Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Calvert County Nursing Ctr. during CMS and state inspections, most recent first.
Unlabeled and Improperly Stored Respiratory Equipment: Surveyors observed multiple residents with oxygen and nebulizer supplies that were not labeled, dated, or properly stored. An LPN and RN confirmed that oxygen tubing, humidifier bottles, and nebulizer masks/tubing should be labeled and stored appropriately, and one resident also lacked an oxygen sign at the door.
Missing Immunization Verification and Vaccine Offering: Record review showed that several residents lacked documentation of TB, influenza, SARS/COVID, and pneumococcal immunization status, and one resident had TB testing documented but no record of the other vaccine statuses. The Infection Control Preventionist stated she did not obtain residents’ immunization status or offer vaccines, the MDS Coordinator said she reviewed status in ImmuNet but did not enter it into the medical record, and the DON acknowledged infection control duties were not being fully completed because the ICP was also working full time as a unit manager.
The facility failed to ensure that GNAs received and had documentation of the required 12 hours of annual in-service training. The NHA stated the DON handled staff training, and the DON reported that GNA education was provided throughout the year, but record review for five GNAs showed only competency checkoffs and tests with no proof of the required annual training. The DON later stated the facility could not locate documentation confirming the training requirement had been met.
A resident’s motorized wheelchair remained nonfunctional for an extended period despite vendor measurements and an approved authorization, limiting the resident’s mobility and independence. The PT director had a vendor assess the resident and forwarded the estimate to the Administrator during a period when there was no BOM. The BOM, who started later, learned that payer authorization had already been granted, but the facility had not tracked or followed up on the process, and the Administrator acknowledged a breakdown in follow-up and communication with the resident regarding the status of the wheelchair.
A resident reported that an agency GNA provided rough and rude care while repositioning them in bed, including being roughly pulled by the neck and arm. During the facility’s investigation of the incident, two other residents also reported that the same agency GNA was rude and provided rough care. The NHA concluded that the agency GNA had abused the resident.
The facility failed to ensure that written advance directive information was offered and documented for four residents reviewed. Record review showed no evidence that the residents or their RP were provided advance directive education, and the MSW stated that documentation of the offer was inconsistent and sometimes not completed.
Missing ADL Care Documentation for Dependent Resident: A resident assessed as dependent for multiple ADLs had no documented evidence of ADL care during two shifts, including bathing, dressing, oral hygiene, personal hygiene, toileting, toileting hygiene, transfers, bed mobility, and bowel care. The resident’s family member raised concerns that ADL care was not carried out, and the DON acknowledged the missing documentation.
A resident who was dependent for incontinent care and required 2 staff assistance was left unattended by a GNA during care with the bed raised high and the resident rolled onto the right side. The resident reported rolling off the bed onto the floor and hitting his/her head, with no injury reported. The NHA and DON confirmed the resident’s dependency status and that the resident was left unattended during the incident.
Medication Refrigerator Temperature Not Maintained: An LPN and unit manager found a medication storage refrigerator on one unit at 64 degrees Fahrenheit while it contained insulin, suppositories, and PPD. Night shift was supposed to check and document the refrigerator temperature nightly, but the log showed no documentation that the refrigerator had been checked, and the facility policy required storage at 36 to 46 degrees Fahrenheit.
Medication administration errors caused the facility’s error rate to exceed the allowed threshold. An CMA omitted ordered ophthalmic drops for one resident during med pass, and an LPN gave Oxycodone instead of the resident’s active OxyContin order for another resident without a provider order for the substitution. The MAR was also signed off as if the ordered OxyContin had been given.
Sanitation and Dishwasher Temperature Deficiencies: A Dietary Aide was observed rinsing pans in a 3-bay sink with only one bay filled, while the wash and sanitizing bays were empty. In addition, the hot water dishwasher’s final rinse measured 138-140 degrees F during observation, despite the temperature log showing a consistent 180 degrees F final rinse and 150 degrees F wash temp for the month.
The facility failed to ensure the QAA committee had the minimum required members present at each QAPI meeting. Review of the QAPI binder showed missing attendance and signatures for the Administrator and/or Infection Preventionist at multiple meetings, and the Administrator confirmed the attendance gaps and acknowledged the concern.
Infection control was deficient when an LPN observed a resident’s Foley catheter bag lying on the floor and later used a portable BP cuff and pulse ox on two residents without cleaning the equipment between uses. The LPN acknowledged the Foley bag should not touch the floor and stated the equipment should have been cleaned after each use; the DON confirmed the BP cuff and pulse ox should have been cleaned before being used on another resident.
Incomplete antibiotic stewardship line listings showed that the facility failed to maintain its ASP. The Unit Mgr serving as the IP confirmed responsibility for monitoring antibiotic use, but the October through February line listings were incomplete for several residents, with missing infection sites, missing CXR information and dates for pneumonia cases, and the healthcare-acquired vs community-acquired infection column not documented for most residents.
Failure to designate a qualified IP for the infection prevention and control program. Record review showed the Unit Manager for the Western [NAME] Unit completed IP training, but interviews confirmed she was full-time in her Unit Manager role and also assigned IP duties. She stated she did not have much time to dedicate to the IP position, and the DON and ADON had previously taken turns serving in that role before it was returned to her.
Laundry room environmental maintenance deficiencies were observed, including a ceiling leak dripping onto the wall and floor, black staining, peeling paint, torn pipe insulation, visible dust on vents and equipment, and a leaking washer with a puddle behind it. Staff reported the leak had been occurring for a while, maintenance was not consistently aware of the issue, and the Laundry area relied on verbal reporting rather than a documented system.
A facility failed to provide a psychiatric evaluation for a resident with a history of trauma from physical abuse. The resident reported an alleged abuse incident involving an LPN, leading to a recommendation for psychiatric assessment. Despite a trauma-informed care assessment confirming the need, the evaluation was not conducted during the resident's stay, as confirmed by the facility administrator.
A resident at high risk for falls was improperly transferred by a GNA who did not use the required sit-to-stand device, resulting in a fractured arm. Despite the resident and another GNA indicating the need for the device, the transfer was done manually, causing injury. The resident was dependent on staff for transfers, as noted in their MDS assessment.
The facility did not promptly report allegations of staff-to-resident abuse and injuries of unknown origin for four residents, including incidents where an LPN was reported to have thrown medication at a resident and unexplained bruising was found on residents with cognitive impairment. These events were either not reported to the DON or state agency as required, or only discussed informally, contrary to facility policy.
Surveyors found that ice machines in both the kitchen and a unit nourishment room had visible smears, debris, and film on their surfaces. The ADM confirmed the unclean conditions, and interviews revealed unclear staff responsibilities for cleaning. The cleaning log did not specify if the entire machine was cleaned, and relevant policies were not provided.
A resident was prescribed an antibiotic for a UTI without documented signs or symptoms to justify the prescription, and there was no evidence that the facility's antibiotic stewardship program ensured compliance with McGeer Criteria. The Infection Preventionist could not confirm the presence of required clinical indicators due to lack of nursing documentation, and the DON acknowledged the oversight in the review process.
The facility did not provide or document required education and consent or declination for flu and pneumococcal vaccines for several residents, despite administering the vaccines. Residents with chronic conditions such as diabetes, COPD, asthma, heart failure, and vascular dementia were affected. Interviews with the IP and DON revealed confusion about responsibilities and errors in documentation, leading to the deficiency.
A resident with severe cognitive impairment wandered into another resident's room, leading to a confrontation where the latter was pushed and fell. The facility's interventions were insufficient to prevent the incident, despite policies ensuring residents' rights to be free from abuse.
Two residents reported incidents of inappropriate conduct by staff members, but their care plans were not updated to reflect these changes in condition. Despite facility policy requiring care plan reviews after such incidents, no updates were made, as confirmed by the DON and Administrator.
The facility failed to provide trauma-informed care for three residents. One resident disclosed past sexual abuse, but the assessment was not updated. Another resident alleged inappropriate touching, and a third reported being slapped, yet no trauma-informed assessments were conducted. The DON and Administrator confirmed assessments should occur at admission and after changes in condition.
Two residents with injuries of unknown origin did not have their cases investigated as required by facility policy. In both instances, staff observed unexplained bruising, reported the findings to supervisors and clinical staff, but no formal investigation was conducted to determine the cause. The DON and Administrator confirmed that these incidents were not investigated, despite policy requiring prompt reporting and thorough investigation of such events.
A resident with multiple medical conditions did not receive prescribed medications as ordered because the medications were not available from the pharmacy. The LPN documented the medications as on hold and did not check facility stock or notify the physician, as confirmed by the DON.
A registered nurse left a medication cart unlocked and unattended with an insulin pen on top while conducting a blood sugar check for a resident. The cart and medication were out of the nurse's sight as she went into the resident's bathroom, contrary to facility policy requiring medication carts to be locked and medications secured when not in direct view.
Staff failed to protect resident-identifiable information by leaving computers with electronic medical records unlocked and unattended during care tasks. Both a registered nurse and a unit manager left computers open on medication carts, exposing resident information, and later acknowledged this was improper. The DON confirmed this practice was unacceptable.
Staff did not consistently use required PPE when caring for a resident on contact precautions for MSSA infection, and failed to properly handle medications after they were dropped during administration. A nurse provided care without donning PPE, and other staff attempted to administer medications that had been dropped onto unclean surfaces, contrary to facility policy and infection control standards.
The facility failed to update its facility-wide assessment, crucial for resource allocation during emergencies, as identified in a complaint survey. The assessment lacked plans for emerging infections, and interviews revealed that the water management program was outdated and not reviewed by current staff, contributing to the deficiency.
The facility failed to inform residents and families of respiratory illness outbreaks and did not monitor water temperatures effectively, leading to potential infection risks. Despite a meeting to address the respiratory illness, documentation was lacking, and water temperatures in several rooms were below the required level.
Unlabeled and Improperly Stored Respiratory Equipment
Penalty
Summary
The facility failed to provide nursing care within the standards of practice for residents receiving supplemental oxygen and prescribed nebulizer treatments. During unit rounds, surveyors observed multiple respiratory supplies that were unlabeled, including oxygen tubing, humidifier bottles, nebulizer masks, and nebulizer tubing for Residents #78, #43, #83, and #15. Some items were also observed out of proper storage, including nebulizer mask and tubing on a bedside floor and on a nightstand, and one humidifier bottle was empty. Resident #78 was observed in bed with oxygen tubing in place and an unlabeled humidifier bottle; Resident #83 was observed in bed receiving oxygen with an unlabeled humidifier bottle; Resident #43 had oxygen and nebulizer tubing on the nightstand without labels; and Resident #15 had a nebulizer mask and tubing on the floor at bedside without labels. Surveyor observations on the following day again found unlabeled oxygen tubing, humidifier bottles, and nebulizer equipment for Residents #78, #43, and #83. One resident’s nebulizer mask was hanging on a gallon water bottle on the nightstand, and no oxygen sign was observed at the resident’s door. Staff interviews confirmed that oxygen tubing should be changed weekly and dated, humidifier bottles and nebulizer equipment should be labeled, and nebulizer masks and tubing should be stored in a plastic bag when not in use. An RN also confirmed that no labels were present for Resident #83’s respiratory equipment.
Missing Immunization Verification and Vaccine Offering
Penalty
Summary
The facility failed to ensure residents’ immunization status was verified and current vaccinations were offered for flu and pneumonia, and the record review also showed missing documentation for TB, influenza, SARS/COVID, and pneumococcal status. During review of the immunization records, Residents #30, #45, and #2 did not have documentation showing their immunization status for TB, influenza, SARS/COVID, or pneumococcal vaccines. Resident #49 had TB testing documented on 2/05/25 and 2/12/25 with education, but there was no record of immunization status for SARS/COVID, pneumococcal, or influenza. During interview, the Infection Control Preventionist stated she did not obtain residents’ immunization status and did not offer vaccines, explaining that the MDS Coordinator handled that task because she did not have time to perform the Infection Control Preventionist role due to her full-time duties as unit manager on the Western nursing unit. The MDS Coordinator stated she reviewed immunization status in ImmuNet when completing assessments, but did not enter the immunization status into the residents’ medical records. The DON acknowledged that the Infection Control Preventionist did not have time to dedicate to infection control and that certain infection control requirements were not currently being completed.
Failure to Document Required Annual GNA Training
Penalty
Summary
The facility failed to ensure that geriatric nursing assistants (GNAs) received at least 12 hours of annual in-service training. During interviews, the NHA stated that the DON handles staff training, and the DON reported that GNA education is completed throughout the year through in-services and educational sheets and that GNAs should receive 12 hours of mandatory training yearly. However, a review of the training records for GNAs #18, #19, #20, #21, and #22 showed only competency checkoff sheets and tests completed by the GNAs, with no documentation confirming that any of the five GNAs had completed 12 hours of annual training. The DON later stated he had started employment three weeks earlier and that the facility had been unable to locate documentation confirming the required 12-hour training for those GNAs.
Failure to Provide Timely Motorized Wheelchair to Support Resident Independence
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to self-determination and freedom of movement by not providing a functional motorized wheelchair in a timely manner. A resident reported during the complaint investigation that their motorized wheelchair had been nonfunctional since 2025. The resident stated that a vendor had come to complete measurements for repair or replacement, but there had been no follow-up or communication regarding the status of the equipment. The resident reported that the lack of a functioning motorized wheelchair limited their mobility within the facility and affected their independence. Record review and staff interviews showed that the Physical Therapy Director had the resident measured for a motorized wheelchair by Freedom Mobility on 08/18/2025 and forwarded the vendor’s estimate to the Administrator because there was no Business Office Manager (BOM) in place at that time. The BOM, who started in December 2025, stated she became aware of the wheelchair issue on 01/16/2026 and learned from Freedom Mobility that authorization from Telligen had been received on 10/10/2025. The Administrator confirmed that from July 2025 through December 2025 there was no BOM and she had assumed Business Office responsibilities, which led to a breakdown in follow-up and tracking of the authorization process. She acknowledged that the facility did not follow up on the approved request and did not update the resident on the status, resulting in a delay in providing the necessary mobility equipment.
Agency GNA Provided Rough and Rude Care During Repositioning
Penalty
Summary
The facility failed to protect a resident from abuse when an agency GNA provided rough and rude care during repositioning in bed. During an interview, Resident #6 reported that Agency GNA #16 roughly pulled the resident by the neck and arm and was very rude while assisting with repositioning. A review of Facility Reported Incident (FRI) #2736958 showed that, following investigation, the Nursing Home Administrator determined that Agency GNA #16 had abused Resident #6. During the same investigation, two other residents also reported that Agency GNA #16 was rude and provided rough care, supporting the finding that the resident was not kept free from abuse.
Failure to Document Offering Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents were offered written information regarding advance directives. Medical record review and staff interview showed no documentation that advance directive information or education had been provided to Residents #6, #10, #89, and #90 or to their resident representatives. These four residents were among six residents reviewed for advance directives during the recertification and complaint survey process. During interview, the Social Worker stated that residents or their responsible party are asked on admission whether an advance directive is in place, and if one is not in place, the facility provides the Maryland Attorney General's Office Advance Directive packet. The Social Worker also stated that documentation of the offer was inconsistent, saying, "sometimes I document, sometimes I don't." A subsequent record review of the four residents' charts and EHR confirmed there was no documentation showing that advance directive information or education had been provided to the residents and/or their Responsible Parties.
Missing ADL Care Documentation for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary assistance to maintain good nutrition, grooming, and personal and oral hygiene. Resident #118’s MDS, completed on 10/03/2025, assessed the resident as dependent for oral hygiene, toileting hygiene, shower/bath self, upper body dressing, lower body dressing, personal hygiene, and tub/shower transfer, with dependent defined as staff performing all of the effort or requiring assistance of two or more staff members. During interview, the resident’s family member reported concerns that the resident’s ADL care was not carried out on 11/09/2025. Record review of ADL documentation for that date showed no documented evidence of ADL care during the 1500-2300 and 2300-0700 shifts, with no documentation for bathing, bed mobility, bowel care, dressing, oral hygiene, personal hygiene, toileting, toileting hygiene, or transfers. The DON was interviewed regarding the missing documentation and acknowledged the concern.
Failure to Supervise Dependent Resident During Incontinent Care
Penalty
Summary
The facility failed to ensure a resident was free of accidents when GNA #7 provided incontinent care to Resident #2. During the care, the bed was raised to a high position and the resident was rolled onto the right side, after which the GNA told the resident she needed to get a washcloth and would be right back. The GNA left the resident unattended in that position with the bed still elevated, and the resident reported rolling off the bed onto the floor and hitting his/her head. The resident reported no injury from the fall. Resident #2’s MDS assessment identified the resident as dependent for incontinent care and requiring 2 staff assistance. During interviews, the NHA confirmed that GNA #7 left the resident unattended on his/her right side with the bed raised to a high position, resulting in the resident falling off the bed to the floor. The DON also confirmed that the MDS showed the resident was dependent and required 2 staff assistance when care was provided.
Medication Refrigerator Temperature Not Maintained
Penalty
Summary
The facility failed to store medications at the proper temperature in 1 of 3 medication storage refrigerators, specifically the refrigerator on the Western [NAME] Unit. During an observation with an LPN, the refrigerator was found to be at 64 degrees Fahrenheit while containing multiple medications, including Mounjaro autopens, Lispro autopens, Humulin 70/30 autopens, Lantus, acetaminophen suppositories, bisacodyl suppositories, and tuberculosis purified protein derivatives (PPD). An LPN stated that night shift staff check and document refrigerator temperatures nightly, but review of the Refrigeration Monitoring Quality Assurance Record log showed no documentation that the Western [NAME] Unit medication refrigerator had been checked on the night shift of 3/22/2026. The unit manager confirmed the temperature was too high, stated the refrigerator should be checked nightly and documented in the log, and confirmed it was not signed off as checked on 3/22/2026. The facility policy reviewed during the survey stated medication and biological storage temperatures should be maintained at 36 to 46 degrees Fahrenheit.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5% during a medication observation task, with 2 medication errors identified out of 37 opportunities for a rate of 5.41%. One error involved Resident #83, who had an active order for Carboxymethylcellulose Sodium ophthalmic drops, 1 drop in both eyes four times daily for dry eyes. During observation, CMA #10 completed medication administration without giving the ordered eye drops, and later stated she had given all medications due and did not see an order for the eye drops. She then confirmed the resident had an active order and returned to administer the drops. A second error involved Resident #2, whose MAR showed an active order for OxyContin 10 mg ER 12-hour tablet. While preparing medications, LPN #3 selected Oxycodone 10 mg instead of OxyContin 10 mg and administered it to the resident. She stated the resident had run out of OxyContin the day before, so she gave Oxycodone in its place, but she had not notified the doctor or obtained an order to substitute Oxycodone. Review of the MAR showed Oxycodone had been discontinued on 3/07/2026 and replaced with OxyContin 10 mg, and the resident had no active order for Oxycodone 10 mg. The MAR was signed off as OxyContin given even though Oxycodone was administered.
Sanitation and Dishwasher Temperature Deficiencies
Penalty
Summary
Food was not prepared and served on sanitary pans, dishes, and utensils. During an observation, a Dietary Aide was seen rinsing silver metal pans in a 3-bay compartment sink while only one bay contained water and the other two bays for washing and sanitizing were empty. When asked why the other bays were not filled, the Dietary Aide stated he was rinsing the pans before placing them in the dishwasher, so there was no need to fill the other two bays. The hot water dishwasher also failed to meet the required final rinse temperature. During an observation in the kitchen, the Surveyor and the CDM ran 5 trays through the dishwasher and the final rinse ranged from 138 to 140 degrees F. The CDM reviewed the March temperature log with the Surveyor, which showed the wash temperature at 150 degrees F and the final rinse at 180 degrees F each day from 3/1/26 through 3/26/26. The CDM stated that the repeated identical temperatures were unlikely because the final rinse was failing to meet 180 degrees F.
QAA Committee Lacked Required Members at Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee consisted of the minimum required members. During review of the QAPI binder, the Administrator reported that QAPI meetings were impacted by unfilled clinical staff positions. Record review of QAA committee meeting attendance and signatures showed that for the 10/23/2025 meeting there was no documented attendance or signature for the Administrator or Infection Preventionist, and for the 11/17/2025 and 12/19/2025 meetings there was no documented attendance or signature for the Infection Preventionist. During interview, the Administrator confirmed the missing attendance and signatures and acknowledged that the facility did not ensure the minimum required members were present at each QAPI meeting.
Infection Control Lapses With Foley Bag and Shared Equipment
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to provide a safe and sanitary environment for 2 of 20 residents observed for infection control. For Resident #2, the surveyor observed the bed in the lowest position with the Foley catheter bag attached to the right side of the bed and lying on the floor. The surveyor reported the observation to LPN #3, who then raised the bed so the Foley bag no longer touched the floor. During interview, LPN #3 acknowledged that the Foley bag should never touch the floor because of infection control concerns and stated she would speak with the unit manager about whether the Foley catheter bag should be replaced. The deficiency also involved reusable equipment used on two residents. During observation, LPN #3 used a portable blood pressure cuff and pulse oximeter on Resident #2 and then left the room and placed both items on top of the medication cart without cleaning them. Later, the same cuff and pulse oximeter were taken from the medication cart and used on Resident #130, and after that use the equipment was again placed on the medication cart without being cleaned. LPN #3 stated she should have cleaned the equipment after using it on Resident #2 and Resident #130, and the DON confirmed that the blood pressure cuff and pulse oximeter should have been cleaned after each use and before being used on another resident.
Incomplete Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to maintain an antibiotic stewardship program, and this deficiency was identified on 5 out of 5 antibiotic stewardship line listings reviewed during the recertification and complaint survey. The report states that the antibiotic stewardship program is intended to optimize the selection, dosage, route, and duration of antibiotic therapy, and that an Infection Preventionist is responsible for the facility's Infection Prevention and Control Program, including monitoring antibiotic usage. A review of a CDC certificate showed that the Unit Manager for the Western [NAME] Unit completed the Nursing Home Infection Preventionist Training Course on 3/06/2026. During interviews, she stated that she was the full-time Unit Manager for the Western [NAME] Unit and was assigned the role of Infection Preventionist, and she confirmed that monitoring antibiotic usage was the IP's responsibility. She later provided antibiotic stewardship line listings for October through March, but reported that the October and November 2025 listings were incomplete. Review of the line listings showed that October through February were incomplete for several residents, with missing infection sites, missing documentation of whether residents diagnosed with pneumonia had a chest x-ray, missing dates for completed chest x-rays, and the healthcare-acquired or community-acquired infection column not documented for most residents.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist at least part time to be responsible for managing its Infection Prevention and Control Program. During the recertification survey, record review showed a CDC certificate dated 3/24/2026 indicating that the Unit Manager for the Western [NAME] Unit completed the Nursing Home Infection Preventionist Training Course on 3/06/2026. During interviews, the Unit Manager stated that she was the full-time Unit Manager for the Western [NAME] Unit and had been assigned the Infection Preventionist role, but she did not have a lot of time to dedicate to the position because of her Unit Manager duties. She later reported that she had served as IP previously, that the role had been passed between the DON and the ADON, and that the IP position had been given back to her about three months earlier. The Administrator confirmed that the Unit Manager was full-time in her Unit Manager position and had the IP role added to that duty.
Laundry Room Environmental Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in the Laundry Washer Room and Laundry Folding Room. During observation, a leak was found dripping from a pipe in the ceiling and running down the wall near the dryer room, with a red bucket placed below to collect the water. Black staining was seen along the wall and on top of the Ecolab dispensing system box where the water had been leaking. A Laundry Aide reported the ceiling leak had been occurring off and on for a couple of months, and another Laundry Aide later reported the leak near the dryer room had been going on for a while and had been reported to maintenance. The Maintenance Director stated he did not know about the Laundry Washer Room leak at first and later reported the leak was coming from a kitchen drain that was old and not sealed well. The Nursing Home Administrator later stated the current maintenance reporting system for the Laundry area was not working and that staff would use a binder at the front desk to report concerns. Additional observations in the Laundry Washer Room showed large areas of peeling paint hanging from the ceiling and heating ducts, and an overhead pipe with torn insulation casing and exposed insulation. Visible dust was also observed on the vent ducts, on top of the washing machines, and on the hoses behind the machines. A washer on the left side of the room was observed leaking with a large puddle behind it, and a blanket had been placed under the leak. The Maintenance Director reported the ceiling needed repainting, the pipe needed to be rewrapped, and two leaks were discovered that needed repair on the washing machine. The Director of Environmental agreed the visible dust should not have been present on the vents, washing machines, or hoses.
Failure to Provide Psychiatric Evaluation for Resident with Trauma History
Penalty
Summary
The facility failed to provide a psychiatric evaluation for a resident who had a history of trauma from physical abuse. During a complaint survey, it was found that the resident reported an allegation of abuse by an LPN, who allegedly threw a cup filled with medication at the resident. Although the facility's investigation could not substantiate the abuse, it recommended a psychiatric assessment for the resident following the incident. A trauma-informed care assessment confirmed the resident's history of physical abuse and the need for psychiatric evaluation. However, a review of the resident's medical records revealed no evidence that the recommended psychiatric assessment was conducted during the resident's stay. The facility administrator confirmed this oversight during an interview.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility staff failed to transfer Resident #417 using a sit-to-stand transfer device, resulting in the resident sustaining a fracture to their right arm. The resident was at high risk for falls, as indicated in their fall prevention care plan. The Minimum Data Set (MDS) assessment showed that the resident depended on staff for transfers and required the support of two or more individuals. On the day of the incident, the resident was preparing to attend an activity when GNA 2 and GNA 3 entered the room to assist with the transfer. Despite the resident and GNA 3 indicating that a sit-to-stand device should be used, GNA 2 opted to manually lift the resident, leading to the injury. The incident report revealed that the resident informed the Director of Nursing that the aide did not transfer her correctly, and the resident experienced pain and heard a snap in her arm during the transfer. GNA 3 confirmed that the resident was a sit-to-stand transfer and offered to retrieve the device, but GNA 2 proceeded with the manual lift due to being in a hurry. The Director of Nursing confirmed that the sit-to-stand lift transfer had been in place since 2022, and GNA 2 did not follow the proper protocol. The resident was subsequently sent to the emergency room for treatment of the fractured arm.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to promptly report allegations of staff-to-resident abuse and injuries of unknown origin for four residents, as required by its own policy and regulatory expectations. In one instance, a cognitively intact resident reported that an LPN was rude and tossed a medication cup onto her roommate's bed, and that a GNA was similarly rude and dismissive when she requested assistance. The resident reported the incident to the Unit Manager, who acknowledged that the incident should have been reported to the Director of Nursing (DON) but was only mentioned informally and not through official channels. Another resident, also cognitively intact, reported to the Unit Manager that an LPN threw her medication cup onto her bed and told her to take what she wanted, which was corroborated by her roommate. The DON admitted that she had not reported the incident because she did not realize it required investigation. In both cases, the facility's policy requiring prompt reporting to authorities was not followed, and the incidents were not officially documented or reported as potential abuse. For two other residents with severe cognitive impairment, staff discovered unexplained bruising and injuries. In one case, a large bruise was found on a resident's left flank, and in another, a bruise was noted on the right eye socket. Staff reported these findings to supervisors and discussed them in clinical meetings, but there was no evidence that the injuries were reported to the state agency as required. Similarly, another resident with severe cognitive impairment was found to have bruising and swelling on the inner thigh, which was reported internally but not to the state agency. Interviews with staff and administration confirmed that these injuries of unknown origin were not reported within the required timeframe, and in some cases, not reported at all.
Ice Machines Not Maintained in Clean Condition
Penalty
Summary
Surveyors observed that the facility failed to maintain cleanliness of the ice machines located in both the kitchen and the Southern Shore unit nourishment room. The kitchen ice machine was found with clear and brownish colored smears, debris on the exterior, and an orangish film on the interior front surface. Similarly, the ice machine in the Southern Shore unit nourishment room had clear and brownish colored smears with debris. The Assistant Dietary Manager confirmed the presence of these smears and debris on both machines. The Maintenance Director stated that maintenance staff cleaned the inside of the machines while kitchen staff cleaned the exterior, but the cleaning log only documented quarterly clean-outs and filter changes without specifying if the entire machine was cleaned inside and out. The DON was unsure who was responsible for cleaning the ice machines, noting that it had been a group effort involving maintenance, kitchen, and housekeeping staff. Requested policies regarding ice machine cleaning were not provided before the end of the survey. This deficiency had the potential to affect 97 of 98 residents in the facility, as noted by the surveyors.
Failure to Implement Functional Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain a functional Antibiotic Stewardship Program in accordance with its own policy and the McGeer Criteria for antibiotic prescribing. Specifically, a resident with diagnoses including diabetes mellitus and morbid obesity was prescribed Ciprofloxacin for a urinary tract infection (UTI) without documented evidence of signs or symptoms that would warrant the collection of a urine specimen or the initiation of antibiotic therapy. The resident's electronic medical record showed a urine specimen was collected, but there was no prior documentation of a change in condition or physician order for the specimen collection. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the required review of the resident's chart to ensure compliance with McGeer's criteria was not performed. The IP was unable to confirm whether the resident met the necessary clinical criteria for a UTI, as the nurse had not documented any relevant signs or symptoms. The DON acknowledged that it is the IP nurse's responsibility to review each antibiotic order for compliance, indicating a lapse in the facility's antibiotic stewardship process.
Failure to Provide Vaccine Education and Obtain Consent for Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide required education and obtain consent or declination for influenza and pneumococcal vaccinations for four out of five sampled residents, as identified through record review, interviews, and facility document review. According to the facility's own policies and CDC guidelines, residents or their representatives should receive education about these vaccines, and documentation of education, consent, or refusal must be maintained in the medical record. However, for the residents reviewed, there was no documented evidence that education was provided or that consent or declination was obtained for either the flu or pneumococcal vaccines. Specifically, one resident with diabetes mellitus and chronic obstructive pulmonary disease received a flu vaccine and previously refused a pneumococcal vaccine, but there was no documentation of education or offer of the pneumococcal vaccine since a prior date. Another resident with asthma and myocardial infarction received a flu vaccine, but there was no evidence of education or offer of the pneumococcal vaccine. A third resident with atrial fibrillation, a stage four pressure ulcer, and hypertension received both vaccines at different times, but again, there was no documentation of education or offer of the pneumococcal vaccine since admission. The fourth resident, with heart failure, atrial fibrillation, and vascular dementia, also received both vaccines, but lacked documentation of education or offer of the pneumococcal vaccine since admission. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed confusion regarding responsibilities for providing education, obtaining consent, and documenting these actions. The IP stated that education and consents were provided but admitted to erroneously marking forms in a way that indicated education or offers were not made. This lack of proper documentation and process adherence resulted in the identified deficiency.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 57, who was severely cognitively impaired with a BIMS score of zero, wandered into Resident 58's room. Resident 58, who was not cognitively impaired with a BIMS score of 12, became startled and yelled at Resident 57 to leave. Due to limited impulse control from dementia, Resident 57 shoved Resident 58, causing her to fall. The incident was witnessed by staff, and Resident 58 reported pain in the back of her head but was stable and able to walk with a cane after being assisted up. The facility's policy on abuse and neglect states that residents have the right to be free from abuse by anyone, including other residents. However, the facility's interventions for Resident 57, who was known to wander and become confused about room locations, were insufficient to prevent the incident. Staff had to redirect Resident 57 frequently, and a sign was put up after the incident to help him identify his room. The Director of Nursing at the time of the report was not aware of the incident, as she was not in the position when it occurred.
Failure to Update Care Plans After Allegations of Abuse
Penalty
Summary
The facility failed to update the care plans of two residents following allegations of inappropriate conduct by staff members. Resident #406 reported being touched inappropriately by a male GNA, as documented by a hospice volunteer. Despite the allegation, a review of the resident's medical record revealed no evidence of any changes made to the care plan to address this change in condition. Interviews with the Social Work Director and nursing staff confirmed that the facility's policy requires a review and update of the care plan following such incidents, but this was not done in this case. Similarly, Resident #407 alleged being slapped in the face by a staff member, as reported to the resident's spouse. A review of the medical record showed no updates to the care plan following this allegation. The Director of Nursing and the Administrator acknowledged that the care plan should have been reviewed and updated in response to the change in condition, but confirmed that no such changes were made. These findings were identified during a complaint survey conducted by the State of Maryland's Office of Health Care Quality.
Failure to Implement Trauma-Informed Care
Penalty
Summary
The facility failed to develop and implement a process to ensure that residents with a history of trauma received appropriate trauma-informed care. This deficiency was identified for three residents. Resident #421 felt uncomfortable during a bath by a Geriatric Nursing Assistant, and later disclosed a history of sexual abuse, which was not updated in the trauma-informed care assessment. The Director of Social Work acknowledged the oversight in updating the assessment after the resident revealed the trauma. Resident #406 alleged inappropriate touching by a male staff member, but no trauma-informed care assessment was conducted following the allegation. Similarly, Resident #407 reported being slapped by a staff member, yet there was no evidence of a trauma-informed care assessment after the incident. Interviews with the Director of Nursing and Administrator confirmed that trauma-informed assessments should be conducted at admission and after any change in condition, but these were not completed for the residents involved.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of unknown origin for two residents who were reviewed for abuse. For one resident with severe cognitive impairment, a nurse discovered swelling and bruising on the right inner thigh during medication administration. The incident was reported to the on-call advanced practice nurse, the resident's daughter, and the supervisor, but no investigation was conducted to determine the cause of the injury. Both the DON and the Administrator confirmed during interviews that the incident was not investigated, despite acknowledging that it should have been. For another resident, who had no cognitive impairment, staff observed a bruise on the left flank during routine care, and the resident exhibited discomfort. The bruise was reported to the unit manager and discussed in clinical meetings, but staff were unable to determine the cause. Additionally, a bruise to the right eye socket was noted, which the unit manager did not report immediately, believing it was not severe. The DON and Administrator both confirmed that these injuries were not investigated, and documentation regarding the determination of the cause was not provided. The facility's policy requires all injuries of unknown origin to be promptly reported and thoroughly investigated, which was not followed in these cases.
Failure to Provide Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident's prescribed medications were available and administered according to the physician's orders. The resident, who was admitted with diagnoses including complete intestinal obstruction, surgical aftercare, and hypertension, had orders for Pramipexole Dihydrochloride ER for restless leg syndrome and carvedilol for hypertension. Review of the Medication Administration Record showed that Pramipexole was marked as on hold for several consecutive days, and carvedilol was also marked as on hold on one occasion. Documentation indicated that the medications were not available from the pharmacy during these times. During interviews, the LPN responsible for administering the medications stated uncertainty about why the medications were documented as on hold, but suggested it was likely due to the medications not being received from the pharmacy. The LPN also indicated that they did not check the facility's stock for available medications. The Director of Nursing confirmed that if the medications were not present, the nurse should have notified the physician, but there was no confirmation that this occurred.
Medication Cart Left Unlocked and Unattended During Medication Pass
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to secure a medication cart during a medication pass. The RN left the medication cart unlocked and unattended outside a resident's room, with an insulin pen placed on top of the cart. While the RN was inside the resident's bathroom, both the cart and the medication were out of her sight. This action was observed during a blood sugar check for the resident. Facility policies require that medication carts be locked at all times when not in the nurse's view and that all drugs and biologicals be stored securely. The RN confirmed during an interview that she had left the cart unlocked with the insulin pen on top, acknowledging that she should have secured the medication. The Director of Nursing also stated that the expectation is for medications to be securely stored and carts to be locked when not within staff sight.
Failure to Safeguard Electronic Medical Records
Penalty
Summary
Facility staff failed to safeguard resident-identifiable information in accordance with their policy on electronic medical records. During a blood sugar check, a registered nurse left a computer unlocked and unattended on top of the medication cart, exposing resident information while washing hands in a resident's bathroom. The nurse confirmed the computer was left open and acknowledged this was improper. In a separate incident during a medication pass, a unit manager left the computer open with resident information visible on the medication cart while leaving to obtain cups, with the computer out of reach and sight. The unit manager also acknowledged the failure to lock the computer. The Director of Nursing confirmed that exposing protected health information was unacceptable.
Failure to Follow Infection Control Protocols and Safe Medication Handling
Penalty
Summary
Staff failed to follow appropriate infection prevention and control protocols for a resident on contact precautions due to a methicillin-susceptible Staphylococcus aureus (MSSA) infection. The resident, who was cognitively intact and had a history of MSSA bacteremia, pneumonia, and congestive heart failure, was placed on contact isolation as indicated by physician orders and facility policy. Despite clear signage and policy requirements for the use of gowns and gloves upon entering the resident's room, a registered nurse entered the room and connected intravenous antibiotics to the resident's PICC line without donning any personal protective equipment (PPE). When questioned, the nurse stated a belief that PPE was unnecessary because the resident's infection was limited to the lungs, which contradicted both the facility's policy and the infection control preventionist's instructions. Additionally, staff did not adhere to infection control procedures during medication administration. During medication passes, a medication technician dropped a pill onto the medication cart, picked it up with bare hands, and intended to administer it to a resident. In a separate incident, a unit manager dropped a pill onto a piece of paper on the medication cart and then scooped it up with a medication cup, expressing uncertainty about the cleanliness of the paper. Both staff members acknowledged during interviews that these actions were not in line with proper infection control practices, and the director of nursing confirmed that dropped medications should be disposed of and not administered. These observations demonstrate a failure to consistently implement the facility's infection prevention and control policies, specifically regarding the use of PPE for residents on contact precautions and the handling of medications to prevent contamination. The deficiencies were identified through direct observation, interviews with staff, and review of facility policies and resident records.
Deficiency in Facility-Wide Assessment and Water Management Program
Penalty
Summary
The facility failed to revise and document an accurate, up-to-date facility-wide assessment, which is crucial for determining the necessary resources to care for residents during both regular operations and emergencies. This deficiency was identified during a complaint survey, which included a review of the facility's emergency preparedness plan. The assessment did not account for potential emerging infections and illnesses, nor did it include a plan for identifying, treating, and preventing the spread of organisms within the facility. This oversight has the potential to affect all residents in the facility. Interviews with facility staff revealed further issues with the facility's water management program. The Infection Control Preventionist (ICP) confirmed the existence of a water management program but noted a lack of meetings or discussions regarding water-based infections or risk assessments. The director of maintenance acknowledged that the water management plan was developed under a previous administrator but admitted that the current staff has not reviewed the plan since its creation. These inactions contributed to the facility's failure to maintain an effective and updated facility-wide assessment.
Infection Control Deficiencies in Respiratory Illness Notification and Water Temperature Monitoring
Penalty
Summary
The facility failed to maintain an effective infection control program by not informing residents, their representatives, and families of the occurrence of three or more residents or staff with new onset of respiratory symptoms within 72 hours of each other. This was evident on three different occasions in June 2024. Despite the facility administrator meeting with staff and residents on June 21, 2024, to discuss precautions for a respiratory illness, there was no documentation of resident and staff attendance at this meeting. The health department was first informed of the pneumonia outbreak on June 6, 2024, after two cases were identified on June 5, 2024, and the facility remained on outbreak status as of June 26, 2024. Additionally, the facility did not ensure consistent infection prevention monitoring for waterborne infections, as evidenced by low resident hand sink water temperatures. During a walking tour, it was found that seven rooms on the East Wing had hot water temperatures below the required minimum of 100 degrees Fahrenheit. The maintenance department's records showed that the hot water temperatures were consistently below the required level on several days in June 2024. The assistant director of maintenance confirmed that individual resident room temperatures were not measured, and the recorded temperatures were taken from the facility boiler room.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 167 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Prince Frederick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Charlotte Hall Veterans Home | 11.3 mi | ★★★★★ | 7 | 0 |
| Asbury Solomons | 16.5 mi | ★★★★★ | 0 | 0 |
| Solomons Nursing And Rehab Center | 16.6 mi | ★★★★★ | 1 | 0 |
| St. Mary's Nursing Center Inc | 18.2 mi | ★★★★★ | 0 | 0 |
| Waldorf Center | 18.4 mi | ★★★★★ | 27 | 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.