Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Blue Point Healthcare Center during CMS and state inspections, most recent first.
A resident with bilateral BKA was discharged home without all of the DME identified in therapy and discharge planning. Therapy documented the need for an elevated toilet seat/3-in-1 commode, and staff also discussed a shower chair, but the utilization report listed only a wheelchair. The family reported the home was not set up for a safe discharge and that the resident still needed a commode and shower chair.
Facility Failed to Keep Resident Rooms in Good Repair: Surveyors observed multiple areas of disrepair during environmental rounds, including scraped and peeled wall paint behind beds and on bathroom doors, broken curtain rods, a bathroom sink partially pulled from the wall, and a door handle/knob nearly off the hinges. The NHA and DON acknowledged the damaged rooms and stated they were aware of the concern.
The facility failed to send discharge notices to the Ombudsman for resident discharges. A resident was sent to the hospital for a medical condition and later returned, while the Ombudsman reported not receiving discharge notifications for months. The NHA and DON confirmed the facility was not notifying the Ombudsman, and the NHA stated the last copy sent was months earlier due to a gap in the social work team.
Unlabeled Oxygen Tubing and Humidifiers: Several residents receiving O2 via nasal cannula were observed with tubing and humidifier bottles that were not labeled with change dates. The ADON and DON stated that tubing is changed every 7 days and humidifiers are changed when emptied, and that both should be labeled, while the facility policy identified oxygen as a medication and required nasal cannula tubing to be labeled when opened.
Missing Advance Directive Documentation: The facility failed to ensure advance directives were discussed and/or documented for two residents. One resident’s chart had no evidence of an advance directive, no checked advance directive options, and no documentation of a discussion or care plan. For another resident, a note said an advance directive was uploaded, but no copy could be found in the record, and staff gave conflicting accounts about who handled advance directive documentation.
A resident had ordered CBC and CMP labs that were not obtained after repeated attempts, and the lab work was rescheduled and later cancelled. The record did not show that the physician was notified when the labs could not be drawn, although a late entry later stated the NP was made aware and repeat orders were given. Staff and the DON stated that the nurse is expected to notify the physician and document that notification when ordered labs cannot be obtained.
A resident with multiple pressure injuries, including a Stage 4 right hip wound, did not receive the wound care regimen recommended by the wound NP. The TARs showed the facility continued using the original hip wound order with calcium alginate instead of the updated Santyl-based treatment, and later had two different wound orders active at the same time. The DON confirmed the recommended change was never implemented for the right hip wound during the review period.
A resident with a left-hand contracture was not provided the resting hand splint and left elbow extension splint recommended by therapy. The Rehab Director and Therapy Manager confirmed the splints were not available, and the DON verified there were no task instructions for GNA application in the resident’s record at the time of review. The resident reported being unable to use or straighten the contracted left hand, and the OT note showed the splints were intended to support ROM and positioning.
A resident with back pain was observed moaning and reported inadequate pain relief despite receiving medication. Record review showed oxycodone was given multiple times for pain scores below the ordered severe-pain range, and acetaminophen was given once for a pain score of 5. The Unit Manager RN confirmed the pain meds were not administered according to the ordered pain parameters, and the DON stated nurses are expected to follow the physician’s pain management orders.
The facility failed to timely respond to a consulting pharmacist’s MRR recommendation for a resident. The MRR called for a TSH level to monitor a change in therapy, but the copy was unsigned and undated, and the medical record showed no documented order for the lab test. The DON said pharmacy recommendations are emailed to the DON and in-house NP, but the NHA confirmed there was no documentation that the recommendation was completed and that the facility missed the order.
Medication error rates were found to be 13.33%, exceeding the 5% limit. During med pass observations, an RN failed to give a resident ordered ophthalmic medications because they could not be found, and a CMA did not administer another resident's ordered eye drops, instead using artificial tear drops as substitutes without a physician order. An RN confirmed the substitutions were not authorized, and the DON stated that assigned nurses were responsible for reordering medications when supplies were running low.
Improper Medication Storage and Labeling: Surveyors found a resident keeping pills and an inhaler at the bedside, and staff confirmed the medications should not have been left there. They also found several meds on carts and in a med refrigerator that were not dated with an open date, including Vit D3, Famotidine, and liquid Gabapentin; an LPN confirmed meds should be dated when opened.
Failure to Provide Ordered Dental Services: The facility did not provide dental services for multiple residents who had dental concerns and consult orders. A resident reported missing teeth and needing dentures, another said they had not seen a dentist or hygienist in years and was losing teeth, and a third had an order for a dental consult for a broken tooth. Facility records and staff interviews showed these residents were not on the dental service list and had not been seen or scheduled by the contracted dental provider.
Infection prevention staff did not use a systematic, data-driven method to track and trend in-house infections, and the IP binder contained worksheets and resident printouts without analysis or trending data. Staff also failed to maintain 3 laundry dryers according to the manufacturer’s instructions; the dryer drums contained debris such as melted diapers, gloves, and food, and the facility did not keep the dryer instruction book on hand.
The facility did not provide necessary behavioral health care and services to residents who required them, as evidenced by a lack of appropriate assessment, planning, or delivery of behavioral health interventions.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
Surveyors found that two residents had medication cups with multiple pills left at their bedsides without documented assessments for self-administration. Both residents were cognitively intact and able to make their own medical decisions, but there was no evaluation in their records confirming their ability to self-administer medication without nursing supervision. LPNs reported that medications were given and residents were watched, but the required assessments were missing.
Facility staff did not inform the attending physician when a resident, admitted for IV antibiotics and substance use disorder treatment, repeatedly refused Suboxone doses. Despite documentation of multiple refusals and a physician note indicating the resident appeared high, neither the physician nor mental health services were notified prior to the resident experiencing a suspected overdose requiring Narcan.
A resident reported theft of personal funds after being transferred to a new room without being provided a lock box to secure valuables. The resident kept money unsecured in a drawer, and the DON confirmed that the lock box was not present in the new room, leading to the loss.
Facility staff failed to provide written notice and required documentation to two residents and their representatives during transfers to a hospital, including missing information about the transfer, lack of communication to the receiving institution, and absence of discharge and bed-hold policy notifications. The DON confirmed that only minimal documentation existed for these transfers.
The facility did not develop individualized care plans for residents with SUD, as evidenced by three cases where residents experienced unresponsiveness and required Narcan administration. Care plans lacked documentation of SUD-specific interventions such as group meetings, 1:1 support, and mental health services, despite residents' participation in these activities. Facility leadership did not provide explanations for these omissions.
The facility failed to intervene when a resident with a history of substance use disorder showed signs of relapse, including refusing Suboxone and being found unresponsive, without notifying mental health or the physician. Additionally, another resident admitted with multiple injuries did not have hospital wound care instructions implemented or documented, and the care plan did not address surgical wounds. These deficiencies were confirmed through record review and staff interviews.
The facility failed to consistently document and administer pain medications as ordered, did not provide adequate parameters for PRN pain medications, and did not ensure pain assessments or non-pharmacological interventions were completed prior to administering narcotics. Several residents with significant pain were affected, with missing documentation of pain levels, medication effectiveness, and appropriate interventions.
A deficiency occurred when a radiology report indicating a femoral neck fracture was not promptly reviewed or acted upon by the attending physician after being received by the facility. The delay in physician follow-up extended from the evening the report was received until midday the next day, despite recommendations for further imaging.
Facility staff did not ensure that a resident's court-appointed guardian was contacted, educated, or given the opportunity to consent or decline a COVID-19 vaccine booster, as required. Documentation only reflected the resident's refusal, despite the resident being unable to make decisions, and did not indicate guardian involvement.
Failure to Provide Recommended DME Before Discharge
Penalty
Summary
The facility failed to ensure that Resident #4 received the recommended durable medical equipment prior to discharge home. Resident #4 had bilateral below-knee surgical amputations, was admitted to the facility on an unspecified date, and was discharged home on 4/22/2026. Record review showed that discharge planning was discussed with the complainant, who requested medical devices for a safe discharge home and reported that the home environment had limited space and was not equipped to meet the resident’s needs. The complainant also stated that the needed devices had been discussed with therapy staff and social work and had been emailed to the facility. Therapy documentation showed that the resident needed an elevated toilet seat/3-in-1 commode, and an assistant occupational therapist reported that he documented the need for a toilet seat/3-in-1 commode and verbally told the social worker that the resident also needed a shower chair. The social worker confirmed awareness that the complainant requested a shower chair, wheelchair, sliding board, and toilet commode, but the utilization report dated 4/21/26 listed only a wheelchair as needed. The social worker later stated that the shower chair and commode could have been ordered before discharge, but they were not ordered because she had been instructed to order only the wheelchair.
Facility Failed to Keep Resident Rooms in Good Repair
Penalty
Summary
The facility failed to ensure that all areas were in good repair, as observed during environmental rounds on all units during the recertification/complaint survey. Surveyors found multiple damaged areas in resident rooms, including scraped and peeled wall paint behind beds and on bathroom door edges, broken curtain rods that had been taken down, a bathroom sink partially pulled away from the wall leaving a visible hole, and a door handle/knob that was almost off the hinges. In one room, the wall adjacent to the bed had paint scraping coming off the wall, and in another room the wall paint behind the head of the bed was scraped off. Similar wall damage was also observed in additional rooms, including large areas of scraped paint behind the head of beds and on walls beside beds.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to send a copy of discharge notices to the representative of the Office of the Long-Term Care Ombudsman. Record review showed that resident #3 was sent to the hospital for a medical condition on 10/28/25 and later returned to the facility. During interview, the ombudsman stated that she had not been receiving discharge notifications from the facility since April/May 2025. The NHA acknowledged that the facility had not been notifying the ombudsman of resident discharges, and the DON confirmed that the facility did not notify the ombudsman when residents were discharged. The NHA later stated that March 2025 was the last time the ombudsman received a copy of discharges and explained that the responsibility had been assigned to social work, but a gap in the social work team caused the notifications to be missed.
Unlabeled Oxygen Tubing and Humidifiers
Penalty
Summary
The facility failed to label oxygen tubing and humidifier bottles with the date of change for residents receiving respiratory care. During observation, Resident #49 and Resident #90 were seen receiving oxygen through unlabeled nasal cannula tubing attached to an unlabeled humidifier. On a later observation, Resident #11 and Resident #65 were also found with nasal cannula tubing and humidifiers that were not labeled, and Resident #134 had unlabeled nasal cannula tubing with no humidifier in place. During interview, the ADON stated that oxygen tubing is changed every 7 days and as needed, and humidifiers are changed when emptied, and both should be labeled with change-out dates. Record review for Resident #49 showed an order for oxygen at 2L via nasal cannula continuously for shortness of breath, and the care plan directed staff to provide oxygen therapy as ordered and change oxygen tubing per facility policy. The facility’s supplemental oxygen procedure stated that oxygen is treated like a medication and that nasal cannula tubing should be labeled when opened. The DON also stated that oxygen tubing should be changed out and labeled, and that staff had been educated that tubing and humidifier bottles should be labeled.
Missing Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that advance directives were discussed with residents and/or responsible representatives and/or that a copy of an advance directive was maintained in the medical record for 2 residents reviewed. For one resident, the admission record identified the resident as his/her own representative, but the chart contained no evidence of an advance directive. Review of the social history assessment showed none of the advance directive options were checked, and there was no documentation of any discussion with the resident about the right to formulate an advance directive. The medical record also lacked an advance directive care plan, and the Administrator confirmed there was no record of one or documentation that such a discussion occurred. For another resident, the social worker assessment note stated that an advance directive was uploaded under the document tab, but the surveyor could not locate a copy in the medical record. During interviews, the social worker stated residents are informed of their right to an advance directive and that the admission director handled advance directives, while the admission director stated she/he only handled PASARR and MOLST forms, not advance directives, although advance directives were discussed during admissions. The surveyor requested the documented copy, and the Nursing Home Administrator confirmed there was no record of an advance directive for that resident.
Failure to Notify Physician When Ordered Labs Were Not Obtained
Penalty
Summary
The facility failed to notify the physician that ordered labs were not obtained for one resident. A physician order dated 12/01/2025 required a CBC and CMP to be drawn the next morning on 12/02/2025. On 12/02/2025, staff documented that blood specimen collection could not be completed after two attempts and that the lab work was rescheduled for the morning of 12/03/2025. The medical record later showed that the CBC and CMP orders dated 12/03/2025 were cancelled, with documentation stating the labs were unable to be obtained and the facility was aware. However, there was no documented evidence that a physician was notified of the inability to obtain the ordered labs on either 12/02/2025 or 12/03/2025. A late entry note added after surveyor intervention stated that the resident’s labs were unable to be obtained, the NP was made aware, and orders were given to repeat the labs. Staff and the DON stated that when labs cannot be obtained, the nurse is expected to notify the physician and document that notification in the medical record.
Failure to Implement Wound Consult Orders
Penalty
Summary
Failure to implement recommended wound care treatments based on wound consults was identified for one resident with multiple pressure injuries, including wounds to the sacrum, right and left hips, right ischium, and left lateral ankle. Physician orders in the treatment administration record included daily and as-needed wound care with Dakin's solution, Medihoney, calcium alginate, ABD pads, bordered gauze, and later Aquacel Silver with gentle packing for all wounds. However, wound assessment reports signed by a wound NP on multiple dates consistently documented a Stage 4 pressure injury on the right hip and recommended a different treatment plan of daily cleansing, Dakin's moistened fluffed gauze, and Santyl secured with bordered gauze and an ABD pad. Review of the treatment administration records for September, October, and November showed the resident continued to receive the original 9/23/2025 hip wound order with calcium alginate rather than the wound NP's recommended Santyl-based treatment. The DON stated the wound NP makes treatment recommendations and the wound nurse is responsible for implementing and updating orders, and confirmed the recommended change for the right hip wound was never implemented between 9/24/2025 and 11/12/2025. The record also showed that for a five-day period in November, the resident had two different wound treatment orders active at the same time, and later wound clinic documents recommended daily wound care with Dakin's, Aquacel Silver, and packing for all wounds.
Failure to Provide Ordered Splints for Resident With Left-Hand Contracture
Penalty
Summary
The facility failed to ensure that Resident #10 was provided splints in accordance with rehabilitation staff recommendations for a left-hand contracture. During observation and interview, the resident reported being unable to use or straighten the contracted left hand. The Rehab Director confirmed the resident had received therapy for a left-hand contracture and that therapy had recommended a resting hand splint and a left elbow extension splint. The Therapy Manager verified that no splints were available for the resident and stated they would need to be ordered. Review of the occupational therapy note showed a goal for the resident to wear a resting hand splint on the left hand and left wrist, and a left elbow extension splint for up to 2 hours with minimal signs or symptoms of redness, swelling, discomfort, or pain. The DON stated that splint use should have been communicated in the morning clinical meeting, with therapy training GNAs and documenting the task for application, but no splint application instructions were found in the resident’s task section at the time of review. The Rehab Director later stated the splint had been ordered and received, and therapy re-evaluated the resident with a focus on application, wearing schedule, and caregiver education after surveyor intervention.
Failure to Follow Pain Medication Parameters
Penalty
Summary
The facility failed to provide appropriate pain management for Resident #75. The resident was observed on 12/02/2025 sitting in a wheelchair in the hallway and moaning in pain, and later that day was again observed moaning and reported inadequate back pain relief despite receiving medication. The resident’s record showed physician orders for oxycodone oral solution 5 mg/5 mL, 5 mL by mouth every 8 hours as needed for severe pain rated 7-10, and acetaminophen 650 mg by mouth every 6 hours as needed for mild pain rated 1-3. Review of the November MAR showed oxycodone was administered 11 times for pain scores below 7, and acetaminophen was given once for a pain score of 5 on 11/5/2025. Staff #5, the Unit Manager RN, described the pain protocol as assessing pain, trying non-pharmacological interventions first, then using the pain scale to give the appropriate medication and reassessing effectiveness, and confirmed the resident’s pain medication was not administered according to the established pain parameters. The DON stated that nurses are expected to follow the pain management parameters in the physician’s order and was informed of the concern.
Delayed Response to Pharmacy Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to a consulting pharmacist’s recommendation for Resident #5. During review of the Medication Regimen Review documents, the surveyor found that the 10/8/2025 MRR included a recommendation to consider monitoring a TSH level on the next convenient lab day to monitor a change in therapy, but the copy provided was not signed or dated. Review of the resident’s medical record showed no documented order for a TSH level from 10/8/2025 through 12/4/2025. During interview, the DON stated that pharmacy recommendations are emailed to the DON and in-house NP on the same day they are made, and that the NP reviews them as soon as possible before the unit manager or nurse is informed. However, when the surveyor requested documentation showing the 10/8/2025 recommendation had been completed, the NHA stated there was no documentation that it was completed and that the facility missed the order.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
Medication error rates were found to be 13.33%, which is greater than the allowed 5 percent threshold. During observation of medication pass on two units, staff failed to administer ordered eye medications to two residents. One RN did not give Resident #90's Cosopt ophthalmic solution and artificial eye drop because the medications could not be found, and stated she would call pharmacy to bring them stat. Later, the RN confirmed that the resident did not receive the morning doses of the eye medication and that the medications were supposed to be reordered when they were noted to be running low. During another medication pass observation, a CMA did not find Resident #36's ordered Visine ophthalmic and Systane ophthalmic eye drops for dry eyes and stated that the facility allowed artificial tear drops to be used as substitutes. Review of the physician's order did not show any order permitting substitution with artificial tear drops. An RN standing by confirmed that both medications would be reordered and stated that the eye drops could not be substituted without orders. The DON stated that assigned nurses were responsible for reordering medications when they were running low or calling pharmacy for stat delivery.
Improper Medication Storage and Labeling
Penalty
Summary
Drugs and biologicals were not appropriately stored and labeled for multiple residents. For Resident #121, surveyors observed a medicine cup in the resident’s room containing 4 pills, an inhaler labeled Symbicort 160 mcg/4.5 mcg with directions for 2 puffs twice a day, and an Icy Hot Max Pain Relief lidocaine cream bottle. The resident identified the pills as Gabapentin and Tylenol and said the inhaler was from the hospital. A CMA confirmed that medications should not be left at the bedside and agreed with the surveyors’ findings. The DON/Administrator stated there was a protocol for bedside medications and that Resident #121 could keep only the Icy Hot pain medication, but no other medication. Surveyors also found multiple medications on carts and in the medication refrigerator that were not dated with an open date. On the basement floor med cart, Resident #54’s Vit D3 25 mcg tablet was not dated. On the A/B wing med cart, an in-house stock Famotidine 20 mg tablet container was not dated. In the A/B wing medication room refrigerator, Resident #60’s liquid Gabapentin 250 mg/5 mL bottle was 1/3 full and also not dated. An LPN confirmed that medications should be dated with an open date to show when they were opened. Physician orders showed that Residents #54 and #60 were actively receiving these medications.
Failure to Provide Ordered Dental Services
Penalty
Summary
The facility failed to provide dental services for 3 of 4 residents reviewed for dental services. Resident #4 stated that their teeth were falling out and that they needed dentures, and surveyors observed missing teeth in the upper and lower areas of the mouth. The medical record showed a dental consult order dated 10/3/2025, but Resident #4 was not listed on the facility’s dental service lists provided by the NHA for the prior months and was not shown as seen or scheduled for dental care. Resident #12 stated that they had been at the facility for a couple of years, had not seen a dental hygienist or dentist, were losing teeth, and wanted dentures. The medical record showed a dental consult order dated 11/29/2023, but Resident #12 was also not listed on the facility’s dental care lists. Resident #8 had a physician order dated 10/29/2025 for a dental consultation for a broken tooth, but was not on the Health Drive list as being seen or scheduled to be seen. Staff interviews described a process in which the SW faxed resident names to Health Drive and residents had to be enrolled to receive services, and the DON and Administrator confirmed that Resident #8 had not received dental services and required an enrollment form.
Infection Tracking and Laundry Dryer Maintenance Deficiencies
Penalty
Summary
The facility failed to follow its infection prevention policy to use a systematic and organized data-driven method to track and trend in-house infections in an effective and timely manner. During observation on the 2nd floor, infection isolation signs were posted on some resident doors, but staff were not sure why the signs were in place. The Infection Preventionist stated that she used daily infectious diagnosis information to format her worksheet, but she did not follow the facility policy to run a systematic and organized method to track and trend the raw data, and she could not provide backup reports from the Regional office using McGeer Criteria. Review of the Infection Prevention binder showed about one year of worksheets and resident printouts in chronological order, but no data analysis or trending records. The DON stated she was aware that the Infection Preventionist did not have a method to track and trend in-house infections. The facility also failed to maintain and use laundry dryers according to the manufacturer’s instructions for use. Observation of the laundry area showed 3 dryers in poor condition with debris caught in the drum walls, including melted diapers, gloves, food, and unknown items. The Administrator was present and agreed the condition was not acceptable. The Laundry Manager stated it was her mistake to ensure staff screened dirty laundry and removed all objects, and maintenance staff stated they did not keep a washer/dryer manufacturer instruction book on hand. Record review showed only a recent service record for the dryer exhaust air duct, with no dryer manufacturer instructions available. After surveyor intervention, the inside drum metal walls of all 3 dryers were cleaned and the temperature was tested by the service company.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. The lack of appropriate behavioral health care and services was directly related to the facility's inaction in assessing, planning, or delivering the necessary interventions for residents with behavioral health needs.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process to identify, review, and address quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
Failure to Assess Residents for Self-Administration of Medication
Penalty
Summary
Surveyors observed that the facility failed to assess residents for their ability to self-administer medications. During a tour of one unit, surveyors found medication cups containing multiple pills left at the bedsides of two residents. In one instance, a medication cup with seven pills was found on a bedside table, and the resident explained that the nurse left the medication there because the resident needed to use the bathroom. The resident then took the medication in the presence of the LPN. In another instance, a resident was found with a medication cup containing six pills at the bedside and stated they had been distracted and would take the medication now. Interviews with LPNs revealed that medications were given to residents and they were supposed to be watched while taking them, but no narcotics were left at the bedside. Review of the medical records for both residents showed they were cognitively intact and able to make their own medical decisions, but there was no documented assessment or evaluation in the records to determine their ability to self-administer medication without nursing supervision.
Failure to Notify Physician of Medication Refusals in Resident with Substance Use Disorder
Penalty
Summary
Facility staff failed to notify the attending physician when a resident was refusing prescribed Suboxone, a medication used as part of substance use disorder treatment. The resident, who was admitted for a minimum six-week course of intravenous antibiotics due to septic wounds and endocarditis suspected to be related to drug use, refused nine doses of Suboxone in January and five of eight doses in February. Despite these refusals, there was no documentation that the physician was informed of the missed doses. Additionally, after a note was made by a physician indicating the resident appeared high, there was no report to mental health services or a multidisciplinary meeting prior to the resident experiencing a suspected overdose that required Narcan administration. Interviews with facility staff confirmed that neither the physician nor mental health services were notified of the medication refusals or the concerning behavior prior to the overdose incident.
Failure to Provide Secure Storage for Resident Valuables After Room Transfer
Penalty
Summary
A deficiency was identified when a resident reported that $110.00 was stolen from their room. The facility's records indicated that the resident had previously been provided with a lock box to secure valuables. However, after being transferred to a new room, the resident did not have access to a lock box and was keeping valuables unsecured in a drawer. During an interview, the resident confirmed the absence of a lock box in the new room, and the DON acknowledged that the lock box had not been provided following the room transfer. This failure to provide a means for the resident to secure their valuables resulted in the misappropriation of the resident's personal funds.
Failure to Provide Required Transfer Documentation and Notifications
Penalty
Summary
Facility staff failed to provide written notice to a resident and their representative regarding a transfer to a local hospital for evaluation. Medical record review showed that the resident was treated for abnormal laboratory results by their primary provider, and nursing staff documented the resident's hospitalization the following day. However, there was no evidence in the medical record of documentation regarding the resident's change of condition or the transfer for treatment prior to the hospitalization. The Director of Nursing confirmed that nursing staff did not create or provide the required transfer documentation to the resident or their representative before the transfer occurred. Additionally, another resident's medical record indicated that the resident called 911 and was transported to the emergency room, but the record lacked documentation of the transfer location, reason for transfer, and required information provided to the receiving health care institution. There was also no evidence that the resident received a written discharge notice or information about the facility's bed hold and return policy. The record did not document the resident's orientation or physician notification. The Director of Nursing confirmed that the only documentation related to this hospital transfer was a nurse's note indicating the resident called 911, with no additional documentation available.
Failure to Individualize Care Plans for Residents with Substance Use Disorder
Penalty
Summary
The facility failed to develop and implement individualized care plans for residents with substance use disorder (SUD), as evidenced by medical record reviews of three residents. One resident with intact cognition and a diagnosis of SUD was found unresponsive and required emergency interventions including CPR, multiple doses of Narcan, and use of an AED. The care plan for this resident only included general monitoring and medication administration, omitting specific interventions such as participation in SUD group meetings, 1:1 support, and mental health or recovery services, despite the resident's involvement in these activities. There were also no documented notes from the social worker or evidence of interdisciplinary discussion regarding interventions in the quality assurance records. Another resident with SUD was found unresponsive in the courtyard and required Narcan administration before regaining consciousness. The care plan for this resident lacked documentation of SUD-specific interventions, such as group meetings or mental health services, even though the resident was receiving these services. A third resident with a history of opioid use and recent Narcan administration did not have an updated care plan reflecting behavioral health involvement, behavioral contracts, or references to SUD nurse practitioner visits or group participation. In all cases, interviews with facility leadership yielded no responses regarding the deficiencies in care planning.
Failure to Intervene for Substance Use and Address Hospital Wound Care Instructions
Penalty
Summary
The facility failed to provide appropriate interventions and care for two residents with significant medical needs. In the first case, a resident with a known history of substance use disorder was admitted following hospitalization for septic wounds and endocarditis related to suspected drug use. The resident had a central catheter and was prescribed Suboxone for opioid withdrawal, but repeatedly refused the medication. Staff documented that the resident appeared to be under the influence and was unavailable for medications and wound care on multiple occasions. Despite these observations and the resident later being found unresponsive and requiring Narcan administration, there was no evidence that mental health services were notified or that a multidisciplinary meeting occurred to address the relapse concerns. The physician was also not informed of the repeated Suboxone refusals. In the second case, another resident was admitted with multiple traumatic injuries and surgical wounds following a motor vehicle accident. The hospital discharge summary included specific instructions for wound care and follow-up appointments. However, the facility's admission assessment did not identify the presence or location of the surgical wounds, and there were no physician orders or documentation on the Treatment Administration Record (TAR) for wound care as outlined in the hospital instructions. The care plan addressed only the prevention of pressure ulcers and did not include the resident's surgical wounds or their care. The Director of Nursing confirmed that wound care orders should have been present upon admission, but no additional documentation was found. These deficiencies were identified through interviews, medical record reviews, and discussions with facility leadership, demonstrating failures to intervene appropriately for substance use concerns and to ensure continuity of care for surgical wounds as directed by hospital discharge instructions.
Failure to Provide Consistent and Documented Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for multiple residents, as evidenced by inconsistent documentation and administration of pain medications, lack of adequate medication parameters, and insufficient assessment and monitoring of pain. For one resident, Dilaudid (Hydromorphone) was ordered as needed for pain, but records showed that the medication was removed from the controlled lock box on several occasions without corresponding documentation in the Medication Administration Record (MAR) or evidence that the resident's pain level and the effectiveness of the medication were monitored. The Director of Nursing confirmed that staff did not ensure the medication was administered as ordered. Another resident with a history of dementia, chronic pain, and a previous hip fracture had orders for both Acetaminophen and Tramadol for pain, but the orders lacked clear parameters for when each medication should be used. Documentation showed that pain medications were administered without recording the location or source of pain, and there was no evidence that non-pharmacological interventions were attempted prior to giving narcotic pain medication. Pain assessments before and after medication administration were inconsistently documented, and the effectiveness of interventions was not always evaluated as required. A third resident experienced a right humeral fracture and was described as being in excruciating pain, but the MAR did not show that scheduled or as-needed pain medication was administered during the period of severe pain, except for a single dose. There was no documentation of further pain interventions prior to the resident's transfer to the emergency room, despite orders allowing for additional pain medication. These findings were confirmed through record review and interviews with facility leadership.
Delay in Physician Review of Radiology Report Following Resident Injury
Penalty
Summary
A deficiency was identified when the facility failed to ensure timely accessibility of a radiology report to the attending physician for a resident who sustained an injury of unknown origin. Medical record review showed that an x-ray was ordered and completed for the resident, revealing a right femoral neck fracture with a recommendation for further imaging. Although the radiology report was received by the facility in the evening, there was no documented response or follow-up by the attending physician until the following day at midday. The Director of Nursing was informed of these findings during the survey, and no additional information was provided regarding the delay in reviewing the x-ray report.
Failure to Obtain Guardian Consent for COVID-19 Vaccination
Penalty
Summary
Facility staff failed to ensure that the court-appointed guardian of a resident who was incapable of making decisions was provided with education and the opportunity to consent to or decline a COVID-19 vaccine booster on the resident's behalf. The resident's medical record confirmed the presence of a court-appointed guardian since 2017, yet the immunization record only showed electronic consent forms indicating that education was provided and the resident refused the vaccine. There was no documentation that the guardian was contacted, educated, or given the opportunity to provide or withhold consent for the vaccine. Interviews with facility staff, including the current and former Infection Preventionists (IPs), revealed that the established process required contacting the guardian, providing education, and obtaining consent or declination, either verbally or in writing. The electronic documentation system allowed for specifying whether the resident or guardian provided consent, but in this case, the records only reflected the resident's refusal, not the guardian's involvement. The Director of Nursing acknowledged that the electronic documentation did not reflect the required guardian contact.
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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.
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Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Levindale Hebrew Ger Ctr & Hsp | 0.2 mi | ★★★★★ | 11 | 1 |
| Northwest Healthcare Center | 0.7 mi | ★★★★★ | 16 | 0 |
| Autumn Lake Healthcare At Arlington West | 1.3 mi | ★★★★★ | 0 | 0 |
| Roland Park Rehabilitation And Healthcare Center | 1.5 mi | ★★★★★ | 9 | 1 |
| Autumn Lake Healthcare At Alice Manor | 1.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.