Autumn Lake Healthcare At Overlea
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 6116 Belair Road, Baltimore, Maryland 21206
- CMS Provider Number
- 215209
- Inspections on file
- 20
- Latest survey
- October 22, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Overlea during CMS and state inspections, most recent first.
Facility staff did not ensure that handrails on the third floor were properly repaired and safe for use, as multiple handrails were found with protruding screws and nails, gaps, holes, and loose attachments. These issues were observed in several locations, including near the elevator, outside resident rooms, and between storage areas, with some handrails shaking when touched. The Administrator acknowledged the problem after it was reported by a surveyor.
Two residents with suprapubic catheters did not receive care according to specialist recommendations, including routine flushing and timely catheter changes. Documentation was lacking for both catheter flushes and exchanges over several months, and staff interviews confirmed these lapses. Communication issues with consulting providers and inaccurate information given to a resident's representative further contributed to the deficiency.
Surveyors identified that two residents with suprapubic catheters did not have complete or consistent documentation of catheter changes in their medical records, despite orders and urology consult recommendations for routine exchanges. The DON confirmed that documentation was missing for several months, and staff interviews revealed inconsistent communication and documentation practices between the facility and consulting providers.
Staff did not ensure that two shower rooms on the third floor were properly cleaned, as evidenced by persistent stains and soiling observed over two days. The rooms are used daily by residents, and cleaning was not performed as required, with staff acknowledging challenges in cleaning due to inadequate equipment.
Facility staff did not allow residents whose funds were managed by the facility to access their money outside of normal business hours, with no access available on weekends. This affected 94 residents with open accounts, as confirmed by the Business Office Manager.
Surveyors identified multiple deficiencies in food service sanitation, including failure to achieve proper dish sanitization temperatures, excessive buildup of food debris and grease on equipment, improper placement of trashcans near ice machines, unsanitary storage of beverage dispensers, and visibly soiled portable ice chest coolers and knife holders. Maintenance staff could not verify inspection or replacement of backflow prevention devices, and cleaning schedules for certain equipment were not provided.
Staff failed to label basins and urinals in shared bathrooms, leading to potential cross contamination, and did not maintain proper separation between clean and soiled linens in the laundry area due to damaged infrastructure and improper cleaning practices.
Surveyors observed that several residents did not have their call bells within reach, with some call bells found on the floor or on the opposite side of the room. A GNA confirmed the lack of accessible call bells, and the ADON stated that staff are expected to ensure call bells are always available, though they may sometimes fall and are checked during regular rounding.
Staff failed to conduct required annual performance reviews for several GNAs, as confirmed by personnel file review and staff interviews. Three employees who had been employed for over a year did not have documented yearly evaluations.
Surveyors found expired medication and multiple instances of loose, unidentified pills in medication carts and storage areas. Staff present were unable to account for the origin of the loose pills, and expired medication was confirmed during review. These findings indicate lapses in proper medication storage and labeling practices.
Surveyors observed multiple deficiencies in the facility's environment, including broken furniture, missing privacy curtains, non-functioning bathroom fixtures, and accumulation of trash under a resident's bed on repeated occasions. Staff confirmed these issues and described a maintenance reporting process involving binders and an electronic system, but the deficiencies persisted across several rooms and days.
A resident who was totally dependent for bathing did not receive scheduled showers over several weeks, as confirmed by documentation and family interviews. The resident only received bed baths and expressed discomfort and dissatisfaction, while the GNA task records showed no showers were provided during the period in question.
Two resident rooms were found to be dirty and in disrepair, with issues such as sticky floors, brown stains on bathroom walls, broken blinds, damaged ceiling tiles, and cracked flooring. Facility staff acknowledged these environmental concerns during surveyor interviews.
Staff did not create or implement care plans for dental care in two residents with poor dentition and failed to initiate an integumentary care plan for a resident receiving twice-daily skin treatments, as confirmed by record review and DON interview.
Staff failed to clarify a physician's order for a dermatologic cream, resulting in a resident with Atopic Dermatitis not receiving the prescribed treatment due to unclear instructions and the cream being unavailable. Another resident on psychotropic medication was not monitored for extrapyramidal side effects as recommended by pharmacy review, and a third resident did not receive all required iron-related lab monitoring despite provider acceptance of the pharmacist's recommendations. These deficiencies reflect failures in order clarification, treatment administration, and laboratory monitoring by nursing and pharmacy staff.
Staff did not follow up on a pharmacist's recommendation to specify the dosage for a prescribed supplement for a resident. The pharmacy review form was left unsigned, and the supplement order lacked a strength until a dose was added much later. An LPN also documented administering the supplement twice in one day, and the DON could not explain the lack of action on the recommendation.
The facility failed to document and investigate abuse allegations for four residents, with missing or incomplete investigations attributed to previous ownership. Incidents included verbal and physical abuse allegations, inappropriate touching, and incomplete documentation of alleged abuse by a GNA. The NHA was unable to locate necessary investigation files, highlighting issues with documentation during ownership transitions.
The facility failed to maintain complete and accurate medical records for several residents, including missing documentation from medical appointments, discharge details, and wound assessments. Additionally, care conferences were not documented following MDS assessments. The DON confirmed the absence of necessary documentation, indicating a failure to adhere to professional standards.
A resident was found on the floor with low oxygen saturation and required hospital transfer. Although the physician was notified and 911 was called, the resident's representative was not informed of the hospital transfer until several hours later. The facility administrator could not provide evidence of immediate notification.
The facility failed to timely report abuse allegations for two residents. In one case, a GNA allegedly abused a resident, but the report to OHCQ was delayed. In another case, a resident alleged physical abuse by a staff member, but local law enforcement was not contacted. The NHA confirmed the reporting delays and lack of evidence for police contact.
The facility failed to accurately code MDS assessments for two residents. One resident's MDS did not reflect their Hospice care status, while another resident's MDS inaccurately documented behavioral symptoms and medication use. The MDS coordinator confirmed these discrepancies during interviews.
A facility failed to revise a care plan for a resident with a history of banging their arm on the side rail, leading to skin tears. Despite placing padding on the side rail to prevent further injury, the intervention was not included in the care plan. The Director of Nursing confirmed the omission during an interview.
A facility failed to provide complete discharge documentation for a resident who was discharged to an assisted living facility. The medical record lacked a physician's discharge summary, medication instructions, and a summary for the receiving facility. Additionally, there was no nursing documentation regarding the resident's condition at discharge or the items and documentation provided to them and the receiving facility.
A resident with dementia, requiring assistance for bathing, did not receive the expected two showers per week over several months. Despite a care plan indicating the need for staff assistance, documentation showed inadequate showering frequency, with no recorded refusals by the resident. The DON confirmed the deficiency in meeting the showering schedule.
A resident with existing pressure ulcers developed new open areas on the sacrum and right buttocks, which were not assessed by the wound care physician for 24 days despite being documented by nursing staff. The delay in evaluation and treatment was confirmed by the DON, highlighting a deficiency in the care provided.
Two residents in the facility were administered Metoprolol outside of the physician-ordered parameters for blood pressure and heart rate. One resident received the medication twice when their heart rate and blood pressure were below the specified limits, while another resident was given the medication despite a low blood pressure reading. These actions were confirmed by the DON.
A resident with hydronephrosis did not receive a scheduled follow-up urology appointment due to insurance network issues, and no further attempts were made to reschedule. The resident's discharge plan included a urology follow-up and a voiding trial, neither of which were completed during their stay. The DON confirmed these findings.
Handrails Not Properly Secured and Maintained on Third Floor
Penalty
Summary
Facility staff failed to ensure that handrails on the third floor were properly repaired and safe for resident use. Multiple handrails were observed with screws and nails that were not flush with the surface, creating a potential for injury to residents' hands. Specific observations included handrails with protruding screws, a gap near the elevator, a nail sticking out, a hole in the handrail, and several areas where the handrails were loose or not secured to the wall. The handrail between the Storage Room and EVS Room was noted to shake with minimal pressure, and the handrail near the Central Supply Room was also loose with an unflushed screw. These deficiencies were widespread on the third floor and were confirmed through both observation and staff interview. The Administrator acknowledged the issue when informed by the surveyor, stating that attempts were being made to secure the handrails with screws, but the surveyor pointed out that the screws were not flush and posed a risk of injury.
Failure to Provide Proper Suprapubic Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper care and treatment for residents with suprapubic catheters, as evidenced by the lack of adherence to physician and specialist recommendations for catheter flushing and routine catheter changes. For one resident with a history of benign prostatic hyperplasia and urinary retention, medical records showed that urology and pelvic medicine specialists repeatedly recommended flushing the suprapubic catheter twice daily and exchanging the catheter every 4-6 weeks. However, documentation revealed significant lapses, including no record of catheter changes for several months and a prolonged period without ordered or documented flushes following a hospitalization. The care plan also indicated a need for monthly catheter changes, but there was no evidence these were performed as required. Interviews with the DON confirmed that there was no documentation of catheter flushes or changes during the specified periods, and that communication issues with multiple consulting providers contributed to the lack of consistent care. The DON acknowledged that catheter changes were expected to be performed by facility staff unless otherwise specified by the consulting provider, but could not provide records to support that these tasks were completed. The consulting provider also clarified that unless specifically documented, catheter changes were not performed by their team and were the responsibility of the facility per the resident's care plan. A second resident with a history of obstructive and reflux uropathy and overactive bladder also did not receive routine suprapubic catheter changes as ordered. The resident's medical record showed an order for catheter changes every four weeks, but this was discontinued and changed to 'as needed,' with no documentation of changes for several months. Urology consultation notes continued to recommend routine exchanges every 4-6 weeks, but there was no evidence these were carried out. Staff communication with the resident's representative incorrectly indicated that monthly changes were being performed by urology staff, despite a lack of supporting documentation.
Failure to Maintain Complete Medical Records for Suprapubic Catheter Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents with suprapubic catheters (SPC). For one resident with a history of benign prostatic hyperplasia and urinary retention, the facility was unable to provide medical health information to the hospital emergency room staff upon transfer. Review of the resident's records showed inconsistent documentation of SPC changes, with the last recorded change in December, and no documentation of changes from January through May, despite care plan and urology consult recommendations for routine exchanges every 4-6 weeks. The Director of Nursing (DON) confirmed that there was no documentation available to support that the SPC was changed during this period and indicated that different urology providers had varying communication methods, which contributed to the lack of documentation. For another resident with obstructive and reflux uropathy and an overactive bladder, the facility's records also lacked documentation of SPC changes as ordered. The resident had an order for SPC changes every four weeks, which was later changed to 'as needed.' However, there was no documentation in the Treatment Administration Records (TARs) of any SPC changes from January through July, despite ongoing urology consult notes recommending routine exchanges every 4-6 weeks. The DON was unable to provide documentation to confirm that the SPC was changed as recommended during this time frame. Interviews with facility staff and urology consultants revealed that while providers may have performed SPC changes during consultation visits, these were not consistently documented in the residents' medical records. The lack of documentation meant that the facility could not demonstrate compliance with physician orders or care plan interventions regarding SPC management for the affected residents.
Failure to Maintain Cleanliness in Shower Rooms
Penalty
Summary
Facility staff failed to ensure that the third-floor shower rooms were cleaned for resident use, as evidenced by observations and interviews during a complaint survey. On two consecutive days, surveyors observed large stains under the sink, water and stains around the commode in one shower room, and multiple round brown stains on the floor in front of the sink and in the shower stall of another shower room. The stains remained present on the second day, and a surveyor was able to remove one of the brown spots with a wet paper towel, indicating the area had not been properly cleaned. Geriatric Nursing Assistant (GNA) stated that the shower rooms are used daily by residents, and the Environmental Services (EVS) Director confirmed that showers should be cleaned daily, with deep cleaning on weekends, but noted difficulties in cleaning due to the condition of mop heads.
Residents Denied Access to Managed Funds Outside Business Hours
Penalty
Summary
Facility staff failed to ensure that residents whose funds were managed by the facility had access to their money at any time. During an interview, the Business Office Manager stated that residents could only access their funds during normal business hours, which are 8:30 AM to 5:00 PM, Monday through Friday, and that no one could access funds on weekends. Prior to the COVID-19 pandemic, the Receptionist would provide residents with money, including on weekends if present, but this practice had ceased. At the time of the survey, there were 94 open resident accounts with balances being managed by the facility, and none of these residents could access their funds outside of business hours.
Multiple Food Service Sanitation and Equipment Deficiencies Identified
Penalty
Summary
Facility staff failed to ensure that the high temperature dishwasher reached the required final rinse temperature of 180°F for proper sanitization, as observed during multiple cycles where temperatures only reached 162°F and 163°F. The dishwasher was also found to have excessive food debris and grease buildup both inside and outside the unit. Additionally, clean dish warming carts were observed to be visibly soiled, and the 3-compartment sink's sanitizing solution was found to be too strong, exceeding 400 ppm. The grease trap interceptor was unable to handle the flowrate of greywater discharge, resulting in overflow onto the kitchen floor. A trashcan was placed less than five inches from the ice machine and in front of a cracked wall-mounted ice scoop holder, and a beverage dispenser was stored in unsanitary conditions near a food prep area. The maintenance director was unable to verify that backflow prevention devices on various waterlines had been replaced or inspected by a licensed plumber. Surveyors also observed a visibly soiled, broken non-commercial portable ice chest cooler used for resident ice storage, placed on an unclean rolling cart, and noted that cleaning schedules for this equipment were not provided. Excessive buildup of dirt, dust, debris, and food spills was found on a wall-mounted knife holder. These findings were evident for all food service and kitchen equipment observed during the survey, indicating a failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety procedures.
Failure to Prevent Cross Contamination in Shared Bathrooms and Laundry Areas
Penalty
Summary
Facility staff failed to properly label residents' basins and urinals in shared bathrooms on the second floor, resulting in the potential for cross contamination of bodily fluids. During observation rounds, multiple unlabeled basins and a urinal were found in shared bathrooms between resident rooms. When questioned, a Geriatric Nursing Assistant stated that staff typically write room numbers on basins to identify ownership, but this was not done at the time of observation. The Assistant Director of Nursing/Infection Preventionist acknowledged the issue and indicated that it had been previously addressed with staff. Additionally, the facility did not ensure that clean linens were kept separate from contaminated linens in the laundry area. The dividing wall between the dirty and clean laundry rooms was damaged, with exposed wall frames and a gap caused by water damage. Grey water was observed splashing onto the drywall, saturating it and extending moisture to the ceiling. The washing machine drain line was improperly supported, and the washing machines themselves had significant residue buildup on both interior and exterior surfaces. Staff acknowledged the accumulation and the need for cleaning.
Failure to Ensure Call Bells Accessible to Residents
Penalty
Summary
Facility staff failed to ensure that residents had their call bells within reach to notify staff when assistance was needed. During observation rounds, five residents were found without accessible call bells: some had their call bells on the floor, while others had them placed out of reach on the opposite side of the room. These findings were confirmed by a Geriatric Nursing Assistant present during the observations. The Assistant Director of Nursing acknowledged that all residents should have their call bells accessible at all times, but noted that call bells can occasionally fall and that staff are expected to check on residents and their call bells during regular two-hour rounding.
Failure to Complete Annual Performance Reviews for GNAs
Penalty
Summary
Facility staff failed to conduct yearly performance reviews for Geriatric Nursing Assistants (GNAs) as required. During a review of five nursing assistant personnel files, it was found that three employees who had been employed for over a year did not have annual performance evaluations documented in their files. Interviews with the Assistant Director of Nursing, who was responsible for staff development, and the Nursing Home Administrator confirmed that annual evaluations for GNAs were not being completed. These findings were based on direct review of personnel files and staff interviews, with no evidence provided that the required yearly performance reviews had been performed for the identified staff members.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified that the facility failed to comply with professional standards for medication storage and labeling. On the 2nd floor, a blister pack of Famotidine 20 mg tablets was found to be expired, and this was confirmed by the LPN present. Additionally, on the 3rd floor, 11 loose pills were discovered in a medication cart, with the RN unable to specify their origin, only stating that they might have fallen out of packets. On the ground floor, 4 loose pills were also found in a medication cart, and the LPN present could not determine their source. In both instances of loose pills, staff indicated that such findings would be reported to the unit manager. These observations were made during reviews of medication storage areas and carts, and the deficiencies were confirmed through staff interviews and direct observation. No information about the medical history or condition of any residents was provided in the report.
Failure to Maintain Clean, Comfortable, and Home-like Environment
Penalty
Summary
Facility staff failed to consistently maintain a clean, comfortable, and home-like environment for residents, as evidenced by multiple observations during a recertification survey. Specific deficiencies included a clothing armoire door hanging off in a resident room, accumulation of trash such as empty bottles, snack packs, and tissues under a resident's bed on multiple days, a broken toilet paper dispenser, and a non-functioning light bulb in a shared bathroom. Additional issues noted were the absence of privacy curtains in a resident room, a loose faucet that could not be turned off, a missing drawer in a resident's dresser, and stains on the wall behind a commode. These conditions were confirmed by a GNA during the surveyor's rounds. Interviews with facility staff revealed that maintenance concerns are reported via binders on each unit, with urgent issues communicated directly to the Maintenance Director. However, staff do not determine what constitutes an urgent issue and simply document all concerns in the binder. The Maintenance Director stated that room audits are conducted based on identified issues, with a goal of auditing one room daily and every resident's room quarterly. Maintenance issues are addressed by the maintenance assistant, and staff use both binders and an electronic system (TELS) to report problems. Despite these processes, the observed deficiencies indicate lapses in maintaining a safe and comfortable environment.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
Facility staff failed to provide adequate personal hygiene care to a dependent resident by not offering or providing scheduled showers. The resident, who is totally dependent for bathing and requires extensive assistance for all activities of daily living as documented in the Minimum Data Set (MDS), did not receive any showers between 3/25/2025 and 4/18/2025, despite being scheduled for showers every Tuesday and Friday. This was confirmed through review of the Geriatric Nursing Assistant (GNA) task documentation on the Task Administration Record (TAR), which showed no showers were documented during this period. Interviews with the resident's family revealed that the resident expressed dissatisfaction with only receiving bed baths and desired a shower. The resident's son reported that the resident's spouse, who is physically unable to assist with showers, provided a sponge bath instead, during which the water and washcloth became black with dirt. The resident also reported feeling itchy due to lack of proper washing. The Director of Nursing (DON) confirmed the absence of shower documentation for the resident during the specified timeframe.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
Surveyors observed that two out of eleven ground floor rooms reviewed were not maintained in a clean, comfortable, and homelike condition. Specifically, one room was found to have a dirty and sticky floor, brown stains smeared on the bathroom wall, broken window blinds, ceiling tiles coming apart, a toilet pipe not fixed in the wall with surrounding wall cracks, and a cracked and broken floor at the bathroom entry. These environmental deficiencies were confirmed during interviews and observations with the Administrator, Maintenance Director, and Account Manager of the Healthcare Services Group, who acknowledged the concerns raised by the surveyors. No information was provided regarding the medical history or condition of the residents occupying the affected rooms at the time of the deficiency.
Failure to Develop and Implement Care Plans for Dental and Integumentary Needs
Penalty
Summary
Facility staff failed to develop and implement individualized care plans addressing dental and integumentary needs for three out of five residents reviewed during the recertification survey. Specifically, two residents with poor dentition did not have care plans for dental care documented in their electronic medical records, and another resident receiving physician-ordered skin treatments twice daily did not have an integumentary care plan initiated. These omissions were confirmed through medical record reviews and an interview with the DON, who acknowledged that care plans should have been in place for each of the affected residents.
Failure to Clarify Orders, Provide Treatments, and Complete Monitoring
Penalty
Summary
Facility staff failed to clarify a physician's order for a dermatologic cream for a resident diagnosed with Atopic Dermatitis, resulting in unclear instructions regarding the application site. During observations, the prescribed cream was not available on the treatment or medication carts, and staff were unable to locate it. The resident's skin was observed to be extremely dry and scaly, with ashen arms and a dry face, indicating the treatment was not administered as ordered. The lack of clarity in the order and failure to reorder the cream contributed to the resident not receiving the prescribed therapeutic treatment. Additionally, staff did not monitor a resident prescribed psychotropic medication for extrapyramidal side effects (EPS), despite a pharmacy recommendation to do so. There was no documentation of EPS monitoring in the medication administration records for several months. In another case, a pharmacist recommended specific laboratory monitoring for a resident on iron supplementation, which was accepted by the provider. However, the required iron-related labs (ferritin, TIBC, TSAT) were not ordered, and only a CBC, CMP, and lipid panel were completed. These failures demonstrate lapses in following through on medication regimen review recommendations and ensuring appropriate monitoring and treatment according to physician orders.
Failure to Act on Pharmacy Recommendation for Supplement Dosage
Penalty
Summary
Facility staff failed to act upon a pharmacist's recommendation to specify the dosage for a prescribed supplement, Cyanocobalamin, for one resident. The pharmacist's recommendation, dated 02/19/25, was not addressed by nursing staff, and the pharmacy review form remained unsigned. The process described by the DON involved receiving recommendations via email, printing and forwarding them to physicians, and then checking for new orders before filing the signed form, but this process was not followed in this instance. The supplement order lacked a specified strength, and a dose was not added until over two months later. Additionally, an LPN signed off that the supplement was administered twice on the same day, and the DON was unable to explain why the recommendation was not addressed.
Failure to Document and Investigate Abuse Allegations
Penalty
Summary
The facility failed to provide documentation that allegations of abuse were thoroughly investigated for four residents during a complaint survey. In the case of one resident, an allegation of verbal and physical abuse was reported by a hospital social worker, but the facility's documentation only included an initial and 5-day email confirmation without the actual investigation. The Nursing Home Administrator (NHA) could not locate the investigative file, attributing the issue to previous ownership. Another incident involved a resident alleging inappropriate touching by another resident, which led to a physical altercation. The NHA was unable to find the investigation report, again citing previous ownership as a reason. In another case, a resident alleged abuse by a geriatric nursing assistant, but the investigation was incomplete, lacking comprehensive interviews and documentation. The NHA confirmed the investigation's incompleteness and noted that he was not employed at the facility during that time. Additionally, the facility could not locate the investigation for another resident's abuse allegation, with the NHA indicating that it occurred under prior ownership. Despite reaching out to the previous administration, the investigation could not be found. These deficiencies highlight a lack of thorough documentation and investigation of abuse allegations, particularly during transitions of facility ownership.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by the findings during a complaint survey. For one resident, there was no documentation from a neurology appointment, despite notes indicating the resident left and returned to the facility on the day of the appointment. The Director of Nursing confirmed the absence of this documentation. Another resident's medical record lacked nursing documentation of their discharge to an assisted living facility, including details about the resident's condition, how they left, and what documentation was provided. The Nursing Home Administrator later provided a discharge summary but confirmed the absence of nursing notes regarding the discharge. A third resident had a physician's order for a CT scan of the chest, but the medical record did not contain the results or documentation explaining why the scan was not performed as scheduled. The Director of Nursing and medical records staff could not find documentation to explain the delay, although a later CT scan was documented. Additionally, a fourth resident's medical record showed inconsistencies and lack of documentation regarding the monitoring and assessment of pressure wounds. The record failed to provide clear ongoing documentation of the progress or lack of progress related to the resident's wounds. Furthermore, the facility did not document care conferences to update a resident's plan of care following MDS assessments. The Director of Nursing, who was not employed at the facility during the time of these deficiencies, confirmed the absence of documentation after reviewing the medical records. These deficiencies highlight the facility's failure to adhere to professional standards for maintaining accurate and complete medical records.
Failure to Immediately Inform Resident Representative of Hospital Transfer
Penalty
Summary
The facility staff failed to immediately inform the resident representative of a resident's transfer to the hospital. The incident involved a resident who was found lying on the floor with no apparent injuries but had an oxygen saturation level of 75%, which is below the normal range of 95%-100%. A respiratory assessment revealed diminished lung sounds and grunting-like breathing. The physician was notified and ordered oxygen administration, with instructions to send the resident to the emergency room if there was no improvement. Although the resident's oxygen saturation improved to 85%, 911 was called for ER evaluation. The progress notes did not indicate that the resident's representative was updated about the hospital transfer until 6:00 AM, several hours after the initial incident. The facility administrator could not provide additional evidence that the representative was informed immediately of the hospital transfer.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to provide timely documentation of abuse allegations to the appropriate agencies for two residents during a complaint survey. For one resident, an incident was reported where a geriatric nursing assistant allegedly abused the resident during care. The initial report to the Office of Healthcare Quality (OHCQ) was not filed within the required two-hour window, as it was submitted at 5:25 PM, despite the incident occurring early in the morning. The Nursing Home Administrator (NHA) confirmed the delay in reporting and noted that he was not employed at the facility at the time of the incident. In another case, a resident alleged that a staff member scratched, grabbed, and shoved them after requesting to be sent to the hospital. Although the facility submitted the initial and final reports to OHCQ, they failed to contact local law enforcement as required. The Administrator was unable to provide additional evidence to confirm that the police were contacted, indicating a lapse in the facility's reporting protocol.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents during a complaint survey. For one resident, the quarterly MDS assessment did not capture that the resident was receiving Hospice services, despite being admitted to Hospice on a previous date. This oversight was confirmed by the MDS coordinator during an interview. For another resident, there were discrepancies in the MDS coding related to behavioral symptoms and medication administration. The resident exhibited verbal aggression towards staff, which was documented in progress notes, but the MDS assessment inaccurately indicated no such behaviors. Additionally, the MDS documented the use of a hypnotic medication, but the Medication Administration Record did not reflect this. The MDS coordinator clarified that the medication Lorazepam, which the resident was receiving, was intended for anxiety, not as a hypnotic, according to the physician's order. These errors were confirmed by the MDS coordinator.
Failure to Revise Care Plan for Resident with History of Injury
Penalty
Summary
The facility staff failed to revise a resident's care plan, which was evident during a complaint survey for one of the residents. The incident involved a resident who alleged that a GNA hurt their arm. The facility's investigation revealed that the resident had a history of banging their arm on the side rail, and padding had been placed on the side rail to prevent further injury. However, the care plan did not include the intervention of padding the side rail, despite the resident's history of skin tears and behavior problems related to banging their arm on the side rails. An interview with the Director of Nursing confirmed that the padding was not added to the care plan.
Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to ensure a complete recapitulation of a resident's stay was conducted following their discharge. This deficiency was identified during a complaint survey for a resident who was admitted in July 2017 for physical and occupational therapy after an above-the-knee amputation. The resident was discharged to an assisted living facility, but the medical record lacked a physician's discharge summary and documentation of medications to be taken post-discharge. Additionally, there was no summary provided to the receiving facility. Further investigation revealed that the last documented note in the resident's medical record was dated after the discharge date, and there was no nursing documentation regarding the resident's condition at discharge, how they left the facility, or what items and documentation were provided to them and the receiving facility. The Director of Nursing confirmed the absence of a discharge summary, and the Nursing Home Administrator later provided a discharge summary but acknowledged the lack of nursing notes and a physician's discharge summary.
Failure to Provide Adequate Showering for a Resident with Dementia
Penalty
Summary
The facility staff failed to provide showers twice weekly to a resident diagnosed with dementia, who was admitted to the facility with a need for supervision and/or touching assistance for showering and bathing. The resident's care plan, initiated shortly after admission, specified the requirement of one staff member's participation in bathing. However, documentation revealed that the resident received no showers for the last five days of October 2023, only one shower in November 2023, two showers in December 2023, and four showers in January 2024. There was no documentation of the resident refusing showers during this period. The Director of Nursing confirmed that the resident did not receive the expected two showers per week from October 2023 until January 2024.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility staff failed to provide adequate treatment and services to prevent and heal pressure ulcers for a resident. The resident was admitted with pressure ulcers on both heels and was under the care of a wound care physician who conducted weekly assessments. However, on 8/19/24, a nurse's note documented new open areas on the resident's sacrum and right buttocks. Despite notifying the doctor and receiving recommendations for treatment, the wounds were not assessed by the wound care physician until 9/12/24, 24 days after they were first noted. The delay in assessment and treatment of the sacral and right buttock wounds was confirmed by the Director of Nursing during an interview. The lack of timely evaluation and documentation of the wounds' status by the wound care physician contributed to the deficiency in care provided to the resident, as the wounds were not properly monitored or managed for nearly a month after their discovery.
Failure to Adhere to Medication Parameters for Two Residents
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary drugs, as evidenced by the administration of Metoprolol outside of the physician-ordered parameters. Resident #15, who was admitted with a diagnosis of hypertension, was ordered Metoprolol 25 mg daily with instructions to hold the medication if the blood pressure was less than 110 or the heart rate was less than 60. However, the resident was administered Metoprolol on two occasions, on 4/8/24 and 4/13/24, when the heart rate and blood pressure were below the specified parameters, respectively. This was confirmed by the Director of Nursing during an interview. Similarly, Resident #6, also diagnosed with hypertension, was ordered Metoprolol 50 mg daily with the same parameters to hold the medication. On 2/16/25, the resident received Metoprolol despite having a blood pressure reading of 107/73, which was below the ordered threshold. This administration was also confirmed by the Director of Nursing. These instances indicate a failure to adhere to physician orders, resulting in the administration of medication outside of the prescribed parameters.
Failure to Schedule Follow-Up Urology Appointment
Penalty
Summary
The facility staff failed to schedule a follow-up appointment with a urology consultant for Resident #15, who was admitted with a diagnosis of hydronephrosis. The resident's hospital discharge summary indicated the need for an outpatient urology follow-up for moderate right hydronephrosis and a voiding trial, with a referral for a urology appointment already made. A nurse's note documented that a follow-up urology appointment was initially scheduled but later canceled due to out-of-network insurance issues. No further attempts were made to reschedule the appointment during the resident's stay, and there was no evidence of a voiding trial or completed follow-up with a urologist. The Director of Nursing confirmed these findings during an interview with the surveyor.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
