Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Glen Burnie during CMS and state inspections, most recent first.
A facility failed to accurately code MDS assessments for multiple residents. Documentation showed one resident had a Stage 3 pressure ulcer, a surgical wound, and wound treatments that were not captured; another resident’s admission MDS missed glaucoma, hyperparathyroidism, and scheduled pain treatment; a third resident’s annual MDS missed a diuretic and anticoagulant; and a fourth resident’s quarterly MDS incorrectly coded corrective lenses as no despite documented and observed use of glasses.
Resident wheelchairs and a reclining geriatric chair were observed in disrepair, including torn vinyl, missing foam padding, and missing armrests. Staff described an inconsistent repair reporting process, with verbal reports to the charge nurse, unit manager, ADON, or DON, while the DOM stated there was no specific wheelchair process and that housekeeping or staff would sometimes submit work orders or report issues informally.
The facility failed to timely report an alleged abuse involving a resident found restrained by a sheet and an alleged misappropriation involving another resident’s missing money. Staff accounts showed the abuse concern was not reported to OHCQ within 2 hours, and the missing funds concern was not reported within 24 hours. The NHA stated the abuse allegation should have been reported immediately, and staff had only completed a grievance form for the missing money.
Incomplete Annual MDS Assessment: A resident’s annual MDS was incomplete because cognition and mood were not assessed. The record showed no BIMS score and no assessment of memory, recall, or daily decision-making skills, and the mood section was also left blank. The issue was identified during review of an incident in which the resident alleged money had been stolen from a wallet, and the MDS Coordinator stated the sections were assigned to social work but the assessment window was missed due to staffing issues.
Failure to provide grooming and personal hygiene services for a dependent resident. The resident, who had a stroke and was coded as dependent for personal hygiene on the MDS, was observed unshaven with long untrimmed fingernails and black debris under the nails on more than one occasion. The care plan included weekly grooming, beard shaving, and nail trimming, but the resident remained unkempt and stated he should not have to beg for the care.
A resident with prostate cancer did not receive Nubeqa timely. The resident and RP reported the medication was given late over the weekend, and the MAR audit showed the 8 AM dose was administered hours late on one day and again late the next day, with the 5 PM dose given only 1 hour and 36 minutes later. The DON confirmed the untimely administration.
Failure to Follow BP Hold Parameters for Antihypertensive Medications: A resident with hypertensive heart disease received ordered BP medications despite BP readings below the physician's hold parameter of systolic BP less than 100. The MAR showed Isosorbide Mononitrate ER, Losartan, and Atenolol were administered when BP was 86/54, 94/57, and 77/52, and the DON confirmed the medications were given when the ordered parameters were not met.
Unlocked medication and treatment carts were found unattended on multiple units, allowing surveyors to access resident medications and treatment supplies. The surveyor observed opened Lidocaine with no date opened, two opened bottles of 0.9% sodium chloride irrigation that were not dated, and two unlabeled medication cups containing pills. An LPN stated she had left one cart unlocked while responding to a dialysis patient, and the DON was informed of the concerns.
A resident’s breakfast was served with pancakes at 110 degrees, below the stated hot food standard of 135 degrees, and the tray did not include the milk listed on the meal ticket. The resident and RP reported that coffee and milk were often missing and that breakfast food was frequently cold.
Incomplete Care Plans, Smoking Assessments, and Non-Individualized Kardex Documentation: The facility failed to accurately document a resident’s trach and O2 needs in the baseline care plan, and the resident later had an incident involving secretions and transfer to the hospital after the daughter requested it. The facility also missed required smoking safety screens for multiple smokers, including newly admitted residents and others with overdue quarterly assessments, and a resident’s Kardex was not individualized to match the care plan.
Residents were not transported on time for scheduled dialysis, and staff acknowledged that late arrivals were occurring daily due to transport issues. One resident was observed waiting in bed with a Hoyer sling while the dialysis chair sat outside the room, and another resident reported treatment was shortened because staff did not assist in time. Surveyors also found too few dialysis chairs and observed a broken chair being used with a stool supporting the leg rest, while the facility had no maintenance records for the chairs.
Failure to timely report an allegation of misappropriation of a resident’s property to OHCQ. A resident’s RP reported that rings were stolen by a staff member, and the NHA was informed while the allegation was under investigation, but the initial report was not submitted within the required 24-hour timeframe.
A facility failed to provide written transfer notifications and bed hold policy information for two residents sent to the hospital. In one case, a resident’s RP was onsite during the transfer for chest pain, but the bed hold policy was not signed. In another case, the resident representative’s record did not show written notice for two hospital transfers, and the NHA confirmed the missing documentation.
Late Medication Administration and Documentation: A resident’s MAR audit showed multiple scheduled meds were not documented until after midnight, including topical cream, anticoagulant, dementia meds, pain/nerve pain meds, and bowel regimen meds. The NHA stated meds should be given within one hour before or after the due time, and an LPN said she administered the meds on time but documented them late because the unit was busy; she also stated meds should be documented immediately after administration.
Failure to document a resident's advance directive choice. During record review, the surveyor could not locate the resident's advance directive or any documentation that the resident declined the opportunity to complete one. The NHA later confirmed that the resident did not have an advance directive in place and that the facility had no documentation showing the resident declined to complete one when offered.
A facility failed to protect residents’ privacy when a private video monitoring device was used in a shared room without prior written consent from all roommates and their representatives. Surveyors observed no monitoring sign posted in the room, and later reviewed consent forms that were incomplete, contradictory, and missing consent for one roommate.
A resident's Annual MDS and Discharge MDS were completed and submitted late. The RN Assessment Coordinator signed both assessments more than 14 days after the ARD, and the MDS Director confirmed the surveyor's findings during interview.
Inaccurate MDS coding was identified when several residents listed as current smokers were coded as not using tobacco on annual MDS assessments, and another resident receiving oxygen via nasal cannula had an admission MDS that did not indicate oxygen therapy. Record review and staff interview confirmed the coding errors, including a resident with chronic respiratory failure and dependence on supplemental oxygen whose baseline care plan documented oxygen use.
A resident’s PASARR was not re-evaluated to reflect a current diagnosis of major depressive disorder. The most recent PASARR did not list SMI, while the EMR showed the diagnosis had been added later. The SW and NHA reviewed the record with the surveyor and acknowledged the discrepancy.
A resident with liver cell carcinoma, malignant ascites, and an aggressive osseous lesion did not have a timely oncology follow-up scheduled despite a discharge recommendation to see the oncologist at JHH next available. The DON acknowledged the appointment was not made until after surveyor intervention, while the administrator said the unit clerk was waiting for the resident’s wife to provide the oncologist’s name and there was no documentation of that conversation; the resident had documented decision-making capacity and no POA or advance directive was present.
A resident was observed in bed with 1/4 side rails raised on both sides and the HOB elevated. Record review showed the Assist Bar/Side Rail assessment did not document alternatives tried before side rail use or discussion of risks and benefits with the resident and representative, and no resident-specific care plan for side rail use was found. The DON acknowledged the findings, and the facility could not provide the care plan documentation at exit.
Failure to complete annual GNA performance evaluations. Surveyors found that yearly performance reviews were not consistently completed for GNAs, with 72 of 75 staff affected. The DON said unit managers were responsible for the evaluations, but neither the DON nor the Administrator could explain the process or documentation method. Record review showed missing or incomplete evaluation documentation for multiple GNAs, and a UM reported completing only one evaluation.
The facility failed to keep daily staffing information current and prominently displayed. Surveyors found staffing information at the front desk dated several days earlier, and no other complete posting was seen in the main areas. Staff acknowledged the concern and stated the posting was supposed to be in a side hallway rather than at the front desk.
Failure to provide dental services for a resident who reported aching back teeth and was unable to clean the teeth without assistance. The resident had a hx of stroke with hemiplegia, dysarthria, and DM2, and the admission orders called for annual dental consultation as needed. An LPN stated awareness of the dental issue but did not follow up, and the Administrator confirmed the facility did not schedule the dental appt.
Failure to document and honor a resident’s food preferences led to inconsistent meal selections. A resident with a hx of CVA with hemiplegia, dysarthria, and DM2 was served fish despite stating they had received fish or pork multiple times and staff noting the resident would not eat fish. The meal ticket showed only a No Pork restriction, and the dietitian’s notes did not include the resident’s dislike for fish.
A resident reported not receiving meat at breakfast and said meal portions were too small, leaving him/her still hungry afterward. The resident stated no dietary staff had met with him/her since admission to review menu options, alternatives, or food preferences. Staff said new admissions are expected to be seen soon after admission, but no documentation showed the resident had been seen.
The facility failed to update care plans using an interdisciplinary team and did not ensure resident representatives were involved in care plan reviews. A resident with wound issues had an outdated care plan, and another resident's diet orders were not communicated, leading to improper care. Additionally, care plan meetings were not documented or conducted as required for several residents. The DON and staff acknowledged these deficiencies.
The facility failed to provide meals according to the menu and did not respect residents' dietary choices. During a lunch service, a DM substituted a hamburger for the Dijon Pork Loin due to a shortage caused by over-portioning. Ten residents who chose the pork loin received the alternative meal without being informed or given a choice. A resident confirmed she did not request the hamburger. The CDM acknowledged that residents were not informed of the change, although no complaints were reported.
The facility's kitchens exhibited multiple food safety and sanitation deficiencies, including a non-operational plate warming device, unlabeled and improperly stored food, and contaminated kitchen surfaces. Personal items were found on food prep surfaces, and the kitchen ceiling had chipping paint. These issues were confirmed by dietary staff and the Kitchen Account Manager.
The facility failed to ensure consistent attendance of required members at monthly QAPI meetings. A GNA missed four meetings, while the Medical Director and DON each missed one meeting. These absences were confirmed by the DON and Administrator.
The facility failed to implement an effective infection control program, with issues such as outdated oxygen tubing, improper signage for transmission-based precautions, and inadequate use of personal protective equipment for residents requiring enhanced barrier precautions. These deficiencies were observed through staff interviews and medical record reviews, highlighting lapses in protocol adherence.
The facility failed to provide effective communication training for nine staff members, as revealed by missing documentation in their educational files. The Director of HR, responsible for onboarding education, and the DON, overseeing annual education, could not provide additional records, highlighting a deficiency in staff training oversight.
The facility failed to ensure all staff received annual compliance and ethics training, as five staff members lacked documentation of such training. The Director of HR, responsible for onboarding education, and the DON, responsible for annual education, did not have a staff educator in place. Despite additional documentation, the files for these staff members still lacked evidence of the required training.
The facility did not honor the dining preferences of three residents, as documented in their care plans, during a survey. Breakfast trays were delivered to the unit, but only one resident was in the dining area. Interviews revealed that the residents preferred to eat in the dining room, a preference documented in their records. The DON was initially unaware of the documentation but later confirmed the residents' rights to choose their dining location.
A facility failed to provide a resident with necessary information to formulate an advance directive, despite the resident expressing interest in doing so. The resident's records showed two assessments indicating interest, but no follow-up or provision of information was documented. Interviews revealed that Social Services is responsible for offering assistance, but this was not reflected in the resident's documentation, leading to a deficiency noted by surveyors.
A resident on dialysis experienced a dietary change from a renal diet to a regular diet without being notified, as required by facility protocol. The facility's staff failed to document any notification to the resident or their family, which was confirmed by the DON and acknowledged by the Nursing Home Administrator during a complaint investigation.
The facility failed to follow its grievance process, as two residents reported issues with missing and damaged personal items that were not documented or addressed. One resident's missing items were acknowledged by staff but not replaced, while another resident's damaged clothing was reported but not documented. The NHA was unaware of these grievances until the surveyor's intervention, indicating a breakdown in the facility's grievance handling.
The facility failed to implement its policies for abuse, neglect, and exploitation, as well as its policy for employment background investigations. A GNA was employed despite having a criminal background and suspended credentials due to errors in the background check process, including incorrect name entry and misspellings. The HR Director admitted to the mistake, which led to the oversight.
A resident reported a sexual abuse incident involving a GNA to a Kitchen Account Manager weeks after it occurred. Despite notifying the Director of Nursing, the facility delayed reporting to authorities. The resident had already informed the police before the facility's report. Discrepancies in the reporting timeline and staff actions were noted, including a Unit Manager advising against reporting the allegation.
A facility failed to thoroughly investigate abuse allegations involving a resident, lacking key documentation and interviews. In one case, conflicting staff statements were not addressed, and in another, a delayed investigation into a sexual abuse report was noted. The facility's leadership acknowledged the deficiencies but provided no further information.
A facility failed to notify a resident or their representative in writing about the bed hold policy during a transfer to an acute care facility. The medical record lacked evidence of notification, and interviews with LPN staff confirmed the policy was not completed or provided. The DON could not produce written evidence of the notification.
A facility failed to accurately document a resident's dental status in the MDS assessment. The resident had missing and loose teeth, but the MDS did not reflect these issues. Staff interviews confirmed the oversight, and the DON acknowledged the discrepancy.
A facility failed to complete a Level II PASARR evaluation for a resident before admission. The resident's PASARR Level I screening indicated a need for referral to AERS, but this was not done. A Social Services designee confirmed understanding of the referral process, and the DON acknowledged the findings.
The facility failed to provide baseline care plan summaries, including medication lists, to three residents within 48 hours of admission. A resident reported not receiving their care plan summary, and the DON confirmed the lack of documentation. Another resident's care plans were completed late, and for a third resident, there was no evidence that the care plan was reviewed with them or their representative.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. One resident lacked a care plan for oxygen therapy, another had unaddressed dental issues and a change to palliative care, and a third resident with PTSD and depression had an incomplete care plan. Staff interviews revealed gaps in care plan updates and documentation.
A resident dependent on staff for personal hygiene did not receive scheduled showers, as documented inconsistencies showed only three showers provided over two months. Staff interviews revealed a lack of awareness and adherence to the shower schedule, and the DON confirmed the resident was not offered showers as planned.
A facility failed to provide an ongoing program of activities for a bedbound, alert but non-verbal resident. Despite documented preferences for group activities and religious services, the resident was often left in bed with only the TV on. Staff interviews revealed inconsistencies in activity provision, particularly during the resident's isolation period, contrary to facility policies.
The facility failed to ensure follow-up care for a resident with Crohn's disease and did not carry out a lab order for a resident on anticoagulant therapy. The GI follow-up was not scheduled as recommended, and the lab order was incompletely entered, leading to it not being drawn. These deficiencies were confirmed by the DON and unit manager.
A facility failed to monitor a resident's weight according to its protocol, which required weekly weights for the first four weeks post-admission. The resident, assessed as underweight and at risk of malnutrition, had only two weights recorded over a period of nearly two months. Interviews with the RD and DON confirmed that the expected weight monitoring was not conducted due to nursing staff not obtaining the necessary weights.
Two residents in the facility experienced deficiencies in respiratory care. One resident received oxygen at an incorrect flow rate, and the tubing was not labeled as required. Another resident with a tracheostomy had no comprehensive care plan addressing their respiratory needs, despite having serious medical conditions. These issues were identified during a survey, indicating a failure to meet professional standards in respiratory care.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 4 residents reviewed during a complaint survey. For one resident, the 6/2/26 skin and wound note documented a left Achilles pressure injury present on admission that was assessed as a Stage 3 pressure ulcer measuring 3 cm by 2 cm by 0.1 cm, along with a surgical wound on the left hip, but the 6/7/26 MDS coded no pressure ulcer/injury, no unhealed pressure ulcers/injuries, no surgical wounds, and no skin or ulcer/injury treatments. The MDS Coordinator later confirmed the findings. For another resident admitted with end stage renal disease on dialysis, spinal stenosis, and knee effusions, the admission MDS failed to capture glaucoma and hyperparathyroidism documented in the physician history and physical, and also coded no scheduled pain medication regimen despite daily Lidocaine 4% patches being applied to both knees for pain. A third resident’s annual MDS failed to capture use of Furosemide and Apixaban even though the June 2026 MAR showed both medications were administered. For a fourth resident, the quarterly MDS coded corrective lenses as no even though the resident wore glasses, had glasses documented on the admission record, and was observed with glasses at the bedside while requesting to be seen by an eye doctor; the DON confirmed the incorrect coding.
Resident Equipment Maintenance Process Failure
Penalty
Summary
The facility failed to have an effective process to maintain resident equipment, affecting 6 of 21 residents reviewed during a complaint survey. During walking rounds, surveyors observed resident wheelchairs in disrepair for Residents #17, #16, #18, #19, #20, and #14, with damage or missing components including torn vinyl covering, missing foam padding, and missing armrests. An unattended reclining geriatric chair in the hallway by room [ROOM NUMBER] also had a missing armrest. Interviews showed staff used inconsistent reporting methods for repairs: a GNA stated she reported repairs verbally to the charge nurse or unit manager, an LPN stated she would tell the ADON or DON, and the DOM stated there was no specific wheelchair process, that housekeeping would normally clean wheelchairs and submit work orders if they were in disrepair, and that staff sometimes reported issues informally to maintenance. The NHA was informed of the concern.
Failure to Timely Report Alleged Abuse and Missing Resident Funds
Penalty
Summary
The facility failed to report an alleged abuse involving Resident #8 immediately to the Nursing Home Administrator and within 2 hours to the Office of Health Care Quality (OHCQ). Facility records showed that GNA #18 alleged she found Resident #8 sitting in a chair at the nurses’ station restrained by a sheet when she came on duty for the 11:00 PM to 7:00 AM shift. The facility’s investigation documented that the alleged incident occurred on 7/5/26 at 11:10 PM, but the initial report was not submitted to OHCQ until 7/10/26 at 6:09 PM. During interview, the NHA stated that the staff member’s story changed and that the report should have been made immediately when the incident allegedly occurred. The facility also failed to report an alleged misappropriation of Resident #7’s property within 24 hours to OHCQ. Resident #7 reported that $106 was missing from the resident’s wallet, and staff statements documented that the resident told GNA #27 and RN #25 on 7/3/26 that the money was missing. RN #15 stated she was notified by the charge nurse and told the charge nurse to complete a concern/grievance form, but no incident report was started at that time. The facility reported the incident to OHCQ on 7/6/26 at 4:06 PM, and the NHA was later informed that the missing money had not been reported within 24 hours.
Incomplete Annual MDS Assessment
Penalty
Summary
The facility failed to complete a complete and accurate annual assessment for Resident #7 by not assessing cognition, mood, and behavior on the resident’s annual MDS. The annual MDS had an assessment reference date of 6/3/26, but Section C, Cognitive Patterns, was not assessed. There was no BIMS summary score, and the resident’s short-term and long-term memory, memory/recall ability, and cognitive skills for daily decision making were not assessed. Section D, Mood, was also not assessed. The deficiency was identified during review of facility reported incident 3094393 and the resident’s medical record on 7/29/26. The incident report stated that Resident #7 alleged money had been stolen from the resident’s wallet and initially reported the concern to a GNA on 7/3/26, stating the money had been stolen sometime over the prior month. During interview on 7/30/26, the MDS Coordinator stated that social work was responsible for completing Sections C and D and that the assessment time period had been missed because of staffing issues in the department.
Failure to Provide Grooming and Personal Hygiene Services
Penalty
Summary
Facility staff failed to provide thorough grooming and personal hygiene services for one resident who was unable to perform activities of daily living independently. The resident was admitted with a diagnosis including cerebral infarction (stroke), and the most recent Quarterly MDS coded the resident as dependent for personal hygiene in Section GG Self-Care. The resident’s care plan for ADL self-care performance deficit included an intervention for complete grooming services, including beard shaving and weekly nail trimming. During observation, the resident was found to be unshaven with long untrimmed fingernails and black debris under the fingernails. When asked if he would like to be shaved and have his fingernails trimmed, the resident said yes. A later observation showed the same condition, with the resident still unshaven and with long untrimmed fingernails with black debris under them. The resident again stated yes when asked about shaving and nail trimming and said, "I don't feel like I should have to beg them to do it." A Unit Manager confirmed the resident was unshaven and had dirty untrimmed nails, and the DON was informed of the findings.
Delayed Administration of Cancer Medication
Penalty
Summary
Facility staff failed to administer a resident’s cancer medication in a timely manner. Resident #15, who was admitted with a diagnosis including malignant neoplasm of the prostate, and the resident’s responsible party both stated that the resident received the medication late over the weekend. The resident reported the medication was supposed to be given with breakfast, but on Sunday it was not administered until after 2 PM. Review of the medication administration audit report showed the resident was ordered Nubeqa 300 mg, 2 tablets twice daily for prostate cancer, with scheduled times of 8 AM and 5 PM. The record showed the 8 AM dose was given at 11:14 AM on 7/25/26 and at 2:54 PM on 7/26/26, and the 5 PM dose on 7/26/26 was given at 4:30 PM, resulting in two doses being administered 1 hour and 36 minutes apart. The DON confirmed the findings during interview.
Failure to Follow BP Hold Parameters for Antihypertensive Medications
Penalty
Summary
The facility failed to keep a resident's drug regimen free from unnecessary drugs by not following physician-ordered blood pressure parameters for administering blood pressure medications. During review of Complaint 3031582, surveyors reviewed the medical record of Resident #11, who had been in the facility for 18 days in 2026 and had a diagnosis of hypertensive heart disease. The April 2026 MAR showed the resident received Isosorbide Mononitrate ER 30 mg in the evening, Losartan Potassium 25 mg in the evening, and Atenolol 25 mg twice daily even when the resident's blood pressure was below the ordered hold parameter of systolic blood pressure less than 100. The record showed these medications were administered on 4/9/26 and 4/10/26 when blood pressure readings were 86/54 and 94/57, and Atenolol was also administered on 4/16/26 when the blood pressure was 77/52. The Surveyor reviewed the April 2026 MAR with the DON, and the DON confirmed that the resident was given blood pressure medications on 4/9, 4/10, and 4/16/26 when the blood pressure did not meet the physician-ordered parameters.
Unlocked medication and treatment carts with undated and unlabeled medications
Penalty
Summary
Drugs and biologicals were not consistently stored in locked compartments, and expired or improperly dated medications and treatment supplies were found during observations on two nursing units. On the Gateway unit, two medication carts were observed unattended and unlocked at the nurse's station, and the surveyor was able to open both carts and see resident medications including over-the-counter and prescription drugs such as cardiac, blood pressure, neuropathy, antipsychotic, antidepressant, antianxiety, diabetic, and other medications. One opened vial of Lidocaine 2% had no date opened on it, and no licensed staff were present at the nurse's station while the carts remained unlocked. On the Gateway unit, an unlocked treatment cart in the hallway contained two opened 100 ml bottles of 0.9% sodium chloride irrigation that were not dated when opened. On the Chesapeake unit, an unlocked and unattended medication cart in the hallway contained two unlabeled medication cups with pills inside, and an LPN later stated she had left the cart unlocked because she had been called away to check on a dialysis patient. The facility policy reviewed by the surveyor stated that all drugs and biologicals are to be stored in locked compartments and that only authorized personnel are to have access to the keys.
Breakfast Tray Missing Items and Served at Improper Temperature
Penalty
Summary
Food and drink were not consistently served at a palatable temperature and all items listed on a resident’s meal ticket were not delivered for Resident #15. The resident’s responsible party reported that the resident had complained about not receiving coffee, not receiving milk for oatmeal, and being served cold breakfast food. The resident also stated that coffee and milk were not always provided and that the food was often cold, leading the resident not to eat it. During a surveyor observation, pancakes served to the resident measured 110 degrees, below the stated hot food temperature of 135 degrees, and no milk was present on the breakfast tray. The unit manager was present during the observation and confirmed the surveyor’s findings. Review of the resident’s breakfast meal ticket showed the resident was to receive 8 ounces of milk.
Incomplete Care Plans, Smoking Assessments, and Non-Individualized Kardex Documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices and failed to accurately document baseline care plans for multiple residents. For one resident with a tracheostomy, the record showed orders for oxygen at 5 L/min via trach continuously, suctioning as needed, tracheostomy care every shift and PRN, and tracheostomy site dressing changes every shift and PRN if soiled. However, the baseline care plan did not accurately reflect the resident’s tracheostomy and oxygen care needs, and instead documented that the resident was not on oxygen therapy while also listing trach-related information in a different section and selecting suctioning without selecting tracheostomy care. The same resident’s care was also discussed after an event in which the daughter entered the room and requested transfer to the hospital because of secretions coming from the trachea. A GNA stated that tracheostomy and suction care had been provided about 20 to 30 minutes before the daughter arrived and that the resident was positioned with the bed elevated, while the nurse’s progress note documented that the daughter saw the resident and requested hospital transfer despite the resident stating they were fine. The facility’s complaint report stated that the daughter saw the resident lying flat with secretions from the trachea and insisted on transfer, and the facility sent the resident to the hospital. The facility also failed to complete smoking safety screening assessments for residents identified as smokers and failed to keep a Kardex individualized for another resident. Several residents on the smoker list had overdue or missing Smoking Safety Screen assessments, including two newly admitted smokers with no admission screening found and other smokers whose last documented assessments were months overdue. In addition, a resident’s Kardex under the GNA task section contained general categories such as mobility, hygiene, transferring, eating, bathing, safety, and toileting, but did not reveal individualized care needs to reflect the resident’s comprehensive care plan and clinical record.
Late Dialysis Transport and Unsafe Chair Availability
Penalty
Summary
The facility failed to ensure residents were transported on time to scheduled dialysis treatments and failed to maintain an adequate supply and proper maintenance of dialysis chairs used for transport to dialysis. Surveyors observed multiple residents waiting for dialysis transport while staff were still completing preparation tasks, and staff acknowledged that residents were late to dialysis appointments due to transport issues. One resident scheduled for a 10:00 AM dialysis appointment was still in bed with a Hoyer sling in place while the dialysis chair remained outside the room, and staff later confirmed the resident arrived late to dialysis that day. A second resident reported being late to dialysis and having treatment cut short because nursing staff did not assist in a timely manner. Review of the dialysis communication form showed that this resident had a late arrival that shortened treatment, and the dialysis schedule showed the treatment was planned for 3 hours and 30 minutes but was cut short by 1.5 hours. Staff interviews confirmed that the resident required a Hoyer lift and two staff for transfer, and one RN stated that when staff were tied up with another patient, they could not get the resident down to dialysis on time. Staff also stated that residents were late to dialysis daily due to transport. Surveyors also observed problems with dialysis chair availability and condition. One resident stated there was not enough quantity of dialysis chairs and reported defective chairs that were unsafe and wobbly, with legs not supported at times. Another resident was observed using a dialysis chair with a broken leg rest that was propped up by a stool. The Administrator stated there were no extra chairs available and reported being notified about the need for more chairs approximately two weeks earlier. The Maintenance Director stated there was no maintenance documentation or records for dialysis chairs, and the facility acknowledged that it did not have maintenance records for the chairs at the time of survey.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to OHCQ within the required 24 hours after the allegation was made. Resident #158’s resident representative reported that the resident’s rings were stolen by a facility staff member and stated that he/she called the police and informed the Nursing Home Administrator, who was investigating the allegation. The investigative file showed that the night supervisor was made aware of the allegation on 4/26/2026 at about 8:00 AM and the Nursing Home Administrator was made aware at about 9:00 AM the same day, but the facility did not submit the initial report to OHCQ until 4/28/2026 at 9:48 AM. This deficiency was identified during review of Facility Reported Incident #3004409.
Failure to Provide Written Transfer and Bed Hold Notifications
Penalty
Summary
The facility failed to provide written notification of transfer and the bed hold policy for residents who were transferred to the hospital. For one resident, the medical record showed a hospital transfer for chest pain, and the resident’s responsible party was onsite and aware of the transfer, but the facility did not obtain the responsible party’s signature on the bed hold policy when the resident was sent out to the hospital. The Nursing Home Administrator acknowledged that the responsible party was present at the facility during the transfer, yet the bed hold policy was not signed. For another resident, the electronic medical record showed hospital transfers on two occasions, but there was no documentation that the resident representative received written notification of the transfers or the bed hold policy. When the Surveyor requested the written reason for transfer/discharge notification and bed hold documentation for those hospitalizations, the documentation provided did not show that the required written notifications had been sent to the resident representative. The Nursing Home Administrator confirmed the findings during interview.
Late Medication Administration and Documentation
Penalty
Summary
The facility failed to adhere to professional standards of practice when administering medications to Resident #6. Complaint reviews and the resident’s Medication Admin Audit Report showed that multiple medications scheduled for the afternoon and evening of 1/28/26 were not documented until 12:47 AM on 1/29/26, including Miconazole Nitrate external cream, Icosapent Ethyl, Methenamine Hippurate, Tamsulosin HCl, Gabapentin, Memantine HCl, Xarelto, Melatonin, Mirtazapine, Lactulose, Donepezil HCl, and Ropinirole HCl. The report identified these medications as late based on their scheduled administration times. During interviews, the Nursing Home Administrator stated that medications should be administered one hour before or one hour after the due time. An LPN reviewed the audit report and stated that she administered the medications on time on 1/28/26 but documented them late because it can get busy on the unit. She also stated that the expectation is to document a medication administration immediately after giving the medication.
Failure to Document Advance Directive Choice
Penalty
Summary
The facility failed to ensure a resident's right to formulate an advance directive for Resident #55, identified during the annual recertification survey. During record review on 5/4/26, the surveyor could not locate Resident #55's advance directive and could not find documentation showing that the resident declined the opportunity to complete one when offered by the facility. During an interview on 5/7/26, the NHA stated that Resident #55 did not have an advance directive in place and initially said she would check the record for documentation. In a later interview the same day, the NHA stated that the facility did not have documentation showing that Resident #55 declined to complete an advance directive when offered the opportunity.
Failure to Obtain Required Consent for Video Monitoring in Shared Room
Penalty
Summary
The facility failed to ensure residents’ rights to personal privacy when a private video monitoring device was used in a shared room without the required prior written consent from all roommates and their resident representatives. Resident #6 had the device installed at the request of the resident representative while residing in a room with Resident #60, Resident #122, and Resident #141, and during a unit tour the surveyor observed that no signage indicating video monitoring was posted in the shared room. The facility’s Audio/Visual Recording in Resident Rooms policy stated that if a resident is in a shared room, recording may not occur without written consent of the roommate and a sign must be placed on the door stating that electronic monitoring is in progress. When the surveyor requested documentation, the facility provided Roommate Virtual Monitoring Technology Consent Forms for Resident #122 and Resident #141 that were completed only by their resident representatives after the surveyor’s inquiry, and the forms contained contradictory signatures both granting and withdrawing consent. The facility did not provide written consent for Resident #60, and signage for video monitoring was later observed on the residents’ door.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure that a resident's MDS assessments were completed and submitted in a timely manner. For Resident #19, the Annual MDS assessment had an ARD of 1/26/2026, but the RN Assessment Coordinator did not sign it as complete until 2/27/2026 and it was accepted on 3/3/2026. A Discharge MDS assessment for the same resident had an ARD of 1/17/2026, but it was not signed as completed until 2/4/2026 and was accepted on 2/6/2026. During review on 5/8/2026, the surveyor identified that both assessments were completed more than 14 calendar days after the ARD, and on 5/11/2026 the MDS Director, in the presence of the Nursing Home Administrator, acknowledged and confirmed the findings.
Inaccurate MDS Coding for Tobacco Use and Oxygen Therapy
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect residents’ status. During review of the smokers list and electronic medical records, five residents identified by the facility as current smokers were found to have annual MDS assessments that indicated “No” for tobacco use in Section J1300 Current Tobacco Use. During interview, the MDS Director, MDS Coordinator, and Nursing Home Administrator acknowledged that Section J1300 is assessed during comprehensive admission, annual, and significant change MDS assessments and that the residents’ tobacco use status had been coded in error. The facility also failed to accurately code oxygen therapy on an admission MDS assessment for another resident. Surveyors observed the resident receiving oxygen via nasal cannula and reviewed the medical record, which showed admission to the facility with chronic respiratory failure and dependence on supplemental oxygen. The baseline care plan documented oxygen therapy at 3 liters, but the admission MDS assessment did not indicate oxygen therapy in Section O C1. The MDS Director later acknowledged and confirmed the finding.
PASARR Not Updated for Current Mental Health Diagnosis
Penalty
Summary
PASARR for Resident #19 was not re-evaluated and updated to reflect a current diagnosis of serious mental illness. The resident’s most recent PASARR, dated 8/14/2024, did not list a diagnosis of serious mental illness, but the resident’s electronic medical record showed a diagnosis of major depressive disorder entered on 12/16/2025. During interview, the Social Worker and Nursing Home Administrator reviewed the PASARR and acknowledged that it did not reflect the resident’s current diagnosis. The surveyor also noted that the Social Work Director had completed and submitted a new PASARR that included the updated diagnosis.
Delayed Oncology Follow-Up Appointment
Penalty
Summary
The facility failed to ensure a follow-up oncology appointment was timely scheduled for a resident with liver cell carcinoma, malignant ascites, and an aggressive osseous lesion identified on the hospital discharge summary before admission. The discharge summary documented a recommendation to follow up with the patient’s oncologist at JHH at the next available appointment, but the resident reported concern during the survey that they had an enlarged area on their body and did not know the plan for medical care of it. Review of the record showed the resident had capacity for decision making and no power of attorney or completed advance directive was present. The oncology follow-up was not scheduled until after surveyor inquiry, despite two consult orders in the record for oncology related to hepatocellular carcinoma. The DON acknowledged that the appointment was not made until after surveyor intervention and that it had been arranged by the unit clerk. The administrator stated the unit clerk was waiting for the resident’s wife to provide the oncologist’s name, but there was no documentation of that conversation, and the administrator did not know whether the wife had decision-making capacity for the resident. The unit clerk stated they saw the discharge summary but did not see where the resident was to go for the follow-up appointment, even though the discharge summary included JHH as the follow-up location.
Side Rail Assessment and Care Plan Deficiency
Penalty
Summary
The facility failed to ensure a resident was properly assessed for the safe use of side rails and failed to develop and implement a person-centered care plan for side rail use. During an initial tour of the Gateway Unit, the resident was observed sitting up in bed with the head of the bed elevated about 75 degrees and 1/4 size side rails raised on both sides of the bed. Review of the resident’s electronic medical record showed an Assist Bar/Side Rail assessment completed on 4/27/2026 that did not document evaluation of alternatives attempted before side rail use or how those alternatives failed to meet the resident’s assessed needs. The record also did not show documentation that the risks and benefits of side rails were discussed with the resident and resident representative. Continued review found no resident-specific care plan developed and implemented for side rail use. The DON reviewed the assessment with the Surveyor and acknowledged the findings, and the facility was unable to provide the required care plan documentation at exit.
Failure to Complete Annual GNA Performance Evaluations
Penalty
Summary
The facility failed to ensure yearly performance evaluations were completed for geriatric nursing assistants, with surveyor review finding this deficiency for 72 of 75 GNAs. During interviews, the DON stated that unit managers were responsible for completing annual evaluations and that the evaluations should occur yearly, but the DON was unable to explain the process or how the evaluations were documented. The Administrator also stated they did not know what process was used for documenting yearly performance evaluations and later confirmed there was a failed process in which some staff had yearly evaluations and some did not. Record review of GNA #22, GNA #23, and GNA #24 showed inconsistent or absent documentation of yearly performance reviews. GNA #22 had a hire date of 5/29/24 with no evidence of a yearly performance evaluation, GNA #23 had a hire date of 9/4/24 with no evidence of a yearly performance evaluation, and GNA #24 had a hire date of 1/20/22 with one evaluation form containing an incomplete date range. A Unit Manager reported having completed only one performance evaluation, and the Administrator later stated that only three staff had received yearly performance evaluations before the surveyor intervention.
Outdated Staffing Information Posted in Non-Prominent Location
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was current and displayed in a prominent location. During the initial tour on 5/4/26 at 8:19 AM, surveyors observed a plastic container at the front desk containing staffing information dated 5/1/26, and no other posting with all required staffing information was observed in the main areas of the facility's main building. At 8:48 AM, Front Desk Staff #4 acknowledged the concern and stated the staffing information was supposed to be on a table in a side hallway rather than at the front desk. Updated staffing information dated 5/4/26 was then observed on the side hallway table, and the outdated front desk posting was removed. On 5/5/26 at 9:49 AM, updated staffing information was observed at the front desk with the date of 5/5/26 present. The Administrator later acknowledged and confirmed that the staffing information should be updated and posted at the facility's main front desk in a prominent location, and the Administrator and DON later reviewed the concerns.
Failure to Provide Dental Services
Penalty
Summary
Provide or obtain dental services for each resident was not met for one resident reviewed for dental services. Resident #8 reported aching in the back teeth during the initial screening and was unsure of the resident’s dental history at the facility or whether a dentist had previously been seen there. The resident was admitted with diagnoses of left stroke with hemiplegia, dysarthria, and type 2 diabetes, and the admission orders included an annual dental consultation as needed. The functional status assessment indicated the resident was unable to clean the teeth without assistance. A nurse stated awareness of the resident’s dental issues but did not follow up to ensure care was provided, and the Administrator confirmed that although residents were eligible for annual dental visits, the facility failed to schedule an appointment for the resident.
Failure to Document and Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor resident food preferences and provide consistent meal selections for one resident who was reviewed for food preferences during the annual survey. The resident was observed being served fish at lunch, and the meal tray and ticket confirmed fish was the entree. The resident stated they had received fish or pork multiple times previously. On another observation, the resident’s lunch ticket showed only a No Pork restriction, and floor staff stated the resident would not eat fish. Record review showed the resident was admitted with diagnoses of left stroke resulting in hemiplegia, dysarthria, and type 2 diabetes, and had a regular diet order. Dietitian notes documented poor intake, but there were no mentions of food preferences. During interview, the dietitian stated resident food preferences should be obtained within 48 hours of admission, but could not explain why the resident’s dislike for fish was missing from the preference list.
Resident Not Seen by Dietary Staff After Admission
Penalty
Summary
The facility failed to ensure that a resident had the opportunity to communicate food preferences upon admission. Resident #192 reported that he/she did not receive meat on a breakfast tray and later stated that the breakfast portions were too small, including only 2 small pancakes, leaving the resident still hungry after meals. During a follow-up interview, the resident said no one from dietary services had spoken with him/her about diet, alternatives, or food preferences since admission. During interviews, Kitchen Account Manager #31, with Certified Dietary Manager #32 present, stated that new admissions are expected to be visited by dietary staff within 24 hours to discuss the weekly menu, always available alternatives, substitutes, the meal process, and likes and dislikes, but no documentation could be provided showing Resident #192 had been seen. Registered Dietitian #30 stated that new admissions are typically seen within 5 to 7 days after admission and that the resident should have been seen by dietary services within 72 hours of admission; the RD also stated the resident was on the schedule for that day and would be assessed regarding the concern about insufficient food portions.
Deficiencies in Care Plan Updates and Interdisciplinary Team Involvement
Penalty
Summary
The facility failed to use an interdisciplinary team to revise care plans to meet residents' needs and did not ensure that residents' representatives were offered opportunities to participate in care plan reviews. This was evident in several cases, including a resident with circulation problems and wound healing issues. Despite a podiatrist's recommendation for hospital transfer due to a wound infection, the care plan was not updated to reflect the change in the resident's condition. The Director of Nursing (DON) acknowledged that the care plan should have been updated following the new skin infection. Another deficiency involved a resident with a diet order that included aspiration precautions and no straw use. The facility failed to communicate these orders to the staff, resulting in the resident using a straw. The dietician and nurse were unable to explain how the information was communicated, and the unit manager confirmed that the order was missed and not included in the care plan. The DON acknowledged that the order was not initiated on the care plan, leading to staff being unaware of the precautions. Additionally, the facility did not conduct care plan meetings as required for several residents. One resident's care plan meeting was repeatedly rescheduled, and there was no documentation of a meeting with the resident's representative. Another resident's care plan was not updated for 17 months, and the facility failed to document care plan meetings for yet another resident. The DON and other staff members acknowledged these deficiencies, indicating a lack of proper documentation and communication regarding care plan meetings and updates.
Failure to Provide Menu-Listed Meals and Respect Dietary Choices
Penalty
Summary
The facility failed to provide meals according to the established menu and did not respect residents' dietary choices during a recertification/complaint survey. The Certified Dietary Manager (CDM) explained that residents typically receive the Regular meal unless they request an alternative. However, during the lunch service, the District Manager (DM) altered a meal ticket to substitute a hamburger for the Dijon Pork Loin, which was the Regular meal option. This substitution occurred because the facility ran out of pork loin due to over-portioning by a dietary staff member. As a result, 10 residents who had chosen the pork loin did not receive it and were instead given the alternative meal without being informed or given a choice. Resident #523, one of the affected residents, confirmed that she did not request the hamburger and did not want it. The Director of Nursing later provided a list of 10 residents who did not receive the pork loin they had selected. The CDM admitted that the residents who received the alternative meal were not informed or given a choice prior to receiving it, although he noted there were no complaints. This incident highlights a failure in meal service management and communication with residents regarding their dietary preferences.
Food Safety and Sanitation Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in its kitchens, as observed during a recertification and complaint survey. The surveyor noted several deficiencies, including a non-operational plate warming device, unlabeled food items, and inaccuracies in food discard dates. Additionally, there were instances of adulterated food, uncovered stored food, and kitchen surfaces contaminated with dust and debris. Personal belongings were found on food preparation surfaces, and the kitchen ceiling had chipping paint, all of which were confirmed by dietary staff and the Kitchen Account Manager (KAM). During the initial tour of the main kitchen, the surveyor observed peeling plastic and black debris on the dishwasher, orange splattering on walls and floors, and liquid stains on the ice machine. There were also no paper towels at the handwashing sink, spilled white powder on the floor, and unlabeled food items in the freezer and refrigerator. In the second kitchen, personal items were found on food preparation tables, and the ceiling had peeling paint. The surveyor also noted a broken dish crate with dried food debris and a hand-held device resting on the floor. The surveyor found several issues with food storage and labeling, including containers with blank labels, expired pancake batter, and uncovered food items with no dates. The plate warming system was not functioning properly, as indicated by cold plates and a non-working indicator light. The KAM acknowledged these concerns and attempted to address them with the staff, but the issues persisted, indicating a lack of adherence to professional food safety standards.
Inconsistent Attendance at QAPI Meetings
Penalty
Summary
The facility staff failed to ensure consistent attendance of required committee members at the monthly Quality Assurance and Performance Improvement (QAPI) meetings. The facility's QAPI Plan policy mandates the inclusion of specific members such as the Administrator, Director of Nursing (DON), Quality Assurance (QA) Coordinator, Infection Preventionist (IP), Staff Development, Department Heads, Vendors (including pharmacy), and a Geriatric Nursing Assistant (GNA). However, a review of the facility's QAPI monthly attendance records from January 2024 to December 2024 revealed that a GNA missed four meetings, the Medical Director missed one meeting, and the DON missed one meeting. These absences were confirmed by the DON and Administrator during an interview with the surveyor.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection control program, as evidenced by several deficiencies observed during the survey. One significant issue was the failure to change oxygen tubing for a resident as per the facility's protocol. The tubing was observed to be 16 days old, despite the facility's policy to change it weekly. This oversight was confirmed by a Licensed Practical Nurse (LPN) and was not initially documented in the resident's medical records. Additionally, the facility did not maintain proper transmission-based precautions and enhanced barrier precaution protocols. Posters indicating special droplet/contact precautions were left on the doors of rooms long after a COVID-19 outbreak had been resolved, and residents in those rooms did not have conditions requiring such precautions. This was confirmed through interviews with staff and medical record reviews, revealing a lack of communication and adherence to updated protocols. Further deficiencies were noted in the handling of residents requiring enhanced barrier precautions. For instance, a resident with a positive Clostridium difficile result did not have an order for contact isolation precautions, and staff were not properly disposing of personal protective equipment. Another resident with a gastrostomy tube did not have a care plan for enhanced barrier precautions, and staff were observed not wearing the required personal protective equipment during care. These lapses indicate a failure to consistently apply infection control measures across the facility.
Lack of Effective Communication Training for Staff
Penalty
Summary
The facility failed to ensure that staff received training in effective communication, as evidenced by the lack of documentation for such training in the files of nine staff members reviewed during the Extended Survey investigation. Interviews and record reviews revealed that the Director of Human Resources (HR) was responsible for onboarding education, while the Director of Nursing (DON) or nursing staff handled annual education. However, there was no staff educator in place, and the HR Director could not provide additional training records beyond what was initially available. During the survey, it was discovered that the employee educational files for the nine staff members lacked documentation of effective communication training. Despite the HR Director's efforts to check an old education system and provide additional documentation, the files remained incomplete. The absence of a staff educator and the reliance on the HR Director and nursing staff for training oversight contributed to the deficiency in ensuring effective communication training for the staff.
Deficiency in Staff Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that all staff received their annual training for the compliance and ethics program, as evidenced by the lack of documentation for five out of nine staff members reviewed during the Extended Survey investigation portion of the recertification/complaint survey. Interviews and record reviews revealed that the Director of Human Resources (HR) was responsible for onboarding education, while the Director of Nursing (DON) or nursing staff handled annual education. However, there was no staff educator currently in place. Despite additional documentation being provided, the files for Staff #42, #43, #44, #46, and #47 still lacked evidence of compliance and ethics training. The Director of HR confirmed that no further training records were available for these staff members.
Failure to Honor Resident Dining Preferences
Penalty
Summary
The facility failed to honor the documented dining preferences of three residents during a recertification/complaint survey. Observations and interviews revealed that breakfast trays were delivered to the unit, but only one resident was present in the dining area. Registered Nurse (RN #28) indicated that most residents stayed in their rooms for breakfast, but did not confirm if this was their preference. Upon interviewing the residents, three of them expressed a preference to eat breakfast in the dining room, which was also documented in their baseline care plans. Further interviews with the Director of Nursing (DON) revealed a lack of awareness regarding the assessment and documentation of residents' dining preferences. The DON initially stated that dining preferences were not documented, but later acknowledged that the preferences were indeed recorded in the medical records. The DON confirmed that residents have the right to choose where they eat, and the failure to honor these preferences was acknowledged during the surveyor's interview.
Failure to Provide Information for Advance Directive Formulation
Penalty
Summary
The facility failed to provide a resident with information necessary to formulate an advance directive, as required by their policy. During the recertification/complaint survey, it was found that a resident did not have documentation related to advance directives in their paper chart or electronic medical record. Interviews with the Unit Manager and the Director of Nursing revealed that the process for new admissions involves Social Services offering information to residents who do not have an advance directive. However, the resident's records showed two assessments indicating interest in developing an advance directive, but no follow-up or provision of information was documented. Social Services staff confirmed that an initial assessment is conducted within 72 hours of admission, and if a resident does not have an advance directive, they are offered assistance in completing one. Despite this process, the resident's records lacked any notes or documentation of follow-up actions after expressing interest in formulating an advance directive. The facility's policy requires that decisions regarding advance directives be periodically reviewed, but this was not evident in the resident's case, leading to the deficiency noted by the surveyors.
Failure to Notify Resident of Dietary Change
Penalty
Summary
The facility failed to notify a resident or their appointed family members after a dietary change, which was identified during a complaint investigation. The resident, who was on dialysis, was initially placed on a renal diet upon admission to the facility. However, the diet was changed to a regular diet with regular texture the following day. Despite this change, there was no documentation in the electronic health record indicating that the resident or their responsible party had been informed of the diet change. The surveyor's review of records and interviews with facility staff revealed that the responsibility for notifying the resident or family members of changes in care or treatment lay with the staff member entering the change notes in the electronic record. The Director of Nursing confirmed that the nurse should have informed the resident and/or the family member and documented the notification, but this did not occur. The Nursing Home Administrator acknowledged the oversight when informed by the surveyor.
Failure to Follow Grievance Process for Residents
Penalty
Summary
The facility failed to adhere to its grievance process, as evidenced by the experiences of two residents. Resident #9 reported missing personal items, including headbands and beads, which were acknowledged by the laundry staff but not replaced. Despite the resident's complaints, there was no documentation of the grievance, and the Nursing Home Administrator (NHA) was unaware of the issue. The laundry manager also confirmed a lack of awareness about the missing items, indicating a breakdown in communication and follow-up within the facility's grievance process. Resident #151 experienced damage to clothing items, with grease and bleach-like stains observed by the surveyor. The resident had previously reported these issues to the unit manager, but no documentation or formal grievance was recorded. The NHA confirmed the absence of any grievance documentation related to the damaged clothing until after the surveyor's intervention. These incidents highlight the facility's failure to properly document and address resident grievances, as required by their policy.
Failure to Implement Background Check Policies
Penalty
Summary
The facility failed to implement its policies for abuse, neglect, and exploitation, as well as its policy for employment background investigations. This was evident in the case of a Geriatric Nursing Assistant (GNA) who was actively employed at the facility despite having a criminal background and suspended credentials. The surveyor discovered that the background check for this employee was improperly conducted, with the last name entered in the first name field and misspelled, resulting in no background information being retrieved. Additionally, the national public sex offender check was performed with the incorrect spelling of the last name, further compromising the accuracy of the background check. The facility's Human Resources Director admitted to the error in inputting the names into the background check system and was unaware that the order of the first and last names mattered. The facility's policies required job reference checks, licensure verifications, and criminal conviction record checks for all personnel applying for employment, but these were not properly executed in this case. The facility's failure to adhere to its own policies resulted in the employment of an individual with a criminal background and suspended credentials, which was only discovered after surveyor intervention.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations concerning a resident who reported a sexual abuse incident involving a Geriatric Nursing Assistant (GNA). The resident initially reported the concern to the Kitchen Account Manager approximately two and a half weeks after the incident occurred. Despite the resident's efforts to report the incident to the Director of Nursing, the facility's documentation indicated that the staff became aware of the incident on a later date, and the report to the Office of Health Care Quality was submitted on the same day. The police and ombudsman were notified on the same day as well, but the resident had already reported the incident to the police two days earlier. The investigation revealed discrepancies in the facility's reporting timeline and actions taken by staff. The Kitchen Account Manager informed a Unit Manager, who reportedly advised the resident that it was not necessary to report the allegation. The facility's Administrator confirmed the completeness of the investigative files, which included grievance forms and a concern form documenting the resident's preference for female care providers. An anonymous source provided additional documentation indicating the resident had informed them of the incident prior to the facility's awareness. The surveyor's review highlighted the facility's failure to act promptly and appropriately in response to the resident's allegations.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident. The investigation file for one incident lacked critical documentation, including statements from key staff members and evidence of interviews conducted. There was no documentation of an interview attempt with the resident, despite the facility's self-report indicating the resident declined an interview. Additionally, conflicting staff statements regarding the location of an alleged assault were not further investigated, and there was no documentation regarding the deprivation of goods and services allegation. In another incident, the facility did not adequately investigate a resident's report of sexual abuse by a Geriatric Nursing Assistant. The resident initially reported the incident to a staff member, who informed a Unit Manager, but the investigation was not initiated until several weeks later. The investigative file lacked statements from key staff involved in the initial report and did not address discrepancies in the facility's self-report. The GNA in question was not suspended until the investigation began, despite the resident's report to the police. Throughout the survey, the facility's Administrator was unable to provide additional information or clarification regarding the deficiencies identified. The surveyor's concerns were acknowledged by the facility's leadership, but no further information was provided before the surveyor's exit. The lack of thorough investigation and documentation in these cases highlights significant deficiencies in the facility's handling of abuse allegations.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident or the resident's representative in writing about the bed hold policy when the resident was transferred to an acute care facility. This deficiency was identified during a recertification/complaint survey for a resident who was admitted to the facility and later sent to an acute care facility due to a change in medical condition. The medical record review revealed no written evidence that the resident or their representative received the bed hold policy notice. Interviews with LPN staff indicated that the bed hold policy was not completed or provided to the resident or their representative. The Director of Nursing was unable to produce written evidence of the notification, despite providing a copy of the bed hold policy.
Inaccurate MDS Assessment of Resident's Dental Status
Penalty
Summary
The facility failed to accurately assess and document the dental status of a resident during the annual Minimum Data Set (MDS) assessment. The resident was observed by a surveyor to have missing teeth and loose incisors, yet the MDS assessment completed months earlier did not reflect any oral or dental issues. This discrepancy was confirmed through interviews with the nursing staff and MDS personnel, who acknowledged that the resident's dental problems were not accurately recorded in the MDS. Further investigation revealed that the resident had a doctor's order for a dental consult due to a failing dental bridge, with a recommendation for extraction. However, the dental procedure was pending, and the resident's dental consults were delayed. The Director of Nursing (DON) acknowledged the discrepancy in the MDS documentation, confirming that the resident's dental issues were not accurately captured, which led to the deficiency noted during the survey.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure the completion of a Level II Preadmission Screening and Resident Review (PASARR) for a resident before their admission. The medical record review revealed that a PASARR Level I screening was conducted on 01/11/2023, which indicated the need for a referral to Adult Evaluation and Review Services (AERS) for a Level II evaluation. However, this referral was not made. During an interview, a Social Services designee confirmed understanding of the process that positive PASARR Level I results should be sent to AERS for further evaluation. The Director of Nursing acknowledged these findings upon review.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with summaries of their baseline care plans, including a list of medications, within 48 hours of admission. This deficiency was identified during a recertification/complaint survey for three residents. Resident #57 reported not receiving a summary of their baseline care plan or medication list, and a review of their medical record confirmed the absence of documentation indicating that the summary was provided. The Director of Nursing (DON) acknowledged the lack of documentation for Resident #57. For Resident #145, the baseline care plans were initiated but completed late, as confirmed by the DON. Similarly, for Resident #5, although the baseline care plan was completed in the electronic system, there was no documentation to verify that it was presented and reviewed with the resident or their representative within the required timeframe. The DON confirmed the absence of such documentation for Resident #5 as well.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. For one resident, the medical record indicated a physician's order for continuous oxygen therapy due to acute respiratory failure and heart conditions. However, the care plan lacked any focus, goals, or interventions related to the use of supplemental oxygen, as confirmed by the Director of Nursing during an interview. Another resident was observed with significant dental issues, including missing and loose teeth, and had a pending dental procedure. Despite these concerns, the care plan did not reflect the resident's dental issues or the change to palliative care. Interviews with staff revealed that each department was responsible for updating care plans, but the dental issues were not documented in the care conference notes or addressed in the care plan. A third resident with a history of PTSD and depression had an incomplete care plan. Although the resident had been diagnosed with PTSD and exhibited depression, the care plan for trauma-informed care was canceled, and no additional plan was developed. The resident was prescribed an antidepressant for anxiety and agitation, but there was no care plan addressing mood and behavior or the use of psychotropic medication. Interviews with social services staff indicated a lack of assessment for PTSD, and the Director of Nursing acknowledged the deficiency in the care plan for PTSD.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility staff failed to ensure that a dependent resident's personal hygiene needs were adequately met by not providing showers as scheduled. The resident, who was totally dependent on staff for personal hygiene, reported not receiving showers for the past two years and expressed a preference for showers over bed baths. The resident's care plan indicated a need for showers per schedule, but the facility's documentation showed inconsistencies in providing these showers. The review of the resident's shower schedule revealed that the resident was supposed to receive showers every Monday and Thursday. However, documentation showed that the resident only received showers twice in January and once in February. There were multiple instances where the staff marked 'Not applicable' or 'No' on the shower sheets without proper documentation or explanation, and there were no records of the resident refusing showers on certain dates as claimed by the staff. Interviews with facility staff, including a Geriatric Nursing Assistant, a Registered Nurse, and the Unit Manager, revealed a lack of awareness and adherence to the resident's shower schedule. The Director of Nursing confirmed the discrepancies in the shower schedule and acknowledged that the resident was not being offered or given showers as per the schedule. The facility's failure to provide the scheduled showers and adequately document refusals or reasons for not providing showers contributed to the deficiency.
Failure to Provide Ongoing Activities for Bedbound Resident
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities, as evidenced by the case of a bedbound, alert but non-verbal resident. The resident's healthcare representatives expressed concerns that the facility did not attempt to engage the resident in any activities, despite the resident's preferences for group activities and religious services being documented as very important. Observations confirmed that the resident was often left in bed with only the TV on, and there was no evidence of other activities being provided. Interviews with staff revealed a lack of clarity and consistency in the provision of activities for the resident. The activity director stated that one-to-one activities were scheduled twice a week, but a review of the participation log showed gaps in service, particularly when the resident was placed on isolation precautions. The Director of Nursing confirmed that activities should have continued despite the isolation status, indicating a failure to adhere to the facility's policies for ongoing activity provision.
Failure to Ensure Follow-Up Care and Lab Orders
Penalty
Summary
The facility failed to ensure proper follow-up care for two residents, leading to deficiencies in their treatment plans. For one resident with Crohn's disease, the facility did not schedule a follow-up appointment with a gastrointestinal (GI) specialist as recommended. The resident had been seen by the GI specialist, who ordered as-needed medication and recommended a follow-up in three months. However, the facility did not arrange any further appointments, which was confirmed by the Director of Nursing (DON) during an interview. In another case, the facility did not carry out a physician's order for an anticoagulant lab draw for a resident on Apixaban therapy. The lab order was entered incompletely into the Electronic Health Record (EHR) and was not entered into the Diamond Lab system, resulting in the lab not being drawn. This oversight was confirmed by the unit manager and validated by the DON during interviews with the surveyor. These failures highlight lapses in the facility's processes for ensuring residents receive timely and appropriate medical care.
Failure to Monitor Resident's Weight as per Facility Protocol
Penalty
Summary
The facility failed to adequately monitor the weight of a resident who was assessed as underweight and at risk of malnutrition. According to the facility's policy and standard practice, residents should be weighed on admission, weekly for the first four weeks, and then monthly. However, for this particular resident, only two weights were recorded during the current admission period, which spanned from December 2024 to February 2025. The resident was readmitted with a weight of 105 lbs, but subsequent weekly weights were not documented as required. Interviews with facility staff, including the Registered Dietician (RD) and the Director of Nursing (DON), confirmed that the expected protocol was not followed. The RD stated that she did not receive the necessary weights from the nursing staff, which led to a lapse in monitoring the resident's nutritional status. The DON reiterated the facility's policy of weekly weights for the first four weeks post-admission, but this was not adhered to in the case of the resident in question.
Deficiencies in Respiratory Care and Care Planning
Penalty
Summary
The facility staff failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration and care planning. For one resident, the oxygen was administered at a flow rate of 1.5 liters per minute, contrary to the physician's order of 2 liters per minute. Additionally, the oxygen tubing was not labeled with the date and initials of the nurse who changed it, as required by facility protocol. This oversight was confirmed by both the Unit Manager and the Registered Nurse during interviews with the surveyor. Another resident with a tracheostomy was observed using oxygen via a trach collar, but the care plan did not include any focus, goals, or interventions for respiratory or tracheostomy care. Despite having multiple medical diagnoses, including chronic respiratory failure and cancer, the resident's care plan was not comprehensive or resident-centered. The Director of Nursing acknowledged the omission and confirmed that the care plan should have addressed the resident's tracheostomy and oxygen therapy needs. The lack of proper labeling and adherence to physician orders, along with the incomplete care plan, demonstrate a failure to provide respiratory care consistent with professional standards. These deficiencies were identified during a recertification and complaint survey, highlighting the need for improved documentation and adherence to care protocols for residents requiring respiratory support.
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 1,702 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Glen Burnie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marley Neck Rehabilitation And Wellness Center | 1.5 mi | ★★★★★ | 9 | 0 |
| Autumn Lake Healthcare At Baltimore Washington | 2.2 mi | ★★★★★ | 28 | 0 |
| Hammonds Lane Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Complete Care At Severna Park Llc | 6.2 mi | ★★★★★ | 16 | 0 |
| Roland Park Place | 7.7 mi | ★★★★★ | 1 | 0 |
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