Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ellicott City Healthcare Center during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and no decision-making capacity was sexually abused by another resident after multiple staff members observed the interaction but did not immediately intervene or separate the residents. A PTA, a GNA, and a maintenance assistant each saw the residents engaged in sexual activity or in a sexual position, yet staff exited the room, closed the curtain or door, or delayed reporting the event instead of stopping it right away.
A facility failed to document whether room change notifications were made to residents and their representatives after a plumbing backflow and drainage water backup led to relocation of multiple residents from affected rooms. During record review, 4 of 9 resident charts lacked a completed Notification of Room Change evaluation, and the DON confirmed staff did not document whether the residents and their representatives were notified of the transfer.
Incomplete investigations of alleged abuse and neglect were documented for multiple residents. The facility failed to obtain resident and staff statements, did not interview witnesses or other involved staff, and in one case did not submit the required follow-up report to OHCQ. For another resident alleging rape and assault, several staff on the relevant shifts were not interviewed or documented, and for a resident alleging abuse, the NHA could not produce the initial report, 5-day report, or investigation.
A resident with legal blindness did not have the call bell within reach. The resident said help was needed for repositioning in bed and did not know where the call bell was. The call bell was observed sitting on top of the oxygen concentrator about 2 feet from the bed, and the UM confirmed it was not in reach.
Failure to timely report alleged abuse: A resident told staff that another resident tried to rape him/her, and later told the speech therapist that his/her gown had been ripped off and that he/she had been raped and beaten. A GNA documented the allegation, but there was no evidence it was immediately reported to administration, the initial report was filed late, and the facility could not produce proof that the 5-day report was sent to OHCQ. An LPN said she only learned of the incident when the DON called her, and the DON stated prior leadership was not following the reporting process.
Inaccurate MDS coding was identified for 3 residents during a complaint survey. One resident’s behavior section was coded as none despite documented lab refusal and multiple elopement attempts, another resident with an ileostomy was incorrectly coded for bowel continence and high-risk drug classes, and a third resident’s MDS failed to capture a documented hypnotic on the MAR. The MDS Coordinator confirmed the errors.
Facility staff failed to administer medications in accordance with nursing practice standards for a resident with severe cognitive impairment and likely frontotemporal dementia. The resident was observed in bed holding a medication cup with pills still inside and additional pills on the chest, and the MAR showed the pills were scheduled 9 AM meds including Lasix, potassium, carvedilol, duloxetine, and buspirone. The DON confirmed the nurse should have stayed with the resident and observed the medications being taken, and should not have left any medication at the bedside.
Failure to provide timely dental services: A resident with mouth and tooth pain was treated with antibiotics and a dental consult was ordered, but the resident remained awaiting dental evaluation for definitive care. The resident and complainant stated the resident had not seen a dentist, and staff reported problems arranging the appointment due to insurance issues and changes in who handled scheduling; the BOM said there was no reason the resident should not have been seen, and the DON confirmed the findings.
Incomplete and inaccurate resident documentation was found for multiple residents. One resident’s podiatry and ophthalmology visits were not initially present in the chart, another resident had uncharted 9 AM meds still present during observation despite the MAR showing them due, and a third resident’s respiratory distress event lacked complete nursing documentation of the assessments and interventions provided by multiple staff members.
Surveyors identified multiple failures to maintain a safe, clean, and homelike environment, including resident rooms with cracked and heavily stained sinks, damaged drywall and unsanded spackle, loose shower thresholds, and a shower chair with jagged plastic where a person would sit. A resident reported frequent lack of soap, towels, and washcloths affecting their ability to bathe, and GNAs confirmed ongoing shortages of towels and washcloths that delayed ADL care such as bed baths and showers. In addition, water temperatures at resident bathroom sinks were repeatedly measured well above the stated acceptable range, with maintenance logs and surveyor checks showing temperatures in the mid‑120s to as high as 137°F, while leadership was initially unaware of these elevated readings.
An unlocked medication cart was observed unattended on one unit, and an LPN and the unit manager confirmed it was unsecured before it was locked. Surveyors also found that controlled meds in five medication storage refrigerators were not stored in separately locked, permanently affixed compartments: one LPN attempted to use a removable lock box that did not fit the med, another box had a broken lid, and an RN showed a new bubble-wrapped narcotics box that was not affixed. The DON confirmed none of the refrigerators had permanently affixed locked containers and that meds such as Lorazepam and Methadone were stored loosely or in removable boxes.
QAPI Program Failed to Address Repeated Deficiencies: Survey findings showed the facility did not have an effective QAPI program to identify quality concerns and develop effective plans of correction. Deficiencies were cited on multiple surveys in areas including resident rights, beneficiary protection notices, abuse, care planning, activities, quality of care, med storage, and infection control. The POC for beneficiary protection notices relied on education and QA auditing by the Social Service Director of his or her own work, and the care plan POC also relied on re-education without any systemic process change. The NHA reported the former ADON had been certified in QA and that training for all departments was requested at the last QA meeting.
Infection control failures were observed in the laundry room, where dryer drums contained melted diapers and other debris, and required service records and manufacturer handbooks were not available. Staff also failed to use PPE and hand hygiene for a resident on contact precautions for C-diff, and an LPN did not clean hands at multiple points during medication administration while handling pills, equipment, and resident medications.
A facility failed to provide written transfer notices and bed hold information to two residents and their representatives when they were transferred to the hospital. One resident had vascular dementia and family involvement in care planning, but the record lacked a transfer notice or proper bed hold documentation; the other resident's chart also lacked transfer paperwork and bed hold notice, and staff could not produce a certified mail receipt or complete transfer documentation.
A facility failed to follow ordered consults and to administer/document several medications and treatments as ordered. One resident had multiple specialist referrals with no evidence they were scheduled, another had inconsistent nystatin application documentation and missed ordered treatment sites, a resident with diabetes had insulin documented as given even though staff could not locate the medication and the nurse said it was not administered, and other residents had repeated gaps in MAR documentation for pain meds, skin treatments, drain care, and monitoring tasks.
The facility failed to ensure two GNAs received annual performance evaluations. Review of employee files showed both records lacked the required evaluations, and the DON acknowledged the evaluations had not been completed and were still in Workday.
Arbitration agreements were included in the admission packet and reviewed with residents on a tablet, but the facility did not separate the agreement from admission paperwork or verify that the signer had decision-making capacity or legal authority. One resident later said s/he did not know s/he had signed the arbitration agreement and declined it when it was read again, while two other residents had documented severe cognitive impairment or lack of decision-making capacity, yet their arbitration agreements were still signed electronically, including one by an unknown person.
Nonfunctioning resident call light systems were found in multiple rooms across both nursing units. A resident with paraplegia, another resident whose bathroom call bell did not work, and other residents reported delayed staff response or no usable call system, while staff described disconnected or malfunctioning equipment and inconsistent reporting of repairs. Surveyors also observed a call light that was missing from the wall, a bell that staff could not hear, and a malfunctioning indicator light that stayed on.
A resident was observed over multiple days with long, unkempt fingernails and exceptionally long toenails that the resident reported as painful. An LPN confirmed the toenails were very long and caused discomfort during assessment. The LPN described a verbal process for requesting podiatry, while the Director of Social Services outlined a formal written Health Drive form process and confirmed no such form had been received at that time. The resident’s toenails remained very long on a later observation, demonstrating that appropriate nail care and podiatry services were not provided in a timely manner, affecting the resident’s dignity and comfort.
Two residents experienced verbal abuse by staff. In one case, a resident with heart failure, depression, and PTSD reported that an activities assistant accused her of taking advantage of others and then responded to her inquiry with profane, aggressive language, with other interviews revealing similar disrespectful comments to another resident. In a separate case, a resident with stroke-related hemiplegia, heart disease, depression, and dysphagia was addressed by a staff member in a loud, profane manner about eating, an interaction directly overheard by surveyors; the resident later stated that the CNA spoke to her that way at times and that she only sometimes felt safe.
Surveyors found that staff failed to provide and document adequate ADL care, including bathing and incontinence care, for two residents who were dependent on staff. One resident with multiple comorbidities, including diabetes and end-stage kidney disease requiring dialysis, was observed disheveled, with body odor, greasy hair, disheveled bedding, and a chest dressing falling off, and reported long waits for incontinence care and only minimal wet towel baths. Documentation for this resident showed multiple days without a recorded bed bath and only one documented bed bath in a later month. Another resident reported receiving showers only about every two months, and initial record review showed no evidence of showers or baths; the RCD cited a tracking error, and the DON later produced limited skin assessment sheets showing only a few bed baths and no showers documented.
A resident council president reported repeated grievances about staff disrespect, slow call bell response, cold food, dirty utensils, and other concerns, but said forms were sent to Social Work and then nothing happened. Staff could not explain the grievance response process, the DON identified himself as the GO but his contact information was not posted, and observations found grievance bins/forms without required posting or clear anonymous access. Review of concern forms showed incomplete documentation, including missing actions taken and signatures.
Failure to notify family of a change in condition: A resident with moderate cognitive impairment and listed family contacts had a change in condition with tachypnea that led to NP orders for blood tests and a CXR. Staff documented self as the person notified, but the record did not show that the resident's family member or RP was informed, and the unit Mgr stated the chart only reflected self-notification despite an emergency contact being listed.
Failure to Provide Medicare Non-Coverage Notices: The facility failed to provide SNF ABNs and timely NOMNCs to two residents when skilled services ended. Both residents remained in LTC after Medicare Part A skilled services stopped, but the facility did not issue the SNF ABN and, for one resident, did not give the NOMNC in time for the representative to appeal the decision.
A resident reported missing clothing and personal documents after a room transfer caused by a plumbing emergency. Social Services had a grievance form for the missing clothing, but it could not be located, and staff did not promptly re-interview the resident or search for the missing items. During the survey, boxes of clothing and an unopened Tylenol bubble pack were found in the resident’s room, and the missing ID card, Social Security card, and birth certificate were still not located.
A resident with moderate cognitive impairment and a strong preference for family involvement wanted transfer to a closer LTC facility, but discharge planning was not consistently updated or followed through. The care plan noted the family’s request for help finding a nearby facility, yet documentation did not show timely social services follow-up, complete referral information, or that the family was told when the chosen facility declined the resident.
Missing PASARR Screening Before Admission: The facility failed to ensure a PASARR was completed before admission for a resident admitted in January 2026. The medical record initially contained no PASARR documentation, and the DSS stated PASARRs are normally expected from the hospital or completed through Telligen if missing. The record review and staff interview confirmed the screening was not documented at the time of survey review.
Failure to develop comprehensive care plans affected residents with self-catheterization needs, activity preferences, and bed side rail use. A resident with neurogenic bladder reported receiving fewer catheter supplies than needed and the wrong catheter size, while the care plan referenced a nephrostomy site that was not documented and did not address self-cath or supply needs. Two residents had no activities care plans despite documented preferences and staff confirmation, and another resident with cognitive impairment had side rails in use without a corresponding care plan.
A resident with moderate cognitive impairment had MDS assessments that required care plan conferences, but the record did not show the full IDT participated or that the resident’s requested family involvement was properly documented. One conference note showed only the resident and SSD present, and a later sign-in sheet showed the resident, an SSD designee, and two family members by phone, but no nursing, activities, or dietary participation and no details of what was discussed. The meeting date also did not match the schedule, and there was no documentation that family was notified ahead of time.
An LPN failed to document medication administration accurately and on time for two residents. One resident’s oxycodone was observed being given but was not entered on the MAR until the omission was pointed out, and another resident had three morning meds that were not documented as given or otherwise accounted for, including one nasal spray that staff said was unavailable because the facility was out of stock. The DON confirmed meds are expected to be documented at the time of administration.
The facility failed to develop or update activity care plans for multiple residents to reflect their stated interests and preferences. One resident wanted fresh air and going outside, another wanted music and outdoor access, and a third long-term resident had no activity care plan at all. Staff gave conflicting information about outdoor access, and the Activity Director acknowledged that a full activity assessment and care plan had not been completed for one resident.
A resident with a history of stroke and left hand contracture was observed not wearing the recommended splint, and the resident stated the hand gets very red and smelly. Record review and interviews showed OT had discharged the resident with instructions for a left hand splint, towel roll positioning, and left elbow extension, but these recommendations were not documented in the care plan or medical orders and were not being followed.
A cognitively intact resident who self-catheterized reported not receiving the full number of catheters needed each day and having to request supplies daily, with the catheters also being the wrong size. The record failed to consistently identify the intermittent catheterization need on the admission assessment and MDS, the care plan did not address self-catheterization or daily supply needs, and nursing documentation showed gaps in orders and follow-through for catheter use and supply provision. The resident also reported bleeding and suspected a UTI.
A resident with a PEG tube, stroke with hemiplegia, contractures, dementia, myasthenia gravis, diabetes, seizure disorder, and dysphagia had tube feed management issues when the feeding pump was found turned off while still connected and the PEG external fixation plate was pulled more than 3 cm from the stomach wall. The resident’s contracted arm was constantly pulling on the tube because the pump was positioned on the same side of the bed, and an RN stated the tube had been in that position for a while without recognizing the dislodgement risk.
A resident with vascular dementia and severe cognitive impairment had grab bars/side rails in use without documentation of informed consent, a physician order, or a care plan. Surveyors observed the bars up on both sides of the bed, noted a gap between the mattress and rails, and found the record lacked documentation that risks were reviewed with the resident or RP before the rails were initiated.
A facility failed to keep ordered medications available for administration as prescribed. A resident with chronic pain reported that oxycodone routinely ran out and was missed multiple times on the MAR, while another resident did not receive ordered fluticasone nasal spray because the facility was out of stock. An LPN confirmed the medication could not be given because it was unavailable, and the DON acknowledged ongoing issues with reordering and stocking medications.
A resident's monthly pharmacy review identified clinically significant irregularities, but the paper chart had no physician-signed copy of the pharmacist's recommendations. The DON acknowledged there was no evidence the physician received or saw the recommendations and that the policy's definition of timely manner was vague.
A resident’s social service care conference notes were not completed in a timely manner and were not readily accessible. Notes for multiple care conferences were entered as late entries, including one note written months after the meeting, and the EHR did not show documentation of a later care plan meeting even though staff reported one had occurred. The SSD acknowledged a pattern of late note entry.
An LPN’s employee file and Relias transcripts showed that required QAPI/Quality Improvement training was missing. The facility provided mandatory training through Relias, and the DON was made aware of the concern.
Failure to Post Daily Staffing Information: Surveyors observed that the Daily Staffing posting at the front desk was outdated and did not show current staffing levels. The most recent sheet displayed was several days old, and the receptionist stated that nursing was responsible for posting the information. No current staffing information was posted when the concern was identified and later discussed with the DON.
The facility failed to have a written transfer agreement with a local hospital. During the survey, the DON and NHA were unable to provide documentation showing an agreement with a hospital, and the papers later given to surveyors were transfer agreements with other SNFs instead. By the end of the survey process, no hospital transfer agreement had been produced.
An LPN was observed administering inhaled medications to a resident, giving one puff each of Fluticasone-Salmeterol and Albuterol. The medication administration record indicated that Fluticasone-Salmeterol and Umeclidinium Bromide were due, but only Fluticasone-Salmeterol and Albuterol were given. The LPN documented that both Fluticasone-Salmeterol and Umeclidinium Bromide were administered, resulting in a failure to follow professional standards for medication administration and documentation.
A resident who was dependent for self-care and cognitively intact was found with long, unclean fingernails, indicating a failure by staff to provide necessary nail care during routine hygiene. The resident reported not receiving needed assistance, and staff confirmed that nail care should have been addressed during shower care.
A resident reported that meals consistently arrived cold, and a test tray confirmed that both hot and cold foods were not maintained at proper temperatures. Observations showed that meal carts were left open during tray distribution, and staff acknowledged this was inconsistent with expectations for maintaining food temperature. These practices led to food being served at improper temperatures, potentially affecting all residents.
A resident with cognitive impairment and a court-appointed guardian experienced a fall while being transported to dialysis, resulting in pain and subsequent medical evaluation. Despite facility policy and accurate records indicating the need to notify the guardian, staff failed to inform the legal representative of the incident at the time it occurred, as confirmed by documentation and staff interviews.
Two residents experienced unresolved grievances related to missing personal items and care concerns, with facility staff failing to document investigations, resolutions, and notifications as required by policy. Communication lapses and incomplete follow-up led to prolonged periods without resolution or proper documentation of outcomes.
A facility did not fully investigate an abuse allegation after a resident with intact cognition reported that an unknown individual made an inappropriate comment at their doorway. Although the resident denied exposure and staff interviews were conducted, the facility failed to interview other residents on the unit as required by policy, resulting in an incomplete investigation.
A resident with paraplegia and multiple medical conditions, who was dependent on staff for ADLs, did not receive consistent assistance with bathing and fingernail care. Observations showed the resident's nails were excessively long and dirty over several days, and staff interviews confirmed that nail care and daily bed baths were not provided as required. Documentation of bathing was inconsistent, and supervisory staff acknowledged that the resident's hygiene needs were not met according to facility policy.
The facility failed to maintain a sanitary and comfortable environment, with multiple observations of disrepair and uncleanliness across three nursing units. Issues included crumbling ceilings, unfinished repairs, and stained walls. Residents reported long-standing problems, and staff interviews revealed ineffective communication and follow-through on maintenance and cleaning issues.
The facility failed to maintain complete and accurate medical records, with missing consult notes for two residents and incomplete documentation of wound care and medication administration for others. A resident's urology consult notes were incomplete until surveyor intervention, and another's oncology consult notes were missing. Wound care treatments and urine output were not consistently documented, raising concerns about whether treatments were performed. Additionally, discrepancies in medication administration times were noted, with the ADON attributing this to high patient ratios.
Failure to Protect a Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident remained free from sexual abuse when multiple staff members observed another resident engaged in sexual activity with that resident and did not immediately intervene. The incident involved a resident with vascular dementia, cognitive communication deficit, major depressive disorder, post-traumatic stress disorder, and hemiplegia following a stroke. The resident’s BIMS score was 11, indicating moderate cognitive impairment, and physician certification forms documented that the resident lacked decision-making capacity, including the ability to make medical treatment decisions. Facility investigative records and staff statements showed that several employees saw the two residents engaged in sexual activity in the resident’s room. One PTA entered the room and observed the residents in bed engaged in sexual activity, then exited without intervening. A GNA later entered the room, saw one resident on top of the other resident’s face, and left the room after closing the curtain and door without separating them. A maintenance assistant also reported seeing the same resident on top of the other resident’s face and did not intervene. Another staff member was asked to check the room and later reported seeing the resident sitting on the edge of the other resident’s bed. The investigation further showed that staff did not immediately stop the interaction or separate the residents when it was first observed. One staff member reported the incident to a nurse, but the nurse stated she was not aware of the event until later and did not receive a report from the GNA. The facility’s records also reflected that the incident was later reported to administration and law enforcement, and that the allegation was verified through witness statements. The deficiency was cited because staff observed the sexual activity but failed to immediately intervene to stop it.
Failure to Document Room Change Notifications
Penalty
Summary
The facility failed to document whether notification of a room change was made to residents and their representatives after 21 residents were relocated from Rooms 111 through 125 on the Magnolia Unit due to a plumbing backflow and drainage water backup. During review of 9 residents' records related to the room transfers, 4 residents did not have a completed Notification of Room Change evaluation in their medical records. The deficiency was identified during a complaint survey after the affected area was observed to be closed off for repairs, with contractors present to replace flooring and clean up the area. Facility documentation showed the residents were moved because of the drainage water backup in the hallway and shower drains affecting Rooms 111 through 125. The DON stated the Social Worker was supposed to ensure the Notification of Room Change was completed for all 21 residents, and also stated the Social Worker was on leave. On interview, the DON confirmed the facility staff failed to document whether the four residents and their representatives were notified of the room change that occurred when the residents were relocated.
Incomplete Investigations of Alleged Abuse and Neglect
Penalty
Summary
The facility failed to document thorough investigations of allegations of abuse, neglect, and injury of unknown origin for multiple residents reviewed during the complaint survey. For one resident, the allegation was that an LPN purposely delayed medication administration to cause anguish, but the investigation contained no statement from the resident, the LPN, or other staff, and the 10 residents interviewed were only asked whether they had been abused, not about the medication delay. For another resident, who alleged hearing a GNA make a statement about not getting a resident up because it was her day off, the investigation contained no staff or resident interviews to determine whether anyone witnessed the statement. A third resident alleged that staff were laughing when assistance was requested, but the investigation had no staff statements or interview of the resident, and there was no evidence the required Follow-up Investigation Report Form was submitted to the Office of Health Care Quality. The facility also had incomplete investigations for additional reported incidents involving serious allegations. One resident reported that he/she had a gown ripped off and was raped and beaten; although one GNA statement was obtained, seven staff members who worked on the relevant shifts were not interviewed or did not have documented statements, and one assigned GNA had no written statement. Another resident alleged that a GNA used profanity toward residents at the elevator, but the investigation included no staff interviews, no documentation of how the GNA worked with residents, and only one resident statement instead of statements from the other residents who were reportedly present. For a sixth resident who alleged abuse, the NHA could not provide an investigation, and the only available documentation was a 5-day report that was not a detailed investigation; there were no resident assessments or staff interviews, and the NHA stated he never found the initial report, the 5-day report, or the investigation.
Call Bell Not Within Reach for a Legally Blind Resident
Penalty
Summary
The facility failed to ensure a resident's call bell was within reach. Resident #12, who was admitted in 2017 and had a diagnosis including legal blindness, told the surveyor that assistance was needed for repositioning in bed and stated the resident did not know where the call bell was because of being legally blind. Observation showed the call bell sitting on top of the resident's oxygen concentrator about 2 feet from the bed and not within reach. The Unit Manager later confirmed the call bell was not in reach, and then stated a clip had been placed on the call bell to ensure it was in reach for the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an alleged abuse immediately to the Nursing Home Administrator and within 2 hours to the Office of Health Care Quality (OHCQ). During review of facility-reported incident 3025308 and Resident #17’s medical record, it was found that Resident #17 told the speech therapist on 5/27/26 at approximately 10:50 AM that his/her gown had been ripped off and that he/she had been raped and beaten. The investigation also included a written statement from GNA #40 documenting that on 5/27/26 at around 9:30 AM Resident #17 told her that another resident tried to rape him/her the night before. There was no evidence that GNA #40 immediately informed administration of the allegation. The facility’s initial report was not filed until 12:43 PM on 5/27/26, which was beyond the 2-hour reporting requirement. The facility also could not produce documentation showing that the final 5-day report was sent to OHCQ. During interview, an LPN stated she did not know about the incident until the DON called her to ask about it, and she was shocked that the GNA had not reported it. The DON stated that the previous DON and NHA were not following the process of sending the 5-day report and investigation to the regional team, so there was no follow-up to ensure the reports were sent timely to OHCQ.
Inaccurate MDS Coding
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 3 residents reviewed during a complaint survey. For one resident, the MDS with an ARD of 5/31/26 was coded as having no behaviors in Section E, even though the medical record documented refusal of a morning lab draw and several attempts to elope. The MDS Coordinator later confirmed the coding errors during interview. For another resident with an ileostomy, the quarterly MDS with an ARD of 6/12/26 incorrectly coded bowel continence as frequently incontinent instead of not rated. The same assessment also failed to capture use of a diuretic medication documented on the MAR and incorrectly coded a hypnotic medication that was not documented, while also failing to identify pain medication use documented as Gabapentin. For a third resident, the MDS with an ARD of 5/14/26 failed to capture the use of the hypnotic Ramelteon documented on the May 2026 MAR. The MDS Coordinator confirmed these errors during interview.
Medication Administration Not Completed as Required
Penalty
Summary
Facility staff failed to administer medications in accordance with nursing practice standards for one resident with significant cognitive impairment. The resident had documented worsening cognitive decline and likely frontotemporal dementia in a nurse practitioner progress note, and the most recent BIMS score was 6, indicating severe cognitive impairment or problems with thinking and memory. During observation, the resident was found lying in bed holding a 30 mL plastic medication cup containing 3 white pills, with 3 additional pills on the resident's chest; 2 of those pills were broken in half. Review of the July 2026 MAR showed the medications were the resident's 9 AM medications: Lasix, 2 potassium tablets, carvedilol, duloxetine, and buspirone. The DON confirmed that the nurse was expected to stay with the resident and observe that all medication was taken, and stated the nurse was not to leave any medication at the bedside.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that a resident who required dental services on a routine or emergent basis received necessary or recommended dental care in a timely manner. After the resident complained of pain on the left side of the mouth, the physician was notified and ordered an antibiotic and a dental consult. A later physician progress note documented that the resident had completed the antibiotic for left tooth pain and that a dental consult had been ordered, with the resident still awaiting dental evaluation for definitive care. A subsequent NP note documented management of antibiotics for a tooth infection and stated that the resident reported the tooth ache was improving but was frustrated about not being able to see the dentist. The NP documented possible dental infection and the need to follow up with a dentist for source control. During interviews, the complainant and the resident stated that the resident had not seen a dentist, and staff reported problems with arranging the appointment, including issues with insurance and the loss of the person who previously made dental appointments. The BOM stated Medicaid had been approved and there was no reason the resident should not have been seen by the dentist, while the DON confirmed the findings.
Incomplete and inaccurate resident medical record documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for residents reviewed during a complaint survey. For one resident, the medical record did not initially contain evidence that podiatry and ophthalmology visits had occurred, and staff stated the documents had not been scanned into the electronic record because the facility was in the process of having a new person upload documents. The DON later located some of the documents and confirmed they should have been scanned into the medical record. For another resident with an allegation of abuse and worsening cognitive decline, the surveyor observed the resident in bed holding a medication cup with pills still present and additional pills lying on the resident’s chest. The July 2026 MAR showed the 9 AM medications, including Lasix, potassium, carvedilol, duloxetine, and buspirone, but they were not signed off as administered at the time of observation. The facility’s medication administration policy stated the nurse should initial the MAR after giving each medication and before administering the next one. For a third resident who experienced respiratory distress and was transferred to the hospital, the medical record contained a late entry note documenting the event, but it did not include complete documentation of the nursing assessments and interventions performed by the staff who initially responded. Interviews identified that multiple staff members responded and provided care, including elevating the head of the bed, stopping tube feeding, oral suctioning, administering oxygen via non-rebreather mask, notifying hospice, and coordinating the emergency response. The DON confirmed there was no additional nursing documentation in the electronic record for those interventions, and the facility’s policy stated the nurse will record information relative to changes in the resident’s medical or mental condition or status.
Environmental Disrepair, Linen Shortages, and Excessive Hot Water Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyors observed in one resident’s bathroom a loose plastic threshold on the shower floor, a shower chair with a jagged piece of plastic where a person would sit, a severely discolored and cracked sink, and multiple gouges in the drywall. In another shared room, two residents identified a large, rough, unsanded spackled area on the wall without paint, additional unsanded or unpainted spackling, gouges in the drywall, stained sinks and toilets, gouges in the toilet bowl, and a gap in the wall near the pipes under the sink. A further resident’s bathroom showed extensive drywall damage with gouges, rough spackling, and holes around piping under the sink, while another resident’s room had peeling paint and drywall, a dresser drawer handle hanging by one screw, multiple areas of chipped paint, and a cracked, discolored bathroom sink. Another resident’s sink was noted to be slow to drain, cracked, and stained. The deficiency also includes the facility’s failure to ensure adequate linens and supplies for activities of daily living (ADLs). One resident reported that the facility was often out of soap, towels, and washcloths, which affected their ability to receive baths or showers. Two GNAs reported frequent or very often shortages of towels and washcloths, stating that these shortages caused delays in providing ADL care such as bed baths and showers, and that they had to plan ahead and improvise because the issue had been ongoing. The Nursing Home Administrator later acknowledged that a systemic change was needed after being informed that residents and staff reported linen shortages impacting timely care. A further deficiency was identified in the facility’s management of hot water temperatures in resident rooms. Surveyors measured bathroom sink water temperatures in several rooms and found readings ranging from 123.7°F to 126.3°F, above the range that maintenance staff stated should be maintained. Maintenance documentation from that same morning showed unit temperatures between 120.9°F and 126.7°F, which had not been reported to supervisors or the Administrator. Subsequent random checks by surveyors found additional room temperatures between 124.3°F and 128.9°F, and the Maintenance Director’s own log showed room temperatures up to 137°F. A resident cautioned surveyors to be careful when checking water temperatures, implying the water became excessively hot. The Administrator and Maintenance Director reported they were unaware of the elevated temperatures recorded by maintenance staff prior to the surveyors’ findings.
Unsecured Medication Cart and Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure medication carts were kept secured when a surveyor observed an unattended and unlocked medication administration cart on the Dogwood Unit while staff and residents passed by. An LPN confirmed the cart was unlocked, stated it was not her unit, and then informed the Dogwood Unit Manager, who also confirmed the cart was unlocked before locking it. The Director of Nursing was made aware of the concern. The facility also failed to ensure controlled medications were stored in separately locked, permanently affixed compartments in five of five medication storage refrigerators reviewed. On the Magnolia Unit, an LPN showed Lorazepam that was not secured and attempted to place it in a lock box that was not permanently affixed to the refrigerator and did not fit the medication; another locking-type box had a broken lid and was also not affixed. On the Apple Unit, an RN removed a bubble-wrapped narcotics lock box from the refrigerator and stated it was new, had never been unwrapped, and was not affixed. The DON toured all five medication storage rooms and confirmed that none of the refrigerators contained permanently affixed and locked storage containers for controlled medications, and that controlled medications such as Lorazepam and Methadone were stored loosely or in removable boxes.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
An effective QAPI program was not in place to identify quality concerns and develop effective plans of correction. Based on staff interviews, review of documentation, and survey findings, the facility failed to ensure an ongoing quality assessment and assurance group was set up to review quality deficiencies and develop corrective plans of action. Survey findings showed deficient practice had been identified during each of the past two recertification surveys and again on the current survey in multiple areas, including F 550 Resident Rights, F 582 Beneficiary Protection Notice, F 600 Abuse, F 656 Comprehensive Care Plans, F 657 Care Plan Revision and Timing, F 679 Activities, F 684 Quality of Care, F 761 Medication Storage, and F 880 Infection Control. Review of the plan of correction for the survey ending 9/10/24 showed that for F 582, the facility stated the social service department was educated on the importance and need to issue Beneficiary Protection Notices, but there was no indication of any systemic change to the process for issuing the notices. The plan also stated that QA auditing would be conducted by the Social Service Director, who would be auditing his or her own work. For F 656, the plan stated the Social Service Director would re-educate interdisciplinary team members on the need and importance of developing comprehensive care plans, but there was no indication of any systemic change to the care planning process. The NHA reported on 2/19/26 that the Assistant DON, who left in December, had been certified in QA and that at the last QA meeting in January he requested training for all departments in quality assurance. Survey review noted that deficient practice had been identified for the third time in a row for multiple regulations and that the plans of correction had failed to actually address the identified issues, with the QAPI program failing to adequately monitor.
Infection Control Failures in Laundry, Isolation, and Medication Pass
Penalty
Summary
In the laundry area, facility staff failed to follow infection control protocols for the laundry process and did not maintain the laundry dryers in a sanitary and hazard-free condition. During observation, there were no washer/dryer service logs or original commercial manufacturer handbooks available in the laundry room, and two dirty laundry carts were covered and waiting to be washed. In the dryer room, the surveyor observed dryer drums with melted diapers and multiple objects inside them. The Environmental Manager and Maintenance Manager acknowledged that the drums had not been cleaned and confirmed that debris with melted diapers and multiple objects were present. Service records showed dryer ductwork cleaning and inspections, but no service was documented for the dryer drums, and the original manufacturer handbooks were unavailable for review. For Resident #150, who had a diagnosis of C-diff and was on contact precautions, staff failed to use required PPE and failed to perform hand hygiene when entering the room and during medication administration. An LPN entered the resident’s room without gloves, without a gown, and without washing hands before and after giving medications, despite a contact precaution sign and PPE supplies being posted outside the room. The LPN later acknowledged that the resident required contact precautions and that gloves, gown, and handwashing with soap and water were required, but confirmed she had not done so. The Activities Director also entered the room without PPE, and Resident #107 was observed in Resident #150’s room without PPE while in close proximity to the resident and bed. During medication administration, an LPN failed to perform hand hygiene at multiple points. While preparing medications, a pill fell onto the cart; the nurse put on gloves, retrieved the pill, discarded it, removed the gloves, and did not perform hand hygiene. She then handled multiple pill packets, the computer keyboard, the medication cart, keys, and medication cups without hand hygiene between tasks, and proceeded from one resident to the next without cleaning her hands. When asked, the nurse did not identify the appropriate hand hygiene intervals, and the DON confirmed staff are expected to perform hand hygiene at multiple points throughout medication administration.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to provide written transfer documentation to the resident and the resident's representative when two residents were transferred or discharged to an acute care facility. For one resident, the medical record showed vascular dementia with incapacity to make informed decisions and family involvement in care planning, and the resident was transferred to the hospital for a mental status change. The record did not show that a written notice of transfer or a bed hold policy was provided to the resident or a responsible representative. A Bed Hold Authorization Form later provided by the facility was dated after the hospitalization and stated that Medicaid would pay for 30 bed hold days, even though Maryland Medicaid stopped paying for bed holds in July 2012. For the second resident, the record showed hospitalization and two unsuccessful attempts to contact the family by phone, but the chart lacked documentation of hospital transfer documents and a bed hold notice. An LPN stated that nursing staff should print transfer paperwork including MOLST, face sheet, medications, care plan, recent labs, bed hold policy, and transfer orders, and complete an electronic Interact form at the time of transfer; however, the Interact form was incomplete. Social work staff stated they were responsible for sending a written notice by certified mail to the family representative after the hospital transfer, but could not locate the paperwork or provide a certified mail receipt. The DON confirmed the incomplete documentation and that written notice of the bed hold was not provided to the resident or resident representative.
Failure to follow ordered consults, medications, treatments, and documentation
Penalty
Summary
The facility failed to ensure that ordered specialty consults were scheduled for a cognitively intact resident who reported concern that physician-ordered referrals had not been followed up on. The medical record contained orders for infectious disease, urology, neurology, and neurosurgery follow-up, but there was no documentation showing what progress, if any, had been made in arranging those appointments. The Unit Nurse Manager stated the orders were entered into the computer system for the secretary to arrange, but the secretary position was open and she could not provide evidence that any of the appointments had been scheduled. The facility also failed to administer and document a topical antifungal as ordered for a resident with erythema and rash to the peri area and under both breasts. The wound specialist recommended nystatin powder twice daily for 14 days, and the corresponding order directed application to the groin and left breast. The MAR showed repeated documentation of administration, but the location entries were inconsistent and often did not match the ordered sites. Survey review found that staff frequently documented application to the groin or breasts without documenting all ordered areas, and the medication was not applied to the area under the breast for multiple consecutive administrations. The Unit Nurse Manager stated that each specific area on the body should have its own order and confirmed staff were expected to read the whole order. A resident receiving insulin for diabetes reported not having received insulin injections for the past couple of weeks, yet the MAR showed daily documentation of insulin administration. During surveyor observation, staff could not locate the ordered Tresiba in the medication cart or refrigerator, and the Unit Nurse Manager confirmed the medication was not available and had not been requested from pharmacy since December 2025. The DON confirmed the Tresiba was not available to be administered on the evening in question, but the MAR documented that it had been given subcutaneously in the left deltoid. The nurse who documented the dose stated he did not administer it and entered the administration because he believed that was the only way to remove it from the red status. The facility also had multiple gaps in documentation for another resident with chronic pain and several chronic conditions, including hypertension, atrial fibrillation, coronary artery disease, peripheral vascular disease, diabetes, and COPD. The record showed missing documentation for ordered medications, vital signs, Aquaphor application, and monitoring for bleeding, antidepressant side effects, and pain on multiple dates, with additional undocumented instances in the prior month. In another case, a resident with a cholecystostomy drainage bag reported that a nurse had left the bag open and caused leakage onto the bed, and the surveyor observed yellowish-brown liquid on the sheets. The care plan included monitoring drain output, but the MAR lacked documentation that the drain output was recorded or the abdominal drain was emptied on specified dates.
Missing Annual Performance Evaluations for GNAs
Penalty
Summary
The facility failed to ensure Geriatric Nursing Assistants received annual performance evaluations. During review of staff records, two GNA employee files were examined, and both lacked annual performance evaluations. GNA #28 had a hire date of 4/22/19, and GNA #29 had a hire date of 3/12/23. In interview, the Director of Nursing acknowledged that the GNA performance evaluations had not been completed and stated, "they're in Workday, its on my list."
Arbitration agreements were not separated from admission packets and were signed without confirming capacity or authority
Penalty
Summary
The facility failed to have a process in place to separate the Arbitration Agreement from the admission agreement and failed to ensure that the person signing the Arbitration Agreement was cognitively capable or had legal authority. The Nursing Home Administrator confirmed the facility had Arbitration Agreements but said no residents were bound by them, and the Clinical Admission Director stated the admission and Arbitration Agreements were included together in one packet and reviewed verbally while residents followed along on an electronic tablet. She also stated that all residents signed the agreements except those who were not cognitively capable. For Resident #6, the resident stated s/he did not recall seeing or signing an Arbitration Agreement and later, after the agreement was read again, declined to enter into it and said s/he did not know s/he was signing an Arbitration Agreement. The signed document showed electronically printed initials on the signature line. Resident #41’s record showed a physician certification that the resident lacked adequate decision-making capacity and a BIMS score of 5 indicating severe cognitive impairment, yet the Arbitration Agreement was signed electronically. Resident #52’s record showed a physician certification that the resident was unable to comprehend information and make decisions and a BIMS score of 7 indicating severe cognitive impairment, yet the Arbitration Agreement contained an electronic signature of an unknown person. The Regional Sales Manager stated there were no documents indicating signing authority for Resident #52, and a temporary Admission Director and the Clinical Admission Director confirmed the tablet-based process could auto-populate signature lines and allow others to check agree/disagree boxes without the resident’s awareness.
Nonfunctioning Resident Call Light Systems
Penalty
Summary
The facility failed to maintain resident call light and bell systems in working order in multiple rooms and on both nursing units. Surveyors observed that some resident rooms had missing, disconnected, or malfunctioning call systems, and in several instances residents were left relying on manual bells that staff reported they could not hear. The report states that the facility had known about intermittent call bell problems since approximately July 2024, but the issue became significantly worse shortly before the survey and multiple rooms were still affected during the survey period. Resident #165 reported that the call light/bell in the room broke and that no replacement was provided at the time of the interview. Surveyors observed that the wall call light was missing from the wall, and later observed the hall call light/bell ringing repeatedly without an audio alert. An LPN stated she was in another resident’s room with a provider and could not hear the bell. Resident #127 reported that the wall call bell in the bathroom did not work and stated that staff often left the resident on the toilet for at least 30 minutes because they could not hear the manual bell. The surveyor confirmed the wall-mounted call bell did not activate when pulled, and a GNA later confirmed the wall call bell had not been working. Additional observations showed Resident #10 had a non-working call bell tied to the bed rail, with the wall end disconnected and draped over a wheelchair. A GNA reinserted the disconnected box into the wall and stated she had not reported the issue, while another GNA said she would enter it into the TELS system and was unsure whether all staff had been trained on that system. Resident #2, who had paraplegia, was observed with a call bell indicator light that was always on, and the nurse stated the light malfunctioned and that the resident would need to come out to the hall to alert staff. The administrator confirmed that multiple rooms on each nursing unit had call bell systems not in working order and that the facility was still working on repairs.
Failure to Provide Timely Nail Care and Podiatry Services Affecting Resident Dignity
Penalty
Summary
Surveyors identified a deficiency in resident dignity and quality of care related to nail care for one resident. On 2/11/26, the resident was observed sleeping in bed with fingernails that were long, unkempt, and had dark buildup underneath. On 2/13/26 at 1:26 PM, the resident’s uncovered foot was observed with exceptionally long toenails, and the resident stated, “I want them cut. They hurt me.” At 1:29 PM, an LPN assessed the toenails; the resident pulled the foot away and stated, “that hurts,” and the LPN verified that the toenails were very long. The LPN reported that the process to schedule a podiatry appointment was to verbally report the need to social work, while the Director of Social Services later described a different process requiring completion and submission of a Health Drive form by nursing and the practitioner. The Director of Social Services confirmed that no Health Drive forms had been received that day. On 2/17/26 at 9:15 AM, the resident’s toenails were again observed to remain very long, indicating that the condition persisted over several days without being addressed through appropriate nail care or timely podiatry services.
Failure to Protect Residents From Verbal Abuse by Staff
Penalty
Summary
The deficiency involves failure to protect residents from verbal abuse by staff. One resident with a history of heart failure, depression, and post-traumatic stress disorder reported that an activities assistant brought cigarettes to another resident and allegedly told that resident that she took advantage of others. When this was questioned, the activities assistant was reported to have become irate and responded with profanity, stating that she had bought the cigarettes and did not care who became upset, followed by additional profane language. The resident stated that this verbal attack upset her and that there had been three prior incidents involving the same staff member. The DON’s investigation, based on staff and resident interviews, substantiated the allegation and identified additional concerns about the staff member’s treatment of residents who were not considered “favorites,” including a separate instance in which the staff member was heard telling another resident that she would not give them anything even if they asked. In a separate incident, a resident with a history of stroke with left-sided hemiplegia, heart disease, depression, and dysphagia was subjected to verbally abusive language overheard directly by surveyors. While standing near the nurse station, surveyors heard a staff member loudly tell the resident to “get your s&it together and eat” and refer to the resident as a “grown a$$” individual, then observed the resident sitting in a geri-chair with a lunch tray and a blank expression as two staff walked away. When questioned, the resident stated that the nurse, identified as a nursing assistant, behaved like that with her sometimes and that she only sometimes felt safe in the facility. Although the resident later recanted, the NHA acknowledged that residents had expressed fear of retaliation from staff and confirmed that, based on the firsthand observations and written statements of the surveyor and survey coordinator, the abusive event occurred, and the allegation was substantiated even though the specific perpetrator could not be conclusively identified.
Failure to Provide and Document ADL Bathing and Incontinence Care
Penalty
Summary
The facility failed to provide adequate ADL care, including bathing and incontinence care, to residents who were dependent on staff. One resident with diabetes, end-stage kidney disease requiring dialysis, and gait and mobility abnormalities requiring assistance with ADLs was observed disheveled, with greasy hair, body odor, disheveled bedding, wearing only an incontinence brief, and with a chest dressing falling off. The resident reported often waiting up to five hours without incontinence care and stated they only received a small wet towel bath rather than thorough cleaning. Review of this resident’s records showed difficulty determining if baths were provided as ordered, and documentation indicated multiple dates in January when no bed bath was given and only one documented bed bath in February. The DON and RCD acknowledged concern that the resident had not been receiving baths as ordered. Another resident, who was dependent on staff for ADL care, reported receiving showers only about every two months and expressed a desire for more frequent showers. Record review initially revealed no evidence that staff had provided baths or showers for this resident. The RCD stated that an error had occurred and that showers and baths had not been tracked. The DON later confirmed they were unable to provide evidence that the resident had received a bath or shower due to a system error in setting up showers and baths. Subsequently provided skin assessment sheets documented only a limited number of bed baths on specific dates in January and February, with no record of any showers and no additional bed baths beyond those listed.
Grievance Process Not Properly Communicated or Documented
Penalty
Summary
The facility failed to demonstrate prompt action in response to residents’ grievances, failed to provide residents with a written response to grievance outcomes, failed to ensure an anonymous means to submit grievances, and failed to post the Grievance Official’s name and contact information. These issues were identified during review of six Activities Team grievances and were discussed in interviews with the Resident Council President, Social Work staff, the Activities Director, the Director of Social Work, the DON, and the NHA. During the Resident Council interview, the president reported recurring concerns including disrespectful GNA behavior, slow call bell response, cold food, unanswered phone calls for order changes, dirty utensils, dirty elevator walls, and residents running out of medications. The resident stated that concerns were submitted on forms to Social Work and then nothing happened, and the resident was not aware of the Grievance Official’s name or contact information. The Social Work Assistant could not identify the process for responding to grievances discussed at the meetings, and the Activities Director confirmed that concern forms were completed and sent to the Director of Social Work, who was supposed to investigate and return them within 7 days. The Director of Social Work identified himself as the Grievance Official but stated residents did not receive written resolutions, although they should. He also stated that grievance forms were located outside his office and at the main entrance, but his contact information was not posted next to the forms. Observation found no grievance bins or posters on the first floor, a grievance bin outside Social Work on the second floor without GO contact information, and a grievance bin near the main entrance without any poster or contact information; a nearby locked box was present but the receptionist did not know its purpose. Review of the grievance policy showed requirements for anonymous reporting, posted GO contact information, daily box checks, and written grievance decisions, while concern forms reviewed were incomplete and lacked actions taken, investigator signature, and Administrator signature, and were resubmitted still incomplete.
Failure to Notify Family of Change in Condition
Penalty
Summary
The facility failed to inform the resident's responsible party of a change in condition for one resident reviewed. The resident had resided at the facility for more than one year, had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15, and the 9/22/25 MDS indicated the resident reported that it was very important to have family or a close friend involved in discussions about care. The medical record also listed two family members as contacts. The record showed a change in condition note dated 1/10/26 stating the nurse practitioner ordered blood tests and a chest x-ray due to tachypnea. In the section for documenting the name of the family or health care agent notified, staff documented self, indicating the resident was notified. However, the medical record did not contain documentation that the resident's family member was notified of the change in condition. When asked about the notification, the unit nurse manager reviewed the record and stated the notification was noted as self even though an emergency contact person was listed, and reported that permission from the resident was needed to notify family. No documentation was found showing the resident did not want family notified.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) were provided to residents before skilled services ended. Review of the facility’s list of residents discharged from a Medicare-covered Part A stay with benefit days remaining in the past 6 months identified two residents who were discharged from skilled services and remained in the facility for LTC. The report states that when a resident remains in the facility for LTC, the resident is expected to receive both the SNF ABN and the NOMNC. For one resident, the NOMNC showed the responsible representative was informed that skilled services would end and the facility stated the resident was discharged from Medicare Part A services because the resident was remaining in LTC; however, the SNF ABN was not provided because the facility stated the resident discharged from the facility and did not receive non-covered services. The resident was still residing in the facility at survey start, and no documentation showed a discharge and readmission after skilled services ended. For the second resident, the NOMNC showed the responsible representative was left a message that skilled nursing facility services would end, but the facility failed to provide the notice in time for the representative to appeal the decision. The facility again stated the resident was discharged from Medicare Part A services because the resident was remaining in LTC and that the SNF ABN was not provided because the resident discharged from the facility and did not receive non-covered services. This resident was also still residing in the facility at survey start, and no documentation showed a discharge and readmission after skilled services ended.
Failure to Promptly Resolve Resident Grievance for Missing Belongings
Penalty
Summary
The facility failed to promptly respond to and resolve a resident grievance involving missing personal belongings after the resident was temporarily transferred to another facility because of a plumbing water emergency in the room. Resident #100 reported that clothing and personal documents, including an ID card, Social Security card, and birth certificate, were missing after the return to the facility, and stated the concerns were reported to Social Services. The resident also indicated that the documents had been left in drawers in the room before the transfer. Survey observations and interviews showed that the resident’s room contained boxes of clothing, and an unopened bubble pack of Tylenol 325 mg tablets was found among the resident’s belongings. The Director of Social Work stated that a grievance form had previously been completed for missing clothing, but the form could not be located. The Director also confirmed that from the time the missing documents were reported to the surveyor until several days later, the resident had not been re-interviewed and no attempt had been made to locate the reported items. The Director further stated that the resident’s room had not been thoroughly searched until later, when the missing documents and clothing still could not be found.
Failure to Follow Through on Resident Transfer Planning
Penalty
Summary
The facility failed to ensure discharge planning was updated and facilitated for a resident with moderate cognitive impairment who had lived at the facility for more than one year. The resident’s MDS indicated it was very important to have family or a close friend involved in discussions about care, and two family members were listed as contacts. The resident’s family member reported that the facility was too far away and that they wanted the resident transferred to a facility closer to them, while also stating that the social worker said she was working on it and that bed availability was an issue. The resident’s care plan documented that the resident had no plans for discharge because of the need for 24/7 care and support, and that the resident would not have adjustment issues with not returning to previous living status. The care plan also noted that the family had requested assistance locating a facility closer to them, but there was no documentation describing what social services would do to help facilitate the transfer. A care conference note documented the family’s desire for the resident to move to a nursing home closer to home and to a specific facility, but there was no documentation that social services contacted that facility in the 6 months after the meeting. Another care conference note later documented that the resident wanted to go to another facility and requested family attendance, but only the resident and the SSD were documented as attending. Social services later documented contact with the identified facility and stated that the resident’s information would be faxed to initiate transfer, but the record did not show follow-up after that contact for several months. When reviewed, the referral packet sent to the facility did not include the current order summary or more recent primary provider notes. The facility later requested additional documentation, and the receiving facility ultimately reported that it could not accept the resident for LTC. The record did not show that the family was informed that their facility of choice would not accept the resident.
Missing PASARR Screening Before Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) was completed prior to admission for one resident. Review of the medical record showed the resident was originally admitted in January 2026, but no documentation was found showing that a PASARR screen had been completed before admission or afterward at the time of the initial record review. During interview, the Director of Social Services stated that PASARRs are supposed to come from the hospital with the admission paperwork, and if one is missing, the admission director is expected to request it from the hospital. The Director of Social Services also stated that if the hospital refuses to complete one, he can complete the PASARR himself and confirmed access to the Telligen system used to review PASARRs. Despite this, further review of the record still did not reveal PASARR documentation for the resident until the Director of Social Services later provided evidence that the PASARR assessment was completed and submitted to Telligen on 2/17/26 at 4:26 PM.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for multiple residents. For one resident with neurogenic bladder who performed self-catheterization, the care plan addressed intermittent catheter use but included interventions referring to a nephrostomy site, even though the record did not show a nephrostomy. The care plan also did not document that the resident was self-catheterizing, that staff needed to provide catheter supplies daily, or that assistance was needed to obtain the correct catheter size. During interview, the resident reported being supposed to receive 6 catheters per day but receiving only 4, sometimes only 3, and having to ask daily for supplies; the resident also reported the catheters provided were not the correct size. The facility also failed to develop activities care plans for two residents and failed to care plan the use of side rails for another resident. One resident’s MDS identified preferences for listening to music and going outside for fresh air, but the care plan did not address activities, and the Activity Director acknowledged the resident had not yet had a full assessment and that the activity care plan still needed to be initiated. A second resident’s care plan also lacked an activities plan, which the Director of Activities confirmed. For another resident with cognitive impairment and mobility issues, small side rails were observed in the up position on both sides of the bed, but the care plan did not address side rail use despite the facility policy stating a care plan should be in place when side rails are used.
Care Plan Conference Lacked Full IDT Participation and Family Notification
Penalty
Summary
The facility failed to ensure the interdisciplinary team, including the resident’s responsible representatives, participated in care conferences to review and revise the care plan after MDS assessments for one resident. The resident had been at the facility for more than one year and had moderate cognitive impairment, with a brief interview for mental status score of 10 out of 15. The 9/22/25 MDS indicated the resident said it was very important to have family or a close friend involved in discussions about care, and the medical record listed two family members as contacts. The record showed a care conference note from 9/23/25 documenting that the resident requested family attendance, but only the resident and the SSD were present. After a later MDS assessment dated 12/23/25 was completed on 1/5/26, no documentation was found in the electronic record showing a care plan meeting had occurred since the September 2025 conference. When questioned, the SSD later produced a sign-in sheet for a meeting dated 12/11/25 that showed the resident, the SSD designee, and two family members by phone, but it did not show nursing, activities, dietary, or other IDT members were present or participated, and it did not document what was discussed. The meeting date also did not match the care plan meeting schedule, which listed the resident’s meeting for 12/12/25, and there was no documentation that the family had been notified ahead of time.
Delayed and Missing Medication Documentation
Penalty
Summary
Facility staff failed to follow professional standards of nursing practice for timely and accurate documentation of medication administration in the medical record. During observation on 2/13/26, an LPN administered medications to Resident #122 and Resident #129, but the corresponding MAR entries were not completed at the time of administration. When the MARs were reviewed later that day, the oxycodone 5 mg given to Resident #122 had not been documented, and three morning medications for Resident #129—loratadine, fluticasone, and hydrochlorothiazide—had not been documented as administered or otherwise accounted for. During interview, the LPN stated she thought she had signed off the medications and later documented the oxycodone only after the omission was brought to her attention. She also stated that Resident #129’s medications were given after she went to central supply to obtain them, except for fluticasone, which she said was unavailable because the facility was out of stock, and she had not yet documented the administration approximately four hours later. Resident #129 confirmed they did not receive the nasal spray because staff said the facility had run out, and the resident recalled the nurse returning later with two additional pills. The DON confirmed that medications are expected to be documented at the time of administration and acknowledged that the oxycodone was documented only after the omission was identified.
Failure to Develop Activity Care Plans for Residents’ Preferences
Penalty
Summary
The facility failed to develop or update activity care plans to address residents’ activity interests for 3 of 4 residents reviewed. Resident #12 had been in the facility for several years, was dependent on staff for mobility, had some cognitive impairment, and preferred family involvement in care discussions. The resident’s MDS indicated it was somewhat important to get fresh air when weather was good, and the care conference note recorded the resident statement, “I need to go outside.” However, the activity care plan did not include interventions related to taking the resident outside, and activity documentation for the prior 90 days did not show activities offered from 12/7/25 through 12/15/25 or any documentation that the resident had been offered fresh air outings during that review period. Resident #2 was admitted in January 2026, was cognitively intact, and was observed independently wheeling in the hallway. The MDS showed it was very important to the resident to listen to preferred music and to go outside for fresh air when the weather was good. The resident reported that the only way to go outside was with residents who smoke during scheduled smoking times. Staff interviews showed conflicting information about access to outdoor areas, including statements that residents could not sit outside unsupervised in front of the building, that the courtyard was available, and that the courtyard required a code and staff assistance to access. Review of the resident’s care plan failed to reveal an activities care plan, and the Activity Director acknowledged that a full assessment and activity care plan had not yet been completed. Resident #89, a long-term resident, also had no activities care plan. On review of the care plan, no activities care plan was found, and the DON confirmed that the resident did not have one. The Activity Director later confirmed that there was no activities care plan for the resident and stated that every resident should have one. The report also noted that the Activity Director was new to the position and that an audit of activities care plans for all residents would be conducted going forward.
Failure to Implement Therapy Recommendations for Hand Splint Use
Penalty
Summary
The facility failed to implement therapy recommendations for Resident #111, a resident with a history of stroke affecting the left side and a left hand contracture. During observation, the resident was seen with the left hand contracted and not wearing a splint. When asked, the resident stated that there was no splint and reported that the left hand gets very red and smelly. Record review and interviews showed that Occupational Therapy had discharged the resident with recommendations to place a soft towel roll between the left trunk and arm, keep the left elbow extended, and apply a blue left hand splint as tolerated daily after morning care for up to 6 hours with assistance from another person. The surveyor found no documentation of these recommendations in the resident's care plan or medical orders. The Rehab Director confirmed the recommendations had not been entered, and the DON stated that the orders had not been followed.
Failure to Assess and Support Self-Catheterization Needs
Penalty
Summary
The facility failed to accurately assess, plan for, and provide for a resident’s urinary catheterization needs. The resident was cognitively intact and reported performing self-catheterization, stating s/he was supposed to receive 6 catheters per day but was only being given 4, and at times only 3. The resident also reported having to ask daily for supplies and stated the catheters provided were not the correct size, with the resident trying to obtain a prescription for the proper size. The medical record did not consistently identify the resident’s intermittent catheterization needs. The nursing admission evaluation left the intermittent catheterization bladder assessment blank, and the admission MDS documented that the resident did not require intermittent catheterization. A history and physical noted neurogenic bladder requiring intermittent catheterization and treatment for a UTI, but the MDS nurse stated there were no orders at the time and that the catheterization need was probably overlooked. The MDS Director stated the catheterization was not coded because there was no physician order supporting it. The care plan initiated for intermittent catheterization did not document that the resident was performing self-catheterization or that staff needed to provide catheter supplies daily. Nursing documentation showed a staff member witnessed the resident successfully self-catheterize, and later an order was entered for catheter insertion four times daily, but the nurses failed to sign off that order when due. The order was then discontinued, and the record showed a gap with no documentation of an order to catheterize or provide supplies until a new order was entered later. The resident continued to report concerns about inadequate catheter supply, catheter size, bleeding related to catheter use, and suspected a current UTI.
Improper PEG Tube Securement and Management
Penalty
Summary
Facility staff failed to properly manage a PEG tube for Resident #13 and did not secure the tube to prevent pulling and dislodgement. During observation, the resident’s feeding pump was turned off while still connected to the PEG site. Record review showed the resident was readmitted with diagnoses including stroke with right-sided hemiplegia, contractures, vascular dementia, myasthenia gravis, diabetes, seizure disorder, and dysphagia. The resident had previously been hospitalized for sepsis, anemia, and a malfunctioning gastric tube, and a new PEG tube was placed during that hospitalization. Further observation of the PEG site showed the external fixation plate was pulled more than 3 cm away from the stomach wall. The resident’s contracted left arm was constantly pulling on the tube because the feeding pump had been positioned on the left side of the bed. The nurse stated the tube had been out like that for a while and that she was aware of the situation, but did not recognize that it could cause dislodgement. The unit nurse manager agreed the tube was too far from the stomach wall and acknowledged that the tube was not properly secured and was being pulled and pinched by the resident’s contracted arm.
Failure to Obtain Consent, Order, and Care Plan for Side Rail Use
Penalty
Summary
The facility failed to ensure informed consent was obtained from a resident or responsible representative before side rails were initiated, failed to obtain a physician order, and failed to develop a care plan related to side rail use for one resident. The resident had vascular dementia, was determined incapable of making informed decisions regarding treatment as of 9/25/25, and had a BIMS score of 6 out of 15 on the 1/28/26 MDS, with family members involved in care planning. On 2/11/26, the resident was observed asleep in bed with grab bars in the up position on both sides of the bed. The facility’s Safe Use of Bed Rails policy required a physician order, completion of a Bed Safety Evaluation, consent for bed rail use, education to the resident or representative, and a care plan for the use or need for bed rails. Review of the medical record on 2/17/26 found no order or care plan addressing the side rails and no documentation that the risks were reviewed with the resident or responsible party before the side rails were started. Multiple Bed Safety Evaluations were completed between June 2024 and February 2026, but none documented that side rails were in use prior to 12/2/25. The 12/2/25 evaluation documented the resident as capable of decision making and that a grab bar was in use, while later evaluations alternated between indicating the resident was capable or not capable of decision making and whether a device was in use. Surveyors observed the grab bars in the up position, noted a gap between the mattress and the grab bars, and the DON and Unit Nurse Manager confirmed there was no current order for the side rails and no documentation showing informed consent or a care plan before their use.
Ordered Medications Not Kept in Stock
Penalty
Summary
The facility failed to ensure ordered medications were maintained in stock and available for administration as prescribed. Resident #8, who has a history of chronic pain, reported that the facility runs out of the resident’s pain medication about every eight days and that the resident must wait several days for refills. The resident stated the pain medication is needed daily and that staff are aware of the need but do not keep it consistently available. Record review showed oxycodone was ordered as needed for moderate to severe pain, scheduled to be available at 5:30 AM and 1:30 PM, but the February 2026 MAR showed multiple missed administrations on several dates and times. The same issue was observed for Resident #129 during a medication pass. The resident received 14 medications, but fluticasone propionate nasal suspension ordered for daily morning use was not administered and was not signed off on the MAR. The LPN stated the facility was out of the medication and could not give it as ordered. The resident confirmed staff told them the facility had run out of the nasal spray and stated it is not unusual for medications to be unavailable for three to four days, with the concern discussed in resident council meetings multiple times without resolution.
Pharmacist Recommendations Not Documented as Reviewed by Physician
Penalty
Summary
Ensure a licensed pharmacist performed a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and staff interviews, the facility failed to acknowledge a pharmacist's recommendation with a physician signature and failed to define a timely manner for review of the consulting pharmacist's recommendations. For Resident #150, the pharmacy monthly review dated 9/12/25 identified clinically significant irregularities, but the paper chart contained no physician-signed hard copy of the pharmacist recommendations. The facility's Medication Regime Review Policy stated that clinically significant irregularities would be addressed with the Medical Director and DON the day the notification was received or communicated from the Consultant Pharmacist, and if the medical practitioner failed to address the irregularity in a timely manner, the DON would escalate the concern to the Medical Director. During interview, the DON acknowledged there was no evidence that the physician received or saw the irregular pharmacist recommendations and acknowledged that the definition of timely manner was vague.
Late and Missing Social Service Care Conference Documentation
Penalty
Summary
The facility failed to ensure social service notes were completed in a timely manner and readily accessible for one resident reviewed for care planning. For Resident #12, care conference notes for meetings held in March, June, and September 2025 were entered as late entries, showing they were not completed on the dates the meetings occurred. The note for the September 2025 care conference was not created until January 2026 by the Social Service Director. Resident #12 had lived at the facility for more than one year. Care conferences are interdisciplinary team meetings that occur after MDS assessments, which are completed at least quarterly. Review of the electronic health record did not show documentation that a care plan meeting had occurred since the September 2025 care conference, and the Social Service Director later reported that a December 2025 care conference had been held by the Social Service Designee, but the note for that meeting had not been entered.
Missing QAPI Training for an LPN
Penalty
Summary
The facility failed to ensure that employees received mandatory training on its Quality Assurance and Performance Improvement (QAPI) program. During record review, the employee file for one LPN showed a hire date of 6/30/22, and the facility’s required training was provided through an online service called Relias. On 2/13/26 at 2:25 PM, review of the LPN’s Relias transcripts showed a lack of Quality Improvement training. The Director of Nursing was made aware of the concern.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that required daily nursing staffing information was posted on a daily basis. During a surveyor observation on 2/11/26 at 11:09 AM, the Daily Staffing posting at the front desk counter showed the most recent staffing sheet was dated Thursday, 2/5/26, five days earlier, and did not reflect the current day's staffing levels. The receptionist reported that nursing was responsible for posting the information and provided a copy of the February 5th Daily Staffing sheet. No current staffing information was posted at the front desk. The survey team had entered the facility on 2/10/26 at 8:30 AM, and the concern was later brought to the attention of the DON on 2/19/26 at 3:30 PM.
Missing Hospital Transfer Agreement
Penalty
Summary
The facility failed to have a transfer agreement with a local hospital, as required to ensure residents can be moved quickly to the hospital when medical care is needed. During the survey, the surveyor asked the DON to review the transfer agreement with a local hospital, and the NHA was contacted by phone because he was not present in the facility. The DON stated that the NHA asked whether the information could be sent to the survey team the next day. The DON later provided transfer agreements, but they were with other skilled nursing facilities rather than with a hospital. By the close of business on 2/23/26, the facility had not provided documentation showing a written transfer agreement with a hospital.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (Staff #13) was observed administering medications to a resident. During the observation, the nurse gave one puff each of Fluticasone-Salmeterol and Albuterol inhalers. However, review of the medication administration record showed that Fluticasone-Salmeterol and Umeclidinium Bromide were due to be administered at that time, not Albuterol. The nurse signed off that both Fluticasone-Salmeterol and Umeclidinium Bromide had been given, despite only Fluticasone-Salmeterol and Albuterol being administered. This discrepancy was confirmed through record review and discussed with the Director of Nursing, who acknowledged the concern. The failure to administer medications as ordered and to accurately document medication administration did not meet professional standards of practice, as evidenced by the observed event and supporting documentation.
Failure to Provide Nail Care to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent for self-care was not provided with appropriate nail care. The resident, who was cognitively intact and had diagnoses including hemiplegia, hemiparesis, aphasia, and type 2 diabetes with complications, was observed to have long fingernails with brown-colored material underneath. The resident reported needing assistance with nail trimming but had not received it, and expressed concerns about overall care due to apparent short staffing. Staff interviews revealed that the expectation was for nail care to be assessed and provided during showers, and that the Geriatric Nursing Assistant responsible for the resident's recent shower should have checked and addressed the fingernails at that time. The deficiency was confirmed through direct observation and staff acknowledgment that the required care had not been provided as expected.
Failure to Maintain Safe and Palatable Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature, as evidenced by observations and interviews during the survey process. A resident reported that meals consistently arrived cold, and this was corroborated by a test tray temperature observation, which showed that both hot and cold foods were not maintained at their required temperatures. Specifically, hot foods such as eggs and hot cereal were below the expected temperature, and cold items like milk and juice were above the recommended cold holding temperature. Staff interviews revealed that meal carts were left open during distribution, which contributed to the temperature decline of the food. Both nursing and dietary staff acknowledged that the expectation was to keep meal carts closed when not actively serving, but this was not consistently followed. The deficiency was further supported by direct observation of meal service practices, where only one Geriatric Nursing Assistant was distributing trays, and the meal cart was left open and unattended at times. Staff interviews confirmed that trays should be delivered immediately upon arrival to the unit and that the responsibility for maintaining food temperature was shared among GNAs and nurses. Despite these expectations, the observed practices did not align, resulting in food being served at improper temperatures. The issue was identified as having the potential to affect all residents receiving meals from the facility.
Failure to Notify Legal Representative of Resident Accident
Penalty
Summary
The facility failed to immediately notify a resident's legal representative following an accident involving the resident. According to the facility's policy, staff are required to inform the resident, their medical practitioner, and the resident's representative or guardian of any significant change in condition, including accidents that result in injury or have the potential to require physician intervention. In this case, a resident with a court-appointed guardian and a history of cognitive impairment, dementia, and end-stage renal disease experienced a fall while being transported in a wheelchair to dialysis. The resident panicked in the elevator, jumped from the wheelchair, and complained of knee pain, prompting a physician to order an x-ray. Documentation and interviews revealed that the resident's guardian was not notified of the incident at the time it occurred. The resident's care plan and admission records clearly indicated the presence of a court-appointed guardian, and the facility's computer system had been updated to reflect this information prior to the incident. Despite this, the eInteract Change in Condition Evaluation documented that only the resident was notified, not the guardian. Interviews with facility staff, including the LPN assigned to the resident and the Director of Social Services, confirmed that the guardian's contact information was accurate and available, but staff could not explain why the notification did not occur. The deficiency was identified through review of facility records, interviews with staff and the resident's guardian, and examination of facility policies. The guardian reported learning of the incident only after the resident was sent to the hospital days later for swelling and bruising. The facility's failure to notify the legal representative as required by policy and the resident's care plan constituted a lapse in communication regarding a significant change in the resident's condition.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to properly investigate and resolve resident grievances related to missing personal property and care concerns for two residents. One resident, with a diagnosis of Alzheimer's disease and severe cognitive impairment, had multiple grievances submitted by their representative regarding missing personal items, including a blue blanket and a hoodie. Despite repeated communications and requests for written plans and updates, the facility's grievance forms lacked documentation of resolution, dates, and notification to the complainant. Interviews with staff revealed confusion about the process, lack of follow-up, and missing documentation, with the Director of Social Services unable to locate an initial grievance form and uncertain about whether written summaries were provided to complainants. Another resident, who was cognitively intact and had a history of cerebral infarction, diabetes, and adjustment disorder, submitted a grievance regarding care issues such as receiving regular showers, hair washing, therapy, laundry return, and timely assistance. The grievance form showed that only therapy services addressed the concerns, with no documented response from nursing or environmental services. The Director of Social Services and the Director of Nursing both acknowledged that the grievance was not fully resolved in a timely manner, and the Environmental Services Director stated he had not seen the grievance until much later. Facility policy required timely investigation and resolution of grievances, generally within five business days, but the documentation and interviews indicated that grievances were not consistently or thoroughly addressed. There was a lack of clear communication, follow-up, and documentation regarding the investigation and resolution of grievances, as well as notification to residents or their representatives about outcomes. These failures resulted in unresolved grievances and a lack of assurance that residents' rights to voice concerns without discrimination or reprisal were honored.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was admitted with a history of blindness in one eye and intact cognition. The resident's emergency contact reported that someone had entered the resident's room and exposed themselves. During the facility's investigation, the resident denied the allegation of exposure but reported that an unknown individual had made an inappropriate comment about the resident's breasts from the doorway before leaving. The police interviewed the resident, who again denied any exposure but confirmed the inappropriate comment. Law enforcement declined to investigate further and advised the facility to follow its own protocol. The facility's investigation included interviews with the resident and staff assigned to the area, but no witnesses were identified. A handwritten statement from an RN indicated that a resident had previously reported that four men entered the room and mentioned the word 'breast.' However, the facility did not conduct interviews with other residents on the same unit to determine if similar incidents had occurred, despite facility policy and statements from the ADON and DON indicating that such interviews should be part of the investigative process. This incomplete investigation led to the deficiency cited in the report.
Failure to Provide Adequate Personal Hygiene and Nail Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain proper grooming and personal hygiene for a resident who was dependent on staff for activities of daily living (ADLs), including bathing and fingernail care. The resident, who had a history of osteomyelitis, necrotizing fasciitis, pressure ulcers, and complete paraplegia, was documented as being dependent on staff for oral hygiene, toileting, showering/bathing, dressing, and personal hygiene. Despite this, observations over several days revealed that the resident's fingernails were excessively long and had a black substance underneath, and the resident confirmed needing assistance with nail care. Staff interviews confirmed that nail care was the responsibility of nursing assistants and should be performed as needed, but the assigned staff could not recall the last time nail care was provided and acknowledged the resident's nails needed attention. Documentation showed inconsistent and infrequent bathing, with records indicating only a few bed baths or showers provided over several months, and some refusals or days marked as not applicable. However, staff interviews and observations indicated that the resident did not consistently refuse care, and when care was refused, it was not always properly documented or reported. Nursing assistants and supervisory staff acknowledged that the resident had not received daily bed baths or complete hygiene care, including washing of legs and feet and removal of socks for skin inspection, as expected by facility policy. Supervisory staff, including the ADON, DON, and clinical manager, confirmed that the resident's hygiene and grooming needs were not met according to facility expectations and policy. They agreed that the resident's nails were in poor condition and that daily bathing and complete hygiene care, including nail care, should have been provided. The lack of consistent documentation, failure to offer or provide daily hygiene care, and inadequate attention to the resident's grooming needs led to the deficiency identified during the survey.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment for residents, as evidenced by multiple observations of disrepair and uncleanliness across three of the four nursing units. Specific issues included a crumbling ceiling with mold and peeling paint in one room, unfinished repairs with exposed nails and spackle marks, and discolored ceiling tiles. Residents reported that some of these issues had persisted for months or even years without resolution, despite assurances from the facility that repairs would be made. In addition to structural disrepair, there were significant cleanliness issues observed. In one room, a dirty fracture bed pan and basin were found on the floor, filled with cans and empty Styrofoam cups. Another room had a kangaroo tube feeding pole with dark brown drip marks, and the wall and radiator were stained with maroon drip marks, possibly from wound cleanser or solution. These conditions were not addressed, leaving the environment unsanitary and uncomfortable for residents. Interviews with facility staff revealed a lack of effective communication and follow-through regarding maintenance and cleaning issues. Geriatric nursing assistants reported that they would inform their supervisors or the charge nurse about disrepair, but there was no indication that these reports led to timely action. The Nursing Home Administrator acknowledged the disrepair and stated that a company had been hired to address the issues, but work had not yet commenced. The Director of Environmental Services also recognized the need for cleaning and maintenance but did not take immediate action to rectify the problems.
Incomplete Medical Records and Documentation Issues
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by missing or incomplete documentation. For one resident, the urology consult notes from an appointment were incomplete until the surveyor intervened, revealing that the facility had not obtained the full notes until months later. Another resident's medical record lacked consult notes from two separate oncology appointments, despite staff confirming the resident attended these appointments. Additionally, the facility did not consistently document wound care treatments and urine output for another resident, with several days showing blank spaces in the treatment administration record (TAR). This lack of documentation raised concerns about whether the treatments were performed, as the standard practice is that if a treatment is not signed off, it is considered not done. Similarly, another resident's GNA tasks documentation showed multiple days with blank spaces, indicating incomplete records. Furthermore, a resident reported not receiving medication on time, and a review of the medication administration record (MAR) revealed discrepancies between the scheduled and actual documented administration times. The ADON acknowledged that nurses often documented medication administration at the end of the day due to high patient ratios, leading to inaccurate records. These deficiencies highlight significant lapses in maintaining accurate and complete medical records, which are crucial for ensuring proper resident care.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,927 citations issued within 25 miles in the last 12 months — including the 10 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ellicott City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Lutheran Village At Miller's Grant | 1.7 mi | ★★★★★ | 0 | 0 |
| Meadow Park Rehabilitation And Healthcare Center | 3.7 mi | ★★★★★ | 5 | 0 |
| Autumn Lake Healthcare At Summit Park | 4.1 mi | ★★★★★ | 1 | 0 |
| Encore At Turf Valley | 4.2 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Catonsville | 4.7 mi | ★★★★★ | 3 | 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 October 2026) and official state health department websites.