Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Long Green during CMS and state inspections, most recent first.
Wound treatments for a resident were not completed on time and were not signed off at the time of completion by the person who performed them. Review of the TAR showed day-shift dressing changes were often documented after the scheduled time, and some day and evening shift treatments were signed off out of sequence. The Administrator and DON acknowledged that treatments may have been completed by one nurse but signed off by another, which was not consistent with Nursing Standards of Practice.
Facility staff failed to notify a resident's designated emergency contacts when the resident became lethargic, difficult to arouse, and was transferred to the hospital for a change in mental status. The record showed the provider was notified and transfer orders were given, but it did not document notification of either emergency contact, and the DON could not find evidence that they were informed.
A resident’s grievance about missed wound care and not being assisted out of bed daily was not fully resolved in writing because the grievance decision did not include the steps taken to investigate or the pertinent findings. The Administrator said he spoke with staff and left a message for the complainant, but there was no documentation that a written decision was issued. Record review also showed wound tx were signed off late on multiple days and the resident was not assisted out of bed on several days.
Facility staff failed to keep complete and accurate records for two residents. One resident lacked an AD and had been found incapable of making medical decisions, but the chart did not document the facility's efforts to pursue a court-appointed guardian. Another resident returned from the hospital with multiple pressure injuries and wound care orders, but the admission skin assessment was blank and did not record the wounds present on readmission.
An LPN and NP failed to use clean technique during wound care for a resident with multiple wounds, including a pressure wound and a suprapubic catheter site. Supplies were placed on a cluttered overbed table without a clean field or barrier, the same gloves were used throughout dressing changes, hand hygiene and glove changes were not performed between dirty and clean tasks, and a catheter bag was handled in a way that caused urine to flow back into the tubing.
Failure to Document Annual GNA Performance Evaluations: The facility did not have documentation showing yearly performance evaluations for multiple GNAs. Record reviews found that several GNAs hired on different dates had no annual evaluation on file, and the DON stated that staff receive informal check-ins and discussions but no documentation was available to verify that evaluations were completed.
Unclean and damaged kitchen, storage, and ware washing equipment were observed throughout the facility, including soiled food carts, exposed ductwork with dust and condensation, rusted and broken surfaces, unlabeled food items, obstructed hand sinks, unclean refrigeration units, and a heavily soiled dish machine with torn curtains, leaking water, and inadequate final rinse performance. Surveyors also found multiple nonfunctional kitchen items, damaged walls and flooring, and an unsanitary ice cooler in the nourishment room.
Essential kitchen and laundry equipment was found out of service or not operating correctly. Surveyors observed a nonfunctional refrigerator, uncalibrated steam thermometers, an oven that would not reach proper temps, a nonfunctional food cart, an air handler draining grey water, and a dishwasher with a nonfunctional booster heater and final rinse gauge; testing showed rinse temps below the required level. In laundry, one washer had been out of order for years, another was not effectively cleaning linens, and a dryer was not reaching proper drying temps, with stained linens still coming out of the wash.
Missing Required Annual GNA Training Documentation: The facility failed to ensure GNAs received the required 12 hours of annual training. The ADON said training hours were tracked on a log, while the HR Director said HR only handled new-hire training and was unsure who was responsible for annual training. Record review found multiple GNAs with no documentation of required yearly training, incomplete competency records, and limited documentation of abuse inservice training.
Resident council meetings were not held regularly, as the facility could not produce minutes or sign-in sheets for several months. Residents said meetings were not occurring regularly until the Activities Director began working there, and the Activities Director stated the first council meeting was held in May. A review of the council binder confirmed no documentation for the earlier months.
A resident complained of feeling cold when a bathroom windowpane was found broken and only loosely taped, allowing cold air into the room. Other areas had water-damaged and buckled flooring, holes in the wall, lifted floor panels, a rusted protruding toilet bolt, a closet door off track, and a Nourishment Room with missing cabinet doors, unclean cabinets, cracked flooring, and unclean refrigerators with torn gaskets.
Failure to post complete daily staffing hours. Review of staffing sheets showed the facility did not document the actual hours worked by licensed and unlicensed nursing staff each shift, and the posted schedules lacked the required staffing totals. An LTC staffing scheduler stated they only entered HPPD and were not aware the daily posting had to include the facility name, date, census, and actual hours worked by staff providing resident care.
The facility failed to follow infection control practices for 2 residents using oxygen concentrators. The humidifier bottle and oxygen delivery tubing were observed without installation dates, even though provider orders directed staff to change the bottle and tubing weekly and label the date on both items.
Inoperable and Missing Ventilation Systems: Surveyors found multiple exhaust/ventilation systems not working or missing in janitors' closets, soiled utility closets, and resident toilet/shower rooms, including a loud grinding motor in one shared toilet room. In the kitchen, the janitor's closet exhaust fan was inoperable, and steam and vapors were seen escaping from the mechanical dishwasher area into the kitchen.
Surveyors found that the facility failed to develop and implement person-centered care plans for two residents. One resident had a long-standing diagnosis of Type 2 DM with orders for blood sugar checks three times weekly, but no corresponding DM care plan was in place. Another resident was admitted S/P surgical repair of the L femur with a documented surgical site requiring wound team follow-up, yet no care plan was initiated for surgical site care. The DON confirmed that baseline care plans are started by the admitting nurse and updated by UMs based on MDS, diagnoses, and changes in condition, but acknowledged that required care plans for these conditions were not completed.
A resident with severe bilateral foot and ankle edema had provider orders for shift-based pedal pulse checks and weekly abdominal girth measurements. While these tasks were marked as completed in the TAR, no actual pedal pulse results or abdominal girth measurements were documented anywhere in the medical record or communicated to the provider. The DON stated that the provider did not initiate the supplemental data command in the PCC EMR, so nursing staff had no designated place to enter the data, and staff confirmed there was no alternate location for recording it. This lack of documentation persisted for months without correction, resulting in failure to provide care according to the physician’s orders.
A resident with a history of DM Type I had glucose checks performed at least BID, but the EHR did not contain an order for glucose monitoring or parameters for when the physician should be notified. The DON acknowledged the issue during interview, and no documentation was provided showing an order with notification parameters.
A CNA was hired and continued working in LTC without obtaining GNA certification within the required 4-month timeframe. Surveyor review of records and the Maryland Board of Nursing website confirmed the CNA did not have a GNA certification, and staffing sheets showed the CNA worked multiple recent shifts on Main Street. An HRD believed the 4-month timeframe applied, and the DON confirmed the CNA was on vacation when questioned.
A medication cart was found with 52 different tablets and capsules loose in the bottom of a drawer during the annual recertification review. The surveyor removed the medications in the presence of an employee administering meds and notified the DON and another employee of the loose medications found in the cart.
A resident with a reopened sacral wound had a wound culture collected while receiving antibiotics, but the specimen was rejected because it was placed in the wrong tube. The DON could not provide documentation that the practitioner or physician was notified or that the culture was redrawn. The resident was later hospitalized with SIRS related to an infected stage 4 wound and sacral osteomyelitis, and hospital cultures grew pseudomonas, Acinetobacter, and Corynebacterium.
A resident reported that meals were often cold and unappetizing, and when a double portion of stir-fried chicken was delivered, the resident described it as cold, spicy, and watery and requested a turkey burger substitution. During dining observations, multiple residents returned plates or requested substitutions, and test tray temperatures showed some items served at low temperatures, including pureed bread at 120 degrees F and an egg and cheese bake at 110 degrees F. At lunch, several residents again refused meals or requested substitutions, and additional residents received substitutions because the kitchen had run out of the main course.
Improper Dumpster Placement and Debris at Loading Dock: The exterior dumpster was observed at the loading dock, and staff were interviewed about its placement. The surveyor and the Maintenance Director found plywood near the rear kitchen entrance that may have been used to prop open the door during food deliveries or trash removal, and they also observed trash and debris scattered around the dumpster area.
Missing bathroom call bell cords were observed for three residents during an annual survey. The surveyor and Maintenance Director found that the call bell cords were absent from the residents' restrooms, and the Maintenance Director acknowledged the missing cords.
Pest Control Program Failed to Maintain Rodent-Free Environment: A resident reported seeing a rodent in the room, and another resident confirmed the room was cluttered and conducive to pest harborage with a rodent observed there. A surveyor also saw a rodent run across the conference room and exit under the door. The ADM and Maintenance Director acknowledged ongoing pest control services but also identified conditions that attracted pests, including boxes, propped-open doors, unsealed penetrations, and a dumpster placed near the kitchen entrance.
Several residents reported a lack of clean, well-maintained linen, and observations confirmed that linen carts were understocked and contained discolored, threadbare items. Staff interviews revealed that the available linen was insufficient, and the EVS Supervisor stated that budget limitations and lack of additional funding from administration contributed to the ongoing shortage. Facility leadership acknowledged the deficiency when interviewed by surveyors.
Several residents reported a lack of clean, well-maintained linen, with observations confirming that linen carts were understocked and the available linen was discolored and threadbare. Staff interviews revealed that the facility had not provided sufficient funds to replace damaged linen, resulting in an ongoing shortage and poor quality of linen for residents.
A resident was moved to a different room without receiving written notice or documentation explaining the reason for the change. Staff and the NHA were unaware of the move until it was brought to their attention, and the EMR was not updated to reflect the new room assignment.
The facility failed to maintain a safe and homelike environment, with issues such as damaged furniture, inadequate housekeeping, and improper storage of residents' belongings. Observations revealed maintenance problems, including improperly installed toilets and soiled carpets. Staff interviews indicated understaffing in housekeeping and maintenance, contributing to these deficiencies.
Surveyors identified deficiencies in medication storage and monitoring, including undocumented refrigerator temperatures, expired medications not discarded, and improper labeling and storage of medications. An unopened insulin pen was found unrefrigerated, and several opened medications were undated.
Facility staff failed to follow professional standards in medication administration, with two residents experiencing significant delays in medication sign-off. For one resident, Methadone doses were signed off hours late on multiple occasions. Another resident's medications were signed off over an hour late more than 85 times. Staff interviews revealed that while medications were reportedly given on time, they were often signed off late due to other duties.
The facility failed to ensure residents' dignity and privacy by not covering a resident's foley catheter bag, making it visible from the hallway, and by not properly storing residents' clothing, leaving them in trash bags or boxes. The LPN confirmed the need for foley bags to be covered, and the ADON and Administrator acknowledged the lack of hangers for clothing storage.
Facility staff failed to ensure residents had accessible call bells, affecting three residents. A resident was found without a call bell, which was attached to their roommate's bed. Two other residents had their call bells on the floor, confirmed by a GNA who was in the process of assisting them.
The facility did not complete a thorough investigation of an abuse allegation when a resident reported that their GNA allegedly threw water in their face. The investigation included interviews with staff but failed to include the resident, who had an intact cognitive status. The NHA confirmed the omission of the resident's statement.
A facility failed to complete a baseline care plan for a resident admitted with a stage 4 pressure ulcer. The deficiency was identified during an annual survey, revealing that the care plan lacked interventions for the ulcer. Interviews with staff confirmed the absence of a completed care plan, which is required within 48 hours of admission.
The facility failed to develop comprehensive care plans for two residents, one with a stage 4 pressure ulcer and another prescribed psychotropic medications. Despite treatment changes and medication prescriptions, necessary care plans were absent, as confirmed by staff interviews and record reviews.
A resident's elevated BP of 180/92 was not reassessed in a timely manner. The resident was given Hydralazine as ordered, but no follow-up BP was documented until over 12 hours later, with readings of 144/80 and 142/78. The care plan required documentation of the response to hypertension medication, which was not done. The DON confirmed the oversight, noting that the CMA should have informed the nurse, who should have retaken the BP and reported it to the physician.
A facility failed to implement the ordered treatment for a resident with urinary incontinence. The resident was found with a Foley bag filled to the top and taped due to a hole, contrary to the physician's order to change the bag when needed and empty it regularly. The DON was informed, and it was noted that staff was aware of the issue but was busy with other duties. A Unit Manager was also assigned to the unit.
A resident received incorrect oxygen flow rates due to outdated and unlabeled equipment, contrary to physician orders. Observations showed the resident receiving 4.25 to 4.5 L/min instead of the prescribed 2-3 L/min. The facility's policy on labeling and changing oxygen equipment was not followed, and conflicting medical orders were found.
The facility failed to address pharmacy recommendations for two residents, leading to unreviewed medication regimens. One resident's medication frequency was not clarified, and another's duplicate therapy and improper use of pain patches were not corrected. The ADON was unable to provide signed pharmacy reviews, indicating a lack of physician oversight.
A facility failed to respond to pharmacy recommendations for a resident's PRN anxiolytic medication, Diazepam, which lacked a stop date. The Consultant Pharmacist suggested discontinuation or documentation of its use, but no response was provided. The ADON could not find any documentation of the facility's response and had to contact the Psychiatric Nurse Practitioner and the resident's primary physician to address the issue.
The facility failed to maintain sanitary food service practices, with issues such as expired food, unclean kitchen equipment, and improper food storage. Observations included unlabeled food items, a refrigerator at an unsafe temperature, and a lack of cleaning schedules. The facility administrator does not directly supervise kitchen staff but addresses issues as they arise.
A resident's funds were misappropriated when $1000.00 was withdrawn from their account without permission. The Administrator cited a care cost spend down policy for accounts over $2500.00, but no documentation supported this action. Additionally, $800.00 was withdrawn without explanation, though it was later returned to the resident. The issue was discussed with the Administration team.
The facility failed to report allegations of abuse within the required two-hour timeframe. In one case, an allegation of inappropriate sexual relations between two residents was reported late due to the incident occurring on a weekend. In another case, a resident reported being struck by a GNA, but the report to the state agency was delayed despite the resident's representative being notified promptly.
A facility failed to accurately document a resident's weight, leading to discrepancies in the medical records. The resident's daughter reported weight loss, and surveyors found inconsistent weight entries in the EHR, with a rapid and unlikely weight change recorded over a short period. The DON attributed the issue to a documentation error by an RN, which was not corrected.
The facility was found to have deficiencies in infection control and medication handling. Unsanitary conditions were observed in common areas, with food on the floor and trash in hallways. Additionally, an LPN was seen handling medication without gloves, contrary to facility policy. The Administrator and ADON were informed of these issues.
The facility failed to maintain a safe and homelike environment, as several AC units in resident rooms were found with dust, dirt, and debris. The Administrator and DON were informed, and maintenance logs were incomplete, indicating a lapse in regular maintenance.
The facility failed to maintain an effective pest control program, as flies and fruit flies were observed throughout the building, including in resident rooms and common areas. The Administrator and DON were informed, and standing water conducive to fly activity was noted in the kitchen. A resident's behaviors were mentioned as a contributing factor, but the issue persisted.
Wound treatments were not completed and documented timely
Penalty
Summary
Facility staff failed to follow Nursing Standards of Practice by not ensuring wound care treatments for Resident #7 were completed on time and signed off at the time of completion by the person who performed the treatment. Resident #7 had wound treatment orders scheduled for the day shift, and on 4/24/26 new physician orders changed several wound treatments to every day shift and every evening shift. Review of the Treatment Administration Record audit for April 15-30, 2026 showed that on 7 of 16 days, the day shift dressing changes were not completed until after 3:30 PM. The audit also showed inconsistent documentation of when treatments were completed. On 4/25/26, the wound treatments scheduled for the day shift were signed off at 5:11 PM, while the evening shift wound treatments were signed off at 4:54 PM, 17 minutes earlier than the day shift treatments. On 4/26/26, the day and evening wound treatments were signed off as completed within 2 hours and 15 minutes of one another. During the review, the Administrator stated that the treatments may have been completed earlier but signed off later, and the DON stated that the wound nurse performs the day shift wound care Monday through Friday and that the nurse assigned to the resident signed off that the treatments were done. The DON agreed that medications and treatments are to be signed off by the person administering them and at the time they were done.
Failure to Notify Emergency Contacts of Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's representative when the resident was transferred to the hospital after a change in condition. Resident #7 was capable of making his/her own medical decisions and had a family member listed as Emergency Contact #1 and a friend listed as Emergency Contact #2. An infection note documented that the resident was lethargic and difficult to arouse, responded to tactile stimulation, and the provider was notified with new orders to transfer the resident to an acute care facility for further evaluation. A change in condition progress note stated that the resident was transferred to the hospital due to a change in mental status. Although the record indicated that the resident was the Resident Representative who was notified of the hospital transfer, it did not reflect that either designated emergency contact was notified when the resident had the change in mental status and was transferred for evaluation. The DON later reviewed the record and was unable to find documentation that either emergency contact had been notified.
Grievance Decision Lacked Investigation Details
Penalty
Summary
The facility failed to ensure resolution of a grievance for Resident #7 because the written grievance decision did not include the steps taken to investigate the complaint or the pertinent findings from that investigation. A grievance dated 4/23/26 documented concerns that the resident’s wound care was missed at times and was not completed that morning, and that staff were not assisting the resident to get out of bed daily despite the resident’s request. The grievance form contained signatures in the investigator, grievance official, and administrator sections, but the results section only stated that wound care was completed for that date and that the resident gets out of bed daily. The grievance form also stated that the unit manager and supervisors were ensuring the resident got out of bed daily and that wound care was being completed and followed by the wound provider and in-house wound team, but it did not document how the grievance was investigated or whether a written decision was issued to the person who submitted it. During interview, the Administrator stated he spoke to staff and was told the resident got out of bed every day, and he said he called and left a message for the complainant to call back, but they never did. Record review also showed Resident #7’s wound treatments were not signed off as completed until after 3:30 PM on 7 of 16 days in the reviewed period, and the April 2026 Kardex showed the resident was not assisted out of bed on 6 of 17 days.
Incomplete guardianship documentation and inaccurate wound assessment records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for a resident who had been certified by 2 physicians as lacking capacity to make medical decisions and had no Advance Directive on file. The resident's record did not include documentation of the actions taken to pursue a court-appointed guardian, even though the DON stated the resident's cognitive capacity had gradually declined, Social Services and Admissions were unable to contact the only family member listed, and the Administrator reported that the facility had started seeking guardianship and was working with legal counsel. When asked where this process was documented in the resident's chart, the Administrator stated it was not in there. Facility staff also failed to accurately document another resident's skin status upon readmission after hospitalization for multiple pressure wounds. The resident returned with physician orders for wound care and had multiple wounds, including pressure injuries to both thighs, the upper buttock/sacrum, right hip, left heel, and right lateral foot, with hospital documentation noting wounds present on admission. However, the admission nursing assessment had blank skin integrity diagrams and no documentation of the number, type, stage, size, or condition of the wounds at readmission. The DON confirmed there was no assessment of the resident's wound status upon readmission, and the wound NP later documented multiple wounds, including one unstageable right heel wound.
Failure to Use Clean Technique During Wound Care
Penalty
Summary
Facility staff failed to implement standard infection control practices during wound care for Resident #2, who had multiple wounds including a pressure wound on the right heel that was not assessed upon readmission to the facility on 5/9/26. During observed wound care, the LPN and NP placed wound care supplies directly on the resident’s overbed table among personal items and did not establish a clean field or place a clean barrier under the wounds. They changed multiple dressings on the resident’s right foot, left heel, suprapubic catheter site, right upper thigh, sacrum, buttocks, and posterior left thigh while using the same gloves throughout the process and without changing gloves or sanitizing hands between handling soiled and clean items. The NP also measured wounds with a paper tape, wrote measurements, and took photos with a cell phone, then placed the phone and measuring tape on the resident’s bedsheet between uses. The resident’s urinary catheter collection bag was observed lying on the resident’s groin/lap area and remained there during the dressing changes until it was moved to the mattress. After the wound care was completed, the LPN picked up the bag, struggled to manipulate the hook, and hung it on the bed frame while holding it above the resident’s groin and turning it over several times, causing urine to flow back into the tubing. The facility policy for clean dressing change required a clean area, a barrier cloth or pad under the wound, and hand hygiene and glove changes at specific points during the procedure. The Infection Preventionist stated she did not typically observe wound care and instead checked whether treatments had been done based on dated and initialed dressings.
Failure to Document Annual GNA Performance Evaluations
Penalty
Summary
The facility failed to complete yearly performance evaluations for Geriatric Nursing Assistants, as shown by record reviews and staff interview findings during the recertification survey. On 02/02/26, the surveyor reviewed the employee records for GNA #34 and GNA #35 and found no documentation showing that GNA #34, hired on 07/03/24, had received an annual evaluation since hire, and no documentation showing that GNA #35, hired on 05/29/08, had received an evaluation within the past year. During an interview the same day, the DON stated that after orientation the unit manager asks staff how they are doing, concerns are addressed by the HR Director or Administrator, daily check-ins are done with GNAs and nurses, and every Friday a topic is discussed with nursing staff; the DON also stated that staff are supposed to meet with the ADON every 6 months to re-evaluate progress, but there was no documentation to verify that an evaluation was done. On 02/03/26, review of the records for GNA #39 and GNA #41 also showed no annual evaluation available for review; GNA #39 was hired on 05/05/21 and GNA #41 was hired on 08/01/01.
Unclean and Damaged Kitchen and Ware Washing Equipment
Penalty
Summary
The facility failed to maintain food service equipment and kitchen areas in a sanitary condition during the initial kitchen tour on 01/21/2026. The surveyor observed multiple Cadco mobile food carts in disrepair, with chipped and broken parts, a broken/cracked sneeze guard taped with masking tape, heavy dust and food debris, and soiled wheels with hair wrapped around the axles. Food plates, cups, and utensils were stored on top of these unclean surfaces. The kitchen also contained exposed air handlers and ductwork with peeling tape, dust accumulation, and condensation/gray water discharging onto the floor, along with a cloth drape placed on the floor near a sink to catch the spill. Additional observations showed widespread unclean and damaged conditions throughout the kitchen and storage areas. These included a large hole in the wall exposing a waterline, a rusted and lifted electrical outlet cover on the floor, a rusted electrical panel board exposing wires, a cluttered and poorly lit storage room, an unclean deli slicer, unlabeled bulk food storage containers, and a hand sink obstructed by a lidded 55-gallon trash can. The surveyor also observed unclean cooking equipment beneath the canopy hood, a convection oven not positioned under the hood, cracked floor tiles, a missing hood light bulb, unclean hood baffle filters, an unclean ice machine and ice scoop, an unclean coffee drip pan and floor sink, unclean walls, floors, and ceilings, cracked or chipped floor tiles and cove bases, a damaged rear entrance door jamb, and wall and ceiling penetrations near the food storage room. In the walk-in refrigerator and freezer, the surveyor found unclean fan covers, unlabeled food items, unclean shelving and door gaskets, a torn evaporator cover, ice buildup on opened food boxes, and ice buildup under shelving that prevented removal of a bag of ice on the floor. In the ware washing area, the dish machine was heavily soiled with dust, dirt, food particles, lime, and calcium buildup, with warped or torn curtains, rust and a mold-like substance on the wall, detached vent stacks, unsealed wall panel edges, rusted and unclean floor sink perimeters, undersized floor sink strainers with food debris, a broken stopper for the sanitizing vat, wet nesting of plate dome covers, and food and food contact equipment stored less than 10 inches off the floor. The surveyor also identified multiple nonfunctional items in the kitchen, including a stem thermometer, fountain soda dispenser, floor mixer, reach-in refrigerator, convection oven, Cadco food cart, paper towel dispenser, dishwasher booster heater, and hot water supply at the ware washing hand sink. On follow-up, the dish machine still had a nonfunctional final rinse gauge, leaking drain line, water spraying onto the floor, final rinse temperatures below 120 degrees Fahrenheit, and automatic shutoff during use; a chemical bottle was stored on the clean dish side, a wet rag was in the hand sink, and the ware washing room entrance door was in disrepair. The report also noted a non-commercial ice cooler in the nourishment room with a chipped, cracked, soiled, and broken lid, and slow cold-water pressure at the hand sink.
Essential Kitchen and Laundry Equipment Not Maintained in Working Condition
Penalty
Summary
Essential kitchen equipment was found not to be maintained in proper operating condition during the annual survey. During the initial kitchen tour, surveyors observed a nonfunctional two-door reach-in refrigerator, two steam thermometers that were not calibrated and did not register properly in ice water, a top-level convection oven that did not reach proper baking and cooking temperatures, one of three Cadco mobile food carts that was nonfunctional, an air handler with exposed ductwork draining condensation and grey water onto the kitchen floor, and a dishwasher that was in disrepair with a nonfunctional booster heater. A cloth drape was placed in front of the air handler to prevent grey water from spilling onto the kitchen floor. Surveyors later verified that the dishwasher had been switched from a high-temperature system to a low-temperature chemical dishwasher, but the final rinse temperatures measured during testing were below the manufacturer's required 120 degrees F. The final rinse temperature gauge on the dishwasher registered zero degrees F and was confirmed by staff to be nonfunctional. In the dining/activities room, food held on a Cadco mobile food cart was measured at 106 degrees F after lunch service, and the cart surface was cold to the touch, which staff confirmed suggested it may not have been connected to a power source during service. Laundry equipment was also found not to be functioning properly. Surveyors observed stained washcloths and a pillowcase coming out of the washing machine, and staff stated laundry aides were trained to rewash soiled laundry from the middle unit. The middle washing machine did not effectively clean linens, and staff reported that one washer had been out of order for several years while another dryer was not reaching required temperatures to properly dry linens. Service documentation stated the laundry machines' water temperatures must reach 140 degrees F with proper chemical dispensing, and surveyors measured wash temperatures below that level in two machines during testing.
Missing Required Annual GNA Training Documentation
Penalty
Summary
The facility failed to ensure Geriatric Nursing Assistants (GNAs) received the required 12 hours of yearly training. During interviews, the ADON stated the facility used a log and that the staffing coordinator completed it while HR kept track of hours, but the HR Director stated that HR only handled training for new hires and was not sure who was responsible for ensuring annual training was completed because that had always been handled on the clinical side. Record review showed missing documentation for multiple GNAs. GNA #34, hired on 07/03/24, had no documentation verifying 12 hours of required training in the past year, and GNA #35, hired on 05/29/08, also had no documentation verifying the required yearly training. Additional record review found GNA #39, hired on 05/05/21, had last documented competencies completed on 07/23/23, GNA #40’s record did not allow the surveyor to confirm what training was received upon hire, and GNA #41 had only one documented resident abuse inservice entry with no documentation of any other training.
Resident Council Meetings Not Held Regularly
Penalty
Summary
The facility failed to have resident council meetings regularly, as shown by the inability to provide resident council meeting minutes for January, February, March, and April 2025. During a resident council meeting with nine residents, the residents stated that meetings were not being held regularly until the Activities Director started working at the facility. The Activities Director stated that resident council meetings began in May 2025, and identified the first meeting as occurring on 05/08/25. The facility reported that meetings were scheduled for the second Thursday of every month in the first-floor dining room, but a review of the resident council binder found no meeting minutes or sign-in sheets for the months of January through April 2025.
Environmental Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment in multiple resident areas and the first-floor Nourishment Room. In one resident room, a resident complained of feeling cold, and the bathroom door was open with a cold breeze coming from the bathroom. The bathroom windowpane was broken, with clear tape on the broken part that did not adhere to the glass, allowing cold air to enter. The Administrator and the Regional Director of Nursing were shown the broken windowpane and acknowledged it was an issue, stating the maintenance man would cover it until the pane could be replaced. Additional environmental concerns were identified in other resident and common areas. In one resident room, water-damaged floor panels were lifted and buckled in front of the wall-mounted HVAC unit. In another resident room, multiple holes were observed on the wall near the headboards, laminated floor panels behind the toilet were lifted, the toilet flange bolt was excessively rusted and protruding, and the sliding closet door had fallen off the track and was impeding access to the closet. In the Nourishment Room, cabinet doors were missing, cabinet interiors were unclean and unsanitary, multiple floor panels were cracked, a residential refrigerator was unclean with torn door gaskets, and an inoperable commercial refrigerator was present.
Failure to Post Complete Daily Staffing Hours
Penalty
Summary
The facility failed to record the actual hours worked by categories of licensed and unlicensed nursing staff each shift on the posted daily staffing sheets. During the recertification survey, review of staffing sheets on 01/21/26, 01/22/26, and 01/23/26 showed they did not include the total number of licensed and unlicensed nursing staff providing direct nursing care each shift. In an interview, Staffing Scheduler #26 stated they were not aware the posted daily schedule had to include the facility name, date, census, and the total number of actual hours worked by licensed and unlicensed staff who provide resident care, and said they only write the HPPD while the supervisor does not update it with the numbers. The surveyor and scheduler then reviewed staffing sheets on the Main, [NAME], [NAME], and Joppa units, which were present but did not include the number of hours the licensed and unlicensed personnel were scheduled to work each shift. Additional staffing sheets dated 12/25/25, 01/03/26, 01/17/26, and 01/18/26 also did not document the total number of working hours of licensed and unlicensed personnel every shift.
Oxygen concentrator components were not dated as ordered
Penalty
Summary
The facility failed to ensure appropriate infection control practices during the maintenance of oxygen concentrators for 2 of 2 residents reviewed who used oxygen concentrators. During the initial resident screening, the humidifier bottle and oxygen delivery tubing were observed without the date they had been installed for Residents #67 and #89. Medical record review showed that both residents had provider orders directing staff on the amount of oxygen to be delivered and requiring the humidifier bottle and oxygen delivery tubing to be changed weekly, with the date of those changes labeled on the bottle and tubing.
Inoperable and Missing Ventilation Systems
Penalty
Summary
The facility failed to maintain clean and operational ventilation systems, affecting 2 of 2 janitors' closets, 2 of 2 utility closets, 2 of 2 residents' toilet and shower rooms, and the mechanical dishwasher ventilation systems reviewed during the annual survey. During an initial kitchen tour with Staff #6, the surveyor found that the exhaust system in the kitchen janitor's closet, which was also used to store cleaning chemicals, was inoperable. The Maintenance Director was notified of the concern and stated the exhaust fan would be repaired or replaced promptly. On a later tour with the Maintenance Director, the surveyor observed that the Main Street unit soiled utility closet lacked an exhaust system, the [NAME] unit soiled utility closet's exhaust system was inoperable, the Jappa unit janitor's closet was in disrepair and not in use with an inoperable exhaust system, and the second-floor residents' toilet/shower room near room [ROOM NUMBER] was inoperable. In the second-floor shared toilet room near room [ROOM NUMBER], the motor was making a loud grinding noise. In addition, the Ecolab technician confirmed that the mechanical dishwasher service did not include the dishwasher ventilation system, and both the technician and Staff #6 observed steam and vapors escaping from both ends of the unit and dispersing throughout the kitchen area.
Failure to Develop Person-Centered Care Plans for Diabetes and Post-Surgical Wound
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered care plans addressing all identified diagnoses and conditions for two residents. For one resident with a documented diagnosis of Type 2 Diabetes Mellitus, medical record review showed an onset date of 10/5/2017 and a MAR order to check blood sugar three times a week. Despite this established diagnosis and ongoing blood sugar monitoring, there was no corresponding care plan for Diabetes Mellitus. The DON confirmed that a care plan for this diagnosis could not be provided because it had not been completed and acknowledged that not having a care plan developed and updated based on the resident’s diagnosis and change in condition was an issue. The second resident was admitted status post surgical repair of the left femur, with a surgical site described as having Steri-strips and bruising per provider note. Review of the EHR showed that a person-centered care plan had not been initiated to address care of the surgical site, even though the resident was admitted with this condition and was being seen by the wound team for the surgical site. During interview, the DON stated that this resident should have had a care plan initiated for the surgical site. Staff interviews also clarified that the admitting nurse is responsible for the baseline care plan and that UMs are responsible for updating care plans based on the MDS, diagnoses, and any change in condition, but these processes did not result in care plans for the identified conditions for these two residents.
Failure to Document Ordered Pedal Pulses and Abdominal Girth Measurements
Penalty
Summary
Surveyors identified a deficiency involving the facility’s failure to ensure that ordered clinical assessments were properly documented and available for provider review for one resident with severe bilateral foot and ankle edema. The resident’s medical record showed a provider order, dated 11/13/2025, for pedal pulses to be taken every shift and documented as positive or negative, and another order, dated 9/24/2025, for weekly abdominal girth measurements. Although the Task Administration Record (TAR) indicated that these tasks were marked as completed, there were no actual pedal pulse findings or abdominal girth measurements recorded in the TAR, the resident’s chart, or any other communication to the provider. During interviews, the DON reported that the provider had failed to initiate the supplemental data command in the PCC electronic medical record, leaving nursing staff without a designated place to enter the measurements, and an employee confirmed there was no separate location on the unit to record this data. The DON was unable to explain why, over approximately two months for pedal pulses and four months for abdominal girth measurements, neither nursing staff nor the provider took action to correct the documentation issue or establish a means for recording the ordered measurements. These findings show that the facility did not provide treatment and care according to the physician’s orders, as the required assessment data for pedal pulses and abdominal girth was not documented or communicated to the provider despite the presence of active orders and indications in the TAR that the tasks had been completed.
Missing Order and Notification Parameters for Blood Glucose Monitoring
Penalty
Summary
The nursing facility failed to obtain an order for blood glucose monitoring and failed to obtain parameters for when the physician should be contacted for Resident #103, whose electronic health record showed glucose checks were being performed at least twice daily since admission. The resident had a history of Diabetes Mellitus Type I, but the record did not contain an order for glucose readings or notification parameters. During interview, the DON acknowledged that glucose was being monitored without an order or parameters for when the physician should be notified, and stated that an order should have been written with parameters in place. On follow-up, the surveyor did not receive documentation showing that an order had been written with parameters for notifying the physician or nurse practitioner.
CNA Worked Without Required GNA Certification
Penalty
Summary
The facility failed to ensure that a CNA received GNA certification within 4 months of hire. During record review, the surveyor requested documentation showing when each CNA received GNA certification and learned that CNA #32 was hired on 06/27/25 but did not have a GNA certification. In an interview, the HRD stated they believed CNAs were allowed four months before obtaining GNA certification, and the surveyor identified that the certification should have been obtained by 10/27/25. The Maryland Board of Nursing website confirmed that CNA #32 did not have a GNA certification, although the employee had an initial certificate issued on 05/07/24 with an expiration date of 01/28/27. The surveyor later reviewed staffing sheets for Main Street and found that CNA #32 had recently worked multiple shifts, including 01/21/26, 01/22/26, 01/23/26, and 01/26/26, after the surveyor had already reported the missing GNA certification. During an interview, the DON confirmed that CNA #32 was on vacation at the time of the discussion. Another GNA stated that staff on Main Street provide the same type of care, including ADL care, toileting, feeding assistance, dressing, and use of a Hoyer lift as needed, with only the residents assigned differing between staff.
Loose Medications Found in Medication Cart Drawer
Penalty
Summary
Medication storage was not maintained in accordance with accepted professional principles when surveyors found a large number of different medication tablets and capsules loose in the bottom of a medication cart drawer during the annual recertification review. This was identified in 1 of 3 medication carts reviewed. The surveyor removed 52 tablets and capsules from the drawer in the presence of an employee who was administering medications at the time and then informed the DON and another employee of the loose medications found in the cart drawer.
Delayed Wound Culture Processing and Follow-Up
Penalty
Summary
The facility failed to obtain and process a diagnostic wound culture in a timely manner for Resident #106, who had a sacral wound that had reopened and later measured 8.5 cm x 8.5 cm. The resident was being followed by a wound practitioner, and on 7/21/2025 the practitioner documented that the wound had improved, debridement was performed, and a wound culture was collected while the resident was taking antibiotic pills at the facility. Medical record review showed that the wound culture was rejected because it was collected in the wrong tube, and the lab notified an LPN that the specimen was discarded. When the DON was asked for documentation showing that the practitioner or physician was notified of the rejected culture and what action was taken, no documentation was provided. The resident was later sent to the hospital for further evaluation of the sacral wound and was admitted with SIRS related to an infected stage 4 wound and sacral osteomyelitis; hospital cultures grew pseudomonas, Acinetobacter, and Corynebacterium, and the resident was treated with IV antibiotics.
Meals Served Cold, Unappetizing, and Frequently Replaced
Penalty
Summary
The facility failed to ensure that meals were palatable, attractive, appetizing, adequately portioned, and served at preferred temperatures. Resident #48 reported ongoing concerns that the food served was unappetizing and frequently cold. When lunch was delivered to the resident’s room, the meal ticket showed a double portion of Stir-Fried [NAME] with Chicken, but the resident described the food as cold and spicy, noted that it had a watery consistency, and requested a substitution of a double portion of turkey burgers. Staff #9 explained that a regular portion was one ice cream scoop and a double portion was two ice cream scoops, and also stated that Resident #48 had a history of returning meals and requesting substitutions. During breakfast observation on the second floor, 7 returned plates were noted, including 2 residents who declined breakfast and 5 residents who requested substitutions. Test tray temperatures recorded at that time showed oatmeal at 168 degrees Fahrenheit, pureed scrambled eggs at 155 degrees Fahrenheit, pureed bread at 120 degrees Fahrenheit, and egg and cheese bake at 110 degrees Fahrenheit. During lunch observation in the first-floor dining/activities room, 5 returned plates were observed, including 2 residents who refused lunch and 3 residents who requested substitutions, and 7 residents ultimately received substitutions because the kitchen had run out of the main course. Staff #6 stated that meal substitution requests could be completed by the GNA or other staff members up to two hours before mealtime.
Improper Dumpster Placement and Debris at Loading Dock
Penalty
Summary
The facility failed to ensure the exterior dumpster was appropriately located and maintained to prevent the harborage and infestation of pests and insects. During observation, the exterior dumpster was seen positioned at the loading dock, and staff were interviewed about its placement. The surveyor and the Maintenance Director then went to the rear kitchen entrance area and found a piece of 4-inch by 12-inch plywood next to the door; the Maintenance Director acknowledged it may have been used to prop open the rear kitchen door during food deliveries and/or trash removal. Continuing down the loading dock staircase to the dumpster area, they observed trash and debris scattered around the dumpster location.
Missing Bathroom Call Bell Cords
Penalty
Summary
The facility failed to ensure that a working call bell system was accessible in residents' bathrooms and bathing areas. During the annual survey, the surveyor observed that the call bell cord was missing from Resident #1's restroom, and later observed that the call bell cords were missing from the restrooms of Residents #44 and #109 on the [NAME] unit during a tour with the Maintenance Director. The report states that 3 of 3 residents' toilet facilities reviewed had missing call bell cords, and the Maintenance Director acknowledged the missing cords for Residents #1, #44, and #109.
Pest Control Program Failed to Maintain Rodent-Free Environment
Penalty
Summary
The facility failed to maintain a rodent- and insect-free environment in 2 resident rooms and the conference room. Resident #48 stated that a rodent had been seen in the resident's room, and Resident #39 acknowledged that the room condition was conducive to pest harborage and confirmed that a rodent had been observed in the room. A review of Resident #39's care plan, updated on 9/3/2025, showed that staff had encouraged and educated the resident on the importance of keeping the room clean and clutter-free. During an interview, the Administrator explained that staff had provided containers to organize the resident's belongings, but the resident had consistently declined housekeeping services to enter and remove items from the room. The surveyor also observed a rodent running across the conference room and exiting through the space at the bottom of the door. Pest control service reports showed ongoing pest and insect control services for rodents, bedbugs, and cockroaches, and the Administrator and Maintenance Director acknowledged factors that attract pests, including warehouse boxes, propped-open doors, unsealed wall and ceiling penetrations, and the dumpster being located about 3 feet from the kitchen's rear entrance doors.
Inadequate Supply of Clean, Well-Maintained Linen
Penalty
Summary
The facility failed to provide an adequate supply of clean, well-maintained linen to meet the needs of its residents. Multiple residents reported complaints regarding the lack of sufficient and well-maintained linen, with observations confirming that linen carts on all units were inadequately stocked and contained discolored, threadbare items. Staff interviews corroborated these findings, with a laundry technician confirming that the available linen was insufficient and in poor condition. The technician also noted that the situation had deteriorated compared to previous management. Further investigation revealed that the Environmental Services (EVS) Supervisor was allocated a limited monthly budget for linen replacement and had not received additional funds from facility administration despite requests. The EVS Supervisor confirmed ongoing communication with their supervisor about the linen shortage but was instructed to follow administration's guidance. Facility leadership acknowledged the deficiency when interviewed by the survey team, confirming the lack of adequate, well-maintained linen for residents.
Failure to Maintain Adequate Supply of Clean, Well-Maintained Linen
Penalty
Summary
The facility failed to provide an adequate supply of clean, well-maintained linen to meet the needs of its residents. Multiple residents reported complaints regarding the lack of available and well-maintained linen, with some stating that the linen provided was in poor condition, discolored, and threadbare. Observations by the survey team confirmed that linen carts on all units were insufficiently stocked and the available linen was not in acceptable condition. Interviews with staff, including a laundry technician and the EVS Supervisor, corroborated the shortage and poor quality of linen, with staff indicating that they had to work with the limited and substandard supplies available. The EVS Supervisor reported receiving a fixed monthly budget for linen replacement from an external service provider, with the expectation that the facility would provide additional funds as needed. However, the supervisor stated that no additional funds had been provided by the facility administration during their tenure, despite requests. The issue was acknowledged by both the facility's administration and district management during interviews, confirming the ongoing deficiency in maintaining an adequate and well-maintained linen supply for residents.
Failure to Provide Written Notice of Room Change
Penalty
Summary
A deficiency occurred when a resident was moved from one room to another without receiving written notice of the room change, including the reason for the change, as required. Medical record review showed that the resident had been residing in the same room and bed for several months, with the electronic medical record (EMR) still reflecting the original room assignment. Observations confirmed that the resident was no longer in the documented room, and another resident reported that the individual had moved to the adjacent room. Staff confirmed the resident's new location, but there was no documentation in the EMR indicating that the resident or their representative had been notified in writing prior to the move, nor was there evidence that the move was requested by the resident. Further interviews with staff revealed that the room change likely occurred over a specific period, but the nursing home administrator was unaware of the move until informed by the surveyor. The administrator and staff confirmed that the resident was residing in a different room than what was documented, and acknowledged the lack of written notification or documentation regarding the change. The deficiency was identified during a complaint survey and was evident for one resident reviewed for a facility-reported incident.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by numerous deficiencies observed during the survey. In several rooms, there were issues such as chipped wood on door frames, lifting floor tiles, stained and dirty flooring, and damaged furniture. Additionally, there were reports of inadequate housekeeping services, with food found under beds and personal belongings improperly stored in shared closets. These conditions were confirmed through observations and interviews with residents and staff, highlighting a lack of adequate maintenance and housekeeping services. Further observations revealed significant maintenance issues throughout the facility. Toilets were improperly installed on wooden blocks, creating potential hazards, and some were loose with cracked lids. The carpet on the second floor was heavily soiled, and residents in wheelchairs were seen moving through the dirt. In one instance, a resident reported a broken faucet handle, preventing the use of cold water, which was later repaired. The facility's maintenance system appeared inadequate, with the Assistant Maintenance Director noting the absence of a Director of Maintenance and reliance on informal communication methods to address issues. The survey also identified problems with the storage of residents' personal items, with some rooms lacking sufficient space and organization for clothing and belongings. Residents' rooms were observed with peeling paint, missing floor tiles, and exposed cords, indicating a lack of regular maintenance checks. Interviews with staff revealed that the facility was understaffed in both housekeeping and maintenance departments, contributing to the ongoing issues. These deficiencies were acknowledged by the facility's administration during the exit conference, but no specific corrective actions were detailed in the report.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility failed to maintain appropriate temperature monitoring for the medication refrigerator, as evidenced by the absence of documentation in the temperature log from 07/28/24 to 07/29/24. Additionally, expired medications were found in the second-floor medication storage room, including adhesive remover wipes, self-adhesive fabric, and fluocinonide ointment. These items were not properly discarded, indicating a lapse in the facility's protocol for handling expired medications. Furthermore, the surveyors observed improper labeling and storage of medications. In the treatment cart, several opened medications were undated, and one ointment had a resident's name altered with a black marker. On the first floor, a new unopened Lantus insulin pen was improperly stored with opened pens instead of being refrigerated. The Assistant Director of Nursing confirmed the lapses in protocol, acknowledging that house-stocked medications should be dated upon opening and used within 30 days, and that unopened insulin pens should be refrigerated.
Medication Administration Deficiency
Penalty
Summary
The facility staff failed to adhere to professional standards of nursing practice in administering medications to residents, as evidenced by the medication administration audit record (MAAR) review. For Resident #9, there were multiple instances where the 9:00 am dosage of Methadone was not signed off as administered until significantly later, ranging from over an hour to several hours past the scheduled time. This discrepancy was confirmed during an interview with an LPN, who admitted to not signing off medications immediately after administration, despite the standard practice of administering medication within one hour before or after the scheduled time. Similarly, for Resident #88, the MAAR review revealed that medications were signed off as given one hour or more past the prescribed time on over 85 occasions between March and April. Interviews with the ADON, a CMA, and an LPN indicated that while medications were reportedly given on time, they were often signed off late due to staff assisting with other tasks, such as meal service. The standard practice of signing off medications immediately after administration was not consistently followed, contributing to the deficiency.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold residents' rights to dignity and privacy, as evidenced by two main deficiencies. Firstly, a resident with a foley catheter bag had their drainage bag uncovered, with the amber-colored liquid visible from the hallway due to the open door. This was observed during a surveyor's rounds, and the Unit Manager LPN confirmed that foley bags should be covered, indicating a lapse in maintaining the resident's dignity and privacy. Secondly, the facility did not ensure that residents' clothing was properly stored. During observation rounds, it was noted that 30 out of 33 residents had their clothing in trash bags, boxes, or stacked in armoires, rather than being hung up or put away in drawers. Interviews with the ADON and the facility's Administrator revealed that there was a lack of hangers available for residents' use, and the GNAs were not following the process of hanging or folding the clothing properly. This oversight further contributed to the failure in maintaining residents' dignity.
Inaccessible Call Bells for Residents
Penalty
Summary
The facility staff failed to ensure that residents had their call bells readily accessible when assistance was required, affecting three residents. Resident #11 was observed in bed with a torn diaper and without a call bell, which was found attached to their roommate's bed. The Unit Manager confirmed that each resident should have their own call bell but could not explain why both call bells were with the roommate. Additionally, Residents #13 and #14 were found with their call bells on the floor, making them inaccessible. Geriatric Nursing Assistant #9 confirmed the call bells were on the floor and was in the process of providing assistance to the residents.
Failure to Interview Resident in Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation of an abuse allegation involving a resident. On May 26, 2024, a resident reported to the Nursing Home Administrator (NHA) that their assigned Geriatric Nursing Assistant (GNA) allegedly threw a cup of water in their face. The facility's investigation included interviews with the alleged perpetrator, another GNA, and the nursing supervisor of the involved staff members. However, the investigation did not include an interview with the alleged victim, despite the resident having an intact cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview on July 30, 2024, the NHA acknowledged that a thorough investigation should have included a statement from the resident. This oversight was confirmed by the NHA, who admitted that the resident's account was missing from the investigation documentation.
Failure to Complete Baseline Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to complete a baseline care plan for a resident admitted with a stage four pressure ulcer. This deficiency was identified during the facility's annual survey, where it was found that the baseline care plan for the resident, who was admitted in March 2024, did not include any interventions for the pressure ulcer on the left buttock. A baseline care plan is crucial as it serves as a written guideline of care based on the individual resident's needs and is developed by an interdisciplinary team. Interviews with facility staff, including the Regional Nurse and the Assistant Director of Nursing (ADON), revealed that they were unable to provide a completed baseline care plan for the resident's pressure ulcer. The absence of a care plan was confirmed during a medical record review conducted on July 22, 2024. The lack of a completed care plan indicates a failure to meet the requirement of having a baseline care plan in place within 48 hours of the resident's admission.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident #98 was admitted with a stage 4 pressure ulcer on the left buttock, but a review of the medical records revealed no comprehensive care plan addressing this condition. Despite several treatment order changes documented in the Treatment Administration Record, the necessary care plan was not found. Interviews with the Regional Nurse and the Assistant Director of Nursing confirmed the absence of a care plan for the pressure ulcer, and by the time of the survey exit, the resident still lacked a plan of care for this critical condition. Similarly, Resident #88 was prescribed psychotropic medications, yet there was no comprehensive, patient-centered care plan for their administration. The surveyor's review of the medication administration record and electronic medical record confirmed this oversight. During an interview, the Assistant Director of Nursing acknowledged that residents on psychotropic medications should have a care plan, but none was in place for this resident. These findings highlight the facility's failure to ensure that care plans were developed and implemented for residents with specific medical needs.
Failure to Reassess Elevated Blood Pressure
Penalty
Summary
The facility staff failed to reassess a resident's blood pressure (BP) when it was outside of the resident's usual parameters. On 07/23/24 at 10:07 pm, the resident's BP was recorded as 180/92, which was elevated. However, no follow-up BP was documented after this abnormal reading. The resident was prescribed Hydralazine 100 mg at 10 pm, and the medication was administered as ordered. The resident's care plan for coronary heart disease required that medication for hypertension be given as ordered and the response to the medication be documented. Despite this, there was no documentation of a follow-up BP or a clinical note in the electronic medical record (EMR) or paper chart. The Director of Nursing (DON) was informed of the elevated BP and the lack of follow-up documentation. It was noted that the Certified Medication Aide (CMA) should have notified the nurse of the elevated BP, and the nurse should have retaken the BP and reported the findings to the physician. The follow-up BP was eventually taken over 12 hours later, with results of 144/80 and 142/78, indicating a delay in reassessment and documentation.
Failure to Implement Ordered Treatment for Urinary Incontinence
Penalty
Summary
The facility failed to implement the ordered treatment for a resident with urinary incontinence. During observation rounds, a resident was found sitting in the hallway with a Foley bag that was filled to the top with yellow-colored fluid and had a large piece of tape attached to it. The resident reported that the Foley bag had a hole, and instead of changing it, the nurse had taped it. A review of the medical record revealed a physician's order to change the catheter/Foley bag when needed and to empty the Foley drainage bag at least once every eight hours or when it becomes half to 2/3 full. The Director of Nursing (DON) was informed of the findings, and during a follow-up interview, it was revealed that staff was aware of the full and possibly leaking catheter but was occupied with passing out medications. The staffing schedule indicated that a Unit Manager was also assigned to the unit.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility staff failed to provide necessary respiratory care services for a resident by not properly labeling oxygen administration equipment and not administering oxygen as prescribed. During observations, the resident was receiving oxygen at a flow rate of 4.25 to 4.5 liters per minute, which was not in accordance with the physician's order of 2 to 3 liters per minute. The oxygen tubing was found to be labeled with a date from nearly two months prior, and the humidifier bottle was not labeled at all. Interviews with the LPN and ADON revealed that the facility's policy required oxygen tubing to be changed weekly and labeled with the date and initials, which was not adhered to in this case. The resident's medical record showed conflicting orders for oxygen administration, with an outdated order from June still active alongside a more recent order from November. The ADON acknowledged that the older order should have been discontinued but could not explain why it remained active. The facility's policy on oxygen administration emphasized the need for adherence to physician orders and proper labeling of equipment, which was not followed, leading to the deficiency observed by the surveyor.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to respond to pharmacy recommendations after a monthly clinical review, and did not ensure that the attending physician reviewed these recommendations. This deficiency was identified for two residents during the survey. For one resident, the pharmacist recommended clarifying the frequency of a medication used for constipation, but there was no documented response from the facility. The Assistant Director of Nursing (ADON) was unable to provide any response documentation and had to contact the Nurse Practitioner and the resident's primary physician to address the issue belatedly. For another resident, the ADON was initially unable to provide the pharmacy reviews and later presented them unsigned, indicating that the physician had not reviewed them. The pharmacy recommendations highlighted issues such as duplicate medication therapy and improper use of pain patches, as well as missing blood work. Despite these recommendations, no changes were made to the resident's medication regimen, and the ADON was uncertain if the recommendations had been addressed.
Failure to Respond to Pharmacy Recommendations for PRN Anxiolytic
Penalty
Summary
The facility failed to respond to pharmacy recommendations regarding the use of unnecessary medications for a resident. During the facility's annual survey, it was found that a resident had a PRN order for an anxiolytic medication, Diazepam, without a stop date. The Consultant Pharmacist had recommended discontinuing the PRN Diazepam or documenting the indication for its use, the intended duration of therapy, and the rationale for the extended period. However, there was no response from the facility to these recommendations. The Assistant Director of Nursing (ADON) was unable to provide any documentation of the facility's response to the pharmacy review and had to contact the Psychiatric Nurse Practitioner and the resident's primary physician to address the issue.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure sanitary practices in food service safety, maintain a clean working environment, and manage food storage properly. During an initial observation of the kitchen, the surveyor found that dry cereal bins lacked expiration dates, and a can of pears was expired. The kitchen ovens were observed to be brown, greasy, and dirty, and there was no cleaning schedule available. Additionally, the dishwashing area was unkempt, with food particles and a cigarette butt present. Staff acknowledged the issues but did not provide a cleaning schedule. Further observations revealed that nourishment rooms in two clinical units had food items without labels or expiration dates, and a refrigerator was found to be at an unsafe temperature of 52 degrees. A resident's food item was noted to be over three days old. The facility administrator stated that he does not directly supervise the contracted kitchen staff but would address issues if they arise. These deficiencies were discussed with the administrative staff during the exit interview.
Misappropriation of Resident Funds
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their funds. During a survey, it was discovered that $1000.00 was withdrawn from the account of a resident without their permission. The Administrator explained that the facility conducts a care cost spend down if a resident's account exceeds $2500.00, but there was no documentation supporting that the resident owed any money to the facility. Furthermore, the Administrator could not provide an explanation or documentation for the withdrawal of $800.00 from the resident's account, although he did present a returned check for the same amount to the resident. This incident was discussed with the Administration team during the survey exit meeting.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required two-hour timeframe to the Survey Agency, the Office of Health Care Quality (OHCQ). In the first incident, an allegation of inappropriate sexual relations between two residents occurred, and the facility's documentation showed that the administrator did not submit the initial report to OHCQ until over four hours after the incident. During an interview, both the Director of Nursing (DON) and the administrator acknowledged their awareness of the reporting requirements but could not provide a reason for the delay other than the incident occurring on a weekend. In the second incident, a resident reported being struck by their assigned GNA. The facility's investigation revealed that the Shift Supervisor was notified of the incident in the morning, but the initial report to the state agency was not submitted until late afternoon, well beyond the two-hour requirement. The DON confirmed the reporting timeframe during an interview and noted that the resident's representative was notified shortly after the incident, but the report to OHCQ was delayed.
Inaccurate Documentation of Resident's Weight
Penalty
Summary
The facility failed to ensure that a resident's medical records were accurately documented in accordance with accepted professional standards. This deficiency was identified during a survey when the surveyors reviewed the medical records of a resident who had reportedly lost weight. The resident's daughter mentioned the weight loss during an interview, prompting the surveyors to examine the Minimum Data Set (MDS) assessment and the Electronic Health Record (EHR) for the resident. The MDS assessment indicated a significant weight loss, and upon reviewing the EHR, surveyors found discrepancies in the recorded weights over a short period. The discrepancies included a rapid and unlikely weight loss of approximately 12 pounds in one day, with weights recorded using different types of scales, such as a standing scale, mechanical lift, Hoyer lift, and a wheelchair scale. The Director of Nursing (DON) acknowledged the inconsistency and attributed it to a documentation error by a registered nurse, which the facility failed to correct. The dietician's note also highlighted a weight warning and the need for a reweigh, but no follow-up notes were found addressing the discrepancy.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by observations of unsanitary conditions and improper handling of medications. On one occasion, food resembling meatballs was found on the floor in the Atrium near the dining room, with splatters noted on the baseboards. The Administrator was informed and housekeeping services were called to clean the area. Additionally, a hallway leading to the laundry area and kitchen was observed to be dirty, with trash on the floor and large dark marks. A clean linen cart was left uncovered in the hallway, and a fan was blowing air, causing trash and particles to circulate. The Administrator was again informed of the issue. In another instance, an LPN was observed handling a medication capsule with bare hands, without wearing gloves, while administering Gabapentin to a resident. The LPN acknowledged that it was not appropriate to handle medications without gloves, despite claiming to have washed his hands. The Assistant Director of Nursing confirmed that it is never appropriate for staff to handle medications without gloves. The facility's policy on medication administration explicitly states that care should be taken not to touch medication with bare hands.
Deficiency in Maintaining Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment for its residents, as evidenced by the condition of air conditioning (AC) units in several resident rooms. During a survey, it was observed that AC units in rooms #121, #123, #124, and #126 had dust, dirt, and debris on the front and inside the screen filters. Additionally, a tan/brown substance was noted on the AC unit in another room, and the unit in room #219 also had dust, dirt, and debris inside. These observations were made during a tour of the building, and the facility's maintenance logs were found to be incomplete, with missing records for February, March, and June 2024. The Administrator and Director of Nursing were informed of these findings, and the Maintenance Assistant was summoned to assess the situation. The Administrator confirmed the issues and acknowledged the need for cleaning the AC units. Despite the facility's claim of conducting monthly maintenance on the AC units, the lack of comprehensive maintenance logs suggests a failure in maintaining the physical environment of the residents' rooms. This deficiency was discussed with the administration team at the time of the survey exit.
Pest Control Deficiency Due to Flies and Fruit Flies
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies and fruit flies throughout the building during a survey. Observations were made of flies in the conference room on multiple dates, and in resident rooms and hallways on July 25, 2024. The Administrator and Director of Nursing were informed of these findings, and the Administrator confirmed the presence of flies. A review of the pest control service summary report revealed an invoice for general pest control maintenance on July 24, 2024, and noted standing water in the main kitchen on June 17, 2024, which was conducive to small fly activity. Standing water was again observed in the kitchen on July 30, 2024, near resident rooms and the conference room where flies were present. During the survey, multiple observations of flies and fruit flies were made throughout the building. On the first day of the survey, surveyors noted flies and fruit flies in a facility room, including in a resident's room where they were seen circling and landing on the resident and their bedside table. A sticky paper with dead flies was also observed near the resident's bed. The Nursing Home Administrator was informed of the issue on July 19, 2024, and again on July 31, 2024. The Administrator acknowledged the problem and mentioned that the resident's behaviors might contribute to the issue, but stated he would investigate further.
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What surveyors actually found near you
We read the 1,636 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near 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 Homewood | 0.2 mi | ★★★★★ | 12 | 0 |
| Holly Hill Healthcare Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Complete Care At Multi Medical Center Llc | 1.6 mi | ★★★★★ | 13 | 0 |
| Roland Park Rehabilitation And Healthcare Center | 1.9 mi | ★★★★★ | 9 | 1 |
| Good Samaritan Nursing Home Operator, Llc | 2 mi | ★★★★★ | 4 | 0 |
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