Below average — CMS composite of the measures below.
The next survey window likely opens around June 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 Homewood during CMS and state inspections, most recent first.
The facility failed to ensure that a PIP was identified and implemented through the QAA/QAPI process annually. The NHA stated the ADON coordinated the QAA committee, while the DON was asked to respond to QAA/QAPI questions. Review of the QAA/QAPI binder showed several months of data collection, but no identified PIP and no evidence that a PIP had been implemented.
QAA Committee Attendance and Documentation Deficiencies: The facility failed to maintain and account for scheduled QAA meetings. Record review and interviews showed missing attendance forms for several months, the ADON identified as the QAA lead was absent from multiple meetings, and the QAA/QAPI binder contained some data without a documented plan or leadership, with no data for the final months reviewed.
Unsafe and Unclean Resident Areas and Courtyard: Dirty meal trays were left on resident tables while breakfast was served, and a resident said the trays were from the prior meal. Multiple rooms had environmental and maintenance problems, including stained toilets, a loose grab rail, rusty pipe covers, a stuck bathroom door, a loose handle, a damaged ceiling, torn furniture, and a loose vent. The courtyard also had about 100 cigarette butts scattered across the area, and a staff member supervising smoke break was unaware of any cigarette disposal policy.
A facility failed to ensure reasonable accommodation of the call bell system for two residents. One resident’s call light cord was rolled up and hanging at the wall port out of reach, and another resident’s call light cord was on the floor and out of reach. A follow-up observation showed the same conditions, and an LPN stated staff were expected to keep resident call bells within reach at all times.
A resident’s admission MDS assessment was not completed within the required timeframe because the RDCS did not sign it until after the deadline, resulting in a late completion date. The MDS Coordinator stated the assessment itself was done on time, but the delayed signature caused the admission assessment to be considered late.
Failure to Reinitiate Care Plans After Hospital Return: A resident was observed with supplemental O2 and a BiPAP machine, and stated concerns about the bed and falling. Record review showed no respiratory, oxygen, or fall care plan despite new orders for O2 and BiPAP and a fall assessment identifying the resident as high fall risk. The DON confirmed the appropriate care plans were not reinitiated after the resident returned from a recent hospital stay.
Care plan deficiencies involved two residents. One resident could not recall a recent care plan meeting, was not listed on the meeting sign-in sheet, and was instead documented as meeting with only the SW in the resident's room during lunch, which the DON confirmed was not an interdisciplinary care plan meeting. Another resident's care plan was not updated to match the medical record, which showed a prior UTI history and suprapubic catheter exchange, while the care plan still listed bladder incontinence and IV antibiotics for a UTI even though the DON confirmed the resident was not on antibiotics and was not currently incontinent.
Failure to Provide Finger Nail Care: Two residents were observed with long finger nails on repeated checks, and both stated they wanted their nails cut down. An LPN said staff were expected to monitor nail length, and the DON acknowledged the nails were trimmed after surveyor intervention.
The facility failed to ensure a resident’s urology follow-up appointments were completed after transportation problems caused missed visits, and it also failed to document ordered wound care for another resident. One resident had two urology appointments rescheduled after transportation issues, while another resident’s TAR showed multiple blank entries for ordered sacral and coccyx wound treatments and an inaccurate skin check entry that did not reflect documented wounds.
Failure to use ordered mechanical lift during transfer: A dependent resident reported knee pain after being transferred by two staff members without a Hoyer lift. Records showed the resident was care planned for transfer with a mechanical lift and 2-person assist, and the MDS coded the resident as dependent for transfers. The DON confirmed the transfer was done by standing and pivoting rather than using the Hoyer lift, despite the resident's TASK record indicating the transfer method.
Respiratory care was not provided in accordance with physician orders for three residents receiving O2. Two residents had O2 tubing and humidifiers that were not dated or labeled as required, and one had an empty humidifier bottle. Another resident was observed on an O2 flow rate below the ordered level, and when staff increased the flow to the ordered setting, the equipment made a whistling sound. An LPN, unit manager, and DON were aware of the concerns.
A provider failed to review and revise a resident’s care after a urology consult for urinary retention. The consult noted the resident could not communicate voids, had dry diapers on assessment, and raised concern for silent retention, with a plan for bladder scans and continued straight catheterization per policy. A later provider note mentioned monitoring for UTI or retention symptoms and using bladder scans for discomfort or poor voiding, but did not address the straight catheterization recommendation. The DON stated the facility did not have a bladder scan machine and used bladder ultrasounds instead.
The facility failed to maintain evidence of consistent narcotic count reconciliation for a unit reviewed after a complaint alleging narcotic misappropriation. A resident reported not receiving ordered Suboxone timely, and review also found oxycodone orders on the MAR. The shift-to-shift narcotic count sheets showed multiple missed counts in one month, and an entire month’s count sheet was missing. An LPN described the expected two-nurse count process at every shift change, but the required documentation was not available.
A facility failed to carry out repeated Pharmacist MRR recommendations for a resident receiving Risperidone for schizophrenia. The same irregularity was identified multiple times in pharmacy reviews, but the facility did not act on the recommendation to change the medication administration route or document why it was not done. The DON described the MRR process during interview, including email review of irregularities by the DON and Unit Managers and forwarding to the MD for review.
PRN narcotic pain meds were given outside ordered pain parameters for two residents. MAR review showed oxycodone administered when pain was zero or below the prescribed range for one resident, and when pain was below the ordered 6-10 range for another resident. An LPN stated PRN pain meds should only be given within ordered parameters, and the DON was informed that staff were not following the MD orders.
Food Storage and Labeling Deficiencies: Surveyors found food in the kitchen refrigerator and nourishment refrigerator stored without required dates or labels, including open containers, juices, and resident food items. Food temperature logs were also incomplete, with missing documentation for breakfast and lunch on multiple days. The DON stated that items kept in the nourishment refrigerator must be labeled with a name, room number, and the date placed in the refrigerator.
The facility failed to employ an RN in accordance with MD law when the DON was found to have a valid compact RN license from FL but no verifiable MD license on file or through the MBON website. The HR Director stated she verified licenses through MBON and believed a compact RN license was sufficient, while also confirming the DON was the only staff member working with a FL compact license and an expired LPN license. The DON stated she claimed dual residency in MD and FL and would get the MD license, and the NHA acknowledged the concern.
The facility failed to maintain infection control practices by leaving an opening between the clean and soiled laundry areas and by not consistently identifying residents requiring EBP. A staff member said the laundry opening had to remain for dryer maintenance, and in 3 of 10 rooms with EBP signage, the orange dot identifying the resident’s bed was missing. An LPN stated they could not tell who was on EBP without the dot, and the DON acknowledged confusion about the signage process.
Pest control was not effective, as flies and gnats were repeatedly observed in a resident room, the surveyor conference room, and during med administration. A resident reported flies frequently in the room and on food and objects, and an LPN-equivalent staff member said she saw a fly at least once per shift. The NHA said he noticed more flies and gnats during the survey week, and pest control logs showed pests were addressed during several visits.
Nursing staff failed to follow ordered SBP parameters and failed to document BP before giving Midodrine to a resident with lupus, epilepsy, hypotension, and adult failure to thrive. The MAR showed doses were given when SBP was above 130 mm/Hg, and after the order changed to PRN, BP checks were not documented every 8 hours to determine whether the med was needed; the MD stated BP had to be obtained to decide if the PRN dose should be given.
Failure to Provide Grievance Outcome: A resident with vascular dementia and moderate cognitive impairment had a grievance about staff and level of care, but the grievance form had no documented resolution, follow-up, or written outcome. Interviews showed the grievance was remembered, but the facility did not complete follow-through and the Ombudsman had identified prior issues with grievance follow-through.
Verbal and Mental Abuse of a Resident: A GNA entered a resident’s room yelling and threatened to have a family member come to the facility to "take care" of the resident. The resident, who had quadriplegia, chronic pain syndrome, anxiety, depression, neurogenic bowel, opioid dependence, and generalized weakness, confirmed the incident, and the facility’s investigation substantiated a verbal altercation based on resident, witness, and staff statements.
Failure to prevent a resident from falling from bed during incontinence care. A cognitively intact resident with a C5 spinal cord injury and dependence for ADLs was being turned by an agency GNA who had not reviewed the care guide and was unaware of the resident's paralysis. During the change, the resident's legs slipped off the bed and the resident was guided to the floor, with redness noted to the left knee and no fracture found on x-ray.
A resident experienced a significant medication error when a nurse administered meropenem, a broad-spectrum carbapenem antibiotic, instead of the cefepime that had been ordered by the physician to treat a UTI. Review of a complaint and the medication administration audit confirmed that the resident received an antibiotic that was not prescribed, constituting a failure to follow the five rights of medication administration, specifically the right medication, although no adverse outcome was documented.
A resident with elevated liver enzymes had a physician order for a right upper quadrant ultrasound, but nursing staff did not complete the ordered test. Review of the medical record showed no ultrasound results, and the DON confirmed that the ordered diagnostic study was never carried out, resulting in a failure to follow the practitioner’s order for necessary testing.
The facility did not complete annual performance reviews for GNAs or provide regular, individualized in-service education based on those reviews. During a survey, it was found that none of the reviewed GNA employee files contained performance reviews, and the DON confirmed that these had not been done for some time, resulting in a lack of tailored training for staff.
Staff did not maintain a safe, clean, and comfortable environment, as evidenced by stained ceiling tiles, peeling paint and laminate, rusted equipment, missing toilet paper, and unpainted spackled walls. Multiple residents were observed using wheelchairs with torn or cracked vinyl armrests, exposing foam padding. The maintenance department was understaffed, with only one staff member and recent changes to the repair reporting system.
The facility did not report multiple allegations of abuse, neglect, and theft to the regulatory agency within the required timeframes. Incidents included residents alleging physical and verbal abuse by staff, missing narcotic medication, and theft of personal items. In several cases, the administration was not promptly informed, resulting in delayed reporting to OHCQ, and in some instances, there was no documentation of when reports were submitted.
The facility did not thoroughly investigate or document multiple allegations of abuse and misappropriation of property, including incidents involving physical abuse by a phlebotomist, missing money, rough handling by an agency GNA, missing narcotic medication, and threatening behavior by staff. Investigations were incomplete, lacking necessary interviews with staff, residents, and witnesses, and in some cases, documentation was missing entirely.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in care that was not individualized or consistent with documented directives.
Surveyors identified multiple environmental deficiencies, including mold growth on window blinds, air conditioning units, and ceiling tiles, as well as damaged base molding, missing toilet paper holders, and unsanitary shower rooms with broken tiles and soiled washcloths. Facility leadership and staff confirmed these conditions during the survey.
Facility staff did not consistently hold or document interdisciplinary care plan meetings with residents and their representatives following required assessments. Medical record reviews for multiple residents showed missing or insufficient documentation of care plan meetings after several MDS assessments, and staff interviews confirmed these omissions.
The facility did not ensure fall precautions were in place for a resident with a history of falls, as a required floor mat was not positioned correctly. A resident assessed as high risk for unsafe smoking was found with multiple lighters in their room, contrary to the care plan and facility policy. Additionally, two residents who required supervision while smoking were observed smoking unsupervised, with one not using a required smoking apron and both having smoking materials in their possession. Staff interviews confirmed these lapses in supervision and adherence to care plans.
The facility did not consistently provide timely medications to residents, resulting in missed doses of essential treatments such as nicotine patches, IV antibiotics, and blood pressure medications due to delays in reordering and pharmacy delivery. Additionally, narcotic and controlled substance counts were not consistently reconciled by two nurses at shift changes, as required, with multiple missing signatures documented in log binders across all medication carts.
Staff did not properly dispose of expired yogurt and spoiled tomatoes in the kitchen, and failed to maintain sanitary and safe storage conditions in the nourishment room, including a leaking ice machine, mold-like substances, dirty cabinets with inappropriate items, and excessive ice build-up in the freezer.
Staff failed to follow infection control protocols, including improper storage and labeling of personal care items, lack of PPE use during medication administration to a resident with a G-tube and foley catheter, and absence of required signage and orders for residents needing Enhanced Barrier or Contact Precautions. Mold and unsanitary conditions were observed in multiple areas, and staff interviews confirmed awareness of these issues.
Staff failed to notify two residents' representatives and a physician about significant changes in condition, including a BiPAP machine malfunction for a resident with chronic respiratory failure and a hospital transfer for a resident with dementia. In both cases, required notifications were either delayed or not documented, as confirmed by the DON.
A resident with bone cancer, while in pain and expressing distress, was subjected to verbal abuse by a staff member who made a disparaging remark in the presence of another staff member and the resident's family member, who was on the phone. The incident was confirmed by both the family member and the second staff member, and the facility's investigation verified that verbal abuse occurred.
A resident was not protected from the wrongful use of their belongings or money, as staff or facility management failed to safeguard personal property or funds, resulting in unauthorized use.
Surveyors identified that MDS assessments were inaccurately coded for three residents, including failures to document regular pain medication, anticonvulsant use, behavioral refusals, and opioid administration, despite clear evidence in medical records and care plans. These errors were confirmed by the MDS Coordinator through record review and staff interviews.
Surveyors identified incomplete and inaccurate medical record documentation for three residents, including a physician's erroneous medication entry, multiple blank spaces on a MAR making it unclear if medications were administered, and missing care plan meeting documentation that was not accessible to the interdisciplinary team.
Staff did not ensure that two residents had their call bell controls within reach, as both were found with the call bells on the floor and inaccessible. A GNA/CMA confirmed that the call lights should have been accessible but were not at the time of observation.
Residents were not given the opportunity or support to organize and participate in resident or family groups, as required. The facility did not facilitate or respect the formation and participation of these groups.
A resident was admitted without a baseline care plan (BLCP) being completed within the required 48-hour timeframe, and no summary or current medication list was provided to the resident or their representative. The DON was unable to locate the BLCP in the medical record and confirmed it was never completed.
Facility staff did not develop a care plan for a resident with an indwelling urinary catheter as required, despite physician orders and documentation in the MDS. Although the IDT agreed to create a care plan, none was implemented for approximately three months after admission, and the DON confirmed the delay when interviewed.
Two residents did not receive proper pain management due to incomplete pain assessments, lack of pain medication parameters, and failure to document or provide non-pharmacological interventions before administering PRN opioids. Staff administered stronger pain medications outside of prescribed parameters and missed a scheduled dose of a long-acting opioid due to medication unavailability, with the DON confirming these deficiencies.
Nursing staff did not consistently monitor or document the behaviors and mental health status of three residents with mental disorders or psychosocial adjustment difficulties. One resident on multiple antidepressants lacked physician orders and monitoring for depression symptoms and medication side effects, while two others with behavioral monitoring orders and care plans had no documentation of required monitoring for extended periods. These deficiencies were confirmed by the DON and administrative staff.
Facility staff did not hold Midodrine as ordered for a resident with orthostatic hypotension when systolic blood pressure readings were above the specified threshold. Despite clear physician instructions, the medication was administered multiple times when it should have been withheld, as confirmed by MAR review and DON interview.
Staff failed to properly secure medications by leaving a narcotic on a resident's bedside table and leaving a treatment cart unlocked and unattended in a hallway. The cart contained various prescription medications, some of which were expired, and an opened bottle of Dakins solution without a cap. Facility policy requires locked storage, and both the DON and ADON confirmed these actions were not in compliance.
A resident with a history of dental pain and missing/broken teeth did not receive timely follow-up for recommended dental extractions after a dental consult. Despite ongoing complaints and a care plan noting oral health issues, staff did not arrange the necessary dental appointment, and the facility's dental provider had no referral on file. The deficiency persisted until identified by surveyors.
Failure to Identify and Implement a QAPI Performance Improvement Project
Penalty
Summary
The facility failed to ensure that a Performance Improvement Project (PIP) was identified and implemented through the QAA committee and/or QAPI program annually. During an interview, the NHA stated that the ADON was responsible for running and coordinating the QAA committee, and that the DON would answer QAA/QAPI questions because the ADON was out of the country. When the surveyor asked the DON for an example of a PIP, the DON stated she would review the QAA/QAPI notes and follow up. Review of the QAA/QAPI binder and notes showed several months of data collection, but there was no identified PIP and no evidence that a PIP had been implemented. The concern was then reviewed with the NHA regarding the absence of a performance improvement project.
QAA Committee Attendance and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain and account for scheduled Quality Assessment and Assurance (QAA) meetings. Based on record review and interviews, the surveyor found that the facility did not have documented attendance for several months of QAA meetings, including no attendance forms in the QAA/QAPI binder for August 2025 through December 2025. The surveyor also reviewed attendance for the last 6 months and found that the Assistant Director of Nursing (ADON), who was identified by the Nursing Home Administrator (NHA) and Director of Nursing (DON) as the facility’s QAA lead and the person responsible for running and coordinating the committee, was not in attendance from January 2026 through April 2026. During the review of the QAA/QAPI binder, some months contained data, but no direct plan or leadership was identified based on the data. The months of May and June had no data in the binder. The NHA stated that the ADON was responsible for the QAA committee, and the DON confirmed that the ADON was the designated lead for the QAA committee and meetings. The surveyor further reviewed the concern with the NHA that the lead for the QAA committee was only documented to be in attendance 2 out of the 11 months reviewed.
Unsafe and Unclean Resident Areas and Courtyard
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, comfortable, and homelike environment in multiple resident rooms and in the courtyard. During the initial tour, dirty meal trays from the previous meal were still sitting on tables in rooms 46-A and B, and breakfast trays were placed next to the dirty dishes without the old trays being removed. In another room, what appeared to be last night’s dirty meal tray was still on the resident’s table when breakfast was served. A resident stated the trays were from last night’s dinner and was unsure why staff had not removed them after meals. A CNA stated dirty meal trays should be removed by CNAs 30 to 45 minutes after residents finish eating and said the trays were left by night shift. Further observations found multiple environmental and maintenance issues in resident rooms, including dark stains in toilet bowls, a bathroom baseboard coming off, a wobbly grab rail, rusty pipe covers, a bathroom door that was stuck and would not open, a loose door handle with the door dragging on the floor, an opening in a bathroom ceiling measuring about 2.5 x 0.5 feet, a recliner with torn leather exposing the inner material, a loose bathroom vent, and a bedroom ceiling coming off about 4 feet long. In the courtyard, approximately 100 cigarette butts were spread across a large area during smoke break, and a resident was observed tossing a cigarette butt onto the patio. A staff member supervising the smoke break was not aware of any policy for cigarette disposal, and the NHA stated housekeeping cleaned the courtyard periodically.
Call Bells Not Within Reach
Penalty
Summary
The facility failed to ensure reasonable accommodation of the call bell system for 2 residents observed during the annual survey. Resident #5 was observed with the entire call light cord rolled up and hanging at the wall port, out of the resident’s reach, and Resident #32 was observed with the call light cord on the floor and also out of reach. Follow-up observations later the same day showed the same conditions for both residents. When the surveyor requested a dual observation, an LPN stated that staff were expected to ensure resident call bells were within reach at all times. The DON later reviewed the concern and indicated understanding.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete an admission comprehensive MDS assessment within the required timeframe for Resident #73. The resident’s admission assessment had an ARD of 4/16/2026 and was completed on 4/24/2026, which was after the required completion timeframe for an admission MDS assessment. Surveyors reviewed the record on 7/15/2026 and later interviewed the MDS Coordinator, who stated that the assessment was completed on time but the RDCS did not sign it until 4/24/2026, resulting in a late completion date. Surveyors informed the Regional Administrator and Administrator that the admission MDS assessment had been completed late.
Failure to Reinitiate Care Plans After Hospital Return
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to meet the needs of Resident #13. On 7/13/26, the resident was observed resting in bed with supplemental oxygen via nasal cannula in hand and a BiPAP machine in a bag on the side rail of the bed. The resident stated having concerns with the bed and falling, but could provide no further details. Review of the medical record on 7/15/26 showed no respiratory or oxygen care plan and no fall care plan for Resident #13. The record also showed orders beginning 7/13/26 for supplemental oxygen and BiPAP at night and while resting during the day, along with a fall assessment dated 7/3/26 that identified the resident as high fall risk. On 7/16/26, the DON confirmed that appropriate care plans for Resident #13 were not reinitiated after the resident returned from a recent hospital stay and should have been.
Care Plan Not Updated and Resident Not Included in Interdisciplinary Planning
Penalty
Summary
The facility failed to update a care plan and failed to involve the resident in the interdisciplinary care planning process for 2 of 45 residents reviewed. Care plans were required to be developed within 7 days of completion of the comprehensive MDS assessment and revised at least quarterly, but the report states that the resident care plan process was not completed as required by an interdisciplinary team. Resident #7 told the surveyor that he/she could not recall having a recent care plan meeting. The Unit Manager stated that care plan meetings occurred about once a month and that the social worker arranged them, but she could not recall whether Resident #7 recently had a meeting. The surveyor reviewed the care plan sign-in sheet with the NHA and found that Resident #7 was not listed as attending the May 2026 care plan meeting. The NHA then provided a note written by the social worker stating that the resident was met with in the resident's room during lunch for a care plan meeting. The DON confirmed that a care plan meeting should involve an interdisciplinary team and should not take place in the resident's room during lunch with only the social worker. For Resident #11, the medical record showed a urology consult note after a suprapubic catheter exchange stating the resident had a UTI in February, but no antibiotics were indicated due to absence of UTI symptoms. The care plan still reflected bladder incontinence with an intervention to encourage fluids, and another care plan stated the resident was on IV antibiotics for a UTI and had last been revised on 2/6/26. The DON confirmed that the care plan was not revised and up to date and that Resident #11 was not on antibiotics and was not voiding or currently incontinent.
Failure to Provide Finger Nail Care
Penalty
Summary
The facility failed to ensure finger nail care was provided to two residents, Resident #24 and Resident #71, who were observed with long finger nails. On 07/16/2026, Resident #24 was observed at 8:28 AM with long finger nails, and Resident #71 was observed at 1:42 PM with long finger nails. On 07/17/2026, follow-up observations again showed both residents with long finger nails, and each resident stated they felt their nails were long and wanted them cut down. An LPN stated it was the expectation of all staff to monitor resident finger nails for length. The DON later acknowledged that both residents' finger nails had been trimmed after surveyor intervention.
Missed Urology Appointments and Incomplete Wound Care Documentation
Penalty
Summary
The facility failed to provide ordered treatment and follow-up for a resident’s urology appointments. Resident #11 reported missing two urology appointments because of transportation issues arranged by the facility. A consultation note from the resident’s urology visit dated 6/22/26 stated the appointment needed to be rescheduled related to transportation issues and listed a new appointment for 7/9/26 at 3:20 PM. The resident’s record also contained a reminder note dated 7/2/26 for the upcoming appointment. The DON confirmed that the resident had to have two urology appointments rescheduled, and CNA #12 stated that for the second appointment transportation arrived early, the CNA was not present when transport came, and the transportation company left because it timed out of its transportation window. The facility also failed to document wound treatments as ordered for Resident #92. The resident had orders for daily treatment of a mid sacral wound and twice-daily treatment of a coccyx wound, along with a weekly skin check. Review of the TAR for April and May 2026 showed multiple blank entries for the mid sacral wound care and coccyx wound care on several dates. The skin check list on 4/22/26 documented no skin impairments even though the wound care team had evaluated the resident on 4/21/26 and documented both the mid sacral and coccyx wounds. When shown the blank wound care documentation, the DON stated that if cares are provided they should be documented.
Failure to Use Ordered Mechanical Lift During Dependent Resident Transfer
Penalty
Summary
The facility failed to adequately assist a dependent resident during ADL care and transfers. Resident #11 stated that a few months earlier he/she was transferred by two staff members without the use of a Hoyer lift and experienced knee pain afterward, although an x-ray showed no fracture. A progress note dated 12/6/25 documented that a left knee x-ray was ordered to rule out a fracture, and a provider note dated 12/9/25 stated the resident was seen for follow-up for reported left knee pain and swelling after an injury to the left knee during a transfer with a Hoyer lift. Review of the care plan showed an ADL self-care deficit care plan established on 4/12/25 with an intervention added on 6/9/26 to transfer the resident with a mechanical lift and the assistance of 2. The MDS assessment coded the resident as dependent for both chair-to-bed transfers and toilet transfers. The DON confirmed that the December 2025 transfer related to the knee pain was done by two staff members standing the resident and pivoting rather than using a Hoyer lift, and stated that a Hoyer lift should have been utilized. She also stated that staff should have been aware of the transfer method by referring to the resident's TASK record.
Respiratory Care Not Provided per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician orders for three residents receiving oxygen therapy. Resident #72 was observed receiving oxygen at 2 liters via nasal cannula connected to a humidifier, but the oxygen tubing and humidifier were not labeled with a change date. The resident’s order included oxygen at 2 L/min as needed for COPD and directed that oxygen equipment tubing be changed every 7 days on the night shift. Resident #20 was also observed receiving oxygen at 2 liters via nasal cannula, and the tubing was not dated; the humidifier bottle was empty. The resident’s order directed 2 liters of oxygen via nasal cannula nightly for shortness of breath and required oxygen tubing to be changed weekly and each component to be labeled with date and initials. Resident #73 was observed receiving oxygen at 2.75 liters, then later at 2 liters, although the treatment administration record documented an order for oxygen at 3 liters. When staff reviewed the order and increased the flow rate to 3 liters, the oxygen equipment produced a whistling sound. Staff stated that malfunctioning equipment was to be replaced without delay. The observations and interviews showed that the oxygen settings and equipment conditions for these residents did not match the physician orders or the facility’s documented process for labeling and changing oxygen tubing and humidifiers.
Provider Did Not Address Urology Recommendations for Urinary Retention
Penalty
Summary
The primary medical provider failed to review and revise Resident #28’s total program of care after a urology consult addressed urinary retention. The resident was observed near the nurses’ station on multiple days, with staff using a communication board to communicate with the resident. On 7/15/26, the medical record was reviewed and showed that the resident had been seen by a urology consultant on 6/29/26 for urinary retention. The consult note stated urinary retention had been noted at the hospital, the resident was unable to communicate voids, diapers were dry on assessment, and silent retention was a concern. The plan included checking bladder scans for post void residual at reasonable intervals to establish a trend and continuing straight catheterization for urinary retention per facility policy. A provider progress note dated 7/13/26 documented that urology had noted no acute concern for retention and recommended monitoring UTI or retention symptoms, and it stated to use bladder scan for discomfort or poor voiding and trend volumes. However, the note did not acknowledge the consult recommendation for straight catheterization for retention. During interview, the DON stated the facility did not have a bladder scan machine and would not be able to provide the recommendation, and that the facility used bladder ultrasounds if retention needed to be evaluated. When asked whether the provider should have contacted urology for an alternative plan if resources were not available, the DON confirmed that would be her expectation.
Missing narcotic count records and incomplete shift-to-shift reconciliation
Penalty
Summary
The facility failed to provide evidence that narcotic drug records were consistently used and reconciled for one of three nursing units reviewed during an annual survey related to a complaint alleging narcotic misappropriation. The complaint stated that the night supervisor was misappropriating residents’ narcotics and signing them out without administering them, and residents reported not receiving their medications. Resident #75 stated that Suboxone was not being received as ordered and that the medication was not being renewed in a timely manner when it ran out. Review of the resident’s medication orders showed Suboxone sublingual film ordered for opioid dependency, and the MAR review from May through July 2026 did not show discrepancies with Suboxone administration. Further review identified other controlled substances on the resident’s profile, including oxycodone ordered as a PRN medication for severe pain. The narcotic and controlled substance shift-to-shift count sheets showed multiple dates in February 2026 when shift-to-shift counts were not performed, and the count sheet for May 2026 was missing. An LPN described the expected process as a two-nurse count at every shift change, including total narcotic counts and individual resident card counts, with both nurses signing to verify accuracy. The Unit Manager later produced a binder of narcotic sign-out sheets from January through July for the station, but May 2026 remained missing.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to carry out Pharmacist recommendations identified during the monthly medication regimen review for Resident #6, who had an order for Risperidone 0.25 mg by mouth twice daily for schizophrenia. Review of the Pharmacist’s irregularity reports showed a recommendation dated 3/27/25 to review and change Risperidone to GT or PEG administration in PCC, but the facility did not complete the recommendation. The same recommendation appeared again on the pharmacy review dated 4/10/26 and was still not acted upon. A third recommendation regarding the same issue was documented on 6/27/26, and the facility still did not act on it or document why it was not done. On 7/15/26, the surveyor discussed the concern with the DON and NHA. During interview, the DON explained that after the Pharmacist reviews medications, irregularities and recommendations are emailed to her and the Unit Managers, who print them and forward them to physicians for review before orders are returned to the Unit Managers to remove any physician orders.
PRN Narcotic Orders Not Followed
Penalty
Summary
The facility failed to ensure that physicians’ orders were followed for PRN narcotic pain medications, resulting in staff administering oxycodone outside the ordered pain parameters for 2 residents reviewed during the annual survey. For one resident, June 2026 MAR documentation showed PRN oxycodone being given when pain was recorded as zero on 6/3, 6/7, and 6/11, even though the order was for 5 mg tablets, 4 tablets by mouth every 4 hours as needed for severe pain rated 6-10. In July 2026, the same resident had a second PRN oxycodone order for moderate pain rated 1-5, but the medication was administered when pain was documented above the ordered range, including pain levels of 10, 8, and 7 on multiple dates. For another resident, a physician order dated 8/31/25 directed oxycodone HCl 10 mg, 1 tablet by mouth every 6 hours as needed for pain rated 6-10. Review of the June 2026 MAR showed the medication was administered for pain levels of 3 and 4 on several occasions, and once when pain was documented as zero, which was outside the ordered parameters. During interview, an LPN stated that pain should be assessed before giving PRN medication and that it should not be given when pain is at zero; he also stated that giving PRN narcotics outside parameters could lead to dependence, respiratory failure, or constipation. The DON was informed that staff were not following the doctor’s orders and were giving PRN narcotics outside the prescribed ranges.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and serve food in a manner that prevents foodborne illness and failed to date and label resident food stored in the nourishment refrigerator. During an observation of the kitchen refrigerator, food was found stored without dates or labels, including a container of diced carrots in an aluminum container covered with transparent film, a partially used jar of barbecue sauce, and multiple one-liter jugs filled with pink juice and lemon juice that were not dated. Review of the food temperature log also showed that breakfast food temperatures were not taken or documented on one day, and breakfast and lunch food temperatures were not taken or documented on another day. In the nourishment refrigerator on the unit, surveyors observed a plate of spaghetti in a black bowl covered with a white lid that was dated but had no name on it, along with a white creamy liquid in an 8 oz plastic cup, a second 8 oz cup partially filled with pink liquid, and a bottle of water that had no date or name on them. The staffing manager verified that the items were not labeled or dated and stated they would be discarded. The DON stated that food kept in the nourishment refrigerator should not stay for more than 3 days and must be labeled with a name, room number, and the date it was placed in the refrigerator.
RN Licensure Not Verified for DON
Penalty
Summary
The facility failed to employ an RN in accordance with Maryland State law for one employee file reviewed during the annual survey. During review of complaint #3055819, surveyors found that Staff #2, the DON, held a valid compact RN license from Florida and resided in Maryland, but the surveyor could not verify a Maryland license through the MBON website, and no copy of a Maryland license was on file. The complaint alleged that the DON's RN license was from Florida and that her Maryland LPN license was inactive with the Maryland Board of Nursing. During the survey, the HR Director stated that nurse licenses are verified through the MBON website and that staff with multistate RN licenses are hired if they have a compact license. She also stated that she was not aware that in Maryland a nurse is required to have an active license in the state of primary residence. When asked for a list of nurses with compact RN licenses, the HR Director provided a list showing that the DON was the only staff member working in the facility with a Florida compact license and an expired LPN license. The DON was informed that Maryland state law requires an MD license if the nurse physically resides in Maryland and claims Maryland on the W-2, and she stated that she claimed dual residency in Maryland and Florida and would get the MD license. The NHA was present and acknowledged the concern.
Infection Control Deficiencies in Laundry Separation and EBP Signage
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when it did not separate the clean and soiled laundry areas with a closed barrier and did not maintain a clear process to identify residents requiring Enhanced Barrier Precaution (EBP). During observation, the surveyor found an opening between the clean and dirty laundry areas, and a staff member stated the opening had to remain for dryer maintenance and could not be closed. The Administrator acknowledged the concern and said the facility would explore solutions. In a separate observation of 10 rooms with EBP signage, orange dots identifying the bed for precautions were present in 7 rooms, but rooms 40, 44, and 54 did not have an orange dot. An LPN stated they were not sure who was on EBP without the dot and believed supervisors were responsible for placing the orange dot on the sign, while the DON later acknowledged confusion about the signage process and stated the former ADON had implemented it.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to ensure an effective pest control program was in place to keep the facility free from pests. During the annual survey, a fly was observed in Resident #9’s room while the resident reported seeing flies frequently in the room and stated that flies had landed in food and on objects around the room. Additional observations during the survey found a gnat and multiple flies in the surveyor conference room on several occasions, including one fly found in a fresh cup of coffee. A fly was also observed during medication administration by Certified Medication Aide Staff #42, and the staff member stated she would observe a fly at least once per shift. The Nursing Home Administrator stated he had noticed flies and gnats more during the week of the annual survey and said the facility had pest control come frequently. Review of the last 3 months of pest control logs showed that pests were addressed during several visits.
Failure to Follow BP Parameters and Document Vital Signs Before Midodrine Administration
Penalty
Summary
The facility nursing staff failed to follow the physician’s ordered pulse and blood pressure parameters before administering Midodrine to Resident #6 and failed to document an associated blood pressure before giving the medication. Resident #6 was admitted with diagnoses including lupus, epilepsy, hypotension, and adult failure to thrive. A facility policy on medication administration stated that nursing staff must obtain and record vital signs when applicable or per physician orders and hold medication when vital signs are outside the prescribed parameters. A review of Resident #6’s record showed a physician order dated 04/29/26 for Midodrine HCl 5 mg by mouth three times a day for orthostatic hypotension, with instructions to hold the medication for SBP greater than 130 mm/Hg. The MAR showed doses were administered on multiple occasions when the documented SBP was above 130, including readings of 134/76, 132/80, 132/72, 132/76, 132/71, 136/70, and 132/70. A later order dated 05/26/26 changed Midodrine to 5 mg every 8 hours as needed for hypotension, still with a hold parameter for SBP greater than 130 mm/Hg, but the MAR did not show blood pressure documentation between 05/26/26 and 06/10/26 every 8 hours to determine whether the medication was needed. The physician stated that because the medication was written as needed, nursing staff needed to obtain the resident’s blood pressure to determine if it should be administered.
Failure to Provide Grievance Outcome
Penalty
Summary
The facility failed to provide a resident or representative with an outcome and/or resolution after a grievance investigation was completed for one sampled resident, R#12. The facility policy titled, Resident and Family Grievances, stated that the Grievance Official or designee would keep the resident appropriately apprised of progress toward resolution, and that prompt efforts included acknowledgment of complaints/grievances and actively working toward a resolution. However, the grievance form dated 3/26/2026 for R#12 documented a concern about a staff member and the resident’s level of care, and the form contained no recommendations, resolutions, or follow-up information. R#12 was admitted with diagnoses including vascular dementia, and the quarterly MDS described the resident as moderately cognitively impaired. The resident was independent with toileting hygiene and required set-up assistance with lower body dressing. During interviews, the Ombudsman stated issues related to grievance follow-through had been identified at the facility, SW9 stated grievance forms were typically forwarded to department heads and summaries of investigations and resolutions were generally provided in writing, and the Administrator stated the grievance for R#12 was remembered but follow-through was not completed due to an oversight.
Verbal and Mental Abuse of a Resident
Penalty
Summary
The facility failed to ensure Resident #5 was free from verbal and mental abuse when a GNA entered the resident’s room yelling and threatened to have the GNA’s father come to the facility to "take care" of the resident. The facility’s Abuse Prevention Policy prohibited verbal and mental abuse, including verbal threats, intimidation, harassment, and abusive language by staff. The incident was reported by the resident and documented in the facility-reported incident as occurring on 12/24/2025, and the accused staff member was removed from resident care pending investigation. Resident #5 was admitted with diagnoses including quadriplegia, chronic pain syndrome, anxiety disorder, depression, neurogenic bowel, opioid dependence, and generalized weakness, and the care plan indicated the resident required extensive assistance with ADLs and interventions for psychosocial well-being and emotional support. The facility’s investigative documentation showed the accused GNA acknowledged making statements about calling their father to deal with the resident, and witness interviews and staff interviews corroborated that a verbal altercation occurred. During interview, Resident #5 confirmed the verbal incident, and the DON stated the allegation was substantiated based on resident, witness, and staff statements.
Failure to Prevent Resident Fall During Incontinence Care
Penalty
Summary
The facility failed to ensure staff implemented interventions to prevent a resident from falling from bed during an incontinence change. The resident was admitted with an unspecified injury at the C5 level of the cervical spinal cord, was cognitively intact, and was dependent on staff for activities of daily living. The care plan identified a bed mobility focus and stated the resident required assistance from one staff member to reposition and turn in bed. During care, a GNA who was agency staff and new to the facility entered the room after the resident requested to be changed. While the resident was being turned with a pad, the resident's legs slipped off the bed and the resident was guided to the floor. The resident was observed sitting on the floor next to the bed, denied pain or discomfort, and had redness around the left knee. A witness reported the resident slid out of bed while care was being provided, and the GNA stated the resident care guide had not been reviewed and that they were unaware the resident was paralyzed.
Significant Medication Error Involving Wrong Antibiotic Administration
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors when a nurse did not administer medication as prescribed by the physician. Review of a complaint and the resident’s medication administration audit showed that on 12/6/25 at 6 PM, the resident received meropenem, a broad-spectrum carbapenem antibiotic used to treat severe bacterial infections, instead of cefepime, a fourth-generation cephalosporin antibiotic that had been ordered by the physician for a urinary tract infection. This constituted a failure to follow the five rights of medication administration, specifically administering the wrong medication, and resulted in the resident receiving a medication that was not prescribed, although no negative outcome was documented for the resident. The deficiency was identified through observation, record review, and interviews, which confirmed that the medication was not given as ordered and that the resident’s medication administration record reflected the administration of an unprescribed antibiotic for the urinary tract infection.
Failure to Complete Ordered Diagnostic Ultrasound
Penalty
Summary
Facility nursing staff failed to follow a physician’s order to obtain a right upper quadrant ultrasound for a resident whose laboratory tests showed elevated liver enzymes. The resident’s medical record showed that in September 2025 labs revealed elevated liver enzymes, and on 9/18/2025 the physician ordered a right upper quadrant ultrasound. Subsequent review of the medical record revealed no evidence that the ultrasound was completed or that results were obtained. During an interview, the Director of Nursing confirmed that nursing staff did not complete the ordered ultrasound, and the surveyor identified this as a concern related to failure to follow a physician’s order. The deficiency was identified during a complaint survey initiated after a complaint alleging the facility failed to monitor the resident’s status and well-being during the stay. Medical record review on 1/12/26 confirmed the absence of ultrasound results despite the prior order, and the DON’s interview on 1/12/25 further verified that the ordered diagnostic test was not carried out by nursing staff.
Failure to Conduct Annual Performance Reviews and Provide Individualized In-Service Education for GNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for Geriatric Nursing Assistants (GNAs) and did not provide regular, in-service education based on the outcomes of those reviews. This deficiency was identified during a recertification survey, where a review of five randomly selected GNA employee records revealed that none contained documentation of a performance review, despite all being employed for varying lengths of time. The Director of Nursing (DON) confirmed that performance reviews had not been completed for some time and that the process was not current at the time of the survey. Further, the DON acknowledged that in-service education for GNAs could not be tailored to individual needs without the completion of performance reviews. The absence of these reviews and the lack of individualized in-service training was evident for all five GNAs whose records were examined, indicating a systemic issue in the facility's process for monitoring and supporting staff performance.
Failure to Maintain Sanitary and Comfortable Environment
Penalty
Summary
Facility staff failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on two of three nursing units. Observations during the survey revealed multiple environmental concerns, including stained ceiling tiles, missing toilet paper, peeling laminate on bed headboards and footboards, peeling paint on window sills, missing strings for over-bed lights, rusted frames on toilet risers, and separated molding by windows. Several rooms had spackled walls that were not painted, further contributing to the lack of a homelike and well-maintained environment. Additionally, several residents were observed using wheelchairs with torn or cracked vinyl on the armrests, with some exposing the underlying foam padding. Interviews with the Maintenance Director indicated that he had only recently started in his role and was the sole maintenance staff member, occasionally receiving assistance from housekeeping. The facility had recently implemented a new system for reporting repairs, but these environmental deficiencies persisted at the time of the survey.
Failure to Timely Report Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and misappropriation of property to the Office of Health Care Quality (OHCQ) within the required timeframes for multiple residents. In several cases, reports of alleged physical abuse, verbal abuse, and theft were not submitted within the mandated 2-hour window for abuse or 24-hour window for misappropriation. Documentation and interviews confirmed that the initial reports were delayed, with some incidents being reported a day or more after the event, and in one case, the facility could not provide evidence of when the report was submitted. Facility leadership, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), acknowledged these delays during interviews, often noting that they were not employed at the facility at the time of the incidents but confirmed the findings based on available records. Specific incidents included allegations of staff physically and verbally abusing residents, missing narcotic medication, and theft of personal items and money. In one instance, a resident alleged being punched and wrestled by a phlebotomist during a blood draw, while another resident reported being hit by a GNA and threatened with a wheelchair. There were also cases where residents' personal property went missing, and the facility did not notify the regulatory agency promptly. In another case, a resident with cognitive impairment and a history of stroke developed unexplained wrist swelling, and the incident was not reported as required, despite the resident's vulnerability. The facility's investigations often lacked timely documentation, and in some cases, there was no evidence of an investigation or report submission at all. Staff interviews and record reviews consistently revealed that the administration was not made aware of incidents promptly, leading to delays in reporting to OHCQ. The failure to report these incidents within the required timeframes was confirmed by facility leadership during the survey process.
Failure to Conduct Thorough Investigations of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to provide thorough documentation and investigation of multiple allegations of abuse and misappropriation of property involving several residents. In one instance, a resident alleged physical abuse by a phlebotomist during a blood draw, but the facility's investigation did not include interviews with other residents on the unit who may have had concerns about the phlebotomist. In another case, a resident reported missing money from their purse, but the investigation lacked interviews with all relevant staff from previous shifts and included unsigned staff statements, resulting in an incomplete review. Additional deficiencies were noted in the handling of other incidents. For example, a resident alleged being hit by an LPN, but the facility could not provide any investigation documentation for review. Another resident was observed with a bruise and reported rough handling during ADL care by an agency GNA, but the investigation file was incomplete, lacking staff and resident interviews. In a separate incident, narcotic medication was reported missing, but the facility did not interview all staff who had access to the medication cart during the relevant period, and there was a delay in reporting the discrepancy to nursing administration. Further, the facility did not complete a thorough investigation into a resident's report of missing personal items and money after a hospital stay, as statements from the resident and alleged perpetrator were missing. In another case, a staff member was accused of making a threatening gesture and statement toward a resident, but the investigation did not include statements from named witnesses. In all these cases, the facility's failure to conduct comprehensive investigations and document findings contributed to the identified deficiencies.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required.
Environmental Deficiencies: Mold, Damaged Fixtures, and Unsanitary Conditions
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. In the Human Resources Director's office, black specks resembling mold were found on the window blinds and air conditioning unit, which also had visible condensation. Staff confirmed the presence of mold and stated it had been reported to administration. In the bathroom near the nurse's station, the base molding was detached, exposing debris and an open area behind the wall, and the toilet paper holder was missing its rod. The sink lacked a gooseneck faucet. The Nursing Home Administrator (NHA) was present during these observations and acknowledged the conditions. Further observations included shower rooms with mold-like substances in the grout, chipped and broken ceramic tiles, and exposed mastic. Soiled washcloths were found on the floor and in a bariatric shower chair, and the ceiling in one shower room had visible cracks. In the activity room, a ceiling tile was completely covered in what appeared to be black mold and was sagging, with staff stating it had been in that condition for a month. The NHA confirmed these findings and noted ongoing issues with the building's gutters, which had not yet been addressed.
Failure to Hold and Document Interdisciplinary Care Plan Meetings After Resident Assessments
Penalty
Summary
Facility staff failed to consistently hold and document care plan meetings that included the interdisciplinary team, residents, and their representatives following comprehensive and quarterly assessments, as required. Medical record reviews for five residents revealed missing or insufficient documentation of care plan meetings after multiple Minimum Data Set (MDS) assessments, including annual and quarterly reviews. In several cases, there was no evidence in the electronic medical record or social work documentation that care plan meetings occurred, and when meetings were held, documentation was sometimes limited to handwritten notes not entered into the official record. Staff interviews confirmed the absence of required documentation and, in some instances, the lack of meetings altogether. For example, one resident's records showed no care plan meeting documentation for several assessment periods, and the social work director acknowledged that notes were not entered into the electronic record. Another resident, who had multiple hospital transfers and readmissions, had only two care plan meeting notes documented despite several MDS assessments. Similar patterns were observed for other residents, with gaps between assessments and documented care plan meetings. The DON and social work staff confirmed that care plan meetings should occur after each quarterly MDS assessment, but acknowledged the lack of evidence to support that this was consistently done.
Failure to Implement Fall Precautions and Smoking Supervision
Penalty
Summary
The facility failed to implement and maintain fall precautions as ordered by the physician for a resident with a history of falls. The resident, admitted with diagnoses including cerebral infarction, cognitive impairment, osteoarthritis, and bipolar disorder, experienced multiple falls from bed. Despite a physician's order and care plan intervention for floor mats to be placed on both sides of the bed, observation revealed that only one mat was on the floor while the other was propped against the wall. Staff interviews confirmed the mat was not in place as required, and the Director of Nursing acknowledged the mat should have been on the floor. The facility did not follow the smoking plan of care for a resident assessed as high risk for unsafe smoking practices. The resident was found to have multiple lighters in their room, contrary to the care plan and facility policy, which required smoking materials to be kept at the nurse’s station and not on the resident’s person. Staff interviews provided conflicting information about the policy, but the Nursing Home Administrator ultimately confirmed that lighters should not be kept by residents and validated the concern that the resident was not following the care plan. Additionally, the facility failed to provide required supervision for residents identified as needing assistance while smoking. Two residents, both assessed as requiring supervision and the use of a smoking apron, were observed smoking unsupervised in the designated area, with one resident not wearing the required apron. Both residents also had smoking materials in their possession, despite care plans stating these should be kept at the nurse’s station. Staff interviews confirmed that supervision was not consistently provided, and the Nursing Home Administrator acknowledged the lack of supervision and the presence of smoking materials with residents who required oversight.
Failure to Provide Timely Medications and Incomplete Narcotic Reconciliation
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of residents, as evidenced by multiple instances where residents did not receive their prescribed medications as ordered. For one resident with a physician's order for a daily Nicotine Transdermal Patch, medical record review showed repeated missed doses due to delays in reordering and pharmacy delivery. Nursing notes and the Medication Administration Record (MAR) documented several occasions over multiple months where the patch was not available, and staff interviews confirmed that medications were not always reordered in a timely manner, sometimes due to lapses in communication between staff members responsible for medication administration and reordering. Another resident with a complex medical history, including bacteremia and sepsis, did not receive prescribed IV Vancomycin on several occasions because the medication was not available from the pharmacy or in the facility's automated dispensing system. Documentation in the MAR and nursing notes confirmed missed doses and delays in pharmacy delivery, with blank spaces and notations indicating the medication was not administered. A third resident, admitted with conditions such as hypertension and acute kidney failure, also experienced missed doses of blood pressure medication due to unavailability, as documented in the MAR and confirmed by staff interviews. The facility's own Medication Reordering Policy required nurses to reorder medications when six or fewer doses remained, but staff and leadership acknowledged ongoing issues with timely reordering and medication availability. Additionally, the facility failed to ensure that narcotic medications were consistently reconciled by two nurses at each change of shift, as required for controlled substances. Review of narcotic and controlled substance log binders for all medication carts revealed numerous missing signatures from both oncoming and off-going nurses across multiple shifts and halls. Staff interviews and facility policy confirmed that both nurses were expected to sign off on the narcotic count at each shift change, but this was not consistently done, resulting in incomplete documentation and lack of accountability for controlled medication storage and administration.
Failure to Properly Dispose of Expired Food and Maintain Safe Food Storage Conditions
Penalty
Summary
Facility staff failed to ensure proper disposal of expired and spoiled food items and did not store food in accordance with professional standards for food service safety. During a kitchen tour, multiple yogurt containers with best by dates that had already passed were found in the walk-in cooler. The Dietary Manager acknowledged that these yogurts needed to be discarded. On a subsequent kitchen tour, an open case of tomatoes was found in the walk-in cooler, with several tomatoes displaying white fuzzy material around the stems, indicating spoilage. The Dietary Manager confirmed the tomatoes were bad and removed them for disposal. Additionally, in the nourishment room, there were two vinyl floor tiles placed in front of a leaking ice machine, with a puddle of water and black specks resembling mold on the wall and floor base molding. No caution signs were present to indicate the wet floor. The under-counter cabinets in the nourishment room were observed to be dirty, containing a butcher knife, water spill marks, a red solo cup, a plastic plate cover lid, and a zip lock bag with sweetener packets. The freezer section of the nourishment refrigerator had at least a one-inch ice build-up on all walls. These observations were confirmed with the Nursing Home Administrator during the survey.
Widespread Infection Control Failures and Lapses in Precaution Implementation
Penalty
Summary
Facility staff failed to follow infection control practices and guidelines, resulting in multiple deficiencies related to the prevention and transmission of infection and disease. Observations revealed unsanitary conditions, such as unlabeled and improperly stored basins, urinals, and urine collection hats in resident rooms and bathrooms, as well as soiled gloves and washcloths left in inappropriate places. Mold-like substances were observed in several areas, including shower rooms, the activity room office, and the HR office, with staff confirming awareness of these issues. The facility's own policy required single-resident use and proper storage of bedpans and urinals, which was not followed. During medication administration to a resident with a gastrostomy tube and foley catheter, staff failed to don appropriate PPE and did not post Enhanced Barrier Precautions (EBP) signage as required. Although records indicated an order for EBP and an updated care plan, these precautions were not implemented at the time of observation. Interviews with staff and the DON confirmed that PPE should have been used and signage should have been present for residents with such medical devices. The facility also failed to ensure that residents with infectious diseases or those requiring EBP had appropriate physician orders, care plans, and signage. For example, a resident with a history of sepsis and multiple infections did not have an order or care plan for contact precautions, and staff were unclear about the reason for precautions. Additionally, several residents identified as EBP candidates did not have the required orders or signage on their doors, and staff confirmed these omissions during interviews. These failures were evident across multiple hallways and affected several residents reviewed during the survey.
Failure to Notify Representatives and Physicians of Changes in Resident Condition
Penalty
Summary
Facility staff failed to notify a resident's representative and physician when a BiPAP machine malfunctioned for a resident with chronic respiratory failure and obstructive sleep apnea. The medical record showed that the BiPAP was not administered due to device dysfunction, and while the supplier was contacted and a replacement was arranged, there was no documentation that the resident's representative or physician was informed of the situation or the change in the resident's respiratory support status. Additionally, staff did not notify another resident's representative in a timely manner when the resident, who had dementia, was transferred to the hospital after being found unarousable. The representative was only informed after the hospital had already made contact. Documentation confirmed the delay in notification, and the DON verified that timely notification did not occur in both cases.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse during care provision. On the evening of the incident, two staff members were providing care to a resident who was experiencing significant pain and vocalizing distress, stating that they were dying due to cancer. One staff member responded to the resident by saying, "well go ahead and die then so you can stop all this screaming." This statement was overheard by the resident's family member, who was on the phone with the resident at the time. The family member later visited the facility and received confirmation from the second staff member present that the statement had indeed been made. The resident involved had been admitted with a diagnosis of malignant neoplasm of the bone (bone cancer). The facility's investigation included statements from the family member and the second staff member, both corroborating the incident. The facility's policy defines verbal abuse as the use of disparaging or derogatory terms directed at residents or their families. The administrator confirmed the occurrence of verbal abuse by the staff member during an interview.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or inappropriate use. Specific actions or omissions by staff or facility management led to this breach, directly impacting the resident's rights and property. No additional details about the resident's medical history or condition at the time of the deficiency are provided in the report.
Inaccurate Coding of MDS Assessments for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for three residents during the recertification/complaint survey. For one resident with diagnoses including polyneuropathy, chronic pain, osteoarthritis, and gout, the MDS incorrectly indicated that the resident did not receive regular pain medication, despite documentation showing the use of Diclofenac gel four times daily and Gabapentin twice daily. The MDS also failed to code the use of anticonvulsant medication. These errors were confirmed by the MDS Coordinator upon review. Another resident's admission MDS did not capture a documented refusal of medication and weight, even though behavior notes and a care plan addressed non-compliance with the treatment plan. The MDS Coordinator confirmed this omission and stated that the existence of a care plan was mistakenly considered sufficient. Additionally, a third resident's MDS inaccurately reported the number of injections received and failed to document opioid administration, despite medical records showing multiple injections and opioid use. These inaccuracies were verified through staff interviews and medical record reviews.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents. For one resident, the physician's notes incorrectly documented the administration of Pravastatin 20 mg nightly for secondary stroke prevention, despite the resident not being prescribed this medication since readmission. The Chief Clinical Officer confirmed this was a documentation error and the resident was not supposed to be on Pravastatin. Another resident's Medication Administration Record (MAR) contained multiple blank spaces for several medications, including Seroquel, Metformin, Pregabalin, Senna, Trulicity, Enoxaparin, Normal Saline Solution flush, Humalog insulin sliding scale, and silver sulfadiazine cream. The DON stated that blank spaces on the MAR indicated it could not be determined if the medications were given or signed off. Additionally, a third resident's medical record lacked evidence of care plan meetings in both the miscellaneous section and social work documentation. The Social Work Director reported that notes from a care plan meeting were handwritten in a personal notepad and not entered into the electronic medical record, making them unavailable to other disciplines. These findings demonstrate failures in maintaining legible, accurate, and accessible medical records for residents.
Failure to Ensure Call Bell Accessibility for Residents
Penalty
Summary
Facility staff failed to ensure that residents had access to their call bell controls, as observed during the initial tour. Specifically, one resident was found with the call bell cord and plunger on the floor near the headboard and out of reach, and the resident was unaware of its location. Another resident's call bell was also observed on the floor and out of reach. During an interview, a Geriatric Nursing Assistant/Certified Medication Tech confirmed that the call light should be within reach and acknowledged that it was not accessible to the resident at that time. These findings were identified for two residents out of a sample of sixty-four during the survey, and the facility was informed of these observations at the exit conference.
Failure to Honor Resident Rights to Organize and Participate in Groups
Penalty
Summary
The facility failed to honor the right of residents to organize and participate in resident and family groups. This deficiency was identified when it was observed that residents were not provided the opportunity or support to form or participate in such groups within the facility. The report notes that the facility did not facilitate or respect the organization and participation of these groups as required.
Failure to Complete Baseline Care Plan and Provide Medication Summary Upon Admission
Penalty
Summary
The facility failed to complete a baseline care plan (BLCP) within 48 hours of admission for one resident, as required. Review of the medical record for this resident showed no evidence that a BLCP was created or documented. The BLCP is intended to include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. Additionally, there was no documentation that a summary of the BLCP or a current medication list was provided to the resident or their representative. Interviews with the Director of Nursing (DON) revealed uncertainty regarding the required timeframe for BLCP completion, with the DON incorrectly stating it was within 72 hours instead of 48. The DON also indicated that the admitting nurse initiates the BLCP and that each discipline contributes, but was unable to locate the BLCP in the resident's record or provide evidence that a copy was given to the resident or representative. Ultimately, the DON confirmed that a BLCP was never completed for the resident in question.
Failure to Develop Timely Care Plan for Catheter Use
Penalty
Summary
Facility staff failed to develop a care plan to address a resident's use of an indwelling urinary catheter, despite a physician's order for catheterization and documentation in the Minimum Data Set (MDS) assessments indicating the presence of a catheter. The Care Area Assessment (CAA) from the resident's Admission MDS noted that the Interdisciplinary Team (IDT) agreed to create a care plan for the catheter, but a review of the clinical record revealed that no such care plan was in place for approximately three months following admission. During the survey, the Director of Nursing (DON) was interviewed and initially did not provide evidence of a care plan addressing catheter use. When a care plan was later produced, it was found to have been initiated only after a significant delay, well after the resident's admission and the original physician's order. The DON acknowledged that the resident went without a required care plan for catheter use during this period.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not properly assessing pain, not following physician orders for pain medication parameters, and not documenting or providing non-pharmacological interventions prior to administering PRN pain medications. For one resident, pain assessments were only documented on the day shift, despite orders to assess pain every shift, and pain scores were not consistently recorded. Additionally, the order for oxycodone lacked specific pain parameters after a certain date, and non-pharmacological interventions were not documented as attempted before administering PRN pain medications for several months. For another resident, the MAR showed that PRN oxycodone was administered multiple times without documentation of non-pharmacological interventions being attempted first, as required by the care plan and physician orders. The resident's orders included both Tylenol and oxycodone for different pain levels, but staff administered oxycodone for pain scores that should have been managed with Tylenol, and there was no documentation of Tylenol being given for those pain levels. The DON confirmed that non-pharmacological interventions should be offered and documented prior to PRN pain medication administration and that pain medication parameters should be specified in the orders. Additionally, a scheduled dose of Oxycontin was not administered to a resident because the medication was not available, and the pharmacy had to be contacted for delivery. Staff interviews revealed that medication reordering was based on nursing judgment, and delays could occur due to the need for physician-signed forms for narcotic medications. The DON acknowledged awareness of the missed dose and the issues with pain medication administration and documentation.
Failure to Monitor and Document Behavioral Health Interventions
Penalty
Summary
Nursing staff failed to adequately monitor and document the behaviors and mental health status of three residents with mental disorders or psychosocial adjustment difficulties. One resident, who was prescribed multiple antidepressant medications for depression, did not have a physician order for monitoring signs and symptoms of depression or medication side effects, despite a care plan intervention requiring such monitoring. The lack of monitoring was confirmed by the Director of Nursing, who acknowledged that appropriate orders and monitoring were not in place prior to the surveyor's inquiry. Two additional residents with orders and care plans for behavioral monitoring related to psychiatric or behavioral issues did not have documentation of behavior monitoring as required. For one resident, there was an order to monitor target behaviors every shift, but no documentation was found for several months until after the surveyor raised the issue. Another resident had a physician order and care plan for monitoring specific behaviors associated with schizophrenia, but the required monitoring was not documented on the Medication Administration Record. These failures were confirmed by facility administrative staff during the survey.
Failure to Hold Medication per Physician Order
Penalty
Summary
Facility staff failed to follow physician orders regarding the administration of Midodrine for a resident with orthostatic hypotension. The resident had a specific order to hold the medication if the systolic blood pressure was above 130. Clinical record review showed multiple instances in June and July where the resident's systolic blood pressure exceeded 130, yet the medication was still administered. This was confirmed through review of the Medication Administration Records and an interview with the Director of Nursing, who, along with the surveyor, identified the occurrences where the medication was given contrary to the physician's order.
Improper Storage and Security of Medications and Biologicals
Penalty
Summary
Facility staff failed to properly store and secure medications and biologicals as required. In one instance, a narcotic medication, Methadone 115mg, was left on a resident's bedside table after a staff member administered care, rather than ensuring the medication was taken or following an order to leave it at bedside. The staff member acknowledged that leaving the medication unattended was not appropriate. The Director of Nursing confirmed that medications should not be left at the bedside unless specifically ordered. Additionally, a treatment cart was observed unlocked and unattended in a hallway, allowing access to various prescription creams, ointments, and other medications. The cart contained expired items, including iodoform packing strips and Nystatin Zinc tubs, as well as an opened bottle of Dakins solution without a cap. An agency nurse present at the time stated she had not checked the cart that morning. Facility policy requires that only authorized personnel have access to locked compartments, and both the Director of Nursing and Assistant Director of Nursing confirmed the cart should have been locked.
Failure to Arrange Timely Dental Services After Consultant Recommendation
Penalty
Summary
A deficiency was identified when the facility failed to arrange for timely dental services for a resident following a dental consultant's recommendation. The resident, who had a history of oral/dental health problems including missing and broken teeth, complained of tooth pain to both staff and family. The care plan documented ongoing oral health issues and required staff to monitor and report symptoms such as pain, missing or broken teeth, and other oral abnormalities. Despite a dental consult identifying the need for extractions of fractured and retained root tips, there was no evidence that the facility made arrangements for the recommended dental treatment. Interviews with the resident, the resident's son, and facility staff revealed that the resident continued to experience dental pain and had not received follow-up care after the dental consult. The DON and unit manager confirmed that no appointment had been set for the necessary dental extractions, and the facility's dental service provider had not received a referral for the resident. The lack of follow-up persisted until the surveyor's intervention, indicating a failure to provide or obtain necessary dental services within a reasonable timeframe as required.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,321 citations issued within 25 miles in the last 12 months — including the 7 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Long Green | 0.2 mi | ★★★★★ | 33 | 0 |
| Holly Hill Healthcare Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Complete Care At Multi Medical Center Llc | 1.7 mi | ★★★★★ | 13 | 0 |
| Good Samaritan Nursing Home Operator, Llc | 1.8 mi | ★★★★★ | 27 | 0 |
| Roland Park Rehabilitation And Healthcare Center | 1.9 mi | ★★★★★ | 41 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.