Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chapel Hill Nursing Center during CMS and state inspections, most recent first.
Food service safety standards were not followed in the kitchen and on resident units. Surveyors observed dirty trays, cups, pitchers, carts, and food prep surfaces; food stored with debris, gnats, and unlabeled or outdated items; scoop handles left in dry goods; chemicals stored near food; plumbing backflow and pooling liquid on the kitchen floor; uncovered resident meal trays and beverages in hallways; and a staff member plating food with an artificial nail protruding through a broken glove. Food temperature documentation was incomplete for breakfast.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Missing transfer, discharge, Ombudsman, and bed hold documentation. The facility did not maintain complete discharge paperwork for a resident who left AMA, did not document notification to the local Ombudsman for resident transfers and discharges, and did not provide written transfer notices or bed hold policy notices to residents or their reps for multiple hospital transfers. Several bed hold forms also lacked the resident’s actual signature.
Loose and worn hallway handrails were observed on both nursing units. Survey findings noted handrails on Unit 1 with chips, splintering, holes, and worn finish, and three handrails that were loose and movable in the Main Unit 1 hallway, the hallway connecting Units 1 and 2, and the Unit 2 hallway. The concerns were shared with the DOR, DON, AIT, and Regional Administrator at exit conference.
Two residents’ rights were not upheld when one resident’s urinary catheter bag was repeatedly observed uncovered, with the bag cover at one point lying on the floor, and another resident was refused feeding assistance while on the phone with family despite the family’s consent to proceed. The staff member told the resident they would only be fed after ending the call, and leadership later acknowledged the resident had the right to be fed while on the phone but cited staff discomfort as the reason this did not occur.
Surveyors found that the facility failed to develop and implement comprehensive care plans for two residents. One resident used a motorized wheelchair and had a documented safety assessment and an ED note describing a leg injury that occurred while using the device, yet the care plan contained no documentation or interventions related to motorized wheelchair use. Another resident had a documented diagnosis of PTSD and a history of childhood sexual abuse, and while the care plan noted trauma as a focus, it listed no specific interventions to address PTSD or the trauma history.
Surveyors identified that the facility failed to revise person-centered care plans after significant changes in two residents’ conditions. For one resident, the MOLST and paper chart were updated from Full Code to DNR-B with No CPR and palliative/supportive care orders, but the care plan continued to list the resident as Full Code. For another resident who sustained a fall with injuries and was sent to the ER, the existing fall-prevention care plan was not updated to reflect the incident or any new interventions, and no timely review was documented. During interviews, the rehab director reported that therapy provides recommendations after falls but does not revise care plans, and the DON and regional administrator confirmed that no care plan revisions or fall investigation documentation were available.
A resident’s rights and the resident representative’s rights were not upheld when staff refused to feed the resident while the resident was on the phone with family at mealtime. The DON confirmed that the resident had the right to be fed while on the phone, but a staff member would not do so because they were not comfortable feeding the resident during the call, and the resident was told feeding would occur only after the conversation ended.
Resident council concerns were not addressed or reported back to residents. During an observed council meeting, residents raised issues about staff behavior during care, nighttime noise, housekeeping, weekend maintenance availability, and poor communication about prior concerns. Interviews showed the AA gave minutes to the SW, but prior concerns were not reviewed at later meetings and residents said they never received responses. Meeting minutes also showed multiple unresolved concerns, and the suggestion box was hidden in an unmarked cabinet.
Incomplete CMS-10055 notices were found for three residents when the facility failed to document the per diem rate for non-covered services and the reason Medicare was no longer covering those services. The Social Services Director said she had been told the information was optional, and the BOM reportedly gave residents verbal notice instead of the required written details.
Inaccurate MDS Assessment: A resident with an ostomy had an MDS that did not correctly reflect the ostomy in Section H 100, although Section H 400 noted the resident was not rated for bowel continence because of the ostomy. The MDS Coordinator said she was familiar with the resident but was unsure why the ostomy information did not carry over from the prior MDS.
Missed Follow-Up Eye Appointment Not Rescheduled Timely: A resident missed a scheduled follow-up eye appointment because transportation was not arranged, and the missed visit was not rescheduled promptly. The resident reported receiving eye injections for a medical condition and said no update had been provided about the new appointment. The AS stated she was unaware of the appointment and that nursing usually informs her of resident appointments; the DON later confirmed a new eye appointment was ordered.
The facility failed to ensure annual performance reviews were completed for 2 GNAs reviewed during the survey. Personnel file reviews showed no yearly performance review for two GNAs, and the DON, DHR, NHA, and former NHA all confirmed that performance reviews were not conducted or were not in the files.
An unlocked medication cart was observed on a Unit 1 hallway with resident medication packs, bottled meds, and supplies accessible, and an LPN locked it only after surveyor intervention. Surveyors also found expired Nepro in two storage areas, including the Unit 1 nursing supply closet and the clean supply room.
The facility failed to follow the posted lunch menu during meal service. During a tray pass observation, the FPM said a resident needed a new tray because food had been left exposed in the hallway and lasagna was no longer available, and also stated that the prime rib listed on the menu was not served because it was not available when ordered. The FPM confirmed residents were not notified of the menu substitutions before the meal, and the resident later reported receiving a sandwich and carrots instead of the menu meal.
Expired GNA Certification: The facility failed to ensure that a GNA had an active, current certification. Staffing sheets showed the GNA worked multiple resident care shifts, while the employee file and MBON license lookup confirmed the certification was non-renewed and expired. The DON and NHA were informed that the GNA had been providing resident care with an expired license.
A resident’s EMR and paper chart did not contain a personal inventory sheet, despite staff stating that residents’ belongings should be logged in the chart. The facility policy required personal property to be inventoried on admission and kept in the medical record, and the DON acknowledged the missing documentation.
Clean linen and resident personal laundry were observed being handled and transported without full coverage, including uncovered garments carried on hangers and an uncovered clean linen cart moved through the facility. Surveyors also observed a clean supply storage room with cracked, damaged ceiling areas, debris, and dust on stored supplies, as well as resident laundry placed in mesh bags with open spaces in a soiled laundry container.
Kitchen equipment was not maintained in working order during the survey. The surveyor observed a freezer thermometer reading 110, food debris on a warmer base and clean utensil rack, cloudy liquid under the dishwasher drain area, a disconnected drain stopper, a cracked chemical line dripping into the rinse compartment of the 3-comp sink, and a reach-in refrigerator that was not cooling. Staff said the dishwasher had been leaking for about a week, no temp logs were kept for the dish machine, and a kitchen service report noted electrical connections needed review.
Failure to maintain effective pest control was cited after surveyors observed gnats in a shared resident bathroom, at the nurses' station, in a hallway, in a resident room, and in the kitchen. A resident reported the facility had an issue with gnats, and surveyors also saw gnats flying around and on onions stored in an open plastic container. The DOM stated the facility uses a pest control company monthly and as needed, and staff report pest sightings to maintenance.
Missing GNA Training and Clinical Competency Documentation: The facility failed to maintain required annual in-service education and clinical skills competency records for multiple GNAs. The surveyor found missing 12-hour training documentation and absent 2025 clinical competencies for several GNAs, including two GNAs confirmed by the DON to lack competency records, while another GNA’s packet appeared to be an identical copy of others and was dated before the GNA was hired. Documentation for an agency GNA was also not available.
A resident with dementia and epilepsy fell and suffered a subdural hematoma after a GNA left them unattended with the bed raised, despite a care plan requiring two-person assistance. The facility's inconsistent communication and incomplete staff training on resident assistance levels contributed to the incident.
The facility's dietary staff failed to maintain temperature logs for refrigerators and freezers, did not date or label food items with expiration dates, and handled residents' food without wearing beard covers. These deficiencies were observed during a recertification survey, with the Dietary Manager citing short staffing as a reason for incomplete logs and aides unaware of the beard cover requirement.
The facility failed to provide evidence of annual training on abuse, neglect, and exploitation for all nursing staff. A review of six staff members' records revealed no documentation for 2022 and 2024. The DON confirmed the absence of records for these years, despite providing documentation for 2023.
The facility failed to conduct background checks on certain staff members, including a GNA and an LPN, as revealed during a re-certification survey. The Director of Human Resources could not provide documentation for these checks, and the Administrator was unable to identify or provide files for staff involved in an alleged verbal abuse incident.
A facility failed to promptly report a suspected abuse incident involving a GNA and a resident. The incident, where a GNA placed a wedge pillow on a bed after becoming discouraged, was reported by the resident's family to the ombudsman. The NHA was informed the next day but did not report to OHCQ until the ombudsman raised the issue days later. Both the resident and the GNA denied any abusive intent.
The facility failed to thoroughly investigate incidents involving a resident's injury of unknown origin, an elopement, and an abuse allegation. Inadequate documentation and lack of staff interviews were noted, and training was insufficiently attended. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to accurately code the MDS assessment for a resident's smoking status. The resident was found smoking in their room, but the MDS inaccurately documented no cigarette use. The MDS coordinator confirmed that smoking status should be assessed initially, quarterly, and upon any significant change, but this was not accurately reflected. The NHA validated the inaccuracy in the resident's initial MDS record.
The facility failed to update care plans for two residents, one of whom reported feeling unsafe after an incident, and another who required Ativan for anxiety. Despite investigations and ongoing medication orders, care plans were not revised to reflect these changes, as confirmed by the DON and Activity Director.
A resident with adequate cognitive ability did not receive scheduled showers due to inadequate facility accommodations, resulting in bed baths without documented refusals or encouragement for showers. Staff interviews revealed the lack of appropriate shower facilities for residents unable to sit in a shower chair, and the resident eventually received a shower after surveyor intervention.
A resident on blood-thinner medication underwent a tooth extraction without holding the medication, leading to excessive bleeding and hospital admission. The RN was unaware of the dentist's visit and did not document informing the dentist about the medication intake. The facility ceased using the dentist due to communication issues.
A facility failed to monitor a resident's significant weight changes, resulting in a 20-pound loss over two months without physician notification. The resident, with failure to thrive and swallowing difficulties, required full meal support. Despite documented weight refusals, there was no evidence of further intervention or communication with the physician. Staff interviews revealed inconsistencies in communication and documentation processes, which were validated by the Nursing Home Administrator.
A facility failed to ensure the justified use of psychotropic medication for a resident with anxiety. The resident was prescribed Ativan without implementing or documenting non-pharmacological interventions or behavior monitoring. The facility did not monitor the resident's psychiatric symptoms, and interviews confirmed the lack of non-pharmacological interventions before administering the medication.
The facility failed to ensure GNAs received training on resident safety and care after an alleged abuse incident. One GNA had no records of training on safety and mobility, while another was involved in an incident with a resident but lacked training on customer service and timely reporting. The Nursing Home Administrator confirmed the absence of these training records.
The facility failed to ensure a safe and clean environment in two bathrooms, where floor radiator heaters had missing end caps, exposing sharp, rusted edges. In one bathroom, two unsecured metal pieces were also present, and a paper towel dispenser was missing. The Director of Maintenance acknowledged these issues, but the radiator heater in one bathroom remained uncapped, posing a risk to residents.
The facility failed to notify a resident and their representative in writing about the bed hold policy when the resident was transferred to an acute care facility. During a recertification survey, it was found that there was no written evidence of the policy being communicated. Interviews with the DON and a Social Worker confirmed the lack of documentation.
A facility failed to maintain an effective communication system for a non-English speaking resident who speaks only Russian. Staff interviews revealed reliance on basic sign language and family assistance for communication, with no consistent tools or interventions in place. The care plan noted the language barrier, but lacked specific strategies to address it. The Nursing Home Administrator mentioned tools like a picture board and Google Translate, but their use was not verified.
The facility failed to properly store medications, with two opened insulin vials not discarded within the required 28-day period and expired supplies found in the medication storage room. These issues were identified during a recertification survey and confirmed with the ADON.
The facility failed to prevent infection and protect the dignity of residents with indwelling catheters by improperly using pillowcases for Foley bags. Additionally, a resident did not receive complete TB screening, and an RN did not sanitize hands between medication administrations, breaching infection control protocols.
Food Service Sanitation and Storage Failures
Penalty
Summary
The facility failed to ensure professional standards for food service safety were followed in the kitchen and on resident units. During the survey, dirty trays, dishes, cups, and food items were observed in hallways and dining areas, including an open cart with dirty food trays, wilted lettuce with orange liquid, an open sleeve of unused cup lids next to dirty items, and snack trays that were warm to the touch. Some resident snacks were labeled with prior meal times and dates, and one tray in the dining area refrigerator was labeled with an earlier date. An ice water pitcher on a medication cart was also observed with a sticky substance and dark areas on the exterior. In the kitchen, the surveyor observed multiple sanitation and storage concerns. Dirty items were present at the sink area, including knives in a brown pitcher and a container with red liquid stored near clean dessert bowls and mugs. The steam table, warming plate base, clean item storage rack, food cooking equipment, ice machine, trash cans, and carts were observed with food debris, sticky residue, drip stains, or other unclean conditions. The kitchen also had onions in a container with brown and black debris and gnats present, a container of noodle soup labeled with an earlier date, damaged disposable gloves on the prep table, and the hand soap dispenser detached and lying on the windowsill. Additional observations showed plumbing and sink problems in the food prep area, including a rag stuffed in a sink drain to hold water, pink liquid pooling across the floor from under the sink, and backflow from plumbing onto the kitchen floor. Dry storage concerns were also observed, including scoop handles left in thickener, flour, rice, and other food containers, chemicals stored directly in front of dry food supplies, and a food mixer being used to store hairnets and other items. The surveyor also observed uncovered resident meal trays and beverages in hallways, dirty breakfast trays placed on a clean food cart, and a staff member plating food with an artificial nail protruding through a broken glove. Food temperature logs reviewed by the surveyor did not include breakfast temperatures for the meal served that morning.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Missing Transfer, Discharge, Ombudsman, and Bed Hold Documentation
Penalty
Summary
The facility failed to maintain discharge documentation, notify the local Ombudsman of resident transfers and discharges, and provide written notification to residents or their representatives regarding hospital transfers and the facility’s bed hold policy. This was identified for 4 of 5 residents reviewed for transfers and discharges during the annual recertification survey. The report specifically noted missing documentation for a resident who was transferred to the hospital and for a resident who discharged against medical advice, as well as missing written transfer and bed hold notices for residents who were sent to the hospital on multiple occasions. For one resident who discharged against medical advice, the electronic record contained a social services note stating the resident chose to proceed with discharge AMA, and staff stated that a signed Resident-Initiated Release of Responsibility for Discharge Against Medical Advice form had been placed in the chart. However, the surveyor could not locate the signed form in the medical record, and the facility was unable to provide it by the exit conference. For another resident, the record showed multiple hospital transfers across 2025 and 2026, but the record review failed to reveal documentation that the resident or representative received written notification of the transfers or the facility’s completed bed hold policy for several of those transfers. A similar lack of documentation was found for a second resident who had hospital transfers in March 2026. The surveyor also found no documentation that the local Ombudsman was notified of the facility’s transfers and discharges for the residents reviewed. During interviews, the NHA stated that the Social Services Director was responsible for notifying the Ombudsman by email weekly or monthly, but the Social Services Director stated she did not know she had to notify the Ombudsman about transfers and discharges. The NHA later stated that this notification process did not begin until the end of February 2026, and that no other department was sending transfer and discharge notifications before then. The report also noted that the facility’s bed hold forms were missing the resident’s actual signature on several transfer dates.
Loose and Worn Hallway Handrails
Penalty
Summary
Handrails on both nursing units were found to be in poor condition and not firmly affixed. During the initial tour, handrails on Unit 1 were observed to be worn with chips, splintering, holes, and areas where the wood finish had worn off. Later rounding of the nursing units identified three handrails that were loose and movable: one on the Main Unit 1 hallway, one in the hallway connecting Units 1 and 2, and one in the Unit 2 hallway. The surveyor shared these concerns with the Director of Maintenance, who observed and acknowledged the findings, and the concerns were also discussed with the Administrator, DON, Administrator in Training, and Regional Administrator during the exit conference.
Failure to Maintain Dignity and Respect Resident Communication Rights
Penalty
Summary
The facility failed to promote resident dignity for a resident with an indwelling urinary catheter. On 3/23/2026 at 8:30 AM, a surveyor observed that this resident’s urinary catheter bag was hanging from the bed without a cover. On 3/24/2026 at 12:35 PM, the same resident was observed with a cover over the urinary catheter bag. However, on 3/26/2026 at 2:43 PM, the resident was again observed lying in bed with the urinary catheter bag uncovered, and the bag cover was seen lying on the floor next to where the catheter bag was hanging. These observations showed that the facility did not consistently ensure the catheter bag was covered, which the surveyor identified as a failure to maintain the resident’s dignity. The facility also failed to uphold a resident’s right to self-determination and communication during a mealtime. A facility-reported incident and subsequent interviews revealed that a resident was on the phone with their sister, who was also the resident representative, and their mother at lunchtime when staff arrived to assist with feeding. The staff member told the resident they would be fed after they finished their phone conversation and refused to feed the resident while they remained on the phone, despite the sister stating it was acceptable to feed the resident during the call. The staff member left, stating they would return once the resident was off the phone. During an interview, the DON acknowledged that the resident had the right to be fed while on the phone but stated that staff could not be made to do something they were uncomfortable with. The surveyor informed the DON that the resident’s rights had been denied because the resident had to end the phone call in order to receive their meal.
Failure to Develop Comprehensive Care Plans for Motorized Wheelchair Use and PTSD
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive care plans for two residents. For one resident who used a motorized wheelchair, interviews with the DON, Administrator, and Occupational Therapist confirmed that the resident had a power mobility device and that a safety assessment for its use had been completed by therapy. The resident’s medical record included an Emergency Department physician note documenting the resident’s report that they were in their motorized wheelchair when they sustained a leg skin tear or laceration after running into their bed. The facility’s matrix and records showed the resident had been admitted and later discharged, and a power mobility indoor driving assessment dated several months prior was provided. Despite this information and the confirmed use of a motorized wheelchair, review of the resident’s care plan showed no documentation addressing the resident’s use of a motorized wheelchair. For another resident, record review showed documentation in the facility matrix and in a Quarterly MDS that the resident had a medical diagnosis of post-traumatic stress disorder (PTSD) and a history of trauma related to childhood sexual abuse. The resident’s care plan focus reflected this trauma history; however, the only listed intervention for that focus was the word “trauma,” with no specific interventions identified to address the PTSD diagnosis or trauma history. During an interview, the Nursing Home Administrator was informed that the resident had a PTSD diagnosis, but the surveyor could not locate any detailed interventions in the care plan beyond the generic trauma notation.
Failure to Revise Care Plans After Code Status Change and Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure person-centered care plans were timely updated and revised by the interdisciplinary team following significant changes in residents’ status and events. For one resident, a social services note documented that the Maryland MOLST was reviewed and changed from Full Code to DNR-B on a specified date, and the paper chart contained a MOLST form with orders for No CPR, Option B, Palliative and Supportive Care. However, the resident’s care plan still contained a focus stating that the resident’s Full Code MOLST would remain in place through the review date, and this care plan was not revised to reflect the updated code status. During record review with the Nursing Home Administrator, it was confirmed that the MOLST had been updated but the care plan had not been revised accordingly. The deficiency also includes the facility’s failure to revise a resident’s care plan after a fall event. A progress note by an LPN documented that another resident experienced a fall, sustained several injuries, and was transferred to the emergency room. Review of this resident’s care plan showed that no revisions were made to the existing fall interventions in response to the fall, and the care plan was not documented as reviewed and revised until a later date. During interviews, the Director of Rehabilitation stated that therapy makes recommendations and sees residents after falls but does not revise the care plan and was unsure if nursing was responsible for care plan revisions. The DON and Regional Administrator confirmed that no care plan revisions had been made in response to the fall and that there was no recollection or documentation of a fall investigation.
Resident Representative Rights Not Upheld During Mealtime
Penalty
Summary
The facility failed to ensure that the resident representative’s rights were upheld when Resident #61 was not allowed to remain on the phone with family while being fed. During the investigation of a facility-reported incident involving an allegation that the resident was not being fed, staff found the resident on the phone with the resident’s mother and sister at lunchtime. A staff member told the resident that feeding would occur after the phone conversation ended and refused to feed the resident while the family remained on the call, despite the sister stating that it was okay to feed the resident because they were not really speaking on the phone. The DON and NHA were interviewed about the complaint from the resident’s family regarding the incident. The DON stated that the resident’s sister was the resident representative and that the staff member continued to refuse to feed the resident while the family was on the phone. The DON acknowledged that the resident had the right to be fed while on the phone, but stated staff could not be made to do something they did not feel comfortable doing. When asked whether the resident’s rights had been denied, the DON stated no, although the surveyor explained that both the resident’s rights and the resident representative’s rights had been denied because the resident was required to get off the phone in order to be fed.
Resident Council Concerns Not Addressed or Reported Back
Penalty
Summary
The facility failed to ensure that recommendations and suggestions from the resident council were addressed and reported back to residents. During a resident council meeting observed by the surveyor, residents discussed concerns about staff using phones and earbuds during resident care, loud staff conversations and music at night, housekeeping not cleaning room floors unless requested, maintenance not being available on weekends, and a lack of communication about what was being done regarding prior concerns. The resident council president stated that residents preferred earlier meeting times and did not know why the meeting time had been changed. The Activities Aide later changed the meeting time back and notified residents by word of mouth. The Nursing Home Administrator and social worker were interviewed about the process for resident grievances and council concerns. The social worker stated that when she received the minutes, she wrote up grievances to be addressed and would speak with the resident involved if possible, but she was unsure how recommendations were addressed. The administrator stated that responses should be readdressed at the next meeting. The Activities Aide who facilitated the council stated that she gave the minutes to the social worker, but that prior month’s minutes were not discussed at each resident council meeting and were not resolved through that process. Review of the resident council meeting minutes for January and February 2026 showed multiple resident concerns, including a suggestion box in an accessible area, nighttime interruptions affecting sleep, condiments being more readily available, speaking with the dietary manager about cold food, and having snacks throughout the day. The minutes did not include revisiting past concerns or how they were addressed. The resident council president later stated that the facility did not go over prior minutes and that residents never received responses back. An Activities Aide also located the suggestion box in a small kitchenette cabinet with no writing on it to identify it as a suggestion box, and several papers were inside.
Incomplete Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to complete the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (CMS-10055) forms for Residents #3, #5, and #64 by omitting the facility’s per diem rate for services no longer covered under Medicare/Medicaid and the reason Medicare was no longer covering those services. During record review on 03/27/26, the surveyor reviewed the CMS-10055 forms provided by the facility and found that these required details were not documented for all 3 residents reviewed during the annual recertification survey for beneficiary notification. During an interview on 03/27/26, the Social Services Director stated she had been told it was optional to list that information on the CMS-10025 form and said the Business Office Manager verbally informs residents about the facility’s per diem rate for services no longer covered under Medicare/Medicaid. Later, on 03/30/26, the Nursing Home Administrator was informed that the CMS-10055 forms for the three residents did not include the per diem rate or the reason Medicare was no longer covering the services, and he stated he would check into the concern.
Inaccurate MDS Assessment
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to accurately complete the MDS for Resident #14. During record review, the resident was found to have an ostomy, but the current MDS did not indicate that the resident had one in Section H 100, which showed only an indwelling catheter. In Section H 400, the assessment indicated the resident was not rated for bowel continence because of an ostomy. During interview, the MDS Coordinator stated she was familiar with the resident and explained that MDS assessments are completed within 72 hours of admission, quarterly, annually, and within 14 days of a significant change, but she was not sure what happened or why the ostomy information did not carry over from the previous MDS assessment.
Missed Follow-Up Eye Appointment Not Rescheduled Timely
Penalty
Summary
The facility failed to ensure that Resident #45 attended a scheduled follow-up eye appointment on 2/27/2026 and failed to ensure the missed appointment was rescheduled in a timely manner. During interview, the resident stated the appointment was missed because the facility did not arrange transportation, and that the Appointment Scheduler told the resident the appointment would be rescheduled immediately, but no information about a new appointment had been provided. The resident also reported that the eye appointment was important because he/she was receiving eye injections for a medical condition and his/her eyes felt uncomfortable while watching television. Record review showed no order for a follow-up eye appointment in the resident’s electronic medical record. The Appointment Scheduler stated she was unaware of the 2/27/2026 appointment and that nursing staff usually informs her of resident appointments, and she said she was in the process of rescheduling it. The DON later stated he would call the eye company himself to reschedule the appointment. A physician’s order dated 3/25/2026 documented a follow-up eye appointment for 4/22/2026 at 1:30 PM, confirmed by the DON.
Missing Annual GNA Performance Reviews
Penalty
Summary
The facility failed to ensure required Geriatric Nursing Assistant (GNA) performance reviews were completed every 12 months for 2 of 5 employees reviewed for sufficient staffing during the annual recertification survey. A review of GNA #15's personnel file on 3/30/2026 at 12:15 PM did not reveal a yearly performance review conducted at least every 12 months, and a similar review of GNA #37's file on 3/30/2026 at 12:30 PM also did not show a yearly performance review within the required timeframe. During interviews, the DON confirmed that no yearly performance review had been conducted for either GNA #15 or GNA #37, the DHR stated that performance reviews would be in the personnel files if completed and that DHR does not conduct them, and the NHA and former NHA #21 stated that they did not conduct performance reviews.
Unsecured Medication Cart and Expired Nutritional Supplements
Penalty
Summary
Drugs and biologicals were not securely stored when an unattended and unlocked medication cart was observed on the Unit 1 hallway during the recertification survey. All drawers of the cart were accessible and contained resident medication pill packs, bottled medications, and medical supplies. When the concern was reviewed with Nurse #26, the cart was then locked. Nurse #26 stated that the cart had been assigned to a nurse who had not yet arrived for the shift, and when asked who was currently assigned to the cart, indicated that it was theirs. Nutritional supplements were also found to be expired in two storage areas. During the initial tour, a box of Nepro in the Unit 1 nursing supply closet was observed with an expiration date of [DATE]. Later, during a dual surveyor tour of the clean supply room, another box of Nepro was observed with an expiration date of [DATE]. The expired supplements were identified in both storage areas during the survey observations.
Posted Lunch Menu Not Followed
Penalty
Summary
The facility failed to ensure the posted menu was followed during the lunch meal service. During a tray pass observation, the Food Protection Manager stated that a new tray would be made from scratch for Resident #33 because the resident’s food had been left exposed in the hallway and there was no more lasagna available. The Food Protection Manager also reported that the prime rib listed on the menu was not served because it was not available when the food was ordered, and confirmed that residents were not notified of the menu substitutions before the meal was served. The surveyor later interviewed Resident #33, who reported receiving a replacement meal tray consisting of a sandwich and carrots instead of the menu meal. Review of the facility’s menu confirmed that the posted lunch menu was not followed.
Expired GNA Certification
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistant (GNA) staff had an active, current certification. During the annual recertification survey, a review of staffing sheets showed that GNA #15 worked resident care assignments on multiple days and shifts, including repeated 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM assignments, as well as additional 3:00 PM to 11:00 PM shifts. GNA #15 was also scheduled to work on another date for both the evening and overnight shifts. A review of GNA #15's employee file showed a Maryland Board of Nursing Licensee Details sheet listing an expiration date for the certification. The surveyor requested a current GNA license, then reviewed the MBON Look Up A License feature, which showed the certification status as non-renewed and confirmed that the license had expired. The surveyor discussed the concern with the DON and later with the NHA, who acknowledged that GNA #15 had been providing resident care while the license was expired.
Missing Personal Inventory Sheet in Resident Record
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices for one resident reviewed for communication/sensory concerns. A review of the resident’s electronic medical record and paper chart did not reveal a personal inventory sheet, even though staff stated that residents with personal belongings should have those items logged on a personal inventory sheet in the paper chart. The facility’s Personal Property policy states that residents’ personal belongings and clothing are to be inventoried and documented upon admission and updated as necessary, with a copy of the personal inventory sheet maintained in the resident’s medical record. During interview, the DON acknowledged the surveyor’s concern that a comprehensive personal inventory sheet had not been completed and maintained for the resident.
Clean Linen and Supply Storage Handling Concerns
Penalty
Summary
The facility failed to ensure clean linen was handled, transported, and stored in a safe and sanitary manner. Surveyors observed Laundry Staff #33 carrying clean, uncovered resident garments on hangers while walking up the facility steps, with the garments draped over the staff member’s arm. Surveyors also observed Laundry Staff #20 transporting an uncovered yellow clean linen cart with folded facility linen on Unit 1 and then down the freight elevator. During interview, the Environmental Services/Laundry Manager confirmed that clean linen and resident personal linen should be fully covered while being transported through the facility. Surveyors also observed the supply room used for storage of clean supplies and noted several long cracks in the ceiling with damaged open areas, dust, debris, and light brown discoloration. Pieces of white crumbled debris were observed on the floor and white dust was observed on stored supplies. In the laundry area, surveyors observed a rolling cloth-type laundry container with soiling and discoloration holding two residents’ personal laundry in mesh bags, and the mesh bags had open spaces within the material. The Director of Housekeeping confirmed that mesh bags were used for resident personal laundry and acknowledged the surveyors’ concerns.
Kitchen Equipment Not Maintained in Working Order
Penalty
Summary
The facility failed to ensure maintenance of essential kitchen equipment during the recertification survey. During the initial kitchen tour, the surveyor observed the digital exterior thermometer on Freezer #3 reading 110, food debris on the warming plate base in the warmer, and food cooking equipment on the clean utensil rack with a layer of food debris and clear liquid present. The surveyor also observed a rectangular bucket of cloudy liquid beneath the dishwasher filter container and drain, with the drain stopper disconnected from the machine. In the dishwashing area, the chemical line for the wash compartment of the three-compartment sink was draped over the middle rinse compartment and was dripping from a cracked area in the line, which had a small pad affixed near it and was held with a metal piece. The reach-in refrigerator nearest the food serving line was observed not to be working, with no refrigeration occurring and refrigerator parts sitting inside the unit. Staff interviews confirmed the dishwasher had been leaking for about a week, that no temperature logs were maintained for the dish machine, and that the machine was hot water and chemical. Documentation reviewed showed one kitchen service report dated 2/25/26 noting electrical connections needed review, but no notes were provided.
Failure to Maintain Effective Pest Control
Penalty
Summary
The facility failed to ensure effective pest control to keep the environment free from gnats. During an initial tour of Unit 2, flying gnats were observed in the shared bathroom used by Resident #19 and Resident #45, and the bathroom had a musty odor. On a later tour of Unit 2, flying gnats were also observed at the nurses' station and in the hallway. During an interview with Resident #28, flying gnats were observed in the resident's room, and the resident stated the facility had an issue with gnats. The Director of Maintenance stated the facility uses a pest control company that comes monthly and as needed, and that staff report pest sightings verbally and in the maintenance log at the nurses' station. In the kitchen, surveyors observed gnats flying around and in an open plastic onion container, and later observed gnats on and around the onions in the same container. The Food Protection Manager acknowledged the concern, and the onions were observed being removed and discarded after surveyor intervention.
Missing GNA Training and Clinical Competency Documentation
Penalty
Summary
The facility failed to maintain an in-service training program to consistently evaluate each Geriatric Nursing Assistant (GNA) based on individual performance of mandatory education and clinical skills competencies of no less than 12 hours per year. During review of employee personnel files, the surveyor found that GNA #15, GNA #35, GNA #36, and GNA #37 did not have documentation showing annual mandatory in-service training and clinical competency completed in the last 12 months, which was 4 of 5 employee files reviewed for sufficient staffing during the annual recertification survey. When the surveyor requested documentation, the NHA provided 2025 Mandatory Education & Training Manual individual packets for GNA #15, GNA #35, and GNA #37, but did not provide 2025 clinical competencies for those GNAs. The facility also did not provide documentation for GNA #36 and stated the GNA was agency staff and the facility would have to contact the agency for that documentation. The surveyor observed that the packets for GNA #15, GNA #35, and GNA #37 were identical copies, each signed with an ink signature and dated 1/31/2025. The DON confirmed that GNA #15 and GNA #37 did not have clinical skills competencies for 2025, and stated that GNA #35 was hired in September 2025 and completed clinical skills competency during orientation. The facility also had not started 2026 Mandatory Education & Training Packets.
Failure to Provide Adequate Staff Support Leads to Resident Injury
Penalty
Summary
The facility failed to provide the specified number of staff support needed when providing care for residents, resulting in a serious accident. A resident with a history of dementia, epilepsy, and seizure disorder, who was dependent on activities of daily living, fell out of bed and suffered a left acute frontal subdural hematoma requiring surgery. The incident occurred when a Geriatric Nursing Assistant (GNA) left the resident unattended with the bed raised to her waist level, contrary to the care plan that required two-person assistance. The investigation revealed that the GNA admitted to leaving the resident unattended while she went to the bathroom to wet a towel, during which time the resident fell. The facility's investigation also showed that the GNA was aware of the resident's squirming behavior but failed to ensure the resident's safety by not lowering the bed or securing the resident. The care plan clearly indicated the need for two-person assistance, which was not followed, leading to the resident's fall and subsequent injury. Interviews with other staff members indicated inconsistencies in how they were informed about the required assistance levels for residents. Some staff relied on information from the rehabilitation team, while others referred to notes on the resident's bed or electronic health records. The facility's documentation and training records were incomplete, as not all staff received the necessary in-service education on resident safety and transfer mobility, contributing to the deficiency.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The dietary staff at the facility failed to maintain proper temperature logs for the refrigerators and freezers from January 4 to January 6, 2025. During an initial tour of the kitchen, it was observed that the temperature logs were not completed, and the Dietary Manager attributed this to being short-staffed during those days. However, during a follow-up visit, the missing temperature logs were found to be completed, but the Dietary Manager could not provide a reason for this discrepancy. Additionally, the dietary staff did not date or label food items stored in the refrigerator and freezer with expiration dates. Items such as a large bowl of beefaroni meal, tomatoes, carrots, cheese, sour cream, frozen vegetables, and French fries were found without proper labeling. Furthermore, a dietary aide was observed handling residents' food without wearing a beard cover, and during a follow-up visit, two dietary aides were seen without beard covers despite having beards. The aides mentioned that they were unaware of the requirement and that beard covers were being ordered.
Deficiency in Annual Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide evidence that all nursing staff received annual training on abuse, neglect, and exploitation, as required. During a recertification and complaint survey, the surveyor reviewed the training records of six randomly selected nursing staff members, including registered nurses and geriatric nurse aides, and found no documentation of the required training for the years 2022 and 2024. The Director of Nursing stated that the facility offered annual abuse training and provided documentation for 2023, but confirmed the absence of records for the other years. This deficiency was identified for all six staff members whose records were reviewed.
Failure to Conduct Background Checks on Staff
Penalty
Summary
The facility administration failed to ensure that background checks were conducted for certain employees, which is a critical measure to protect residents from abuse, neglect, and theft. During a re-certification survey, it was found that four out of nine employees reviewed did not have documented background checks. Specifically, the Director of Human Resources was unable to provide a background check for GNA #26, despite reviewing both paper and electronic employee records. Additionally, the Administrator could not identify or provide employee files for GNA #46, LPN #47, and GNA #48, whose initials were listed in a facility reported incident for alleged verbal abuse. This lack of documentation and identification indicates a significant oversight in the facility's hiring and record-keeping processes.
Delayed Reporting of Suspected Abuse Incident
Penalty
Summary
The facility staff failed to immediately report an allegation of suspected resident abuse involving a Geriatric Nursing Assistant (GNA) and a resident. The incident allegedly occurred when the GNA was attempting to position a wedge pillow under the resident's feet but became discouraged and placed the wedge on the bed, stating she would return later. The resident did not perceive this action as abusive, nor did the roommate, but the family reported the incident to the ombudsman during a care plan meeting. The Nursing Home Administrator (NHA) was informed of the incident the day after it occurred but did not report it to the Office of Healthcare Quality (OHCQ) until it was brought up by the ombudsman four days later. The NHA conducted interviews with the resident and the GNA, both of whom denied any abusive intent. Despite this, the facility's delay in reporting the incident to the OHCQ was noted as a deficiency during the recertification survey.
Investigation and Documentation Deficiencies in Resident Incidents
Penalty
Summary
The facility failed to thoroughly investigate a resident's injury of unknown origin, as evidenced by the lack of documentation for interviews with other residents. Resident #30 was found with a bruise on the left flank and coccyx, and while the facility conducted staff interviews and hospital follow-ups, they did not interview other residents to verify their safety. The Nursing Home Administrator confirmed the absence of these interviews during a review with the surveyor. Additionally, the facility did not adequately address an elopement incident involving Resident #23, who left the building unnoticed by staff. The investigation lacked an interview with the staff member who initially observed the resident leaving via camera. Although in-service training was provided on the day of the incident, only nine nursing staff members attended, despite the facility having more staff. The Nursing Home Administrator acknowledged these shortcomings. Furthermore, the facility's investigation into an allegation of abuse involving Resident #19 was incomplete, as there was no documentation of witness statements, skin assessments, or abuse training following the incident.
Inaccurate MDS Assessment for Resident's Smoking Status
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident reviewed for smoking during the recertification/complaint survey. The investigation revealed that the resident was found smoking in their room, and although an initial smoking assessment was completed upon admission, the MDS assessment inaccurately documented no cigarette use. This discrepancy was identified during a review of the resident's medical records, which showed that the resident was admitted in October 2022, and the incident of smoking occurred in November 2022. The MDS coordinator confirmed that smoking status should be assessed initially, quarterly, and upon any significant change, but this was not accurately reflected in the resident's MDS assessment. The Nursing Home Administrator validated the inaccuracy in the resident's initial MDS record.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility staff failed to revise the interdisciplinary care plans to meet the needs of two residents, leading to deficiencies in care. For one resident, an incident was reported where the resident did not feel safe due to being touched by someone. Despite the facility's investigation, which concluded that the resident was confused about their roommate's gender, the care plan was not updated to reflect this incident. The Director of Nursing confirmed that the care plan should have been revised following the incident, but it was not. For another resident, the care plan did not reflect changes in behavior that required the administration of Ativan for anxiety. The initial order for Ativan was placed and renewed multiple times, but the care plan goals and interventions were not updated to address these behavior changes. Additionally, the activity care plan goals and interventions were not revised to reflect the resident's current needs, as confirmed by the Activity Director and other staff members. This lack of revision in care plans indicates a failure to provide appropriate and individualized care for the residents.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility staff failed to ensure that a dependent resident's personal hygiene needs were adequately met by not providing showers as scheduled. This deficiency was identified during a recertification/complaint survey for a resident who expressed dissatisfaction with not receiving showers. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating adequate cognitive ability, confirmed during an interview that he had not been receiving showers and expressed a desire to have them. The facility's records showed that the resident was scheduled for showers twice a week, but instead, he was given bed baths without documentation of refusal or encouragement to take showers. Interviews with facility staff, including a Geriatric Nurse Aide (GNA) and the Director of Nursing (DON), revealed that the resident had been receiving bed baths due to the facility's shower room not having appropriate accommodations for his condition. The GNA stated that refusals were documented, but there was no record of the resident refusing showers or being encouraged to take them. The DON and Nursing Home Administrator (NHA) acknowledged the lack of appropriate shower accommodations for residents who could not sit in a shower chair, but did not provide a solution. The resident eventually received a shower after the surveyor's inquiry.
Failure to Communicate Medication Concerns Leads to Complications
Penalty
Summary
The facility staff failed to communicate and document a concern regarding a resident's medication regimen prior to a dental procedure, which led to complications. The resident, who was on blood-thinner medication, underwent a tooth extraction without the necessary precaution of holding the medication, resulting in excessive gum bleeding. The electronic health record indicated that the resident had been receiving Eliquis and Aspirin as prescribed, and these medications were administered on the day of the procedure. The Registered Nurse (RN) responsible for administering the medications was unaware of the dentist's visit and did not document informing the dentist about the resident's medication intake. The situation escalated when the resident experienced substantial bleeding post-extraction, necessitating a trip to the emergency department. Despite attempts to manage the bleeding with gauze and communication with the on-call physician, the resident's condition required hospital admission. The Nursing Home Administrator acknowledged the communication issues with the contracted dentist, who did not inform the facility of her visits, leading to the decision to cease using the vendor. The dentist was no longer reachable for further clarification as she no longer worked with the facility.
Failure to Monitor Significant Weight Changes in Resident
Penalty
Summary
The facility failed to adequately monitor a resident's significant weight changes, as evidenced by a 20-pound weight loss over a period from April to June 2024. The resident, who was identified as having failure to thrive, swallowing difficulties, and requiring 100% support with meals, had a documented weight of 187.2 pounds in April 2024, which decreased to 166.5 pounds by June 2024. Despite these significant changes, there was no documentation indicating that a physician was made aware of the resident's weight loss or nutritional status. The dietician noted the resident's refusal to be weighed and the need for encouragement, but there was no evidence of further intervention or communication with the physician regarding the resident's condition. Interviews with facility staff revealed inconsistencies in the communication and documentation processes related to the resident's weight management. The dietician and the Assistant Director of Nursing (ADON) described procedures for handling weight refusals and the importance of notifying the physician, yet these steps were not reflected in the resident's records. Additionally, after the resident's readmission to the facility, there was a lack of documented weights or refusals, and no communication with the provider was recorded. The deficiency was validated by the Nursing Home Administrator upon review of the surveyor's findings.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Use
Penalty
Summary
The facility failed to ensure the necessary and justified use of high-risk psychotropic medication for a resident diagnosed with anxiety. The resident was prescribed Ativan, an anxiolytic medication, on an as-needed basis, with the order being renewed multiple times over a period of months. However, the facility did not implement or document any non-pharmacological interventions prior to administering the medication. Additionally, there was a lack of behavior monitoring documentation to justify the administration of the anxiolytic medication. During the recertification survey, it was found that the facility did not have any tasks ordered for monitoring the resident's psychiatric symptoms, including anxiety. Interviews with the Director of Nursing and the Facility Administrator confirmed that the facility did not monitor the resident's behaviors when receiving anxiolytics and did not perform non-pharmacological interventions before administering psychotropics. This deficiency was evident for one of the two residents reviewed for the utilization of unnecessary medication.
Deficiency in GNA Training on Resident Safety and Abuse Prevention
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received necessary training on resident safety and care, particularly after an alleged abuse incident. This deficiency was identified during a recertification/complaint survey, where it was found that GNA #10, hired in July 2023, had no training records for resident safety and transfer mobility. Despite the Director of Nursing's explanation of the training process, there was no evidence of completed training in these areas for GNA #10. The Nursing Home Administrator confirmed the absence of such training in the employee's records. Additionally, the facility's investigation into a self-reported incident revealed that GNA #37 was involved in an incident where a resident reported being hurt and having a dirty brief placed in their face. Although the facility conducted assessments and interviews, and GNA #37 was removed from the assignment, there was no record of the GNA receiving training on customer service or timely reporting related to the incident. The Nursing Home Administrator confirmed the lack of training records for GNA #37 concerning the incident.
Unsafe and Unclean Bathroom Conditions in Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by the condition of the floor radiator heaters in two of the five bathrooms observed during the recertification survey. In the bathrooms shared by rooms 36/38 and 35/37, the floor radiator heaters were found with significant damage, including missing end caps, which exposed sharp, rusted edges. These conditions posed a potential risk of injury to residents using the bathrooms. Additionally, in the bathroom for rooms 36/38, two unsecured long flat metal pieces were leaning against the wall, and the paper towel dispenser was missing. The Director of Maintenance, identified as Staff #8, was shown these deficiencies during the survey. Staff #8 acknowledged the issues, agreeing that the sharp, rusted edges should not be exposed and that the metal pieces should not be present in the bathroom. Despite some corrective actions being taken, such as the removal of the metal pieces and the installation of a paper towel dispenser, the floor radiator heater in the bathroom for rooms 36/38 remained without a cap, leaving sharp edges exposed. This ongoing issue was observed even after initial corrective measures were implemented, with a resident continuing to use the affected bathroom daily.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify a resident and their representative in writing about the bed hold policy when the resident was transferred to an acute care facility. This deficiency was identified during a recertification survey for a resident who was admitted to the facility and later sent to an acute care facility due to a change in their medical condition. A review of the medical record revealed no written evidence that the resident or their representative received notice of the bed hold policy. The Director of Nursing and the Social Worker were unable to provide documentation that the policy was communicated in writing, as confirmed during their interviews.
Failure to Maintain Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to maintain an effective communication system for a non-English speaking resident, identified as Resident #51, who speaks only Russian. During the recertification survey, it was observed that the resident was unable to communicate effectively with staff, as they primarily spoke English and relied on basic sign language and gestures for communication. Interviews with staff revealed that during business hours, an employee from another department assisted with communication, but during off hours and weekends, the staff had to call the resident's family for assistance. This indicates a lack of a consistent and reliable communication method for the resident. A review of Resident #51's medical records showed that the resident was admitted with Russian as their native language, yet there was no evidence of any intervention or tools in place to assist with communication. The care plan noted the language barrier, but no specific strategies were documented to address it. The Nursing Home Administrator mentioned the use of a picture board and Google Translate, but there was no verification that these tools were effectively utilized by the staff. This deficiency highlights the facility's failure to ensure that the resident's communication needs were adequately met, potentially impacting their ability to perform activities of daily living and receive appropriate care.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly store medications, as evidenced by improper labeling and dating of medication vials and expired supplies. During the recertification survey, two opened resident-specific insulin vials were found in the refrigerator of Units 1 A and B. Vial one and vial two were opened on different dates, but neither was discarded within the 28-day period as required by the facility's medication labeling and storage policy. Additionally, in the medication storage room of Unit 2 A and B, an expired spill kit and three expired condom catheter packs were found. These findings were confirmed during a review with the Assistant Director of Nursing.
Infection Control and Dignity Deficiencies in LTC Facility
Penalty
Summary
The facility failed to prevent infection in residents with indwelling catheters and did not protect their dignity. During an initial tour, it was observed that two residents had their Foley bags placed on the floor inside pillowcases, which is not the appropriate method for handling such medical equipment. The LPNs acknowledged the improper use of pillowcases and removed them, but were unsure of the correct alternative. The Director of Nursing admitted to improvising with pillowcases due to a lack of proper dignity bags, which had been ordered but not yet received. Additionally, the facility did not perform complete Tuberculosis screening for a resident, as evidenced by the absence of documentation for the second step of the PPD skin test. Furthermore, during medication administration, an RN failed to sanitize hands between residents, increasing the risk of contamination. The RN also used a medication container lid to measure medication, which was identified as a breach of infection control principles by the Assistant Director of Nursing. These deficiencies were brought to the attention of the Director of Nursing.
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 1,737 citations issued within 25 miles in the last 12 months — including the 6 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 Randallstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Patapsco Healthcare | 3.5 mi | ★★★★★ | 6 | 0 |
| Future Care Cherrywood | 4.4 mi | ★★★★★ | 20 | 0 |
| Future Care Old Court | 4.9 mi | ★★★★★ | 2 | 0 |
| North Oaks Communities | 5 mi | ★★★★★ | 13 | 0 |
| Autumn Lake Healthcare At Birch Manor | 6.1 mi | ★★★★★ | 1 | 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.