loose pills were discovered in another cart under bubble packs.
Food Labeling and Improper Thawing Practices
Penalty
Summary
The facility failed to maintain proper labeling, dating, and expiration practices for food items during the kitchen survey. In the walk-in refrigerator, an opened package of hot dogs, a half onion, a half tomato, and an opened package of American cheese were observed without proper labeling, including open and expiration dates. In the kitchen area, three white Rubbermaid containers holding dry cereal were found on a stainless-steel counter without labels showing the date the cereal was placed in the containers or expiration dates. In the freezer, an unlabeled item appearing to be meatballs also lacked identifying information and an expiration date. The facility also failed to thaw raw meat in the proper area of the kitchen. A staff member was observed thawing raw chicken in the triple sinks designated for sanitizing dishes, while a blender with blended food and utensils were in an adjacent sink. When questioned, the staff member stated the chicken was being thawed for baking. The Dietary Director confirmed that the facility's thawing procedure required thawing meat in the refrigerator over three days or under cold water in the food preparation sink, not in the sanitizing sinks.
Sanitation and Vermin Control Deficiencies Identified Facility-Wide
Penalty
Summary
Surveyors identified multiple sanitation and maintenance deficiencies throughout the facility, including the presence of vermin droppings in the conference room, kitchen, and rehabilitation department. Observations revealed accumulated debris, food remnants, and water under kitchen equipment, as well as broken tiles and voids in the kitchen and laundry areas. Pest management company records indicated repeated recommendations to seal voids and improve sanitation, with documentation of ongoing issues such as unsealed holes and poor cleaning practices. The ice machine room was found with a wall void stuffed with steel wool, a wet dirty towel under the machine, and debris on the floor. Further inspection of the laundry area revealed rusted, broken metal trim with holes, broken tiles, a leaking sink with a bucket collecting drips, and accumulated lint and debris. The clean laundry room contained a dried spill, bottle cap, wrapper, and a shoe behind a linen cart. In the rehabilitation department, vermin droppings, a pistachio nut, and various debris were observed under the AC unit. These findings collectively demonstrate a failure to maintain a sanitary environment in multiple areas of the facility.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of vermin droppings, debris, and unsanitary conditions in multiple areas, including the conference room, kitchen, laundry area, and rehabilitation department. Surveyors noted that recommendations from the pest management company were not consistently followed, such as the need to utilize pest log books, seal voids and holes, and improve sanitation procedures. Despite weekly visits from the pest management company, the same issues were repeatedly documented in treatment reports, including unsealed voids in the kitchen, broken tiles holding dirty water, and poor sanitation in food preparation and dishwashing areas. During the investigation, surveyors observed multiple instances of pest activity and unsanitary conditions, such as vermin droppings under kitchen equipment, food debris, water accumulation, and broken or rusted building materials. In the laundry and rehabilitation areas, additional evidence of pest activity and poor housekeeping was found, including mouse droppings, lint buildup, and various debris. These findings were corroborated by pest management service reports, which documented ongoing mice activity and the need for improved facility practices. A specific complaint was also investigated, in which a resident's family reported that a mouse remained on a trap in the resident's room for 10 hours before removal. The pest management company’s inspection reports confirmed the presence of mice and other pests in resident rooms and common areas during their weekly visits. Facility leadership acknowledged the surveyors' findings and the ongoing pest issues, but no additional information was provided to demonstrate that an effective pest control program was in place.
Failure to Maintain Resident Dignity and Personal Possessions
Penalty
Summary
The facility failed to provide a dignified existence to residents by storing residents’ clothing in clear plastic garbage bags, placing residents’ shoes in a wheelchair, and leaving a bedpan in a resident’s wheelchair. During survey observations, one resident’s shoes were seen in the wheelchair, multiple residents’ clothes were observed in clear garbage bags, and a bedpan was observed in another resident’s wheelchair. In a resident’s room, laminate was observed off the top dresser drawer and the first and second drawers did not have handles. A GNA confirmed the observations and stated the staff needed hangers to hang residents’ clothing in the armoire. The Administrator was informed that multiple residents’ clothing was in garbage bags, and it was reported that most residents on Unit C had clothing stored in garbage bags.
Missing Call Bells for Multiple Residents on Unit C
Penalty
Summary
Facility staff failed to ensure residents on Unit C had their call bells available to notify staff of their needs. During observation rounds, Resident #4 was found without a call bell, and RN #28 confirmed it was not present. Later, Resident #18 was unable to find a call bell, and Resident #97 and Resident #78, who shared a room, were both unable to locate theirs. Resident #40 was also unable to locate a call bell, and Resident #29’s call bell was observed on the floor near the right side of the bed. When asked when staff ensure residents have their call bells, GNA #30 stated they ensure residents have their call bell when they come onto the unit when rounds are done, and GNA #31 stated they make sure residents have their call bell after assisting the resident.
Dirty Carpets and Poorly Maintained Resident Areas
Penalty
Summary
The facility failed to provide clean and sanitary carpets in resident care areas and failed to maintain a clean and comfortable homelike environment. Surveyors observed numerous stains and dark patches on the carpets at both the front and side entrance areas, as well as throughout the hallway leading down the A-wing and across the first floor. The stains persisted on repeated observation, and the Administrator stated the first-floor floors were scheduled for renovation. The Environmental Service Director confirmed that the dark stains on the A-wing carpet were related to the renovation process, while other stains in high-traffic areas were attributed to normal wear and tear and could not be effectively cleaned with chemicals over a long period of time, so EVS staff were permitted to use only hot water for cleaning the first-floor carpets. The facility also had multiple maintenance and housekeeping issues in resident areas on Unit C and in resident rooms. Surveyors observed a clogged commode in one room, Resident #91's damaged foot-board with a significant amount of trash on the floor under the bed, Resident #47's overbed tray table heavily rusted, a commode lid that did not fit properly in the shared bathroom between Rooms 215 and 216, damaged drywall and tile on the floor near a bathroom entrance, and a paper towel dispenser that was not secure and leaning to the side. During interview, the DON stated staff report maintenance concerns through the TELS computer program linked to PCC by entering the room number and the problem.
Medication Administration and Documentation Errors
Penalty
Summary
Staff failed to follow professional nursing standards during medication administration and documentation. On 08/15/25, an LPN prepared polyethylene glycol 3350 for Resident #18 and for Resident #14 by pouring the powder into a cup and adding water, but did not read the manufacturer’s instructions before mixing the medication and did not clarify the order with the pharmacist to verify how much water should be added. During the same observation period, the same LPN administered medications through Resident #50’s gastrostomy tube after checking residual gastric contents, but did not check tube placement before giving the medications. A review of Resident #6’s electronic health record on 08/18/25 showed that an LPN documented the resident complained of gas pain while in dialysis, although the LPN told the surveyor the dialysis nurse had called and reported chest pain. The LPN documented that Tylenol and Mylanta were given, but there was no documentation to verify the resident received those medications. The same record also showed the LPN documented that an EKG was performed, although the resident did not have the test.
Staffing boards and posted nurse staffing sheet were incomplete and not updated
Penalty
Summary
Staff failed to keep the unit assignment boards updated on Units A, C, and D during multiple shifts. On 8/10/25, the surveyor observed that the assignment board on Unit C was not updated to reflect the current date, shift, or staff working; it still showed the prior date and the 11 PM to 7 AM shift with staff from the previous shift. When asked, RN #39 did not respond. The surveyor then checked Unit D and found the same issue, with the board still showing the prior date and overnight shift. RN #37 stated that nurses were responsible for updating the assignment board, and the DON stated that nurses were supposed to update the staffing boards on the units and that the nursing supervisor was supposed to ensure they were updated every shift. LPN Supervisor #29 stated the boards were overlooked because they were busy with a resident safety issue, and the surveyor observed the boards were not updated past the seventh hour of the shift. On 8/15/25, the surveyor also observed Unit A's staffing board was not updated and still reflected the prior date, overnight shift, and staff who were not the staff working. The facility also failed to include all required components on the posted nurse staffing information sheet. On 8/18/25, the surveyor observed the sheet posted near the receptionist desk and employee time clock; it listed the date, employee names, titles, and hours worked, but did not include the facility name or resident census. Although the resident census was displayed separately on a bulletin board at the nurse's station on Unit A-Wing, the posted staffing sheet itself did not contain all required information. The LNHA acknowledged the concern during interview and later stated that the facility name was not on the posted sheet and that it would be handwritten on until the IT/Computer Department corrected the staffing sheet. A record review of July 2025 and August 2025 staffing sheets showed the same omissions of the facility name and resident census.
Improper Dumpster Waste Disposal
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed the facility failing to keep the dumpster area clean and properly managed. During the recertification survey, the surveyor saw Maintenance Director #14 and another male throwing items into the dumpster while the dumpster was full and the lid was open. When the dumpster area was later assessed, waste was observed on the ground in the front, sides, and back of the dumpster, including a large clear plastic garbage bag, a large black garbage bag, a small clear white bag, and a large board behind the dumpster. Several empty water bottles and COVID 19 tests were also found on the ground near the dumpster, 4-5 boxes were seen on top of the refuse in the open dumpster, and part of the dumpster lid was on the ground. Maintenance Director #14 stated that dumpster maintenance was a joint effort between Environmental Services and the kitchen, that the dumpster was emptied on Monday, Tuesday, and Friday each week, and that everyone who throws waste in the dumpster is responsible for keeping it clean.
Infection Control Lapses With Hand Hygiene Supplies, Urinal Storage, and Medication Handling
Penalty
Summary
The facility failed to provide alcohol-based sanitizer and cold running water necessary for hand hygiene procedures in resident rooms. In one room, surveyors observed a two-handle sink faucet with hot water available but no cold running water, and the wall-mounted alcohol-based sanitizer dispenser was empty. A unit manager stated staff used a sanitizer bottle on the medication cart after exiting resident rooms, and the Administrator confirmed the wall-mounted dispensers were being replaced or that sanitizer bottles would be placed in front of each resident room. Later, the surveyors confirmed a bottle of hand sanitizer had been placed on top of a two-tiered plastic drawer in front of the room. On a later visit, the Maintenance Director verified that the water line on the same side of the hall in the A-wing needed to be shut off to repair the valves, and the Administrator stated residents could be relocated to unoccupied rooms during the repair process. The DON later stated temporary water jugs and soap were provided in rooms of residents who lacked water, but the surveyors were unable to validate those claims at the time of the survey. The facility also failed to maintain infection control precautions with residents’ use and storage of urinals and with handling of a stock medication bottle in a resident room. Surveyors observed two unlabeled used urinals in a shared resident room, brown matter on the commode in the shared bathroom, and additional unlabeled urinals in the bathroom. In another resident room, four urinals were hanging over a wastebasket, with urine present in three of them. A GNA stated urinals are supposed to be labeled, and the EVS Director stated the department is responsible for cleaning resident rooms and emptying trash. In a separate observation, a unit manager placed a stock bottle of Docusate Sodium Oral Liquid on a resident’s bedside table while an LPN administered the medication through the resident’s gastrostomy tube; the resident was on Enhanced Barrier Precautions. The nurse then returned the stock bottle to the medication cart without sanitizing it, and the Regional DON stated the bottle should not have been taken into the room and should have been sanitized afterward.
Unsafe Equipment and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain equipment in safe operating condition during the recertification survey. Surveyors observed a black wire hanging from a hole in the wall next to Resident #50’s bed, a charging cord to the standing scale in the hallway next to a room hanging from the wall in two pieces with electrical wires exposed, and a hole in the wall with exposed wires next to the clean utility room on Unit A near the nurse’s station. Surveyors also found that the shared bathroom light in one room did not turn on until the surveyor went to the adjacent room to activate it, and another shared bathroom light for Rooms 209 and another room did not come on at all. In addition, while speaking with Resident #6, the surveyor heard the resident’s bed alarm every few minutes and observed the bed control reading low pressure. When asked about the exposed wires, the Administrator stated the issue would be rectified right away, and the Maintenance Director stated staff are supposed to enter maintenance concerns in TELS so the issues can be addressed.
Call Bell System Not Working or Accessible
Penalty
Summary
A working call system was not available in each resident bathroom and bathing area, as surveyors found multiple failures during the annual survey. Resident #52 stated that he/she could not reach the call bell to request help getting back to bed, and surveyors observed the call bell positioned on the opposite side of the bed while the resident was seated in a wheelchair. When the call bell was activated, GNA #11 responded several minutes later and explained that she had been attending to another resident in the shower room. Surveyors also found that the corridor light cover was missing above one room door and that the call bell lights above Rooms #105 and #106 did not illuminate when the bells were pressed, even though the Administrator and Regional DON later confirmed the system was operational at the nurse's station and that the bulbs above those doors were burned out. In addition, staff and the Director of Rehabilitation confirmed that the Physical Therapy bathroom did not have a functioning call bell system for resident use.
Inaccurate MDS Assessment Documentation for Discharge
Penalty
Summary
The facility failed to accurately document a discharge Minimum Data Set (MDS) assessment for a resident who was admitted as a hospice respite patient. Record review showed that the resident experienced two falls, as documented in progress notes, and was assessed for injury on both occasions. However, the discharge MDS assessment incorrectly indicated that the resident had not experienced any falls since admission, which was later confirmed as an error by the MDS Coordinator. Additionally, the resident had orders for two pain medications, Tylenol and Morphine, both prescribed on an as-needed basis. Review of the Medication Administration Record (MAR) revealed no documentation that either medication was administered. Despite this, the discharge MDS assessment inaccurately documented that the resident was on a scheduled pain medication regimen. The MDS Coordinator confirmed that this was also a documentation error.
Failure to Document Wound Assessments and Responses to Treatment
Penalty
Summary
The facility failed to adequately document wounds and responses to treatment for a resident with a history of peripheral vascular disease and foot pain. A change in condition was identified when a new open wound appeared on the resident's left lower extremity, and a skin assessment was performed. However, the assessment did not include documentation of the wound's size or characteristics. An order for wound care was written, but subsequent skin assessments continued to lack detailed documentation regarding the wound's measurements or characteristics. Further changes in the resident's condition were noted, including the development of a new wound on the right leg, with descriptions of wet dressings, foul odor, and significant pain. Both lower extremities were found to have soaked dressings with serosanguinous drainage and foul odor, and the right second toe was noted to have drainage and black discoloration. Despite these findings, the facility's documentation did not meet its own policy requirements for complete wound assessment, which include type, stage, measurement, and description of wound characteristics.
Failure to Use Appropriate Pain Assessment for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to utilize an appropriate pain assessment tool based on a resident's cognitive status. The resident in question had a history of abnormal weight loss and senile degeneration of the brain, was admitted as a hospice respite patient, and was documented as being very confused and not easily redirected. Despite having as-needed orders for Tylenol and Morphine for pain, there was no documentation indicating administration of Tylenol or Morphine on the MARs, and the pain monitoring documentation lacked clarity regarding the basis for the recorded pain assessment numbers. Pain assessments were inconsistently completed, with one assessment noting multiple pain indicators but then indicating the resident could not communicate pain location or characteristics. Subsequent assessments inappropriately skipped staff assessment for pain, despite the resident's inability to communicate effectively. Review of the facility's pain management policy revealed that staff were required to use a pain assessment tool appropriate for the resident's cognitive status and to reassess pain management at established intervals. However, when Morphine was administered, there was no evidence that a pain assessment was completed before or after administration to evaluate effectiveness, as confirmed by the ADON. No additional pain assessments were provided to the surveyor, and the documentation did not support that pain was being adequately assessed or managed for this resident.
Failure to Accurately Document and Administer Medications
Penalty
Summary
The facility failed to ensure accurate documentation and administration of medications for two residents. For one resident admitted as a hospice respite patient, there were orders for as-needed pain and anxiety medications, including Tylenol, Morphine, and Lorazepam. Although the controlled drug administration records and hospice notes indicated that these medications were administered, there was no corresponding documentation in the resident's Medication Administration Record (MAR). The Assistant Director of Nursing confirmed that all controlled medications taken should be signed out in both the controlled log book and the MAR, but this was not done. For another resident with a history of hypertension, cardiomyopathy, congestive heart failure, pulmonary hypertension, and atrial fibrillation, the MAR showed that several medications were not administered as ordered and were coded with reasons such as vital signs out of parameters or other notes, despite no such parameters being specified in the medication orders. Some medications were also not given due to awaiting delivery or order issues. The Regional Director of Nursing stated that medications were held based on nursing judgment, but could not confirm if the provider was notified when medications were withheld. The attending physician stated that he would expect to be notified if medications were not administered as ordered, especially when coordinated with specialists.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards by not ensuring complete and accurate documentation and by misfiling documents. For one resident with a history of acute respiratory failure, sleep apnea, and thrombotic pulmonary embolism, there was a physician order for continuous oxygen therapy. However, for 21 out of 28 days, the vital sign documentation indicated that oxygen saturation readings were taken while the resident was on room air, despite the order for continuous oxygen. The Director of Nursing confirmed that this documentation was erroneous after speaking with the nursing staff. In another case, a hospice respite resident's medical record did not contain documentation of a hospice staff visit, during which medications were administered for comfort following a fall, even though the hospice provider confirmed the visit and interventions took place. Additionally, during a review of a resident's paper medical record, documentation belonging to a different resident was found misfiled in the chart. The misfiled documents included an appointment slip, a transportation form, and a consultation note. The error was recognized by a registered nurse when returning the documents to the chart, and the issue was reported to the Regional Director of Nursing, who acknowledged that the documents had been filed in the wrong chart.
Failure to Accommodate Married Couple’s Rooming Preference
Penalty
Summary
The facility failed to provide accommodation for a married couple to live together, despite both residents being in the facility and one resident stating a desire to share a room with his wife. During an interview, Resident #56 said his wife also resided in the facility but that they slept in separate rooms, and he stated that he would like to share a room. Social Services Director #1 acknowledged that when Resident #57 was admitted, staff discussed the possibility of the couple sharing a room, but she needed to check the specifics. The Administrator later stated that the issue had not been brought to his attention and that he would check for a policy and assess room availability, and on a later interview said he was not aware the residents wanted to share a room. The surveyor noted that the residents had been in the facility for about a year, which was considered ample time to assess whether they wanted to share a room.
Lack of Documentation for Bed Placement Used as a Physical Restraint
Penalty
Summary
The facility failed to provide documentation for the use of a physical restraint for Resident #39. During multiple observations, the resident’s bed was positioned against the wall with a floor mat placed on the left side of the bed, and the resident was observed in bed during several of those checks. Staff interviews indicated that Resident #39 rolls from side to side and out of bed, and that the bed was placed against the wall because the resident had fallen frequently. The bed was also observed against the wall when the resident was not in bed, and later the bed was seen no longer against the wall. The DON stated that Resident #39 had previously lived on the second floor and had frequent falls, including tripping over a roommate’s belongings, so the resident was moved to the first floor and the bed was placed against the wall to provide more room. When asked for documentation supporting this rationale and proof of consent from the responsible party for the bed placement, no documentation was provided.
Failure to Follow Care Plan for Toileting, Urinal Hygiene, and Oxygen Monitoring
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan interventions for Resident #59, including timely toileting, urinal hygiene, and oxygen monitoring. Resident #59 was admitted with chronic obstructive pulmonary disease and was oxygen dependent, with additional diagnoses of type 2 diabetes, anxiety disorder, morbid obesity, and emphysema. The medical record showed an order for 3 liters of oxygen by nasal cannula continuously, with oxygen, respiratory rate, and pulse oximetry monitoring every shift. The resident’s last mobility assessment indicated the resident was unable to ambulate without 2 assistants. During survey observations and interviews, Resident #59 reported that a night shift staff member refused to empty a full urinal after 11:30 PM and said it would be emptied in the morning, leaving the resident upset because the urinal remained full, smelled, and had not been cleaned after emptying. Surveyors later observed the urinal full at the bedside on multiple occasions. The resident was also observed yelling that the oxygen tank was getting empty and that not enough oxygen was being delivered; after no staff responded for about 10 minutes, a staff member was alerted and found the tank gauge almost empty and replaced it. The Unit Manager observed the full urinal and nearly empty oxygen tank at the bedside and stated that staff should make regular rounds, empty and clean the urinal immediately when known, check oxygen tank gauges each shift, and provide urinal hygiene care. The care plan review showed interventions for room checks, offering assistance with urinal or commode as needed, using consistent routines and caregivers, decreasing anxiety-related respiratory distress, and identifying stressful times of day and scheduling care, but these interventions were not consistently implemented.
Failure to Provide ADL and Incontinence Care
Penalty
Summary
Facility staff failed to consistently provide ADL care to a dependent resident. During observation rounds on 08/07/25, Resident #50 was seen in bed with copious oral secretion on the right side of the face and neck. Later, on 08/15/25, while an LPN was giving Resident #50 medications, the surveyor noted a strong odor of urine. The surveyor told the LPN about the urine odor, and the LPN stated there were no Geriatric Nursing Assistants available at that time and that the facility was looking for someone to work on Unit C. After finishing the medications, the LPN returned to the medication cart to prepare medications for another resident and did not provide incontinence care to Resident #50 or ask for assistance with the resident's needs.
Feeding Tube Bag Not Properly Labeled or Secured
Penalty
Summary
The facility failed to ensure proper care for a resident with a feeding tube when the tube feeding bag was not appropriately labeled and the cap on the tube feeding bag was not securely closed. During observation, tube feeding and normal saline bags were hanging on an IV pole without proper labeling, and the inadequately closed tube feeding bag attracted fruit flies to the resident’s surroundings. The Director of Nursing was taken to the resident’s room and the bags were still missing labels. On a later observation, both bags were found dated with black marker, and the facility’s policy indicated that a licensed nurse should regularly inspect the feeding tube and document when a tube feeding was changed or replaced, including the responsible individual’s name. The resident’s tube feeding was later observed with a printed label containing the information specified in the facility policy.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label medications and biologicals. During observation of the medication storage and labeling task on D-wing, the ear and eye drops for residents #91, #66, and #2 were found without the month, day, and year documenting when the medications were opened. During a separate observation on A-wing, RN #3 left medication cart #2 unlocked. In addition, while reviewing cart 1 on B-wing, a large number of loose pills were found in the back of the cart under the medication bubble packs, and LPN #9 was asked to dispose of the medications. These findings were observed in 2 of 4 medication carts reviewed during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,932 citations issued within 25 miles in the last 12 months — including the 10 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Catonsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Haven Nursing And Rehabilitation Ctr | 0.2 mi | ★★★★★ | 54 | 0 |
| Autumn Lake Healthcare At Summit Park | 0.9 mi | ★★★★★ | 26 | 0 |
| Ridgeway Rehab Center | 1.1 mi | ★★★★★ | 28 | 0 |
| Frederick Villa Healthcare | 1.1 mi | ★★★★★ | 62 | 0 |
| St. Joseph's Nursing Home | 1.1 mi | ★★★★★ | 17 | 0 |
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