Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 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.
Failure to timely notify a resident’s representative after a fall and near miss in the shower room. A resident with recent stroke-related deficits, aphasia, dysphagia, and unsteady gait was found on the floor/knees after one event, and later had a near fall when staff lowered him to the floor while GNAs were in the shower. An LPN documented that no representative was notified because none was listed, and another LPN later learned the family was asking why no call had been made at the time of the shower fall.
A resident with stroke, chronic pain, trigeminal neuralgia, and bruxism had multiple dental orders for eval and treatment by the facility dentist, including for teeth grinding, but had not been seen by a dentist since admission. The resident reported no dental visit, and the MDS/scheduler confirmed the resident had not been seen despite the facility having dental services available.
A resident’s EMR contained a physician order for Full Code, while the paper chart included a MOLST indicating No CPR, DNI, no artificial ventilation, no blood products, and no acute or chronic dialysis. During interview, the administrator and DON were made aware of the conflicting medical record documentation.
Restriction of Room Visitation: The facility prohibited visitors from entering individual resident rooms and required visits to occur only in common areas. A family member reported being denied room visitation despite the resident’s preference for privacy and comfort, and surveyors observed the resident in bed with no clinical or safety reason preventing room visits. The Administrator and DON said the restriction was due to concerns about drugs being brought into the facility, but they could not provide documentation of current drug activity.
A resident’s care plan was not revised after new swallowing difficulty was observed and a modified diet plus SLP swallowing study were ordered. In a separate case, a scheduled care plan meeting for another resident with dementia and Parkinson’s disease was missed, and the SSD said it was not conducted due to human error; the resident’s family member also reported repeated attempts to reach the facility without response.
A resident receiving tube feeding was found with the formula bottle empty at the bedside and no label showing the date, time, or infusion rate. Pump history showed the resident had received far less than the ordered amount, and the physician order did not include specific start or stop times. An LPN said the pump was already off at the start of the shift and needed to review the order to know when to run the feeding, while the DON confirmed the feeding was not labeled correctly and the order was incomplete.
A resident with swallowing difficulty had an SLP swallowing study ordered after coughing and trouble swallowing during a meal, but the study was not scheduled or completed. Another resident with a Foley catheter, chronic UTI, and cystitis reported burning with urination; although the Foley was changed and UA results were abnormal, treatment was delayed while the facility waited for culture results. The resident later became lethargic, hypotensive, and was transferred to the hospital for suspected sepsis.
A resident was observed coughing and having difficulty swallowing while eating, and the NP ordered a swallow test, diet change, and chest x-ray. A later physician note focused on a pre-op H&P and did not address the swallowing change, the diet order, the chest x-ray, or the swallow evaluation order.
Resident call light left out of reach. During observation rounds, a resident’s call light was found on the floor behind the head of the bed. An LPN picked it up and placed it near the resident, and stated that the aide should have ensured the call light was within reach after morning care.
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 returned from the hospital after treatment for acute pyelonephritis, severe sepsis, and bacteremia, but the admission orders were incomplete. The EMR lacked orders for foley care, PICC line care, Enhanced Barrier Precautions, weekly labs for IV antibiotics, and the resident’s maintenance methadone dose; the MAR showed methadone was later given, and the DON confirmed the missing orders.
Failure to Complete Timely Significant Change MDS Assessment: A resident had an unwitnessed fall, was later found to have a left hip fracture, and was transferred to the ED for further evaluation. After hospitalization and surgery, the resident returned with a decline in condition, but the MDS significant change assessment was not completed within the required 14-day timeframe; the MDS Coordinator acknowledged the delay and the DON acknowledged the findings.
Care Plan Missing Foley Catheter Interventions: A resident with paraplegia and neurogenic bladder had a chronic foley catheter, recent hospitalization for acute pyelonephritis, severe sepsis, and bacteremia, and an updated care plan that did not include any catheter-care interventions to prevent recurrent UTI or pyelonephritis. The DON confirmed the care plan lacked reference to the indwelling catheter and needed infection-prevention care.
Delayed provider response to MRR recommendations was identified for three residents. A resident remained on Quetiapine 400 mg despite a signed pharmacist/MD recommendation to reduce the dose, and two other residents had psychotropic or anticholinergic medication review recommendations that were not responded to in a timely manner or tracked through resolution. The facility’s MRR policy required monthly review, prompt reporting of irregularities, documentation of provider responses, and tracking of recommendations, but no response timeframes were specified.
A resident ordered on EBP for CRE, a foley, wound care, and enteral feedings did not have the required gown used during wound care. During observation, the Wound Care NP did not wear the yellow isolation gown required for high-contact care, and the DON acknowledged that PPE should be worn for this resident’s high-contact care.
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.
Failure to Timely Notify Representative After Resident Falls
Penalty
Summary
The facility failed to notify Resident #2’s representative in a timely manner after a fall in the shower room. The complaint alleged that Resident #2 had two falls after admission and that the responsible party was not immediately notified. Resident #2 was admitted after an ischemic stroke with thrombolysis and thrombectomy, aphasia, dysphagia, and unsteady gait requiring assistance with care, and had a BIMS score of 11/15. On 06/12/26, Resident #2 was found on their knees at about 8:00 p.m.; the post-fall SBAR form documented that LPN #1 did not notify the representative because no one was listed, and that Resident #2 had no identified injuries and did not hit their head. The record also documented a near miss/fall on 06/13/26 at 12:15 p.m. when a GNA informed the nurse that Resident #2 was lowered to the floor because both GNAs were in the shower. Nursing documentation stated that Resident #2 said he almost fell and was lowered to the floor. During interview, LPN #2 stated she was aware of the near miss in the shower and later learned from the oncoming nurse that Resident #2 had a fall in the shower around noon, at which time the family was asking why the responsible party had not been called at the time of the fall. The facility Fall Prevention and Management Policy defined a fall as an unintentional change in position to the ground or a lower level and a near miss as a slip, trip, or loss of balance that does not result in a fall to the ground.
Failure to Provide Ordered Dental Evaluation
Penalty
Summary
The facility failed to provide treatment to maintain dental health for Resident #1. The resident was admitted with diagnoses including stroke with left hemiparesis, status post craniotomy with swelling around the right ear, chronic pain, migraines, insomnia, trigeminal neuralgia, and bruxism, and was dependent on nursing staff for several aspects of care. The resident’s June 2026 physician orders included multiple dental orders directing that the resident be evaluated and treated by the facility dentist as needed, by facility dentist services, and specifically for bruxism. During the complaint investigation, Resident #1 stated that they had not been seen by a dentist since admission and reported a history of grinding teeth. The facility Director of Medical Records and Scheduler stated that the facility has dental services that come to the facility to consult with residents and confirmed that Resident #1 had not been seen by a dentist. The deficiency was identified from review of the complaint, clinical record, and interviews with the resident and staff.
Incomplete and Conflicting Code Status Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for one resident reviewed during a complaint survey. During review of the resident’s electronic medical record, surveyors found a physician’s order dated [DATE] indicating Full Code status. Further review of the resident’s paper clinical record revealed a MOLST form stating the resident wanted to be No CPR, Option A-2, Do Not Intubate (DNI), with no artificial ventilation, no blood products, and no acute or chronic dialysis. In an interview on [DATE] at 4:30 pm, the facility administrator and DON were made aware of the discrepancy in the resident’s medical record.
Restriction of Room Visitation
Penalty
Summary
The facility failed to protect residents’ rights by restricting visitation in residents’ rooms. A posted notice at the front desk stated that, effective immediately, visitors would no longer be permitted in individual resident rooms and that visits had to occur in designated common areas such as the game room or front lobby. This restriction was identified during a complaint investigation involving one resident out of five reviewed. A family member reported that she had not been allowed to visit the resident in the resident’s room because the facility had discontinued room visitation, even though the resident preferred visits in the privacy and comfort of the room. During observation rounds, the resident was seen lying in bed, and no clinical, safety, or other factors were identified that would have prevented room visitation. The Administrator and DON stated that room visitation was prohibited because of concerns that visitors could bring drugs into the facility, but they were unable to provide documentation showing current drug activity in the facility. They also stated that exceptions were made only for residents who were bedbound or had health-related concerns, while other residents were not permitted room visits.
Care Plan Not Updated and Scheduled Meeting Missed
Penalty
Summary
The facility failed to revise a comprehensive care plan for a resident after a change in swallowing status. On 05/23/2026, the resident was observed coughing and having difficulty swallowing food during lunch, and the resident stated that swallowing was difficult. That same day, a physician ordered a modified mechanical soft diet with chopped meat and a speech-language pathologist swallowing study. Review of the care plan on 06/24/2026 showed a nutritional focus area with goals and interventions initiated on 12/05/2024, but the care plan was not updated to reflect the resident’s swallowing difficulty or the diet modification. The Administrator and DON were informed of the concern and acknowledged it. The facility also failed to ensure a scheduled care plan meeting was conducted for another resident with diagnoses including dementia and Parkinson’s disease. The resident’s record contained invitations for care plan meetings scheduled for 02/10/2026 and 05/28/2026, along with progress notes dated 05/26/2026 and 05/28/2026, but there were no meeting notes for the February meeting. The resident’s family member stated she had contacted the facility multiple times about concerns and was not contacted about the care plan meeting until May 2026. The SSD stated the February meeting was not conducted due to human error and acknowledged that the scheduled meeting was missed.
Incomplete enteral feeding order and unlabeled pump led to underdelivery of tube feeding
Penalty
Summary
The facility failed to ensure that enteral nutrition was administered in accordance with physician orders and accepted standards of nursing practice for one resident receiving tube feeding. During a complaint investigation, the resident’s enteral feeding formula bottle was observed hanging empty at the bedside without a label showing the date, time, or infusion rate. The resident stated that the tube feeding was supposed to continue until 1:00 p.m., but when the pump history was reviewed, the resident had received only 655 cc of the 1,700 cc ordered. Review of the medical record showed a physician order for Jevity 1.5 via intermittent pump at 85 cc/hour during the evening, but the order did not specify the feeding start or stop times. An LPN stated the pump was already off when she began her shift and said she would need to review the physician orders to determine when the feeding should start or stop. The DON later observed that the feeding remained off and was not labeled correctly, and acknowledged that the enteral feeding order was incomplete because it did not include specific feeding start and stop times.
Failure to Carry Out Swallow Study Order and Delay in UTI Evaluation and Treatment
Penalty
Summary
The facility failed to implement physician orders and provide necessary care and services to assess, monitor, and timely respond to changes in a resident’s condition. For one resident, a progress note documented coughing and difficulty swallowing while eating lunch, and the resident stated he or she was having difficulty swallowing. The NP was notified and ordered a Speech-Language Pathologist swallowing study and a diet change to mechanical soft/chopped meat, but the swallowing study was not scheduled or completed, and the DON later verified that it had not been done. The facility also failed to timely assess and treat another resident with an indwelling Foley catheter and a history of chronic UTI and cystitis. The resident complained of burning with urination, the Foley catheter was changed, and a urine specimen was collected. The urinalysis showed abnormal findings including protein, blood, and leukocyte esterase, and the on-call NP was notified, but the record contained no evidence that antimicrobial therapy or other clinical interventions were initiated at that time. The urine culture later appeared contaminated, and a repeat culture was not ordered until the following day. During the interdisciplinary care plan meeting, the resident was unable to remain awake or participate, and the resident’s sister reported that the excessive sleepiness was not consistent with baseline and requested the meeting be postponed pending medical evaluation. Several days after the initial complaint of burning with urination, orders were obtained for ceftriaxone, Bactrim DS, and STAT CBC, BMP, and CRP. Later that day, the resident became lethargic, difficult to arouse, hypotensive, and was transferred by 911 to the hospital for suspected sepsis. The DON stated the facility delayed initiating treatment while awaiting urine culture and sensitivity results.
Physician Note Did Not Address Resident’s Swallowing Change in Condition
Penalty
Summary
The facility failed to ensure a physician's medically necessary visit addressed a resident's change in clinical status related to swallowing difficulties and the related follow-up orders. Resident #1 was observed coughing and having difficulty swallowing while eating lunch, and the resident stated that he/she was having difficulty swallowing. The NP was notified and ordered a speech-language pathologist swallowing test, a diet change to mechanical soft/chopped meat, and a chest x-ray. However, a physician progress note completed several days later documented a pre-op history and physical for a bilateral retrograde pyelogram and did not address the resident's swallowing change in condition, the diet change, the chest x-ray, or the swallowing test order. During interview, the Administrator and DON were informed of the concern regarding the lack of physician documentation related to the resident's swallowing risks and follow-up for the swallowing evaluation.
Resident Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure that a resident call bell was within reach for Resident #5. During observation rounds, the resident’s call light was seen on the floor behind the head of the bed. A dual observation was completed with an LPN, who picked up the call light and placed it near the resident. The LPN stated that when the resident was provided morning care, the aide should have made sure the call light was within reach. The observation findings were discussed with the Administration team at the exit conference.
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.
Incomplete Admission Orders for Resident With Foley, PICC, and Methadone Needs
Penalty
Summary
The facility failed to obtain complete admission orders for Resident #66 at the time of admission after the resident returned from the hospital on 05/9/2026. Resident #66 had diagnoses including paraplegia, methadone dependence, and neurogenic bladder requiring chronic catheterization, and was observed with an indwelling foley catheter. The resident stated that the foley catheter was used at all times due to paralysis. Review of the EMR showed the resident had been hospitalized for altered mental status and was treated for acute pyelonephritis, severe sepsis, and bacteremia from MSSA and ESBL proteus before returning to the facility. Review of the admission orders showed no documented orders for foley catheter care, right upper extremity PICC line care, Enhanced Barrier Precautions, weekly laboratory tests needed while receiving IV antibiotics, or the resident’s maintenance methadone dose. The MAR documented that methadone was administered on 05/11/2026 at 10:56 AM, and the DON stated that only the Sunday dose was missed because the facility typically did not admit residents on methadone on Fridays or Saturdays due to the Wellness Director’s availability to obtain methadone from community clinics. The DON later confirmed that the admission orders written on 05/9/2026 lacked orders for foley care, PICC line care, Enhanced Barrier Precautions, and weekly laboratory orders, all of which were essential to the resident’s care.
Failure to Complete Timely Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days of a significant change in condition for Resident #11. The resident had an unwitnessed fall on 01/19/2026 and, during unit rounds, stated, "I had a fall right there on the floor" while reporting that he/she had been trying to turn off the television and transfer from the wheelchair to the bed. The resident denied pain and denied hitting his/her head, and no injuries were observed at the time of assessment. Subsequent documentation showed x-ray results indicating a left intertrochanteric fracture, and the physician was notified and ordered transfer to the ED for further evaluation. EMS was contacted and the resident was transferred to the hospital. Review of the MDS assessment showed the resident was assessed as having a significant change in condition. The MDS Coordinator stated the facility became aware of the resident's significant change and decline in condition when the resident returned to the facility on 01/24/2026 after hospitalization and surgery for the left hip fracture on 01/23/2026. The Coordinator stated the significant change assessment was completed on 02/19/2026 and acknowledged that it should have been completed as soon as the facility became aware of the change, or within 14 days. The DON acknowledged the findings during follow-up interview.
Care Plan Missing Foley Catheter Interventions
Penalty
Summary
The facility failed to implement a care plan with interventions for Resident #66's indwelling foley catheter. Resident #66 was observed with an indwelling foley catheter and stated that the catheter is used all the time and had been changed during a recent hospitalization. Record review showed that Resident #66 has paraplegia and neurogenic bladder requiring chronic catheterization. The most recent hospitalization discharge summary documented transfer from the facility on 05/02/2026 to the hospital, where Resident #66 was diagnosed with acute pyelonephritis, severe sepsis, bacteremia from MSSA, and ESBL proteus, and then discharged back to the facility. Review of the EMR showed that the care plan, updated as recently as 05/11/2026, did not address or include interventions for indwelling foley catheter care to prevent recurrence of urinary tract infection and pyelonephritis. The DON confirmed that the care plan lacked any reference to the resident's indwelling catheter and the necessary care to prevent urinary tract infections.
Delayed Response to Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to have provider responses to Medication Regimen Review (MRR) recommendations documented and tracked through resolution for 3 of 5 residents reviewed for unnecessary medications. The facility’s MRR policy stated that each resident’s medication regimen shall be reviewed monthly by a qualified consultant pharmacist, medication irregularities shall be promptly reported, provider responses shall be documented, and recommendations shall be tracked through resolution, but no specific response timeframes were included in the policy. For Resident #8, the consultant pharmacist recommended decreasing Quetiapine from 400 mg to 300 mg, and the recommendation was signed by both the pharmacist and physician, but the resident remained on an active order for Quetiapine 400 mg with no evidence the dose reduction order had been processed or implemented. For Resident #2, who had diagnoses including schizoaffective disorder and major depressive disorder, the consultant pharmacist recommended review of five psychotropic medications for eligibility for a GDR, but the physician did not respond until after surveyor intervention, about three months later, and the recommendation was not tracked to resolution. For Resident #63, the pharmacist recommended discontinuing or replacing Hydroxyzine because it is a highly anticholinergic antihistamine, and the provider response was not signed until about four months later; the provider documented, "Follow up with the Psychiatrist for GDR."
Failure to Maintain Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Enhanced Barrier Precautions were not maintained during wound care for Resident #28, who had been ordered Enhanced Barrier Precautions on 12/8/2025 for CRE, a foley, wound care, and enteral feedings every shift. The facility’s policy required staff to wear a gown and gloves during high-contact resident care activities, including wound care, for qualifying residents with multidrug-resistant organisms. On 5/12/2026 at 10:12 AM, while observing the wound care performed by the Wound Care Nurse Practitioner, the surveyor noted that the staff member did not use the yellow isolation gown required for Enhanced Barrier Precautions during the high-contact care activity. Later that day, the DON stated that Resident #28 was colonized for resistant infections and that PPE should be worn with high-contact care.
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.
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 1,761 citations issued within 25 miles in the last 12 months — including the 9 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 | ★★★★★ | 21 | 0 |
| Future Care Irvington | 1.1 mi | ★★★★★ | 0 | 0 |
| Maryland Baptist Aged Home | 1.7 mi | ★★★★★ | 0 | 0 |
| Westgate Hills Rehab & Healthcare Ctr | 1.7 mi | ★★★★★ | 38 | 0 |
| Charlestown Community Inc | 1.7 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Carroll Park Healthcare.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.