Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Citizens Care Center during CMS and state inspections, most recent first.
Inaccurate MDS coding was identified for multiple residents when staff marked bed rails as not used even though physician orders and TARs showed side rails were monitored every shift and MDS coordinators confirmed they should have been coded as used daily. In another case, a resident’s admission MDS failed to reflect an open sacral wound documented in the chart. The survey findings were based on record review and confirmed by MDS coordinator nurses.
The facility failed to assess residents for bedrail use before siderails were installed and used, and it did not document review of risks and benefits or informed consent. Several residents were observed with 1/4 or multiple siderails in place, including one resident who said he/she could not easily release the rails and another who could not demonstrate use of the controls. Records showed physician orders for bedrails for bed controls, seizure precautions, or positioning, but no documented bedrail assessments or consent.
A resident with an order for morning Tylenol Extra Strength 500 mg for pain reported pain at a level of 8/10 and received the medication, but staff did not document any follow-up assessment to determine the effectiveness of that dose. Later the same day, the physician ordered Tylenol Extra Strength 500 mg every 8 hours for pain, and the first dose under this new order was associated with a documented pain level of 0. Review of the MAR and staff interviews, including with the DON, confirmed there was no evidence that nursing staff reassessed the resident’s pain after the initial morning administration.
The facility failed to maintain a restraint-free environment for two residents by using a bed alarm for one resident and raised side rails for another without documentation that less restrictive measures were tried or evaluated first. Staff interviews confirmed alarms were used for fall-risk residents without other assessment, and the DON described side rail use as part of the facility’s routine process, while the records lacked evidence of ongoing evaluation for continued need.
Failure to Develop Resident-Specific Respiratory Care Plans: The facility failed to develop and implement respiratory care plans for two residents with O2 needs. One resident was receiving O2 with no documented tubing change date and had an active order for supplemental O2 to maintain O2 saturation, but no resident-specific respiratory care plan was found. Another resident had O2 at the bedside with tubing stored unsafely, a humidifier dated 01/13/2026, and staff reported PRN O2 use for anxiety even though the O2 order had been discontinued; no respiratory care plan was documented.
A resident’s care plan was not reviewed and revised by the IDT after changes in health status. The record showed orders for a LUE brace, sling, NWB status, and ongoing PT, but the care plan did not address brace use or maintenance. The resident also developed multiple skin impairments, including buttocks wounds and a suspected DTI on the sacrum, yet the existing care plan only identified pressure ulcer risk and was not updated to include the active wound treatments and interventions.
A resident stated he/she missed BINGO because no one assisted with transport to the activity. The resident’s activity review indicated transportation assistance was needed to support participation, but the AD could not provide documentation showing BINGO attendance. Although the resident had documentation for other activities, the AD acknowledged that staff failed to document BINGO participation and that activity staff were responsible for bringing residents to activities.
A resident had persistent constipation with an 11-day gap in documented BMs despite bowel orders for a routine, PRN Fleet enema, and Senna Plus; the record showed repeated use of MOM, Fleet, and Senna without clear documentation that the bowel protocol was followed. The same resident also had a newly developed pressure ulcer, and the facility failed to document the required weekly wound assessments, including location, measurement, stage, and characteristics.
Respiratory care was not provided as ordered for multiple residents. Surveyors observed a resident with oxygen tubing stored unsanitarily on the concentrator, another resident receiving O2 with an empty humidifier bottle and the flow set above the ordered rate, and a third resident’s oxygen tubing left on the floor and later unbagged when not in use. Staff interviews confirmed the expected oxygen setup and storage practices, and the medical record showed orders for O2 therapy that were not followed.
A resident had an order for morning Admelog insulin to be held if blood sugar was below 70. When the resident's blood sugar was 65, the insulin was held, but there was no evidence that the physician was notified. The DON later confirmed that the physician was not called even though the call should have been made.
A resident did not receive routine dental services, and the resident reported not seeing a dentist or having a dentist visit the facility for over a year. The Unit Manager said staff only call the dentist when residents complain or show a need, and the clinical record contained no dental consult or dental visit. The DON also could not find any record that the resident had ever gone to the dentist.
A resident's wishes regarding life-sustaining treatment were not timely updated or clearly documented, despite the resident expressing a desire for CPR and being alert and oriented. Staff failed to complete a timely capacity evaluation after changes in the resident's condition, resulting in discrepancies and unclear documentation about the resident's code status and decision-making authority.
A resident exhibited increased confusion and tearfulness, which was documented by both nursing and social work staff. However, there was no evidence that the provider was notified of this change in mental status, as required. Nursing leadership confirmed that the notification did not occur or was not documented.
A resident's TAR indicated that heel protector boots were applied as ordered, but progress notes from multiple staff and the physician documented that the boots were missing and unavailable for several days. The DON confirmed discrepancies between the TAR and progress notes, showing that the resident's care was not accurately documented.
The facility failed to maintain water temperatures within an acceptable range, with multiple rooms showing elevated temperatures. The Director of Maintenance confirmed the issue was due to the boiler system, but could not provide documentation of temperature checks. The Administrator admitted that water temperatures in resident rooms were not being monitored, leading to the deficiency.
A facility failed to ensure proper follow-up and care for residents, including a missed urology appointment for a resident with a Foley catheter, improper positioning and timing of enteral nutrition, and incorrect oxygen administration. Additionally, pain management orders were not transcribed, leading to unclear medication administration. These deficiencies were observed in several residents, highlighting lapses in adherence to physician orders and care protocols.
A resident was not assisted out of bed for four out of five days and was not dressed in their own clothing, instead wearing a soiled hospital gown. Staff interviews revealed the resident preferred the gown, but the GNA did not inform the nurse about the resident's prolonged bed stay. The Unit Manager stated that residents typically get out of bed after breakfast unless they refuse, in which case the nurse should be notified.
A facility failed to issue a bed hold notice to a resident or their representative during a hospitalization. The deficiency was identified during a recertification survey when a surveyor found no documentation of the notice in the medical record. The DON confirmed the absence of such documentation.
A facility failed to follow the care plan for a resident with a suprapubic catheter, missing a required urology follow-up. The resident, with Multiple Sclerosis and Benign Prostatic Hyperplasia, did not receive a urology consultation within six months as planned. The DON acknowledged the oversight, attributing it to the physician's inability to accommodate the resident on a stretcher.
An LPN failed to ensure a resident consumed their medication before leaving the room, placing a protein supplement on the bedside table without instructions. The MAR audit showed discrepancies in medication administration times, not adhering to the standard practice of administering within an hour of the scheduled time.
The facility did not conduct annual performance reviews for its GNAs as required. During a survey, it was found that no evaluations were completed for the years 2022 and 2023 for four GNAs. The DON admitted to being behind on evaluations, and a staff educator stated that conducting evaluations was not part of her role. This issue was discussed with the administrative team during the survey exit conference.
A facility failed to timely address a pharmacy recommendation for a resident prescribed PRN lorazepam. The pharmacist's MRR highlighted the need for a stop date or documented rationale for extending the PRN order, but the physician did not respond, and the order remained active without necessary documentation. The issue was identified during a review, and the PRN lorazepam was eventually discontinued after a delay.
A resident prescribed Zyprexa was not monitored for side effects, as required by an existing order. The MAR and TAR lacked documentation of monitoring, despite staff acknowledging the need to report and document behavioral changes. This deficiency was identified during a survey, highlighting a lapse in the facility's monitoring process.
Surveyors found deficiencies in medication management and storage, including an unattended and unlocked medication cart with Baclofen, expired medications, and improperly stored supplies. Temperature logs for biologicals and supplements were inconsistently recorded, and expired items were found in medication rooms. Staff acknowledged these issues, indicating lapses in the facility's practices.
The facility failed to document and maintain accurate inventory sheets for residents' personal effects and ensure the accuracy of medical orders. Two residents' inventory sheets lacked signatures and dates, and staff were uncertain about a resident's denture status. Additionally, a discrepancy was found between a medical order and a wound consult for a resident with a pressure ulcer, with the order directing care on the wrong side of the body.
The facility failed to document that four GNAs completed the required 12 hours of annual clinical training for 2022 and 2023. The DON could not provide evidence of training completion during a survey, and the staff educator indicated that staff education was not her primary role. This issue was discussed with the administrative team during the survey exit conference.
Inaccurate MDS Coding for Bed Rails and Wound Status
Penalty
Summary
Facility staff failed to accurately code resident status on the Minimum Data Set (MDS) for 7 of 13 residents reviewed for MDS accuracy during the recertification/complaint survey. In multiple records, the MDS Section P0100 for bed rails was marked as "not used" even though physician orders and Treatment Administration Records (TARs) showed side rails were ordered and monitored for use every shift. Survey review identified this issue for residents with orders for padded side rails for seizure precautions, bed controls, positioning, or injury prevention, and the MDS coordinators confirmed that side rails are considered a restraint and should have been coded as used daily when applicable. For one resident, the admission MDS also failed to reflect a pressure ulcer/injury finding. The resident had an open area to the sacrum measuring 1.2 cm by 0.7 cm with granulation tissue documented in a progress note on the same day as the admission assessment, yet Section M0100 was coded "No" for the presence of a pressure ulcer/injury, scar over a bony prominence, or non-removable dressing device. The MDS coordinators later confirmed that the acquired wound should have been documented as "yes" on the admission MDS. Additional record reviews showed the same pattern of inaccurate MDS coding for other residents, including residents whose TARs documented side rail use every shift while the MDS indicated bed rails were not used. The survey findings were based on comparisons between physician orders, TAR documentation, progress notes, and the completed MDS assessments, and the discrepancies were confirmed by the MDS coordinator nurses during interview.
Failure to Assess and Obtain Consent for Bedrail Use
Penalty
Summary
The facility failed to properly assess residents for bedrail use before siderails were installed and used. The report states that the facility did not assess residents for entrapment risk, did not review the risks and benefits of bedrails with the resident or representative, and did not obtain informed consent prior to installation. This was identified for 5 residents who were observed with siderails in use during the recertification/complaint survey. Resident #34 was observed lying in bed with a 1/4 bedrail raised at the head of the bed and stated that he/she could not easily and voluntarily release the bed rails. The medical record showed diagnoses including a history of falling, unspecified dementia, muscle weakness, and hemiplegia affecting the left nondominant side, along with an order for 2 1/4 rails up for use of bed controls. The record contained no consent for bedrail use and no documented assessment. Resident #50 was observed with 1/4 bedrails raised on each side of the bed and was unable to demonstrate use of the bedrail controls. The medical record included diagnoses of unspecified dementia, muscle weakness, other abnormalities of gait and mobility, and other lack of coordination, plus an order for 2 1/4 rails up for use of bed controls. The record contained no consent from the responsible party and no assessment for bedrail use. Resident #3 was observed with one 1/4 bedrail raised on each side of the bed with blue padding inside the rails; the record showed an order for 2 1/4 padded bed rails for seizure precautions but no documentation of a bedrail assessment. Resident #4 was observed sitting on the side of the bed with 2 1/4 side rails raised on each side, and the record contained an order for side rails for use of bed controls every shift but no documentation of a bedrail assessment. Resident #6 was observed lying in bed with the upper and lower sections of the quarter-length side rails raised on both sides; the record showed an order for 2 1/4 rails for bed controls and positioning, with every shift use of 4 rails as requested, but no documentation of a bedrail assessment or additional details concerning bedrail use.
Failure to Document Follow-Up Pain Assessment After PRN Analgesic Administration
Penalty
Summary
Facility staff failed to provide appropriate follow-up assessment for a resident who reported serious pain after receiving pain medication. Clinical record review showed that the resident had an existing order for Tylenol Extra Strength 500 mg to be administered in the morning for pain. On 12/30/25, the resident reported pain rated 8 out of 10 and was given the ordered Tylenol at approximately 9:00 AM. However, there was no documented evidence that nursing staff returned to reassess the resident’s pain level or evaluate the effectiveness of the medication after administration. Further review of the clinical record showed that later that same day, at 5:00 PM, the physician added a new order for Tylenol Extra Strength 500 mg, one tablet every 8 hours, for the diagnosis of pain. The resident received the first dose under this new order at 6:02 PM and had a documented pain level of 0 afterward. During an interview, the DON was shown the December 2025 MAR, including the documented pain level of 8 on 12/30/25 and the absence of a follow-up pain assessment. After reviewing the concern with the unit manager, the DON confirmed they could not find evidence that a nurse had followed up on the effectiveness of the morning pain medication dose.
Failure to Document Least Restrictive Measures Before Using Restraints
Penalty
Summary
The facility failed to maintain a restraint-free environment by not documenting that least restrictive measures were attempted or evaluated before using restraints for two residents. Resident #4 had a physician’s order for a bed alarm for safety during all shifts, and during observation the alarm sounded when the resident got out of bed, causing the resident to appear anxious and to comment about the noise. Record review showed no documentation of prior interventions attempted before the bed alarm was implemented and no evidence of ongoing evaluation for its continued need. Staff interviews confirmed that bed and chair alarms were used for residents identified as fall risks, with no other assessment performed. Resident #6 was observed in bed with the upper and lower sections of quarter-length side rails raised on both sides, and record review showed a physician’s order allowing 2 1/4 rails for bed controls and positioning, with every shift able to use 4 rails as requested. The medical record did not contain documentation of prior interventions attempted or evaluated before the use of 4 side rails, nor evidence of ongoing evaluation for continued need. Staff interviews confirmed that all four side rails were raised, that a physician’s order and safety assessment were believed necessary, and that therapy did not complete side rail evaluations. The DON stated the facility’s process was to use side rails primarily for repositioning and bed control, and the facility policy stated its goal was to maintain an environment free of restraints and prioritize non-restraint methods.
Failure to Develop Resident-Specific Respiratory Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans to meet the medical and physical needs of 2 residents reviewed during the recertification/complaint survey. For Resident #2, the surveyor observed the resident receiving oxygen on 01/20/2026 with no date on the oxygen tubing to show when it was last changed. A review of physician orders on 01/21/2026 showed an order dated 01/17/2026 for supplemental oxygen at 2 liters via nasal cannula to maintain oxygen saturation of 90%. On 01/23/2026, the resident’s care plan was reviewed and showed no documented evidence that a respiratory care plan had been developed to include resident-specific treatment as part of the plan of care. For Resident #125, the surveyor observed oxygen at the bedside on 01/21/2026, with the oxygen not in use at the time. The oxygen tubing was on top of the oxygen concentrator machine, which was on the floor, and the tubing was not stored in a sanitary environment; the attached humidifier was dated 01/13/2026. RN #27 stated the resident used 2 liters via nasal cannula oxygen as needed for anxiety. A later review of the resident’s care plan showed no respiratory care plan had been developed to address the resident’s needs. The medical record also showed an order for oxygen 2 liters per minute via nasal cannula as needed that had been started on 03/14/2025 and discontinued on 12/27/2025, but the oxygen was still being used by the resident.
Care Plan Not Updated for Brace Use and Active Wound Care Needs
Penalty
Summary
The facility failed to provide documented evidence that Resident #2’s care plan was reviewed and revised by an interdisciplinary team after changes in health status. Record review showed orders for a hinged elbow brace on the left upper extremity, a sling to the left upper extremity to remain in place except during ADL care, non-weight bearing status to the left upper extremity, and continued skilled PT services. Although the resident was observed wearing a brace on the left upper extremity, the care plan review revealed no documented evidence that the resident-specific needs and interventions related to brace use and maintenance were added to the care plan. The DON acknowledged that the care plan did not address the left upper extremity brace and stated that staff had been educated on removal and replacement of the brace, but there was no documentation to support that education. The facility also failed to update Resident #2’s care plan to reflect active wound care needs after new skin impairments were identified. The resident reported having a bed sore on the sacrum, and record review showed multiple skin assessments and treatments over time, including wounds to the left inner buttocks, right inner buttocks, moisture associated skin damage to both buttocks, and later a suspected deep tissue injury on the sacrum. The existing care plan had identified the resident as at risk for pressure ulcer development due to urinary incontinence and gait/balance issues, but there was no documented evidence that it was revised to include the actual wound treatments and interventions. The DON confirmed that the care plan identified risk but did not address the active wound care needs.
Failure to Document and Assist Resident With Activity Participation
Penalty
Summary
Facility staff failed to ensure that Resident #34 had the opportunity to participate in the activity program and failed to provide documentation of participation in a desired activity. During the survey investigation, the resident stated that he/she missed BINGO twice because no one assisted him/her to BINGO. The resident’s Activities-Initial Review, completed on 7/20/2017, documented past interests including fishing, hunting, and card games, and indicated that assistance should be provided to get the resident to activities. It also specified that transportation assistance to and from activities was needed to encourage and promote participation. The Activities Director stated that activity staff were responsible for bringing residents to activities such as BINGO, although the Administrator had asked nursing, administrative staff, and managers to assist with transport as needed. The Activities Director stated that BINGO was offered on Mondays and Thursdays and that the resident attended, but when surveyors requested documentation of BINGO participation within the past 30 days, none was provided. The documentation supplied showed participation in other activities, but the Activities Director acknowledged that activity staff failed to document when the resident attended BINGO, and the surveyor noted that without documentation the resident’s statement that assistance was not provided could not be refuted.
Bowel regimen not managed and new pressure ulcer not properly assessed
Penalty
Summary
The facility failed to ensure that Resident #123 received treatment and care in accordance with professional standards of practice by not properly managing a bowel regimen that resulted in persistent constipation. The resident had physician orders for a bowel routine, Fleet enema as needed for bowel policy, and Senna Plus for bowel regimen. Facility records showed a significant gap in documented bowel movements, with no applicable bowel movement recorded from 01/09/2026 until a medium bowel movement was finally documented on 01/21/2026, an 11-day period without a recorded bowel movement. The resident’s progress note stated the last documented bowel movement was on 1/9/26 and that Milk of Magnesia had been given with no results, followed by Fleet enema with no results at that time, and an order was obtained for Senna Plus. The facility also failed to appropriately assess, evaluate, and modify interventions for a newly developed pressure ulcer. The report states that the standard of practice for pressure ulcer care includes weekly assessments documenting location, measurement, stage, and characteristics to determine whether the wound is healing or worsening and to evaluate treatment effectiveness. During the survey, the complainant raised concerns regarding a new wound, but the report does not include the resident’s wound assessment details, measurements, staging, or documented weekly evaluation findings. The cited deficiency was based on the facility’s failure to ensure treatment and care were provided according to orders, resident preferences, and goals.
Respiratory Care Not Provided as Ordered and Oxygen Equipment Not Kept Sanitary
Penalty
Summary
Facility staff failed to provide necessary respiratory care services for residents by not maintaining oxygen equipment in a sanitary manner and not administering oxygen as prescribed. For Resident #125, surveyor observation on 01/21/2026 found oxygen at the bedside with the tubing laying on top of the oxygen concentrator rather than stored in a sanitary environment, and the attached humidifier was dated 01/13/2026. The resident stated that oxygen was used in the afternoons, and RN #27 stated the resident used 2 liters via nasal cannula oxygen as needed for anxiety. For Resident #138, surveyors observed oxygen via nasal cannula at 2.5 liters while the humidifier bottle was empty and dated 01/7/2026, and a later observation showed the humidifier remained empty with the oxygen setting still at 2.5 L/min. The medical record showed an order for oxygen 2 L/min via nasal cannula every shift and to check and change the prefilled oxygen humidifier water bottle as needed. For Resident #3, surveyors observed oxygen tubing on the floor and later unbagged on top of the unit when not in use. The resident stated oxygen was used every night, and the medical record showed an order for oxygen 2 liters per minute via nasal cannula at bedtime for shortness of breath. RN and ADON interviews confirmed that oxygen tubing should be bagged when not in use.
Failure to Notify Physician of Low Blood Sugar After Insulin Was Held
Penalty
Summary
The facility failed to ensure a resident's blood sugar was properly monitored in connection with an insulin order. Resident #5 had a physician order for Admelog insulin 100 units/ml, 3 units every morning, to be held if the blood sugar was below 70. On 1/11/26 at 7:00 AM, the resident's blood sugar was 65 and the insulin was held. Review of the clinical record showed no evidence that the physician was notified of the low blood sugar result, and the physician was therefore not given the opportunity to intervene. During interview, the DON reviewed the Medication Administration Record and confirmed that a call to the physician was not made, although it should have been made.
Failure to Provide Routine Dental Services
Penalty
Summary
Facility staff failed to ensure a resident received routine dental services. During interview, the resident stated they had not been to the dentist or had a dentist come to the facility for over a year and reported no mouth or tooth pain. The Unit Manager stated staff assess residents for pain, discomfort, chewing, and swallowing issues and call the dentist when appropriate, but she was unaware the resident needed dental care because the resident had not complained or stated a need to see a dentist. Review of the clinical record found no dental consult or dental visit. The DON later stated she could not find any record of the resident ever going to the dentist in either the paper chart or the electronic clinical record.
Failure to Timely Update and Document Resident's Life-Sustaining Treatment Preferences
Penalty
Summary
The facility failed to update and accurately document a resident's wishes regarding life-sustaining treatment and did not assess the resident's decision-making capacity in a timely manner. The resident, who was their own responsible party, had a Maryland MOLST form indicating a DNR (Do Not Resuscitate) order, but subsequent documentation by staff indicated the resident expressed a desire to attempt CPR and was alert and oriented at that time. Despite this, the MOLST was not updated to reflect the resident's clarified wishes, and there were discrepancies between the resident's expressed preferences and the orders documented in the medical record. Further review revealed that after the resident experienced changes in condition and was transferred to and from the hospital, staff expressed discomfort discussing code status and requested a re-evaluation of the resident's capacity. However, no timely capacity evaluation was completed, and the medical records remained unclear about who the decision maker was during this period. Both the DON and the social worker confirmed these discrepancies and the lack of timely assessment, resulting in unclear and inconsistent documentation of the resident's life-sustaining treatment preferences.
Failure to Notify Provider of Resident's Change in Mental Status
Penalty
Summary
The facility failed to ensure timely notification to a physician regarding a resident's change in condition. Specifically, a resident was observed by a registered nurse to be tearful and experiencing increased confusion, which was also documented by a social worker. Despite these documented changes in the resident's mental status, there was no evidence in the medical record that the provider was notified of the change. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that such changes should be communicated to the provider and documented, but no such documentation or notification was found for this incident.
Inaccurate Documentation of Resident's Treatment Administration Record for Heel Protector Boots
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's Treatment Administration Records (TAR) regarding the use of heel protector boots. During the investigation, it was found that although the resident's TAR indicated that the boots were applied during all shifts from 5/14/25 to 5/18/25, progress notes from multiple staff members documented that the boots were missing and could not be located. Staff notes included reports from both nursing staff and the attending physician, who noted the resident's requests for the boots and the need to order replacements, indicating the boots were not available as required by the physician's order. The discrepancy was confirmed during a review of the records with the Director of Nursing, who acknowledged that the TAR documentation did not match the progress notes. The resident had an active order for heel protector boots to be worn at all times except during bathing, but the documentation failed to accurately reflect the resident's actual care and the absence of the boots during the specified period.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to ensure that water temperatures remained within an acceptable range, as observed during a survey of the Harbor View Unit. On multiple occasions, water temperatures in resident rooms were found to be significantly above the recommended levels, with temperatures ranging from 120 degrees Fahrenheit to as high as 137.5 degrees Fahrenheit. The Director of Maintenance (DOM) was notified and confirmed the elevated temperatures, attributing the issue to the facility's boiler system, which had been powered down for the use of the chiller. However, the DOM could not provide documentation of water temperature checks during this process. Residents in the affected rooms, including two specific residents, were interviewed, and while they did not report any burns or issues, the elevated temperatures posed a potential risk. Further observations revealed that water temperatures in several other rooms were also above the acceptable range. The surveyor and the DOM conducted dual observations, confirming the elevated temperatures. During an interview, the Administrator and the DOM admitted that water temperatures in resident rooms were not being monitored, as they had assumed the temperatures were being taken at the boiler. This oversight led to the deficiency, as the facility failed to ensure a safe environment free from accident hazards related to water temperature.
Multiple Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to ensure that a resident followed up with a urologist for the management of a Foley catheter. Resident #18, who was admitted with multiple sclerosis and benign prostatic hyperplasia, had an indwelling catheter and was recommended to follow up with a urologist within six months. However, the follow-up did not occur as the resident missed an appointment due to the physician's inability to accommodate the resident via a stretcher. The Director of Nursing acknowledged the need for arrangements to be made for the follow-up. Resident #59 experienced multiple deficiencies in care. The resident was observed with a dark red dried substance on the left earlobe, which was not addressed until brought to the attention of an LPN. A physician's order to apply bacitracin to the left ear every morning and evening was not followed. Additionally, the resident was not properly positioned for enteral nutrition, with the head of the bed not elevated to the required 35-degree angle, risking aspiration. The enteral nutrition was also not administered during the ordered times, and medications were given outside the prescribed time frame. Resident #33 was observed receiving 3L of oxygen via nasal cannula, contrary to the physician's order of 2L. The LPN was unaware of the discrepancy and had not assessed the oxygen concentrator. Similarly, resident #100 was on 4.5 liters of oxygen instead of the ordered 2 liters. Furthermore, resident #1 had a physician order for pain management using a pain scale that was not transcribed or processed, leading to a lack of clarity in administering Tylenol and Tramadol for pain relief.
Failure to Uphold Resident Dignity and Personal Preferences
Penalty
Summary
The facility staff failed to uphold the resident's right to be treated with respect and dignity by not getting a resident out of bed for four out of five days and not dressing the resident in their own clothing. This deficiency was observed in one resident during the survey. On multiple occasions, the resident was found in bed wearing a soiled hospital gown, with uncombed hair, and the blinds closed. Interviews with staff revealed that the resident preferred to wear a hospital gown while in bed, and the Geriatric Nursing Assistant (GNA) assigned to the resident did not get them out of bed on several days. The GNA was also unable to confirm if the assigned nurse was informed about the resident not being dressed in their clothing and not getting out of bed for several days. The Unit Manager described the typical routine for residents, which includes getting out of bed after breakfast, but noted that if a resident refuses, the nurse should be informed.
Failure to Issue Bed Hold Notice
Penalty
Summary
The facility failed to issue a bed hold notice to a resident or their representative during a hospitalization event. This deficiency was identified during the facility's recertification survey. The surveyor reviewed the medical record and found a nursing progress note indicating that the resident was transferred to the hospital. However, there was no documentation in the medical record to show that the facility had issued the required bed hold notice. The surveyor requested documentation from the Director of Nursing (DON) to confirm whether the bed hold notice had been provided. During an interview, the DON admitted that the facility did not have any documentation to prove that the bed hold policy was communicated to the resident or their representative.
Failure to Follow Care Plan for Resident with Catheter
Penalty
Summary
The facility failed to adhere to the care plan for a resident with a foley catheter, specifically in managing follow-up urology consultations. The resident, who has a history of Multiple Sclerosis and Benign Prostatic Hyperplasia, was admitted with an indwelling suprapubic catheter due to a neurogenic bladder. The care plan, which was last revised in August 2022, included a requirement for urology consults as ordered. However, the facility did not ensure that the resident received a follow-up urology consultation within six months after the last one in April 2022. During an interview, the Director of Nursing (DON) acknowledged the lapse in following the care plan, citing the physician's inability to accommodate the resident on a stretcher as a reason for the missed consultation. This oversight was identified during a survey, which reviewed the medical records and included interviews with facility staff. The deficiency was discussed with the administration team at the time of the survey's exit.
Failure to Ensure Medication Consumption Before Leaving Resident's Room
Penalty
Summary
The nursing staff failed to meet professional standards of care by not ensuring that medication was consumed prior to leaving the resident's room. This deficiency was observed when an LPN administered medications to a resident and placed a dark amber colored liquid in a small cup on the resident's bedside table without ensuring the resident consumed it. The LPN left the room without providing any directions to the resident regarding the medication. A GNA later identified the liquid as a protein supplement. The LPN confirmed that the standard practice is to ensure the resident completes the medication before leaving the room. A review of the Medical Administration Record (MAR) audit for the resident showed that several medications, including Tylenol, Potassium Chloride, Lasix, and Prostat, were scheduled for administration at specific times. The MAR audit revealed discrepancies in the documentation times, with the Lasix documented at 11:29 AM and the other medications at 11:34 AM, despite the standard practice of administering medications within an hour before and after the due time.
Failure to Conduct Annual Performance Reviews for GNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for geriatric nursing assistants (GNAs) based on their hire dates, as required. This deficiency was identified during a survey when the surveyor reviewed the human resource and staff education files. The surveyor requested records for seven staff members, including four GNAs, and found no evidence of completed performance evaluations for the years 2022 and 2023 for these GNAs. During interviews, the Director of Nursing (DON) admitted to being behind on completing the evaluations and acknowledged the need for improvement. Additionally, a staff educator mentioned that conducting performance evaluations was not part of her primary or secondary roles. The facility was unable to provide completed performance reviews for the GNAs in question, and this issue was discussed with the administrative team during the survey exit conference.
Failure to Address Pharmacy Recommendation for PRN Lorazepam
Penalty
Summary
The facility failed to address a pharmacy recommendation in a timely manner for a resident who was prescribed PRN lorazepam. The pharmacist conducted a medication regimen review (MRR) and issued a letter to the physician on 3/8/24, highlighting the need for a stop date for the PRN psychotropic drug, as required by policy. The letter suggested a 14-day stop date or, if extended, required the prescriber to document the rationale and indicate the duration for the PRN order. However, the physician did not respond to the letter by checking any of the provided options (agree, disagree, or other), nor was there any documentation in the medical record indicating that the PRN lorazepam order was discontinued or adjusted. The deficiency was identified during a record review and interviews with facility staff. The Nurse Manager confirmed the absence of documentation regarding the discontinuation of the PRN lorazepam order, which was initially prescribed on 2/21/24. The Director of Nursing later provided documentation that the PRN lorazepam was discontinued on 5/6/24, indicating a delay in addressing the pharmacist's recommendation. This oversight affected the resident's medication management, as the necessary actions to comply with the facility's policies and procedures were not taken promptly.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility staff failed to monitor a resident for side effects of psychotropic medication, specifically Zyprexa, which was prescribed at different dosages over time. The medication administration record (MAR) and treatment administration record (TAR) for the resident did not contain documentation verifying that the resident was being monitored for side effects. This deficiency was identified during a survey when the records were reviewed, revealing a lack of documentation for monitoring side effects despite an existing order to do so. Interviews with facility staff, including an LPN and the Director of Nursing (DON), highlighted a gap in the monitoring process. The LPN indicated that changes in behavior would be reported and documented, but there was no evidence of such documentation in the resident's records. The DON confirmed that there should have been an order for staff to document side effects, yet the records showed no such documentation. This oversight was evident for one of the two medical records reviewed during the survey.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage, as observed by surveyors. On one occasion, a medication cart on the Bay Lane Unit was left unattended and unlocked, with a Baclofen medication blister packet and scissors left on the work surface. This incident was acknowledged by a registered nurse who admitted to leaving the cart unlocked while searching for tube feeding supplies. Additionally, the surveyor found that expired medications and improperly stored medical supplies were present in the medication storage rooms. The temperature logs for refrigerators storing biologicals and supplements were not consistently recorded, indicating a lack of adherence to proper storage protocols. Further observations revealed multiple deficiencies in the treatment cart and medication room on Harbor View and Bay Lane. Opened and exposed medical supplies, expired medications, and biologicals were found, along with a lack of daily temperature checks for refrigerated items. Interviews with nursing staff and management confirmed these findings, with admissions that maintenance and nursing staff were responsible for checking refrigerator temperatures and ensuring supplies were up to date. The presence of expired and improperly stored items, along with the failure to maintain accurate temperature logs, highlights significant lapses in the facility's medication management practices.
Deficiencies in Documentation and Medical Order Accuracy
Penalty
Summary
The facility failed to properly document and maintain inventory sheets for residents' personal effects, as well as ensure the accuracy of medical orders. During the recertification survey, it was found that inventory sheets for two residents lacked signatures and dates, making it unclear when the inventory was conducted. Specifically, one resident reported broken dentures, but the inventory sheet did not list any dentures, and staff were uncertain about the resident's denture status upon admission. The Director of Nursing confirmed that staff are responsible for updating and documenting items on the inventory form. Additionally, the facility failed to ensure the accuracy of a medical order for wound care. A discrepancy was found between the medical order and the wound consult for a resident with a pressure ulcer. The medical order directed wound care on the right ischium, while the wound consult indicated the wound was on the left ischium. The Director of Nursing confirmed the inconsistency after reviewing the medical record with the surveyor.
Deficiency in GNA Training Documentation
Penalty
Summary
The facility failed to ensure that four geriatric nursing assistants (GNAs) received and completed the required 12 hours of clinical training annually. This deficiency was identified during a survey when the director of nursing (DON) was unable to provide documentation proving that the GNAs completed the necessary training for the years 2022 and 2023. The surveyor requested human resources and staff education records for seven employees, including four GNAs, one licensed practical nurse (LPN), and two registered nurses (RNs). However, the records provided did not include evidence of the GNAs' training completion. During an interview, the staff educator, identified as staff #9, stated that staff education was not her primary or secondary role, although she occasionally assisted with teaching and scheduling clinical in-services. She also did not conduct annual performance evaluations for the GNAs. This lack of documentation and oversight was discussed with the facility's administrative team during the survey exit conference.
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What surveyors actually found near you
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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 Havre De Grace
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lorien Bulle Rock | 4.3 mi | ★★★★★ | 0 | 0 |
| Sterling Care Riverside | 9.4 mi | ★★★★★ | 0 | 0 |
| Lorien Nsg & Rehab Ctr Belair | 10.7 mi | ★★★★★ | 9 | 0 |
| Autumn Lake Healthcare At Calvert Manor | 12.3 mi | ★★★★★ | 4 | 0 |
| Laurelwood Healthcare Center | 14.2 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.