Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 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 Carroll Park Healthcare during CMS and state inspections, most recent first.
Inaccurate MDS coding was identified for two residents. One resident was transferred to the hospital for dehydration after unsuccessful IV access attempts and later died in the ED, but the MDS discharge coding was entered incorrectly. Another resident’s quarterly MDS failed to code an ordered and administered antipsychotic medication, Invega Sustenna, in Section N. The MDS coordinator confirmed the coding errors.
Failure to document and treat prolonged absence of bowel movement: A resident with quadriplegia, a feeding tube, and polyneuropathy had no documented BM for 8 days, with no progress note documentation of constipation, abdominal assessment, or provider notification. The resident also had no PRN constipation medication orders during that period, despite receiving multiple PRN oxycodone doses for pain. The DON and an ADON stated that bowel protocol should be initiated after 3 days without stool and that GNAs should document BMs in the task section.
A resident at the nursing station became upset about delayed laundry and began yelling and cursing at a GNA after being told the dryer was down. The resident then threw an iPad and a heavy metal snack tray toward the GNA and two LPNs seated at the nurses’ station. The GNA caught the tray and slammed it down on the desk, striking the resident’s hand, which was resting on the desk, and causing a broken fingernail. This incident reflects a failure to ensure the resident was free from abuse.
Improper Linen Storage and Laundry Room Door Control: Clean linen was observed exposed on an uncovered cart and table in the clean laundry room while the door from the common hallway was propped open and a fan was blowing air into the room. The door between the clean and dirty laundry rooms was also propped open, and the dirty laundry room had dust-covered vent tubing. The ES Director stated both doors were expected to stay shut, but staff were propping them open because the room was hot and ventilation was poor.
Failure to honor a resident's bathing preference. A resident stated they had not received a shower after moving to another unit and had only been given bed baths, despite an MDS noting it was very important for the resident to choose how they are bathed. Shower logs did not show documentation for the resident, and the UM later confirmed there was no proof the resident received a shower during the month reviewed.
Advance Directive Not on File for A Resident: Staff failed to ensure an advance directive was on file for a resident even though a social service assessment documented that one was on file. The resident’s electronic and paper chart had no evidence of the document, and the DON later acknowledged the facility did not have it on file as previously documented.
Missing PASARR Screening Documentation: A resident admitted with paranoid schizophrenia had no evidence of a Level I PASARR in the chart at the time of survey record review. The DOSS said PASARRs are completed before admission and annually, but she was new and unfamiliar with the EMR. The PASARR was later provided and showed it had been completed by the Regional SW after the surveyor requested it.
Discharge Planning and Care Plan Follow-Up Not Addressed: A resident reported concerns about discharge plans and said they had not participated in a care plan meeting in some time. The record showed the resident asked about possible discharge and the SW said they would look into a waiver program, but later documentation did not show follow-up on discharge or waiver status. The DON could not provide evidence of the housing waiver program status or the attendee list/signatures for the later care plan meeting, and the documentation was inconsistent about whether the resident attended the care plan conference.
Missed Quarterly Care Plan Meetings: The facility failed to hold quarterly care plan meetings for two residents reviewed. One resident reported not participating in a care plan meeting in quite some time, and the record lacked clear evidence of follow-up on discharge and waiver concerns or attendee documentation for a later meeting. Another resident stated he/she had never had a care plan meeting, and the chart showed no documented care plan meeting after the last one noted in the record.
A resident with CHF had repeated gaps and mismatches in weight documentation, with TAR entries not matching the recorded weights or the resident’s updated weight schedule. In addition, two LPNs documented refusals of medications and supplements that were not observed being offered or refused during med pass, resulting in incorrect MAR documentation.
A resident reported itchy, scratchy eyes and said they had not seen an eye doctor. The chart showed multiple ophth consult orders for decreased vision and eye evaluations, and provider notes documented repeated requests for an ophth consult for itchy, watery eyes. Review of consult notes showed the resident had not been seen since early February, and the Unit Manager stated the resident had not been seen when the ophth was last in the facility.
Surveyors observed multiple large insects in common areas and reviewed pest control logs documenting repeated roach and mice sightings throughout the facility, including a significant number of mice on one floor. Staff interviews confirmed awareness of ongoing pest issues, but recent sightings had not been addressed, indicating a failure to maintain an effective pest control program.
The facility did not maintain or provide required investigation documentation for two reported incidents involving two residents—one alleging theft of money and another exhibiting unusual drowsiness. In both cases, only minimal or no investigation records were available when requested by surveyors, and facility leadership acknowledged that these records should have been retained and accessible.
A resident with intact cognition requested that a Geriatric Nursing Assistant stop providing care and leave the room, but the staff member continued despite the resident's wishes. Another staff member present confirmed the resident's request was ignored, resulting in a failure to protect the resident from abuse.
A resident reported an allegation of physical abuse by a staff member, and despite facility policy requiring immediate removal of the alleged perpetrator, the staff member continued to work their shift after the allegation was reported. Timecard records and HR confirmation showed the policy was not followed.
The facility did not report unusual occurrences and abuse allegations within required timeframes, including failing to notify law enforcement when a resident alleged a nurse pulled their mask, yelled, and took a video without consent. In another case, a resident was found unresponsive and the incident was not reported promptly, and a sexual assault allegation was not reported within the mandated two-hour window.
Staff did not ensure accurate nutritional assessment or documentation for a resident with quadriplegia, resulting in outdated weight records and discrepancies between reported and actual meal intake. Additionally, staff failed to follow a physician order for contracture management for another resident, with repeated lapses in the use and documentation of a prescribed palm grip device.
A resident did not receive a scheduled wound dressing change as ordered by the physician, and there was no documentation explaining the missed treatment. The last dressing change was performed outside the prescribed schedule, and the DON confirmed that staff are expected to document all wound care, including missed treatments.
A GNA was found to have an expired certification during a surveyor's review of employee files. The HR Director, responsible for tracking certification expiration dates, acknowledged the lapse as an oversight. The GNA was not on duty at the time the deficiency was identified.
Surveyors found that annual performance reviews for all GNAs reviewed were missing from employee files. Despite repeated requests, neither the HR Director nor the DON could provide the required documentation, revealing a failure to conduct and maintain annual GNA performance evaluations.
Staff documented a blood pressure reading for a resident after the individual had already been discharged and transferred to the hospital. The DON confirmed that no vital signs should be recorded post-discharge and could not explain the inaccurate entry.
The facility failed to adequately assess and supervise residents who were known smokers, leading to multiple incidents of unsafe smoking behavior. Residents were found smoking in their rooms despite being assessed as safe smokers requiring supervision. Additionally, the facility failed to ensure that residents' rooms were free from hazards, contributing to the deficiency.
The facility failed to use the QAPI process to track, review, and analyze drug overdoses, resulting in 23 SPAEs and six fatalities. Despite discussing drug use in QAPI meetings, no performance improvement plan was implemented. The facility's failure to address this issue led to multiple resident deaths.
The facility failed to provide CPR for a resident with a full code status. An LPN found the resident unresponsive and did not initiate CPR, instead calling an RN who also did not perform CPR, mistakenly believing the resident had a DNR order. The resident's chart indicated a full code status, and the facility's policy was not followed.
The facility failed to timely implement physician instructions and orders related to SUD treatment, effectively plan care for residents with SUD, and initiate a SUD care plan for residents identified with SUD. This led to multiple overdose events and placed residents at increased risk for serious harm and possible death.
The facility administration failed to provide effective oversight, resulting in immediate jeopardy for resident safety due to inadequate supervision of smoking, inconsistent monitoring of substance abuse, and poor maintenance and pest control. These failures led to repeated citations and actual harm to residents.
The facility's staff failed to ensure a sanitary and safe environment for a resident. Observations revealed used paper towels under the sink, a ceiling tile off the track, torn curtains, and a damaged bathroom door. Despite daily rounds, staff were unaware of these issues, which remained unaddressed upon follow-up.
The facility failed to store and prepare food in accordance with professional standards, with multiple instances of improperly stored and expired food, a malfunctioning ice maker, low sanitizing solution levels, and wet nesting of kitchenware observed during a survey.
The facility staff failed to ensure that resident rooms were free from mice, as evidenced by observations and interviews with two residents. Despite pest control reports identifying mice as an issue months prior, staff were not using the designated logbooks to report sightings, opting instead for an electronic system. The Maintenance Director was unaware of the reliance on logbooks for pest management.
The facility failed to facilitate care plan meetings for five residents, as evidenced by interviews and medical record reviews. Residents and their representatives reported infrequent or non-existent meetings, and staff admitted to not scheduling these meetings as required.
The facility failed to inform residents of their right to formulate advanced directives, affecting five residents. The Social Service Director and Nursing Home Administrator confirmed that residents were not asked if they wanted to create advanced directives unless they specifically requested it. Additionally, one resident had no MOLST form or code status indicator in their medical record.
The facility failed to maintain appropriate temperature control for medication storage, properly waste narcotic medications, and secure medications and treatments. Observations included expired medications, an unlocked medication cart, a pill on the floor, and a medication cup left on a resident's bedside table. Staff admitted to not following proper procedures.
A facility with over 120 beds experienced a 5-month period without a qualified, full-time Social Worker overseeing social service duties. Employee records indicated a staffing gap from March to September 2022, during which individuals without the required qualifications were employed as Social Service Director. The Nursing Home Administrator confirmed the absence of a qualified Social Worker during this time.
The facility failed to maintain a sanitary environment, with food trays left in hallways and on PPE storage bins. Two residents experienced issues with room conditions: one had unpacked belongings and a non-functional closet, while another had a room with a mattress on the floor, chipped paint, a damaged A/C unit, and a clogged toilet. Staff were aware but did not promptly address these issues.
The facility failed to report allegations of abuse to the state agency within the required timeframe for three residents. One resident alleged being struck and kissed, another felt mistreated and did not want to return to the facility, and a third abuse incident was reported late. These delays in reporting violated the mandated 2-hour reporting window.
The facility staff failed to thoroughly investigate and accurately report allegations of abuse, affecting 12 out of 30 residents reviewed. Incidents involving injuries, theft accusations, and altercations were not properly documented or investigated, compromising resident safety and well-being.
A facility did not develop a care plan for a resident with chronic respiratory conditions and tobacco use, despite identifying the resident as an unsafe smoker requiring supervision. Additionally, the facility failed to involve the Power of Attorney (POA) in care plan meetings for another resident. Several residents reported not being informed about or invited to care plan meetings, and there was a lack of timely scheduling and documentation of these meetings. The Social Work Director, responsible for planning care plan meetings, could not provide sign-in sheets for some residents, indicating organizational issues in the care planning process.
A survey identified deficiencies in medication administration and documentation processes. One resident with Diabetes Mellitus lacked a sliding scale in their insulin order, potentially affecting blood sugar management. Another resident with end-stage renal disease and dialysis dependence had incomplete documentation on the Dialysis Communication Form, raising concerns about the transfer of vital health information between the facility and the dialysis clinic.
The facility staff failed to ensure residents received quality care, including timely medication administration, catheter care, and intervention for acute changes in condition. Several residents experienced delays or missed doses of critical medications, improper documentation, and lack of timely medical intervention, leading to severe health complications.
The facility staff failed to appropriately administer pain medications as ordered for three residents. One resident was given Oxycodone despite reporting a pain level of 0, another received medication outside the prescribed pain scale due to staff intimidation, and a third experienced significant delays in receiving pain medication after hospital readmission. The facility's pain management policy was not followed, and staff interviews confirmed the deficiencies.
A resident with polyneuropathy and kidney failure requiring dialysis experienced significant medication errors due to inaccurate transcription and administration of Gabapentin. The resident missed 74 doses over several months, as the Nursing Unit Coordinator failed to detect discrepancies in the Medication Administration Record (MAR).
The facility experienced issues with maintaining accurate resident records, leading to discrepancies in documentation. For one resident, conflicting information about dental status was found in various assessments. Additionally, incorrect room name displays caused confusion for multiple residents. Another resident faced inadequate documentation and implementation of physician orders, particularly concerning hypoglycemia management and essential care needs like nutritional monitoring and dialysis access. Discharge instructions from hospitalizations were also not promptly addressed or accurately documented, impacting the resident's care plan.
The facility failed to provide timely psychiatric care for two residents with mental disorders. One resident experienced a delay in receiving recommended medication, leading to aggressive behavior and hospitalization. Another resident did not receive individual therapy due to a communication error regarding insurance approval.
A resident expressed a desire to be discharged home but did not receive social work assessments or discharge planning. The Social Services Director noted the absence of an active social work department upon her arrival, with temporary assistance provided only for discharge planning, not for completing social histories or care plan meetings.
The facility failed to provide a bariatric bedside commode for a resident, despite repeated requests. The standard-sized commode was too small, and the bathroom toilet was too low for the resident to use. Staff indicated that obtaining bariatric equipment was straightforward, but the commode was only delivered shortly before the resident's discharge.
The facility failed to provide written transfer notices to two residents and did not notify the Ombudsman of resident transfers in a timely manner. One resident was transferred to the hospital due to an unwitnessed fall, and another due to hypoglycemia, but neither received written notices. Additionally, the facility delayed notifying the Ombudsman of transfers and discharges.
The facility failed to ensure residents and their representatives were informed of the bed hold policy during hospital transfers. Two residents were transferred without proper documentation or communication of the policy, revealing inconsistencies among staff in implementing this procedure.
The facility failed to accurately assess two residents for antipsychotic medications and behaviors. One resident's MDS was incorrectly coded, omitting the need for an antipsychotic medication review. Another resident's MDS had dashes in sections for cognition and behavior, despite a documented history of behaviors, due to incomplete nursing documentation.
The facility failed to develop and implement a baseline care plan for a resident requiring hemodialysis and experiencing recurrent hypoglycemic episodes within 48 hours of admission. The resident was transferred to the ER due to hypoglycemia shortly after being taken to the dialysis clinic, highlighting the lack of proper care planning and coordination between the facility and the dialysis provider.
The facility did not create timely comprehensive care plans for two residents. One resident, admitted with PTSD and adjustment disorder, had a care plan for psychological services developed 10 months post-admission. Despite multiple psychiatric visits, there was a 5-month gap without documented visits, indicating a delay in addressing mental health needs.
Inaccurate MDS Coding for Hospital Transfer and Antipsychotic Medication
Penalty
Summary
Facility staff failed to accurately code residents’ status on the MDS assessments. For one resident, the record showed a readmission to the facility followed by transfer to the hospital via EMS after the resident became dehydrated, required IV normal saline, and had unsuccessful attempts to establish IV access. The provider ordered hospital transfer, the spouse was notified, and 911 was called. Hospital records later showed the resident arrived with altered mental status, dehydration, and shortness of breath, had a history that included peripheral vascular disease, coronary artery disease, chronic kidney disease, hypernatremia, sacral pressure ulcers, an open amputation wound, osteomyelitis, hypertension, and a small bowel obstruction with colostomy, and died shortly after arrival in the ED after cardiopulmonary arrest. The MDS coordinator stated that unplanned hospital discharges were coded as discharge return anticipated when the facility expected the resident to return, and that staff would follow up with the hospital to determine whether the resident had been admitted. She also stated she was not aware the resident had expired shortly after transfer, had not completed the original discharge coding, and acknowledged that the discharge coding was incorrect. The DON stated the resident had declined, was transferred for dehydration and unsuccessful IV access attempts, and the facility later learned the resident died a few hours after transfer to the ED. For another resident, the EMR showed diagnoses including schizoaffective disorder and major depressive disorder, and the facility physician prescribed Invega Sustenna to be given IM every 28 days. The resident’s quarterly MDS failed to document the antipsychotic medication in Section N. The MDS coordinator confirmed that the MDS did not accurately document the resident’s medications because it failed to code for antipsychotics.
Failure to Document and Treat Prolonged Absence of Bowel Movement
Penalty
Summary
The facility failed to provide care in accordance with the standards of practice for Resident #28 when the resident had no documented stool for 8 days, from 05/03/2026 through 05/10/2026. The resident was admitted with diagnoses including C5-C7 complete quadriplegia, status post gastrostomy, and polyneuropathy. During this period, there was no evidence in the bowel movement task section or progress notes that the resident had a bowel movement, and there was no documentation of constipation, an abdominal assessment, or notification of a provider regarding the lack of bowel movement. The resident’s orders also lacked any PRN medication orders to relieve constipation during this time frame. The record showed that the resident received 17 doses of PRN oxycodone for pain during the same 8-day period. During interviews, the DON stated that when a resident has not had a stool for 3 days, staff confirm the absence of stool and initiate the bowel protocol, which includes PRN medications such as a fleets enema, stool softener, and miralax. The ADON/unit manager stated that when residents are without stool for 3 days, the nurse calls the physician for a fleets enema order and confirmed that GNAs should document bowel movements in the bowel movement task section.
Failure to Protect a Resident From Abuse During Altercation With GNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse during an altercation with a GNA. On the date of the incident, the resident was at the second-floor nursing station complaining that their laundry had not been returned. GNA #5 explained that the dryer was down, which was why the clothes were delayed. The resident then began cursing and yelling at the GNA. During this exchange, the resident picked up an iPad and a heavy metal snack tray and threw them toward GNA #5 and two LPNs who were seated at the nursing station. According to the DON and staff interviews, GNA #5 caught the metal tray and then slammed it down on the nursing station desk, striking the resident’s hand, which was resting on the desk. This action caused the resident to sustain a broken fingernail. The incident occurred at the second-floor nursing station and was witnessed by LPN staff who confirmed the sequence of events, including the resident’s verbal outburst, the throwing of the items, and the GNA’s response that resulted in injury to the resident’s hand.
Improper Linen Storage and Laundry Room Door Control
Penalty
Summary
The facility failed to store and process linens to prevent the spread of infection. During an observation of the laundry area, the door from the common hallway into the clean laundry room was propped open all the way, and a large fan in the doorway was on and blowing air from the common hallway into the clean room while staff were actively folding clean linen. Clean laundry, including towels, reusable bed pads, comforters, sheets, resident gowns, and blankets, was folded and stacked on an uncovered linen cart and on a rectangular table in the clean laundry room, with several layers of linen exposed. Additional observation showed more clean linen stacked several layers high across the width of the table, with some layers stacked against the wall and no covering over the linen. In the dirty laundry room, the ceiling had multiple vent tubings extending across the room that were covered in layers of dust. The door between the dirty and clean rooms was also propped open all the way, and there was an additional fan in that doorway. The Environmental Services Director stated that both doors were expected to be shut at all times, but also said the ventilation in the room was poor and that staff prop open the doors and use fans because the clean linen room gets hot. The DON later reviewed the concern and indicated understanding.
Failure to Honor Resident Bathing Preference
Penalty
Summary
The facility failed to honor a resident's preference for how they were bathed by not providing showers as requested. Resident #84 stated that after being moved to the second floor in early November, they had not received a shower and had only been given bed baths. The resident's Annual MDS indicated that it was very important to the resident to be able to choose how they were bathed. Review of the second floor shower logs did not show shower forms completed for the resident in November. A GNA stated that when a resident receives a shower, staff are expected to complete a shower form and place it in the shower log book, and that if the form is not in the log book, the resident most likely did not get a shower. The second floor Unit Manager stated that shower forms should be completed and filed in the log book or documented in PCC if a shower is refused, but no forms for Resident #84 were found, and on follow-up she stated she was not able to find any proof that the resident had received a shower in November.
Advance Directive Not on File for Resident
Penalty
Summary
Facility staff failed to ensure that an advance directive was on file for Resident #75, despite a social service assessment documenting that the resident had an advance directive on file. During the annual survey, the Director of Social Services stated that newly admitted residents should have an advance directive prior to admission, at admission, or be offered the paperwork during the care plan meeting. When asked about Resident #75’s advance directive, she said she would follow up with her team to obtain the information. A review of Resident #75’s medical record showed that the social worker documented the resident had an advance directive on file, but the electronic and paper chart contained no evidence of one. The DON was asked to provide the document and stated that the social worker who completed the assessment was no longer employed at the facility. A later social service note stated that attempts had been made to obtain an advance directive and that the facility had contacted the resident’s family member multiple times without response. The DON later uploaded an advance directive into the chart and provided a copy signed on May 6, 2025, acknowledging that the facility did not have the advance directive on file as previously documented.
Missing PASARR Screening Documentation
Penalty
Summary
Failure to provide evidence that a Level I PASARR screening was completed prior to admission or at the time of admission was identified for a resident admitted in November 2024 with multiple diagnoses, including paranoid schizophrenia. During record review on 11/20/2025, the resident’s electronic and paper medical records did not show evidence of a PASARR. The report states that the PASARR process requires all applicants to Medicaid-certified nursing facilities to be screened for possible serious mental disorders, intellectual disabilities, and related conditions before admission, and that this initial Level I screening is used to identify individuals who may require a Level II evaluation and determination prior to admission. During an interview on 11/20/2025, the Director of Social Services stated that PASARR screenings are completed prior to admission and annually, but she was recently hired and unfamiliar with the electronic medical record system and needed to speak with her team before providing additional information. By 2:30 PM, no response had been received from her, and the surveyor requested evidence of a PASARR from another staff member. The PASARR document was later received on 11/21/2025, and review showed the screen had been completed by the Regional Social Worker on 11/20/25 at 2:52 PM.
Discharge Planning and Care Plan Follow-Up Not Addressed
Penalty
Summary
Facility staff failed to ensure Resident #52’s discharge planning needs were addressed and failed to follow up on the resident’s request for discharge. During an interview on 11/19/25, the resident stated concerns about discharge plans and reported not having participated in a care plan meeting in quite some time. The medical record showed a care plan conference note dated 07/31/25 in which the social worker documented that the resident and interdisciplinary team met, and the resident asked about possibly being discharged at some point. The social worker noted they would look into the waiver program for the resident. Further review of the record showed a social services progress note dated 09/30/25 that did not document any follow-up with the resident regarding discharge or the waiver program. When the surveyor requested evidence of the resident’s housing waiver program status, the DON was unable to provide it. The DON also acknowledged that the facility uses a care plan meeting log, but was unable to provide the list and signatures of attendees for the 09/30/25 meeting. The surveyor noted that the 09/30/25 social worker note did not appear to be a care plan conference meeting note because it did not show the resident attended or that the interdisciplinary team participated, and the facility’s July 2025 care plan log included a note indicating the resident refused, which conflicted with the electronic care plan conference note showing the resident was in attendance.
Missed Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for 2 of 3 residents reviewed for care planning. For Resident #52, the record showed a care plan conference note indicating a meeting was held with the resident and the interdisciplinary team, and the resident asked about possible discharge and a housing waiver program. However, a later social services progress note did not show any follow-up regarding the discharge question or waiver program, and the Director of Nursing was unable to provide evidence of the resident's housing waiver program status or the list and signatures of attendees for the later meeting date that was requested during survey review. For Resident #3, the resident stated that he/she had never had a care plan meeting. Record review showed the last documented care plan meeting was on 04/16/2025, and no further care plan meeting documentation was found after that date. When the issue was reviewed with the Regional Social Worker, she stated there was no documentation of a care plan since 04/16/25 for Resident #3 and that if it was not documented then it was not done. The DON later indicated understanding of the concern.
Inaccurate weight monitoring and medication refusal documentation
Penalty
Summary
Professional standards of practice were not maintained for a resident with CHF when the facility failed to accurately monitor and document weights. Resident #75 was admitted in June 2025 with multiple diagnoses including CHF, and an order was initiated for weekly weights every Wednesday. The Treatment Administration Record showed staff signed off that weights were obtained, but the weight section was marked with an x and no weight was recorded on multiple Wednesdays in October and November 2025. A later order changed the schedule to twice weekly weights on Monday and Friday for CHF, but the resident’s weight documentation in the vital signs section did not match the dates recorded in the TAR. During interviews, the UM stated that GNAs and restorative aides obtain weights and nurses document them, and that the TAR and vital signs entries should correspond, but she could not explain the discrepancies. The restorative aide stated that residents with CHF are weighed on Mondays and Fridays and said Resident #75 had originally been on weekly Wednesday weights, but he began obtaining weights on Mondays and Fridays after the resident returned with CHF; he could not recall when the order changed. The UM also could not explain why the TAR did not reflect the correct weigh schedule. In addition, medication administration documentation was incorrect for two residents: one LPN documented that a resident refused Vitamin D, liquid protein, and fluticasone propionate nasal spray, although the surveyor only observed refusal of the first two items; another LPN documented refusal of gabapentin and Hi Cal, although the surveyor did not observe those items offered or refused.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to provide treatment and services to maintain vision for one resident who reported itchy, scratchy eyes and stated that they had not seen an eye doctor. The resident’s record showed multiple ophthalmology consult orders were placed for decreased vision and eye evaluations, including orders on 6/6/2025, 9/4/2025, and 10/10/2025. Provider notes documented that the resident requested to be seen by an ophthalmologist, complained of seasonal allergies with itchy, watery eyes, and was told consults would be ordered. Review of ophthalmology consult notes showed the resident had not been seen since 2/6/2025, and the Unit Manager stated that the last time an ophthalmologist was in the facility was in October 2025 and that the resident had not been seen.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and documentation of insect and rodent activity throughout the building. On several occasions, large black and brown insects were observed in the lobby, hallways, and conference room. Pest control logs revealed repeated roach sightings over several months, with treatments occurring days after the initial reports. Additionally, a bedbug sighting was reported in the lobby, and although the pest control company treated the area, no bedbugs were found during their inspection. The logs also documented a significant number of mice sightings, particularly on the 4th floor, with 24 instances recorded in one month. Interviews with facility staff indicated awareness of ongoing pest issues, specifically waterbug sightings, but staff were not aware of the most recent insect observations made by surveyors. The facility's pest control records and incident reports further confirmed the presence of pests, including both insects and rodents, in resident areas and common spaces. These findings demonstrate a failure to implement and maintain an effective pest control program, with the potential to affect all residents.
Failure to Maintain Investigation Documentation for Reported Incidents
Penalty
Summary
The facility failed to maintain and provide complete records of investigation documentation for reported incidents involving two residents. In the first case, a resident alleged that $70 was stolen from their possession. Upon review, the investigation file contained only the initial and follow-up self-reports submitted to the Office of Health Care Quality, with no additional documentation such as statements, interviews, in-services, or education. The Director of Nursing confirmed that no further documentation was available beyond what was provided. In the second case, another resident was found to be high, drowsy, and sleeping in a walkway, which was reported as unusual behavior. When surveyors requested the investigation documentation for this incident, facility leadership was unable to locate or provide the investigation packet. Both the Director of Nursing and the Nursing Home Administrator acknowledged that such documents should be retained for five years and made available upon request, but the required investigation records were missing.
Failure to Honor Resident's Refusal of Care
Penalty
Summary
A resident with intact cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, alleged that a Geriatric Nursing Assistant continued to provide care after the resident explicitly requested the care to stop and asked the staff member to leave the room. Another staff member present during the incident confirmed in a written statement that the resident told the assistant to stop and leave, but the care was continued despite the resident's request. Facility documentation and staff interviews corroborated that the staff member did not honor the resident's wishes, resulting in a failure to protect the resident from abuse as required.
Failure to Remove Staff After Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy when an allegation of physical abuse was made against a staff member towards a resident. The incident occurred during a night shift, and the resident reported the alleged abuse and contacted the police. Despite the facility's policy requiring immediate removal of the alleged perpetrator from the facility and away from other residents following an abuse allegation, the staff member in question continued to work their shift after the allegation was reported. This was confirmed through timecard records and an interview with the Human Resource Director. The facility's abuse policy was reviewed and found to clearly state the requirement for immediate removal of the alleged perpetrator, which was not followed in this case.
Failure to Timely Report Abuse Allegations and Notify Law Enforcement
Penalty
Summary
The facility failed to report unusual occurrences and allegations of abuse in a timely manner, as well as to notify law enforcement as required. In one instance, a resident was found lethargic and difficult to arouse, requiring oxygen and Narcan administration before being sent to the ER. The incident, which occurred in the morning, was not reported to the Office of Health Care Quality (OHCQ) until four days later, and the facility leadership was unaware of the 24-hour reporting requirement for non-abuse incidents. In another case, a resident alleged sexual assault by another resident, but the incident was not reported to the appropriate agency within the required two-hour timeframe. Additionally, an allegation involving a nurse pulling a resident's mask, yelling, and taking a video without consent was reported to the state agency but not to law enforcement. The DON confirmed that the absence of a police investigation number indicated that law enforcement had not been notified, as required.
Failure to Meet Professional Standards in Nutrition Assessment and Physician Order Compliance
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards of quality for two residents. For one resident with quadriplegia and complete dependence on staff, the facility did not accurately assess, document, or update the resident's nutritional status in accordance with healthcare standards. The resident appeared malnourished, and family members reported significant weight loss and missed meals. Review of the electronic medical record showed that the last documented weight was several months old, and meal intake records indicated the resident was consuming only about 50% of meals, despite documentation stating the resident was meeting more than 75% of nutritional needs. The registered dietitian admitted that some assessments were not documented in the EMR and that calculations of intake were based on meal orders rather than actual consumption, with no documentation explaining changes in nutritional supplements. For another resident, staff failed to follow a written physician order for contracture management. The order required the use of a left palm grip, to be removed only during daily hand hygiene. Multiple observations by the surveyor found the resident was not wearing the palm grip, and there was no documentation in the medical record regarding its use, contraindications, or resident refusal. Nursing staff were unable to locate documentation of palm grip usage and only after surveyor inquiry was the device observed in use. No explanation was provided by staff for the lack of compliance with the physician order during previous observations.
Missed Wound Care Treatment and Documentation Failure
Penalty
Summary
Facility staff failed to complete wound care treatment as ordered by the physician for one resident. The resident reported that wound dressing changes were scheduled for every Tuesday, Thursday, and Saturday, but the dressing change scheduled for Thursday was not performed. Observation confirmed that the last dressing change occurred on Tuesday, which was outside the prescribed schedule. Review of the treatment administration records showed an order for wound care every other evening shift, with the last documented dressing change on Tuesday and no documentation explaining the missed treatment on Thursday. The Director of Nursing confirmed that staff are expected to document all wound care, including when a dressing change is not completed, but there was no such documentation for the missed treatment.
Expired GNA Certification Not Detected by Facility
Penalty
Summary
Facility staff failed to ensure that a geriatric nursing assistant (GNA) maintained an active certification, as evidenced by a review of employee files during the annual survey. The surveyor requested the employment file for the GNA and found that the certification had expired. The Human Resource Director stated that certification and license expiration dates are tracked on a spreadsheet and reviewed monthly, but acknowledged that the expired certification was an oversight. The Administrator confirmed that the GNA's certification was expired, and the GNA was not working at the time of the survey.
Failure to Conduct and Document Annual GNA Performance Reviews
Penalty
Summary
Facility staff failed to ensure that annual performance reviews were conducted for all geriatric nursing assistants (GNAs). During the annual survey, the surveyor requested complete employee files for several GNAs, specifically requesting the inclusion of annual performance reviews. Upon review, it was found that the annual performance reviews were missing from all the requested files. The HR Director and the Director of Nursing (DON) both acknowledged the process for conducting and tracking annual reviews, but were unable to provide the required documentation during the survey period. Despite multiple requests over several days, the facility was unable to produce the annual performance reviews for any of the GNAs whose files were reviewed. Both the Administrator and DON were informed of the missing documentation, and the surveyor ceased further requests after the files were not provided. The deficiency was evident in all seven GNA files reviewed, indicating a systemic failure to maintain required annual performance evaluations.
Inaccurate Documentation of Vital Signs After Resident Discharge
Penalty
Summary
Facility staff documented inaccurate data in a resident's medical record, as evidenced by a blood pressure reading recorded after the resident had already been discharged and transferred to the hospital. Specifically, a progress note indicated the resident was sent to the emergency room at the family's request, and another note confirmed the resident was out of the facility. Despite this, a blood pressure measurement was documented in the resident's chart after the discharge date. During an interview, the DON was unable to explain how or why this documentation occurred and confirmed that no vital signs should be recorded after a resident has been discharged.
Failure to Assess and Supervise Smokers
Penalty
Summary
The facility failed to adequately assess and supervise residents who were known smokers, leading to multiple incidents of unsafe smoking behavior. Resident #78 was repeatedly found smoking in their room despite being assessed as a safe smoker requiring supervision. The care plan for Resident #78 was updated multiple times to reflect these incidents, yet the resident continued to smoke unsafely. Similarly, Resident #41 was found smoking in their room on several occasions, including smoking marijuana, despite being assessed as a safe smoker requiring supervision. The facility's failure to reassess these residents after repeated incidents of unsafe smoking behavior contributed to the deficiency. Resident #90, who had physical limitations affecting their ability to smoke safely, was found smoking in a room with another resident who was on oxygen, posing a significant fire hazard. Despite being assessed as an unsafe smoker needing supervision, Resident #90 continued to smoke unsafely. Additionally, Resident #63, who had behavior issues and was non-compliant with smoking rules, was placed in a room with Resident #10, who was on oxygen. Resident #63 was also found smoking in the room with friends, further exacerbating the risk. The facility's failure to reassess and adequately supervise these residents contributed to the ongoing unsafe smoking behavior. The facility also failed to ensure that residents' rooms were free from hazards. Resident #368 was found smoking in their room, which was filled with smoke and had cigarette butts in cups of water. Despite being assessed as an unsafe smoker with poor vision and a roommate on oxygen, the resident continued to smoke unsafely. Additionally, a power strip hanging off the wall in Resident #63's room was identified as a safety hazard, yet it remained in place. The facility's failure to remove these hazards and adequately supervise residents contributed to the deficiency.
Failure to Track and Analyze Drug Overdoses
Penalty
Summary
The facility failed to use the Quality Assurance Performance Improvement (QAPI) process to track, review, and analyze serious preventable adverse events (SPAE) related to drug overdoses. The first identified occurrence was a drug overdose resulting in the death of a resident. Despite this, the facility did not implement effective QAPI interventions, leading to 22 additional drug overdose SPAEs, including six fatalities. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy. The surveyors found that the facility did not have a systematic approach to track and analyze drug overdoses. The Medical Director confirmed that drug overdoses were discussed in QAPI meetings but were not tracked or tallied. The facility's QAPI plan indicated the use of various tools for root cause analysis and performance improvement projects (PIP), but there was no evidence that drug overdoses were prioritized or addressed. The facility admitted residents with Substance Use Disorder (SUD) but failed to implement a performance improvement plan for drug overdoses. Interviews with the Medical Director and other staff revealed that while drug use was a significant concern, the facility had not conducted a performance improvement plan on drug overdoses. The Wellness Director confirmed that tracking of overdoses had only started recently, and no PIP was in place. The facility's failure to initiate an effective QAPI response after multiple SPAEs over 16 months resulted in six resident deaths. The facility provided a plan to remove the immediacy, which was accepted by OHCQ after multiple submissions.
Failure to Provide CPR for Resident with Full Code Status
Penalty
Summary
The facility failed to provide Cardiopulmonary Resuscitation (CPR) for a resident with a full code status. During a random observation, a Licensed Practical Nurse (LPN) discovered the resident unresponsive and did not initiate CPR. Instead, the LPN attempted to contact the Director of Nursing (DON) and the Administrator but was unsuccessful. The LPN then called a Registered Nurse (RN) from another floor, who also did not immediately perform CPR upon arrival, mistakenly believing the resident had a Do Not Resuscitate (DNR) order. The RN later confirmed the resident's death without initiating CPR. Upon reviewing the resident's physical chart, it was found that the resident had a Maryland Order for Life Sustaining Treatment (MOLST) form indicating a full code status, meaning CPR should have been performed. The LPN admitted to learning about the resident's full code status only when Emergency Medical Services (EMS) arrived. The facility's policy and procedures for calling a code and performing CPR were not followed, as the staff failed to initiate CPR immediately upon finding the resident unresponsive. The facility's policy mandates that staff provide basic life support, including CPR, in accordance with the resident's advance directives. The policy also requires staff to maintain current CPR certification and follow American Heart Association (AHA) guidelines. The failure to adhere to these policies and procedures resulted in the facility being cited for Immediate Jeopardy by the Maryland Office of Health Care Quality (OHCQ).
Failure to Implement SUD Treatment and Care Plans
Penalty
Summary
The facility failed to timely implement physician instructions and orders related to Substance Use Disorder (SUD) treatment, effectively plan care for residents with SUD, and initiate a SUD care plan for residents identified with SUD. This was evident for five residents reviewed during the survey. These failures contributed to resident overdoses and placed residents at increased risk for serious harm and possible death. For Resident #147, the facility did not verify and restart Suboxone as recommended by the physician, leading to a medical emergency where the resident was found unresponsive and required Narcan administration. The care plan for this resident was created five months after the first overdose and lacked individualized interventions to monitor for triggers or withdrawal symptoms. Similarly, Resident #90 experienced two overdose events before Suboxone was ordered, and the care plan did not include interventions for monitoring individualized triggers or signs of withdrawal. Resident #101 had inconsistent documentation regarding the administration of Buprenorphine and experienced two potential overdose events. The care plan was not revised to monitor for individualized triggers and withdrawal symptoms. Resident #149, with a history of psychoactive substance dependence, experienced multiple overdose events, and no care plan was implemented for managing the resident's substance abuse disorder. Resident #154 suffered three overdose events, and no care plan was ever opened to manage the resident's needs related to substance abuse disorder.
Facility Administration Fails to Ensure Resident Safety and Compliance
Penalty
Summary
The facility administration failed to provide effective oversight activities to ensure that resources were used effectively to meet the health and safety needs of each resident. This was evidenced by the failure to ensure substantial compliance with regulations identified as deficient, failure to implement plans of correction resulting in immediate jeopardy for the safety of residents who required supervision while smoking, and failure to implement plans of correction related to residents' behavioral health. Specifically, the facility failed to identify, monitor, and prevent additional occurrences of substance abuse, and failed to provide oversight and monitoring of the maintenance and pest control plan of correction for the facility and the kitchen, resulting in repeated citations of a non-homelike environment and unsanitary kitchen and food preparation area. These failures had the potential to adversely affect the health and safety of all residents in the facility and resulted in immediate jeopardy for the third consecutive survey regarding smoking safety and actual harm regarding substance abuse prevention in a resident with an identified substance abuse disorder. The facility's Substance Use Tracking tool was found to be incomplete and inconsistent. Resident #63, who was hospitalized twice for an overdose and reported suicidal ideations, was not included in the tracking tool. Additionally, a K-9 search identified multiple resident rooms with drug paraphernalia, but these residents were not initially included in the tracking tool. Orders related to ongoing monitoring for substance use prevention were also inconsistent, with some residents having orders in place while others did not. The facility lacked a policy and procedure for this process, leading to confusion among staff about their responsibilities. The facility also failed to address unsafe smoking practices, resulting in repeated immediate jeopardy citations. Despite corrective measures being indicated, the facility did not consistently implement safety measures for residents who required supervision while smoking. Furthermore, the facility failed to maintain a safe, clean, and homelike environment. Issues such as mice and mice feces throughout the facility, including the kitchen, and concerns related to bed bugs and lice were identified. The facility did not adequately implement pest control recommendations, leaving open holes throughout the facility. These environmental concerns were not reported to the Office of Health Care Quality in a timely manner, further exacerbating the issues.
Failure to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility's staff failed to ensure a sanitary and safe interior environment for one resident. On 09/28/23, a surveyor observed a pile of used paper towels under the sink, a ceiling tile off the ceiling track, torn curtains between two beds, and a damaged bathroom door in the resident's room. Despite daily rounds by the Maintenance Director and Housekeeping staff, they were unaware of these issues. A follow-up observation on 10/03/23 confirmed that the deficiencies remained unaddressed, and the Maintenance Director was notified again of the unacceptable conditions.
Failure to Maintain Professional Standards of Food Service Safety
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards of food service safety. During an initial tour of the kitchen, the surveyor and a cook observed multiple instances of improperly stored food, including opened and undated bags of bread, sausage, personal beverages, and a personal pan pizza in the walk-in freezer. Additionally, a black substance was found inside the ice maker machine, which had stopped working a week prior. The dishwashing area was also found to have a low sanitizing solution level, gnats flying around, food particles in the sink drain, and wet nesting of kitchenware. The dry food storage area contained an undated and unlabeled bag of coconut flakes. Expired containers of dried herbs and seasonings were also found in the food preparation area during a follow-up tour. Interviews with facility staff confirmed that the observed practices were against the facility's food storage policy, which requires securely closing packages and labeling them with open and use-by dates. The cook and dietary manager acknowledged the issues, including the low sanitizing solution level and the presence of gnats, and stated that the maintenance staff was responsible for checking and cleaning the ice machine weekly. The dietary manager also confirmed that all unopened bulk food should be labeled with an expiration date once removed from its original container. The expired food items were identified and acknowledged by the dietary manager during the follow-up tour.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility staff failed to ensure that resident rooms were free from mice, as evidenced by observations and interviews with two residents. Resident #23 reported seeing two mice every night and sometimes during the day. Additionally, a mouse was observed running across the floor in Resident #16's room, and the resident mentioned that the mouse would climb up cords near the head of the bed. These findings were brought to the attention of the Nursing Home Administrator. A review of service reports from Orkin, the pest control company, revealed that mice had been identified as an issue months before the survey. Despite this, the logbooks at the nurses' stations, which were intended for reporting pest sightings, were not being used by facility staff. Interviews with staff members indicated that they were aware of the mice problem but were not using the logbooks to report sightings, instead opting to use the electronic communication program, TELS. The Maintenance Director also acknowledged the issue and mentioned that he was unaware of the reliance on logbooks for pest management treatments.
Failure to Facilitate Care Plan Meetings
Penalty
Summary
The facility failed to facilitate care plan meetings for residents, as evidenced by the lack of such meetings for five residents reviewed for care planning. Interviews with residents and their personal representatives revealed that care plan meetings were either infrequent or non-existent. For instance, Resident #59's Personal Representative reported only two care plan meetings since admission, and Resident #463 stated they were unaware of any care plan meetings. Medical record reviews for these residents confirmed the absence of documented care plan meetings. Further interviews with facility staff, including a social worker, indicated that care plan meetings were supposed to be scheduled 7 days after admission, quarterly, and upon significant changes. However, the social worker admitted to not scheduling these meetings for the residents in question. The Regional Director also confirmed the lack of care plan meeting notes in the medical records. This deficiency highlights a systemic issue in the facility's process for involving residents and their representatives in care planning.
Failure to Inform Residents of Advanced Directives
Penalty
Summary
The facility failed to inform residents of their right to formulate advanced directives, as evidenced by the cases of five residents. Resident #55, admitted initially in January 2022 and most recently in April 2023, had no advanced directive in their medical record and no documentation that they were offered to create one. The Social Service Director confirmed that residents were not asked if they wanted to formulate an advanced directive unless they specifically requested it. The Nursing Home Administrator acknowledged that residents were not given the opportunity to formulate advanced directives upon admission. Similarly, Resident #22, admitted in early 2023, had no documentation of an advanced directive or an offer to create one. Resident #15 and Resident #67 were also admitted without advanced directives and were not offered the opportunity to create them. Additionally, Resident #27 had no Maryland Order for Life Sustaining Treatment (MOLST) form in their chart, and there was no current order or code status indicator in the electronic medical record. Staff confirmed the absence of the MOLST form and acknowledged the issue. The Nursing Home Administrator recognized the problem but did not take immediate corrective action as per the report.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to maintain appropriate temperature control for medication storage, as observed in the 4th floor medication storage room where the refrigerator's temperature was recorded at 52 degrees Fahrenheit, exceeding the acceptable range of 36 to 46 degrees Fahrenheit. Additionally, expired medications were found in the refrigerator, including bags of normal saline with added antibiotics labeled with discard dates that had already passed. The interim DON confirmed the findings and acknowledged the need for education on proper medication storage practices. The facility also failed to properly waste narcotic medications. A bottle of an opioid for a resident was found double locked in the medication cart, despite the resident being out of the facility and the medication needing to be wasted. Staff admitted that the wellness coordinator and physician should have been notified, and the medication should have been wasted with two nurses signing off on it. This issue was discussed with the interim DON, RDCO, and the Administrator. Furthermore, the facility did not maintain a safe and effective system for securing medications and treatments. Observations included an unlocked and unattended medication cart on the 4th floor, a large white pill found on the floor behind the nurses' station, and a medication cup with pills left on a resident's bedside table. Staff admitted to failing to lock medication carts and leaving medications unattended, which is against the facility's policy. These deficiencies were observed and confirmed through interviews with the nursing staff.
Qualified Social Worker Staffing Gap Identified
Penalty
Summary
The facility with more than 120 beds failed to have a qualified, full-time Social Worker employed to oversee social service duties for a period of 5 months in 2022. The review of employee records revealed that there was a gap in qualified Social Worker staffing from 3/5/22 to 9/5/22, during which no qualified social worker was employed. The facility had employed individuals without the required qualifications for the role of Social Service Director during this period, leading to the deficiency identified by surveyors. The Nursing Home Administrator acknowledged the months without a qualified Social Worker during an interview conducted by the surveyor.
Sanitary and Environmental Deficiencies
Penalty
Summary
The facility failed to maintain a sanitary environment, as evidenced by multiple observations of food trays left in hallways and on top of PPE storage bins. On several occasions, surveyors observed partially-eaten food trays labeled breakfast, supper, and other meals left unattended in the hallways and on storage bins. Staff members, including a GNA and an LPN, acknowledged that the trays should not be there and removed them upon being questioned by the surveyor. Despite these removals, the issue persisted over multiple days and was not adequately addressed by the facility's administration or staff. The facility also failed to provide a functional and comfortable environment for residents. Resident #84 reported that after switching rooms, their belongings were not unpacked, and the closet in the new room lacked a rod for hanging clothes, resulting in clothes being placed on the floor. Staff interviews confirmed that the closet should have a rod and that the resident's belongings should have been properly stored. Despite a note in the resident's medical record indicating the room change, the issue remained unresolved for several days. Additionally, Resident #59's room was found to be in poor condition, with a mattress on the floor, chipped paint, a damaged A/C unit, and a bathroom with a strong smell of urine and sewage. The toilet was clogged and filled with brown water. Housekeeping staff were aware of the issue but reported that it had not been addressed by maintenance. The Maintenance Director was new to the role and unfamiliar with the facility's work order system, resulting in a lack of timely repairs. The resident was eventually moved to a new room, but the initial conditions were substandard and not promptly rectified.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility staff failed to ensure allegations of abuse were reported to the state agency in a timely manner for three residents. Resident #150 alleged being struck in the face and later kissed on the cheek on 1/31/23. The nurse informed the unit manager the same day, but the incident was not reported to the state agency until 2/5/23. The Administrator confirmed the delay in reporting during an interview on 10/20/23. Resident #22, admitted in early 2023, expressed to an outside provider on 6/1/23 that they felt mistreated at the facility and did not want to return. The Nursing Home Administrator admitted to not reporting this allegation during an interview on 10/3/23. On 9/14/23, facility staff on the 3rd floor were informed of an abuse incident involving Resident #90 around 5 PM. However, the state agency was not notified until 9:39 PM, exceeding the required 2-hour reporting window. These incidents highlight the facility's failure to report allegations of abuse to the state agency within the mandated timeframe, as evidenced by the delayed reporting for all three residents.
Inadequate Investigation and Reporting of Abuse Allegations
Penalty
Summary
The facility staff failed to ensure allegations of abuse were thoroughly investigated and accurately reported, affecting 12 out of 30 residents reviewed for abuse. For Resident #119, the facility reported an incident to the state survey agency but failed to include that the resident suffered an injury. The Administrator acknowledged this omission during an interview. Similarly, investigations for Resident #161's allegations of physical and sexual abuse lacked witness statements, which the Administrator admitted was an oversight. Resident #165 experienced an incident involving the roommate's daughter, who was also an employee. The daughter accused the resident of theft, leading to a confrontation. Although the daughter was suspended and later terminated, there was no evidence that she was prevented from entering Resident #165's room during visits. The Administrator could not provide proof that the resident was protected throughout the investigation. Additionally, the facility failed to produce investigation reports for several other residents, including Resident #365, Resident #42, and Resident #369, among others. In another case, Resident #22 reported feeling mistreated and did not want to return to the facility after an outside appointment. The facility did not follow up or investigate the resident's concerns upon their return. Furthermore, an altercation between two residents on the smoking patio was not adequately investigated, as the facility failed to interview the staff responsible for supervising the area. These deficiencies highlight a pattern of inadequate investigation and reporting of abuse allegations, compromising resident safety and well-being.
Care Plan Development and Review Deficiencies Identified
Penalty
Summary
The facility failed to ensure the development of a care plan for a resident who was an active smoker upon admission and did not review or revise the care plan after a quarterly assessment. Specifically, for Resident #109, who had diagnoses including chronic respiratory failure, COPD, traumatic brain injury, and tobacco use, there was no care plan initiated for smoking despite being identified as an unsafe smoker requiring supervision. The facility also did not invite the Power of Attorney (POA) to a care plan meeting for Resident #371, leading to a lack of involvement of the POA in the resident's care decisions. Additionally, care plan meetings were not scheduled in a timely manner for several residents, including Resident #10 who reported not being informed about the last care plan meeting and Resident #33 whose care plan meetings had not been held for a year. Resident #39 mentioned not attending meetings as residents were no longer being invited, and Resident #67 expressed unawareness of care plan meetings, indicating a lack of resident involvement and communication regarding care planning. The Social Work Director was responsible for planning care plan meetings but could not provide sign-in sheets for some residents, indicating a lack of documentation and organization in the care planning process.
Deficiencies in Medication Administration and Documentation Processes
Penalty
Summary
The survey conducted at the nursing facility identified several deficiencies related to medication administration and documentation processes. In one instance, it was noted that a resident with Diabetes Mellitus did not have a sliding scale included in their insulin order, leading to potential issues in managing blood sugar levels effectively. The lack of a sliding scale for insulin administration was highlighted during the survey, prompting the need for corrective action to align with professional standards of care for residents requiring insulin therapy. Another deficiency involved a resident with end-stage renal disease and dependence on dialysis, where incomplete documentation on the Dialysis Communication Form raised concerns about the transfer of vital health information between the facility and the dialysis clinic. The incomplete form failed to provide essential details about the resident's health status, potentially impacting the continuity of care and treatment coordination for the resident receiving dialysis services.
Multiple Deficiencies in Medication Administration and Resident Care
Penalty
Summary
The facility staff failed to ensure residents received quality care in several areas, including medication administration, catheter care, and timely intervention for acute changes in residents' conditions. For instance, Resident #121 missed a follow-up angiogram appointment due to a broken Hoyer lift and had multiple medications administered outside the prescribed times. Similarly, Resident #161's medications were administered 2-4 hours past the ordered time, and some were not administered at all. Resident #364 also experienced delays in medication administration, with some medications not given until the following day. Additionally, Resident #381 missed 107 out of 870 medication doses in June 2021, with no documentation of refusal in the progress notes. Resident #63 received an extra dose of Methadone due to a failure in documenting the medication administration properly. The nurse administering the medication did not sign out the medication on the chain of custody form, leading to a double dose. Resident #16 had no active orders for Foley catheter care/maintenance, resulting in a urinary tract infection that led to septic shock. Resident #517, who had multiple health conditions, was visibly unstable and hypoglycemic but was sent to the dialysis clinic without proper assessment or intervention. The resident's condition worsened, requiring emergency transfer to the hospital. Resident #162 did not receive several critical medications until days after admission, and the staff failed to order Narcan despite the resident's history of substance abuse. Resident #131, who required Midodrine for orthostatic hypotension, did not receive a single dose over several months, and staff failed to monitor blood pressure as required. Finally, Resident #108 experienced a significant drop in blood sugar, and the staff failed to provide timely emergency medication, leading to an emergency transfer to the hospital. These deficiencies highlight significant lapses in medication administration, documentation, and timely medical intervention across multiple residents.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility staff failed to appropriately administer pain medications as ordered for three residents. Resident #15 was given Oxycodone despite reporting a pain level of 0 on multiple occasions across July, August, and September 2023. The Director of Nursing (DON) confirmed that medication should not be administered if the pain is rated as 0 and that the nurse should have called the physician for clarification if the pain scale was not included in the order. The DON reviewed the cases to identify the responsible nurses. Resident #63 had an order for Oxycodone to be administered for pain levels between 7-10. However, the medication was administered multiple times in August and September 2023 for pain scores below 7. Staff interviews revealed that the medication might have been given outside the prescribed parameters due to the resident intimidating the staff. The facility's pain management policy states that opioids should be dosed according to professional standards and manufacturers' guidelines, which was not followed in this case. Resident #517 experienced significant delays in receiving pain medication after being readmitted from the hospital. Despite reporting high pain levels, the resident did not receive pain medication from 10/4/2023 to 10/6/2023, and even after the medication was ordered on 10/6/2023, it was not administered until 10/9/2023. The resident's pain assessments consistently showed high pain scores, and the care plan included interventions to administer analgesics as ordered. The interim DON and the physician confirmed the delays and the failure to provide timely pain relief to the resident. The facility staff did not provide additional documentation regarding the missed opportunities for pain relief during the survey.
Significant Medication Errors Due to Inaccurate Transcription and Administration
Penalty
Summary
The facility staff failed to ensure that prescribed medications were correctly transcribed and administered, leading to significant medication errors for a resident diagnosed with polyneuropathy, nerve pain, and kidney failure requiring dialysis. The resident had an admission order for Gabapentin to be administered three times a week after dialysis. However, a review of the Medication Administration Record (MAR) revealed that the resident received Gabapentin only three out of seven days per week, resulting in 74 missed doses from June 24, 2023, through November 3, 2023. This discrepancy was not detected by the Nursing Unit Coordinator, who was responsible for overseeing physicians' order management and ensuring accurate transcription and administration of medications. Interviews with the resident's physician and the Nursing Unit Coordinator confirmed that the admission orders and MAR transcriptions were inaccurate and should have been reviewed and verified by both the physician and nursing staff. The Nursing Unit Coordinator acknowledged that the continuous medication errors were due to undetected inaccurate orders and MARs, which were not properly reviewed. Despite daily reviews and reporting discrepancies, the Nursing Unit Coordinator failed to identify the issues with the resident's medication orders, leading to the significant medication errors observed during the survey.
Inaccurate Resident Records and Documentation Discrepancies
Penalty
Summary
The facility failed to maintain accurate resident records in accordance with professional standards, as evidenced by multiple instances of discrepancies in documentation and record-keeping. For Resident #22, conflicting information was found regarding the presence of teeth in various assessments, highlighting inconsistencies in the medical records. Additionally, the failure to display residents' names outside their rooms accurately led to confusion and potential risks, as observed with Residents #8, #79, #64, and others. Furthermore, inadequate documentation and implementation of physician orders were noted in the case of Resident #517, who experienced issues related to hypoglycemia and other complex medical conditions. The lack of active orders addressing essential care needs, such as nutritional monitoring and dialysis access, raised concerns about the quality of care provided to the resident. The failure to promptly address and accurately document discharge instructions from hospitalizations further compounded the deficiencies in the resident's care plan.
Failure to Provide Timely Psychiatric Care
Penalty
Summary
The facility failed to appropriately treat two residents diagnosed with mental disorders. Resident #115, who had a history of schizophrenia, was recommended by a psychiatrist to start on Prolixin due to agitation and depression. However, the primary provider delayed the medication pending an EKG, which was completed, but the medication was not started until after the resident was hospitalized following aggressive behavior. This delay in administering the recommended psychological medication contributed to the resident's escalating behavior and subsequent hospitalization. Resident #78, diagnosed with post-traumatic stress disorder and adjustment disorder with mixed anxiety and depressed mood, had multiple orders for psychiatric consultations and individual therapy. Despite these orders, the resident did not receive the recommended individual psychotherapy due to a communication error regarding insurance approval. The facility's process for ensuring psychiatric services was found to be inadequate, as the resident's needs were not met in a timely manner, leading to unmanaged anxiety and other symptoms. Interviews with staff and review of medical records revealed that the facility's system for managing psychiatric services was flawed. The facility relied on an external service for psychiatric consultations, but failed to ensure that all recommended services were provided. This resulted in significant lapses in care for residents with mental health needs, as evidenced by the cases of Resident #115 and Resident #78.
Lack of Social Work Assistance for Resident Requesting Discharge
Penalty
Summary
The facility failed to ensure social work assistance for Resident #385, who expressed a desire to be discharged home. Despite the resident's request and the absence of social work notes or evaluations, no social worker assessments or discharge planning were provided. The Social Services Director mentioned the lack of an active social work department upon her arrival, with temporary assistance brought in for discharge planning but not for completing social histories or care plan meetings.
Failure to Provide Bariatric Bedside Commode
Penalty
Summary
The facility failed to provide a bariatric bedside commode for a resident's use, despite the resident's repeated requests. On 09/28/23, the resident stated that the standard-sized bedside commode provided was not big enough to fit their body, making it impossible to use the bathroom. The resident also mentioned that the toilet in the bathroom was too low, preventing them from getting back up. Interviews with staff revealed that obtaining bariatric equipment involved requesting it from the Rehab department, and it was not considered difficult to obtain. However, the bariatric bedside commode was only delivered to the therapy room shortly before the resident was discharged, indicating a delay in meeting the resident's needs.
Failure to Provide Written Transfer Notices and Timely Ombudsman Notification
Penalty
Summary
The facility failed to provide written notice with the reason for transfer to two residents and failed to notify the Ombudsman of resident transfers in a timely manner. Resident #22 was transferred to a hospital due to an unwitnessed fall, but there was no documentation that a written notice was given to the resident informing them of the reason for the transfer. The Nursing Home Administrator (NHA) was only aware of the transfer summary completed by staff and did not provide a written notice to the surveyor by the exit date. Additionally, the NHA admitted that the August transfers and discharges were not sent to the Ombudsman, and the notices from May were sent several months late, with no subsequent notifications sent after August 7th, 2023. Resident #517 was observed in a distressed state and was later transferred to the hospital due to hypoglycemia. The resident's medical records confirmed the transfer, but there was no written notice provided to the resident or their representative. The interim Director of Nursing (DON) was unsure of the facility's transfer/discharge policy, and the Unit Coordinator confirmed that no written notice was sent. The failure to provide written transfer notices for Resident #517's hospitalizations was reviewed with the Regional Director of Clinical Operations (RDCO) and the Administrator.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to implement a process to ensure that residents and their representatives were made aware of the bed hold policy upon transfer to the hospital. This deficiency was identified for two residents during the survey. Resident #517, who had multiple medical conditions including end-stage renal disease and hypoglycemia, was transferred to the hospital twice without being provided with the bed hold policy. The interim Director of Nursing and other staff members were either unaware of the policy or failed to document it properly, resulting in incomplete records and lack of communication with the resident or their representative. Resident #517 was first transferred to the hospital due to hypoglycemia, and no bed hold policy was noted in the transfer summary. Upon readmission and a subsequent transfer, the bed hold policy documentation was incomplete, lacking the resident's signature. Interviews with staff revealed inconsistencies in the understanding and implementation of the bed hold policy, with some staff members being unaware of the policy altogether. The surveyors were unable to obtain documentation indicating that the bed hold policy was provided to the resident or their representative during both transfers. Similarly, Resident #22, who was transferred to the hospital following an unwitnessed fall, did not receive written notice of the bed hold policy. The Nursing Home Administrator acknowledged that there was inconsistency among the nursing staff in providing the bed hold policy and was unable to locate the documentation for Resident #22. This lack of consistent communication and documentation regarding the bed hold policy highlights a significant deficiency in the facility's process for informing residents and their representatives about their rights and the facility's policies during hospital transfers.
Inaccurate MDS Assessments for Antipsychotic Medications and Behaviors
Penalty
Summary
The facility failed to accurately assess two residents for antipsychotic medications and to document their assessments correctly. For one resident, the Quarterly Minimum Data Set (MDS) was incorrectly coded, failing to indicate the need for an antipsychotic medication review despite the resident being on such medication. This error was acknowledged by the Resource MDS Coordinator and the Director of Nursing, who confirmed that the MDS had been amended after the surveyor's notification. For another resident, the MDS assessment had dashes through sections related to cognition patterns and behavior, despite the resident having a documented history of behaviors and a care plan addressing these issues. The Regional MDS Coordinator explained that the dashes were used because nursing staff did not specify the types of behaviors in their documentation, which prevented the resident from being coded correctly for behaviors on the MDS. The omission of a narrative explanation led to the inaccurate assessment.
Failure to Develop Adequate Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident requiring hemodialysis treatments and experiencing recurrent hypoglycemic episodes within 48 hours of admission. This deficiency was identified during a survey when Resident #517, who had been admitted with multiple diagnoses including ESRD, hypoglycemia, and heart failure, was found to have an inadequate baseline care plan that did not address his dialysis needs or hypoglycemic care. The resident was transferred to the ER due to hypoglycemia shortly after being taken to the dialysis clinic within the facility, highlighting the lack of proper care planning and coordination between the facility and the dialysis provider. Further review of the resident's electronic medical record and hospital discharge summary confirmed the need for dialysis three times a week and recurrent hypoglycemic episodes requiring dextrose infusions. Despite these critical care needs, the baseline care plan developed on the day of admission did not include an adequate plan for dialysis or hypoglycemia management. The interim DON confirmed the inadequacy of the care plan during an interview with surveyors. The resident was subsequently rehospitalized due to low blood sugar levels and has not been able to receive dialysis at the facility since the incident.
Delayed Development of Comprehensive Care Plans for Residents with Mental Health Needs
Penalty
Summary
The facility failed to create comprehensive care plans for two residents during an annual and complaint survey. For Resident #78, admitted with a history of post-traumatic stress disorder and adjustment disorder with mixed anxiety and depressed mood, the care plan addressing psychological/psychiatry services was not developed until 10 months after admission. Despite multiple visits to psych between February and November, there was a gap of 5 months without documented visits. The care plan finally created on 10/7/23 highlighted the need for consultation with psych, indicating a significant delay in addressing the resident's mental health needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 1,816 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Elizabeth Rehabilitation & Nursing Center | 0.4 mi | ★★★★★ | 35 | 0 |
| Future Care Irvington | 1.1 mi | ★★★★★ | 23 | 0 |
| Maryland Baptist Aged Home | 1.7 mi | ★★★★★ | 0 | 0 |
| Westgate Hills Rehab & Healthcare Ctr | 1.7 mi | ★★★★★ | 10 | 0 |
| Charlestown Community Inc | 1.7 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.