Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chestnut Grn Hlth Ctr Blakehur during CMS and state inspections, most recent first.
Inaccurate MDS coding was found for multiple residents, including missed entries for antibiotics, anticonvulsants, an antiplatelet, and antibiotic ointment, as well as incorrect coding for turning/repositioning programs and physical restraints. Review of MARs, TARs, resident observations, and MDS assessments showed that several residents were coded for services or devices not supported by the record, and staff confirmed some of the errors.
The facility failed to timely respond to monthly pharmacy review irregularities and did not have clear policy timeframes for the full MRR process. For several residents, the pharmacist documented concerns such as unclear lidocaine patch directions, missing physician responses, aspirin use for osteoarthritis, and medication order issues with bumetanide and metoprolol, but the reports were kept in the DON’s office rather than the medical record and were not acted upon or documented by the physician/NP.
Missing Flu and Pneumococcal Vaccination Documentation: Medical record review and DON interview showed the facility failed to document influenza and pneumococcal vaccine status, failed to record that vaccine education was provided, and failed to document when vaccines were offered and declined for multiple residents. Several charts had no pneumococcal immunization record, and one resident had no documentation that flu vaccine was offered for the current year.
A resident was observed during feeding while a GNA sat beside the bed looking down instead of actively feeding the resident. A cell phone with an open text thread was also seen lying next to the resident on the bed. The facility’s policy prohibits staff from using wireless communication devices during work hours and in work areas to ensure uninterrupted resident service.
A resident’s call light was not within reach during observation, despite the care plan directing staff to keep the call system and frequently used items within reach. The resident was seated in a recliner with the walker nearby and said he/she had to yell for help because the call bell was on the bed and unreachable. Staff reported the resident was usually assisted out of bed by the GNA, but sometimes got up without waiting for help.
The facility failed to ensure RN coverage for at least 8 consecutive hours each day. Review of staffing sheets showed no RN on duty for day, evening, or night shifts on two days, and the Administrator confirmed the absence of RN coverage.
A facility failed to ensure two residents' drug regimens were free from unnecessary drugs. For one resident, Metoprolol was given routinely without documented BP or HR checks before administration, even though the order included hold parameters. For another resident with vascular dementia on hospice, quetiapine continued nightly without a GDR, and nursing did not document side effects or behaviors to show ongoing need; staff reported the resident was now cooperative with care.
A resident admitted after orthopedic surgery was seen by an NP who ordered a CBC, CMP, and Vitamin D level for follow-up lab work. The resident did not have the ordered labs completed, and the Administrator confirmed the staff failed to obtain them.
Delayed x-ray services for a resident with left hip and leg pain and inability to lift the left leg. Hospice approved the x-ray, but the order was handled inconsistently, with calls made to the x-ray provider and the order entered later; the provider arrived when the resident was not available, and the x-ray was not completed until 4 days after it was ordered. The DON and NHA stated they did not know why the x-ray company took so long to come to the facility.
A resident admitted after orthopedic surgery did not have the surgeon follow-up appointment ordered in the hospital discharge instructions scheduled, even though the resident had been in the facility for 7 weeks and had no anticipated discharge date. Review of the scheduling book and interviews with the resident, scheduler, and Administrator confirmed the appointment was not on file.
The facility failed to document COVID-19 vaccine education and vaccination status for three residents and one employee. Records showed no documentation that the residents or the employee were offered education on the benefits, risks, and potential side effects of the vaccine, or that they received or declined it. The DON and Administrator confirmed the missing documentation during interview.
The facility failed to maintain complete kitchen records and store food according to professional standards. Missing documentation for temperature and chemical levels was noted, and improper food storage was observed, including unlabeled and undated items. Condensation from ceiling vents and a leak under a PVC pipe were also identified, with maintenance requests delayed.
A resident was transferred to the hospital on three occasions without receiving a written notice explaining the reason for the transfers. The medical records lacked documentation of such notices, and the DON confirmed the absence of this documentation during an interview.
A facility failed to provide a resident and their representative with written notice of the bed hold policy during hospital transfers. The resident was transferred to the hospital multiple times, but the medical records lacked documentation of the policy being communicated. The DON confirmed the absence of such documentation, which is required by the facility's policy.
A facility failed to accurately document a resident's oral assessments, leading to a deficiency. The resident, with a history of muscle weakness, dysphagia, and other conditions, was observed to have no teeth, yet records indicated otherwise. The MDS assessments documented broken or loosely fitting dentures, while the admission assessment noted upper dentures. The DON confirmed the dentures did not fit well and were taken home by the family, highlighting a documentation inconsistency.
The facility failed to develop and implement person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with communication deficits lacked a care plan for their impaired hearing and vision. Another resident on an insulin regimen did not have a care plan for insulin management, and a third resident on anticoagulation therapy lacked a care plan for associated risks. These omissions indicate a failure to adequately plan and manage the residents' care needs.
The facility failed to obtain accurately documented informed consent and did not update bed rail assessments for two residents. One resident had a history of mobility issues and dementia, but their care plan lacked bed rail interventions, and the consent form was incomplete. Another resident with a history of muscle weakness and dementia also had incomplete consent documentation and missing quarterly assessments. The facility's policy requires bed rail assessments and informed consent, which were not adhered to, leading to the deficiency.
The facility failed to maintain accurate medical records for two residents. One resident's Influenza Immunization Informed Consent form was incomplete, missing the resident's name. Another resident's records inaccurately documented an indwelling catheter, which was not present according to the electronic medical record.
Inaccurate MDS Coding for Medications, Turning/Positioning, and Restraints
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 7 of 23 residents reviewed during the recertification/complaint survey. Medical record review and staff interview showed that multiple MDS assessments contained inaccurate entries for skin and ulcer/injury treatments, medications, and physical restraints. The MDS Coordinator acknowledged that some of the assessments were coded for turning and repositioning when they should not have been, and the Administrator confirmed the survey findings for the restraint-related coding errors. For one resident, the MDS with an ARD of 11/9/25 indicated a turning and repositioning program in Section M1200C, but the medical record did not show documentation that the resident was on such a program. For another resident, the November 2025 MAR showed Gabapentin and Amoxicillin were administered, and the August 2025 MAR showed Gabapentin and Levaquin, but the MDS assessments with ARDs of 11/12/25 and 8/12/25 did not capture the antibiotic or anticonvulsant use in Section N. A third resident’s significant change MDS with an ARD of 9/2/25 failed to capture bacitracin ointment use during the lookback period. Additional review found that one resident’s quarterly MDS with an ARD of 9/27/25 failed to capture Aspirin 81 mg as an antiplatelet and also incorrectly indicated a turning and repositioning program without supporting documentation. Three other residents were coded in Section P0100 for physical restraints as bed rails on MDS assessments with ARDs of 10/19/25, 10/14/25, and 11/5/25, but observations showed no bed rails in use and no restraints in place to restrict movement. Staff #16 confirmed the restraint coding errors for these residents, and the Administrator confirmed the surveyor’s findings.
Failure to Address Monthly Pharmacy Review Irregularities
Penalty
Summary
The facility failed to timely respond to concerns noted on monthly drug regimen reviews and failed to have policies and procedures with time frames for the different steps in the monthly drug regimen review process. Review of the facility policy showed timeframes for the pharmacist to provide written reports and for physician response, but it did not include a timeframe for when the physician was to be notified or how long it should take from notification to correction and response. The DON stated the monthly reviews were kept in her office and not in the residents’ medical records. For Resident #4, the pharmacist completed a monthly regimen review and noted that lidocaine patches should only be applied once daily with a 12-hour on and 12-hour off period, asking for clarification of directions. There was no documented response from the physician/prescriber, and the recommendation had not been addressed in the resident’s medical record. For Resident #6, the pharmacist completed a monthly regimen review and documented irregularities, but there was no documented physician response and the review was not in the medical record. For Resident #26, the pharmacist completed monthly regimen reviews in August and November and documented irregularities, but there were no consultant pharmacist reports in the medical record and no documented physician response. For Resident #28, the pharmacist noted that aspirin 81 mg was not recommended for osteoarthritis and asked to clarify the diagnosis, but the recommendation was not acted upon and the physician response remained blank. For Resident #7, the pharmacist documented irregularities on two monthly reviews; one recommendation stated bumetanide hold parameters were not reflected on the MAR, and another stated metoprolol succinate was ordered twice daily even though it was recommended once daily. These recommendations were not reviewed or acted upon, and the consultant pharmacist reports were not in the resident’s medical record.
Missing Flu and Pneumococcal Vaccination Documentation
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after medical record review and staff interview showed the facility failed to document that residents were offered education about the benefits, risks, and potential side effects of influenza and pneumococcal vaccines, and failed to maintain vaccination documentation in resident records. This was identified for 2 of 5 residents reviewed for influenza vaccination and 4 of 5 residents reviewed for pneumococcal vaccination during a recertification/complaint survey. Resident #1 had no documented pneumococcal vaccination status in the medical record on review, and the facility later obtained documentation from ImmuNet after surveyor intervention. Resident #4 had no documentation that influenza vaccination was offered in 2025 and no pneumococcal vaccination record in the chart, with documentation later obtained from the resident's assisted living setting after surveyor intervention. Resident #5 had no documentation that influenza vaccination was offered in 2025 and no pneumococcal vaccination record; the DON stated the resident's representative had declined vaccinations for years, but the DON later confirmed the facility failed to document that influenza and pneumococcal vaccines were offered and declined for 2025. Resident #36 also had no documented pneumococcal vaccination status in the medical record, which the DON confirmed.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
Facility staff failed to treat a resident with dignity when GNA #5 was observed sitting in a chair next to Resident #12 on the left side of the bed and was looking down rather than feeding the resident. The surveyor observed this before knocking on the door, using the reflection in a picture on the wall to see the GNA seated beside the resident. When the surveyor entered the room, GNA #5 was seen giving the resident a spoonful of pureed food. A cell phone was also observed lying next to the resident on the bed with a text message thread open. The facility’s cell phone policy, reviewed later that day, stated that staff members are not permitted to use wireless communication devices during scheduled work hours and/or in work areas to ensure residents are provided uninterrupted quality service. The NHA and DON were informed of the observation.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that Resident #7’s call light was within reach in accordance with the resident’s individualized care plan, which directed staff to place the call system and most frequently used items within the resident’s reach. During an interview and observation, Resident #7 was sitting in a reclining chair with the walker positioned on the right side and the legs reclined, but the call bell was lying on the bed and could not be reached. When asked how assistance was summoned, the resident stated, “I just yell out for them.” Staff #4 stated that Resident #7 normally had someone help him/her get out of bed into the chair, and Staff #5 stated the resident was typically gotten out of bed by the GNA but at times got out of bed without waiting for assistance. At the time of the observation, Staff #4 placed the call bell next to the resident.
No RN Coverage for Two Days
Penalty
Summary
The facility failed to ensure a registered nurse was on duty for at least 8 consecutive hours 7 days a week. Review of the daily staffing sheets from 12/1/25 through 12/14/25 showed that there was no RN coverage for the day, evening, or night shifts on 12/6/25 and 12/7/25. An interview with the Administrator on 12/17/25 at 3:02 PM confirmed that no RN was on duty on those 2 days.
Failure to Monitor BP/HR for Metoprolol and to Complete GDR for Quetiapine
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs when staff did not monitor blood pressure and heart rate before administering Metoprolol Succinate ER 25 mg twice daily for Resident #7, despite physician orders to hold the medication if systolic blood pressure was below 110 or heart rate was less than 60. Review of the September 2025 through December 2025 MARs showed the medication was routinely given at 9:00 AM and 5:00 PM, but there was no documentation on the MAR showing blood pressure or heart rate checks before administration. The vital sign record from September 2025 through December 2025 was inconsistent and did not show vital signs taken every day or in the evening to match the medication schedule. The pharmacist's monthly medication record reviews also reflected the concern, and the DON confirmed the finding during interview. The facility also failed to complete a gradual dose reduction for Resident #36, who was receiving quetiapine 12.5 mg nightly for vascular dementia. Resident #36 had a history of depression, falls, speech disturbance, asthma, osteoarthritis-related shoulder pain, and prior resistive behavior with care, and entered hospice care on 6/7/24, after which psychiatric services were no longer received. The record showed the resident continued on quetiapine without a gradual dose reduction, and nursing had not documented side effects or behaviors to show whether the medication was still needed. GNA staff reported the resident had been very resistive to care when first admitted but was now very cooperative, and another staff member stated the resident no longer resisted care like before.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
Facility staff failed to obtain laboratory tests ordered by the nurse practitioner for Resident #4. The resident was admitted following a hospitalization that included orthopedic surgery and was seen by the nurse practitioner on 11/11/25, when the nurse practitioner documented that follow-up lab work would be done on Thursday, including a Vitamin D level. The paper medical record showed that on 11/11/25 the nurse practitioner ordered a CBC, CMP, and Vitamin D level, but the resident did not have the laboratory tests as ordered. The Administrator confirmed on 12/17/25 at 10:45 AM that the facility staff failed to obtain the ordered laboratory tests.
Delayed X-Ray Services for Resident With Left Leg Weakness
Penalty
Summary
The facility failed to obtain timely radiology services for a resident who reported difficulty lifting the left leg and stated, "I can walk but just can't lift it." Medical record review showed that a hospice nurse evaluated the resident after the day shift nurse reported that the resident was unable to lift or move the leg and had previously been able to do so. An x-ray was approved by hospice and an x-ray order was placed, with the left hip x-ray later documented as ordered and pending. Subsequent nursing documentation noted the resident had left hip and leg pain and that the x-ray had been ordered several days earlier, with multiple calls made to the x-ray provider and an estimated arrival time given for later that day. Another note documented that the x-ray provider arrived while the resident was not available, so the x-ray was rescheduled. The x-ray was ultimately completed 4 days after it was ordered. During interviews, the DON stated the order should have been entered into the computer first and then the x-ray company called, while the DON and NHA stated they did not know why the x-ray company took so long to come to the facility.
Failure to Schedule Surgical Follow-Up
Penalty
Summary
The facility failed to schedule a surgical follow-up appointment for a resident who had been admitted after a hospitalization that included orthopedic surgery. The resident’s hospital discharge instructions stated that follow-up with the surgeon was needed in 6 weeks or upon discharge from the rehab facility. During interview, the resident stated that no follow-up appointment had been scheduled. Review of the scheduling book confirmed there was no follow-up appointment on file, and the Administrator confirmed the resident had been in the facility for 7 weeks, had no anticipated discharge date, and still did not have a scheduled surgical follow-up appointment.
Missing COVID-19 Vaccination Documentation
Penalty
Summary
The facility failed to document that residents were offered and provided education regarding the benefits, risks, and potential side effects of the COVID-19 vaccine, and failed to maintain documentation showing whether residents received or declined the vaccine. Review of the medical records for Resident #1, Resident #4, and Resident #5 showed no documentation that they were offered education on the COVID-19 vaccination or that they received or declined the vaccine. Resident #1 and Resident #4 were admitted to the facility on dates not specified in the report, and Resident #5 was admitted in 2023. The Director of Nursing confirmed these findings during interview. The facility also failed to maintain COVID-19 vaccination records for an employee. Review of Employee #21’s health record showed the employee was hired on 4/14/25, but there was no documentation that the employee was offered education on the COVID-19 vaccination or that the employee received or declined the vaccine after hire. The Administrator confirmed this finding during interview.
Deficiencies in Kitchen Record-Keeping and Food Storage
Penalty
Summary
The facility failed to maintain complete kitchen records and store food according to professional standards, as observed during the annual survey. The surveyor noted missing documentation for temperature and chemical levels in the kitchen's three-compartment sink and dishwasher area from July 12 to July 15. The Dietary Manager was unaware of the oversight, which was attributed to the weekend staff being busy. The issue was addressed with the staff, and subsequent records were complete. During the kitchen tour, the surveyor found multiple instances of improper food storage. In several refrigerators, items were either unlabeled, undated, or incorrectly stored, such as applesauce containers being moved to a different tray, potentially leading to expired products remaining in storage. Additionally, condensation from ceiling vents was observed dripping onto the floor near food transportation carts, and a pan under a PVC pipe was filled with a tan odorous liquid due to a leak. Further observations in the upper-level kitchen revealed open and undated food items in both the refrigerator and dry storage areas. Items such as egg rolls, spanakopita, and various meats were found without labels or dates, and some foods were open to air. The surveyor also noted that maintenance requests for kitchen repairs had been delayed, contributing to the issues observed.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide written notice with the reason for the transfer of a resident, which was identified during a survey. Resident #45, who was admitted to the facility in early February 2024, was transferred to the hospital on three occasions: 3/28/24, 4/4/24, and 5/1/24. Upon reviewing the medical records, it was found that there was no documentation indicating that Resident #45 received a written notice explaining the reason for these transfers. During an interview, the Director of Nursing (DON) confirmed the absence of such documentation for the three hospital transfers.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a resident and their representative with a written notice of the bed hold policy upon transfer to an acute care facility. This deficiency was identified during a review of the medical records and staff interviews, specifically for a resident who was transferred to the hospital on three separate occasions. The medical records for these transfers did not document that the bed hold policy was communicated to the resident or their representative. The Director of Nursing confirmed the absence of documentation regarding the provision of the bed hold policy during these transfers. According to the facility's policy, residents should receive written information about the bed hold policy at least twice: upon admission and at the time of transfer, or within 24 hours if the transfer was an emergency.
Inaccurate Documentation of Oral Assessments
Penalty
Summary
The facility failed to accurately document oral assessments in a resident's medical record, specifically for a resident with dental concerns. The surveyor observed that the resident appeared to have no teeth, yet the medical records indicated otherwise. The resident was admitted in November 2022 with a history of muscle weakness, dysphagia, malignant neoplasm of the tongue, partial glossectomy, restlessness, agitation, and dementia. The care plan for nutrition aimed to meet the resident's nutritional and hydration needs. However, discrepancies were found in the Minimum Data Set (MDS) assessments, which consistently documented the resident as having broken or loosely fitting dentures, while the admission assessment noted the presence of upper dentures. Upon further investigation, it was revealed that the resident's dentures did not fit well, and the family had taken them home. The Director of Nursing (DON) confirmed that the resident did have dentures, but they were not properly fitting, and the MDS should have been coded as edentulous, indicating no natural teeth or tooth fragments. This inconsistency in documentation between the nursing admission assessment and the MDS admission assessment led to the deficiency identified by the surveyor.
Deficiencies in Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. One resident with communication deficits was observed to have impaired hearing and vision, yet their care plan did not address these communication needs. Despite the presence of a whiteboard and a telephone with large buttons in the resident's room, there were no eyeglasses or hearing aids available, and the resident relied on a magnifying glass to read. Interviews with staff confirmed the resident's communication challenges, but the care plan lacked specific strategies to address these issues. Another resident, who was on a routine insulin regimen with frequent blood sugar monitoring, did not have a care plan addressing insulin management on a sliding scale. This resident had been hospitalized due to a hyperglycemic event, highlighting the need for a comprehensive care plan. Additionally, a third resident receiving anticoagulation medication did not have a care plan addressing the risks and interventions associated with anticoagulation therapy. The absence of these care plans indicates a failure to adequately plan and manage the residents' care needs, as evidenced by the surveyor's findings.
Failure to Document Informed Consent and Update Bed Rail Assessments
Penalty
Summary
The facility failed to obtain accurately documented informed consent prior to the use of bed rails and did not update bed rail assessments for two residents during an annual survey. For Resident #14, the surveyor observed 1/4 length bed rails on both sides of the bed. The resident's medical record indicated a history of difficulty in walking, muscle weakness, joint replacement, and vascular dementia. However, the mobility care plan did not list any interventions for bed rails. The Director of Nursing (DON) confirmed that a bed rail assessment should have been completed following a recent change in the resident's condition, but no such assessment was found. Additionally, the consent form for bed rails was incomplete, with neither the consent nor non-consent box checked. Similarly, for Resident #16, the surveyor noted 1/4 length bed rails on both sides of the bed. The resident's medical record showed a history of muscle weakness, unsteadiness on feet, restlessness, agitation, and dementia. Despite having a fall care plan with multiple interventions, bed rails were not listed as an intervention. The DON provided bed rail assessments dated 11/10/22 and 8/20/23 but acknowledged that no quarterly assessments were completed, as expected. The consent form for bed rails was also incomplete, with neither the consent nor non-consent box checked. The facility's bed rail policy requires that bed rail assessments be completed prior to use, reviewed quarterly, and updated with significant changes in the resident's condition. The policy also mandates informed consent before using bed rails. The surveyor's findings indicate that these procedures were not followed for both residents, leading to the deficiency in accurately documenting informed consent and updating bed rail assessments.
Deficiencies in Medical Record Accuracy and Completeness
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents during the annual survey. For one resident, the Influenza Immunization Informed Consent form was incomplete as it lacked the resident's name, although it was signed by the resident's representative and witnessed by a facility staff. This omission was identified during a review of the resident's medical record, which included multiple diagnoses such as Dementia, Depression, Hypertension, and Arthritis. For another resident, the Physician's Wound Evaluation and Management Summary notes inaccurately documented the presence of an indwelling catheter in the Review of Systems section for several months. However, further review of the resident's electronic medical record did not support this documentation, as there was no evidence that the resident had an indwelling catheter. This discrepancy was confirmed during an interview with the Director of Nursing.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Towson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pickersgill Retirement Community | 0.3 mi | ★★★★★ | 6 | 0 |
| Orchard Hill Rehabilitation And Healthcare Center | 0.5 mi | ★★★★★ | 42 | 0 |
| Autumn Lake Healthcare At Ruxton | 0.6 mi | ★★★★★ | 43 | 0 |
| Greater Baltimore Medical Center Sub Acute Unit | 1.1 mi | — | 0 | 0 |
| Edenwald | 1.4 mi | ★★★★★ | 3 | 0 |
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