Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fayette Health And Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to thoroughly investigate an allegation that a resident’s money was stolen by a GNA. When the resident reported that $150.00 was missing and implicated a specific GNA, the facility’s investigation relied solely on standardized abuse interview forms that asked only about verbal, physical, or sexual abuse, and all responses were marked negative. No residents, including the reporting resident’s roommate, were asked about missing property, prior incidents of missing belongings, or concerns related to the implicated GNA. The DON later confirmed that only the abuse questionnaires were used and that residents were not questioned about the specific allegation of theft because those were the forms they had been told to use.
A resident with Type 2 DM had a physician order for a CCD with no salt packet, and documented allergies to shellfish-derived products and caffeine, along with no juice and no milk restrictions, all clearly listed on the tray ticket and care documents. After the resident declined their original lunch tray, a GNA, without checking the ticket, offered and delivered a shrimp scampi tray at the resident’s request and did not consult a nurse, despite a surveyor pointing out the shellfish allergy. The GNA also attempted to provide apple juice from the cart and stopped only when the surveyor drew attention to the no-juice restriction, while the Dietary Manager confirmed that residents with seafood or shellfish allergies should have received a substitute entrée instead of shrimp scampi.
Staff failed to document insulin administration in real time for a resident receiving multiple scheduled insulin types, including Aspart, Lispro, and Glargine. Review of the MAR and electronic time stamps showed numerous insulin doses recorded between nearly 2 and over 6 hours after scheduled times, and some afternoon and bedtime Lispro doses documented as given at the same time on multiple days, with no explanatory notes. The acting DON could not provide additional documentation, and interviewed RNs admitted they often administered insulin on time but delayed electronic MAR entry, sometimes recording doses on paper and signing them off later, resulting in inaccurate electronic time stamps.
Unverified LPN Licensure and Compact Status: Surveyors found that the facility employed two LPNs whose authority to practice in Maryland was not verified. One LPN had a Virginia license that was not recognized by the MBON because the nursing program did not meet Maryland requirements, and the other LPN’s compact status documentation was not on file. Interviews and personnel record reviews showed the facility had already identified the issue previously but continued to employ the nurses without confirming valid licensure status.
Residents on Patuxent Hall were observed without reachable call bells while in bed. Several call bells were clipped to wall cords, left on the floor, placed out of reach on a bedside table, or not accessible at all. An interview with a GNA indicated that morning rounds are supposed to include checking that each resident has their call bell.
Improper Linen Handling and Infection Prevention Practices: Clean linen was found uncovered in the laundry area and hallway, with soiled tiles in the laundry storage room and particles observed on the clean laundry. In a resident bathroom shared by up to 6 female residents, a trash bin was placed on a chest of drawers and several used, wet washcloths were hanging on a bar instead of being placed in the soiled linen bin. The ES manager, NHA, and IP all confirmed the expected handling of clean and soiled linen.
Clothing was left on the floor and on top of a basket in resident rooms, and multiple residents were observed in bed without pillows. Surveyors also found plastic bags and a soiled gown on the bathroom floor and in rooms, affecting 5 of 33 residents on the unit. An ADON stated clothing should be in the closet or storage, and an LPN stated every resident should have a pillow.
Missing Person-Centered Care Plans for Residents with Vision Needs: Staff failed to develop person-centered care plans for residents with vision-related needs, including a resident with glaucoma and blurred vision and another resident with blindness in one eye and blurred vision in the other eye. Record review showed no vision care plans were initiated, despite an eye exam recommending new glasses and resident reports of ongoing visual impairment.
Facility staff failed to complete quarterly care plan meetings for a resident. The Social Services Director stated that LTC care plan meetings are held quarterly and annually with the resident’s representative and relevant departments, but the resident’s EHR contained no care plan meeting notes over an extended period. The Administrator was unable to verify any meetings, and the regional DCS confirmed none had occurred.
Failure to document hospice orders and monitor psychotropic medication: A resident received hospice services for nearly two weeks without a physician order, and the chart lacked hospice notes or documentation of communication with the hospice nurse. Another resident was prescribed Risperidone/Risperdal for schizophrenia/psychosis, but the EHR showed no monitoring for extrapyramidal side effects or behavioral monitoring, which the RDCS confirmed.
A resident’s personal hygiene needs were not adequately met because regular podiatry services for toenail trimming were not provided. The resident reported very long, uncomfortable toenails, said they had not seen a podiatrist in a while, and stated they were diabetic and knew they should care for their feet. Record review found only one podiatry consult note and an order for podiatry consults PRN, while the ADON could not locate additional consult documentation.
Failure to ensure residents received vision care and a recommended assistive device. Two residents had impaired vision: one reported blurred vision with a history of glaucoma, and another had a prior eye exam recommending new glasses but stated the glasses were never received. The DON said Health Drive provides vision services, but the survey found the residents had not received the needed follow-up care or the recommended glasses.
A resident with a nephrostomy stated that staff did not empty or change the drainage bag and that the resident had to manage it personally, with family supplying bags. A TAR review showed no documentation of the bag being emptied or changed, and the DON stated the bag was being changed but not documented, acknowledging the facility could not prove the care had been provided.
Improper handling of a fallen tray during breakfast service. A Dietary Aide knocked a tray onto the floor, picked up the tray, silverware, napkin, and beverages from the floor, and placed them back on the clean serving line. Breakfast service continued over the contaminated area until the Dietary Mgr stopped the process. The Dietary Mgr and District Mgr later confirmed the action was against protocol and posed an infection control risk.
Facility staff failed to maintain multiple resident and common areas in safe operating condition. Surveyors observed a heating/AC unit front on the floor, holes in a bathroom door, an unsecured electrical outlet plate, dry rotted and missing armoire wood, damaged drywall and an unsecured sink in a resident bathroom, damaged tile in the spa room, and multiple issues in the laundry and linen storage areas including damaged drywall, holes in the wall, damaged pipe insulation, damaged floor tile, and heavily soiled ceiling tiles. The Maintenance Director stated staff use TELS and word of mouth to report repairs and that maintenance tasks are tracked on weekly and monthly schedules.
Unsanitary fly strips were observed in two resident rooms during survey. A fly trap with dead insects was hanging above one resident's bed while the resident was asleep, and an LPN acknowledged it was unsanitary. In another room, a fly strip with dead flies was found above a resident's head, and the resident reported having bugs in the room.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
The facility staff failed to ensure that residents received showers at least twice a week, as required. Multiple residents reported not receiving showers, and clinical records confirmed the lack of showers. Staff interviews revealed misunderstandings and lack of documentation regarding residents' shower schedules and refusals.
The facility failed to ensure the accuracy of MOLST and maintain proper advance directives for several residents. For example, one resident's MOLST form contained errors, and another resident had no documentation of a MOLST or advance directive despite residing at the facility for over 11 months. The Social Worker admitted to not routinely asking residents if they wanted to complete an advance directive.
The facility failed to hold timely care plan meetings with an interdisciplinary team for three residents, as required by the MDS assessment schedule. One resident reported never being invited to a care plan meeting, another had no documented meetings since 2020, and a third had not had a meeting since admission.
The facility failed to safeguard resident-identifiable information and maintain accurate medical records. An unattended medication cart displayed a resident's medication profile, and several instances of inaccurate documentation were found, including incorrect notes about dialysis, dressing changes, and medications. Additionally, a resident did not receive prescribed medications, yet the LPN documented that they were administered.
The facility failed to sanitize medical equipment between residents and did not maintain gown availability for Enhanced Barrier Precautions (EBP). A CMA used a blood pressure monitor on two residents without sanitizing it, and rooms with EBP signs lacked gowns. Staff interviews revealed a lack of awareness and proper procedure for obtaining gowns.
The facility failed to notify residents and their representatives in writing of the bed hold policy upon transfer to the hospital. This deficiency was identified for four residents, with medical records lacking documentation and staff interviews confirming the policy was not provided as required.
The facility failed to accurately document MDS assessments for four residents, including errors in recording dialysis dependence, tobacco use, mental health diagnoses, and assistance levels for a resident with bilateral above-knee amputations. These inaccuracies were confirmed through medical record reviews and staff interviews.
The facility failed to provide proper wound care for four residents, resulting in inconsistent and inaccurate documentation, lack of supervision, and missing wound care orders. The staff acknowledged the deficiencies but did not provide additional information or corrective actions.
The facility staff failed to ensure the privacy and confidentiality of residents' personal and medical information. A discharge summary and PASRR form for one resident were incorrectly placed in another resident's clinical record. The Administrator confirmed the error during an interview.
The facility failed to protect residents from verbal abuse in two separate incidents. In one case, an RN used profane language and was dismissive towards a resident. In another case, a video of a staff member verbally abusing a resident was circulated online, leading to the staff member's termination.
The facility staff failed to ensure resident dignity as evidenced by staff not wearing name tags and using personal cell phones during resident care. One GNA and one RN were observed without name tags, and another GNA was seen using a personal cell phone while assisting a resident with lunch.
The facility failed to ensure that a resident's personal property was not lost. Despite the resident reporting missing clothes to multiple staff members, no grievance forms were found, and the personal inventory sheet was missing from the resident's chart. The Housekeeping Supervisor suggested the clothes might have been mistakenly donated, and the NHA only completed a grievance form after the surveyor's intervention.
The facility failed to report a reasonable suspicion of abuse resulting in serious bodily injury within the required 2-hour timeframe. A resident complained of right hip pain and mentioned a fall three days prior. An x-ray confirmed a hip fracture, and the resident was transferred for urgent surgery. The initial self-report was delayed by 2 days and 7 hours, violating reporting requirements.
The facility failed to provide written notice with the reason for transfer to residents and failed to notify the Ombudsman of residents that transferred. This deficiency was identified in three residents who were hospitalized, with staff providing only verbal notifications and no written notices.
The facility failed to develop and provide a baseline care plan for two newly admitted residents within 48 hours of their admission. For one resident, the nursing evaluation did not indicate that care planning was discussed or that the resident received a summary, and it lacked documentation of planned therapy services, goals, and a summary of medications with dietary instructions. The Nursing Home Administrator did not provide additional information by the time of the surveyor's exit.
The facility failed to develop and implement appropriate care plans for three residents, leading to deficiencies in their care. One resident's smoking habits were not addressed in the care plan, another resident's discharge planning was overlooked, and a third resident's incontinence was not managed according to their care plan. The Nursing Home Administrator acknowledged these deficiencies during the surveyors' visit.
The facility staff failed to ensure that a resident's toenails were cut, resulting in a long toenail on the big toe of the right foot. The resident reported that no one had cut the toenails even after dressings were changed, and the issue persisted for several days.
The facility failed to provide an activities program that meets the interests and needs of residents based on their comprehensive assessments and care plans. Two residents expressed preferences for specific activities, but the documented activities were minimal and did not align with their stated interests. The Administrator and Regional Clinical Director acknowledged the deficiency when shown the activity logs.
The facility failed to maintain a medication error rate of 5% or less. A CMA did not administer Vitamin D to a resident as ordered and incorrectly documented it as given. Additionally, the CMA administered Levothyroxine to another resident after breakfast, contrary to the order specifying it should be given before breakfast. The error rate was found to be 8%.
The facility failed to secure medication and treatment carts, as observed during random tours. Unlocked carts containing medications and medical supplies were found on the 1st and 3rd floors. Staff confirmed the carts should have been locked when unattended.
The facility staff failed to assist a resident in making necessary appointments for dental care or treatment. Despite a dentist's recommendation for extractions, no extractions were performed during subsequent visits, and no further appointments were scheduled. The resident, who had only three teeth left and reported gum pain, did not receive the necessary dental care.
The facility failed to employ an LPN in accordance with Maryland State laws. The LPN had an active Virginia license but lacked necessary documentation and currently resides in Maryland. The NHA confirmed awareness of the licensing requirement and informed the LPN to apply for a Maryland license.
The facility failed to ensure that residents' bed mattresses were properly secured to the bed frames, leading to safety concerns. This deficiency was observed in two residents, one with a history of falling and another with bilateral amputation, both requiring assistance with transfers and moving in bed. The Maintenance Director acknowledged the issue but failed to resolve it promptly.
The facility failed to maintain an effective pest control program, as evidenced by multiple gnats swarming in a resident's room. The DON confirmed the infestation and reported it to the NHA, who was initially unaware of the issue. Pest logs showed prior extermination treatments for gnats.
The facility failed to ensure required in-service training for nurse aide staff was completed, specifically for a Geriatric Nursing Assistant hired in October 2023. Despite using computer-based training programs and messaging systems, the facility could not provide documentation of the necessary training, revealing a deficiency in monitoring and record-keeping.
The facility failed to inform a resident's representative of changes to the care plan, leading to confusion about who should be contacted for decisions. Despite evaluations indicating the resident's incapacity, the social history assessment incorrectly listed the resident as having decision-making capacity, resulting in inconsistent notifications to the resident and their ex-spouse.
Failure to Thoroughly Investigate Allegation of Missing Resident Money
Penalty
Summary
Facility staff failed to conduct a thorough investigation into an allegation of missing money involving a resident and a Geriatric Nursing Assistant (GNA). On 2/21/26, a resident reported that $150.00 had been stolen by GNA #8. The facility’s investigation documentation consisted of seven Resident Interview forms that only addressed abuse-related questions (verbal, physical, or sexual), all of which were checked “No,” indicating the residents denied being abused or witnessing abuse. There was no evidence that any residents, including the reporting resident’s roommate, were interviewed about missing property or money, prior experiences with missing belongings, or any concerns specifically related to GNA #8. During an interview on 4/9/26 at 1:35 PM, the DON confirmed to the surveyor that the abuse questionnaire forms were the only interviews conducted as part of the investigation. The DON acknowledged that the reporting resident’s roommate was not asked whether they had witnessed or had any knowledge of the alleged theft of money. When asked why residents were not questioned about issues specific to the allegation of missing money, the DON stated that “that’s what we were told to use,” referring to the abuse questionnaire forms, demonstrating that the investigation did not address the specific allegation of theft.
Failure to Follow Documented Allergies and Diet Restrictions During Meal Service
Penalty
Summary
Facility staff failed to provide food that accommodated a resident’s documented allergies, diet order, and restrictions. The resident had Type 2 Diabetes and a physician’s order for a carbohydrate controlled diet with regular texture, thin liquids, and no salt packet. The medical record, plan of care, and GNA Kardex all documented allergies to shellfish-derived products and caffeine, as well as restrictions of no juice and no milk. On the survey date, the resident reported not eating lunch because they did not like the meal provided. Their declined tray ticket clearly listed the carbohydrate controlled diet, shellfish and caffeine allergies in bold, and the no salt packet, no juice, and no milk restrictions. Later, a GNA was observed at the doorway with the meal cart and asked the resident’s roommate why they had not eaten their shrimp scampi. Upon hearing this, the resident stated they wanted shrimp scampi as well. The GNA took another tray containing shrimp scampi from the cart and, without reviewing the resident’s tray ticket for diet, restrictions, or allergies, offered it to the resident. A surveyor intervened and pointed out the documented shellfish allergy on the ticket, but the GNA proceeded to deliver the shrimp scampi tray to the resident and did not refer the request to a nurse. The GNA then picked up a cup of apple juice from the cart to take to the resident and only stopped when the surveyor called attention to the resident’s no-juice restriction printed on the ticket. The Dietary Manager later confirmed that shrimp scampi was the main entrée and that residents with seafood or shellfish allergies should have received a substitute entrée of country fried steak.
Failure to Document Insulin Administration in Real Time
Penalty
Summary
Facility staff failed to document insulin administration in real time and in accordance with accepted professional standards and practices for one resident. The resident had physician orders for multiple insulins: Insulin Aspart 7 units before meals at 6:00 AM, 11:00 AM, and 4:00 PM; Insulin Lispro before meals and at bedtime at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM with dosage based on blood sugar readings; and Insulin Glargine 20 units at bedtime. Review of the April 2026 MAR and associated electronic time stamps for doses administered between 4:00 PM on 4/3/26 and 11:00 AM on 4/13/26 showed that 19 of 80 insulin doses were signed as administered between 1 hour 50 minutes and 6 hours 38 minutes after the scheduled administration time, outside the standard of administering time-critical medications such as insulin within 30 minutes before or after the scheduled time. There was no documentation in the medical record explaining these deviations from scheduled administration times. Further review showed that the 4:00 PM and 8:00 PM Insulin Lispro doses were documented as being administered at the same time on three separate dates, without any explanatory documentation. During interviews, the acting DON was unable to provide additional documentation or explanation for the late or overlapping time stamps. Two of the four nurses responsible for the late insulin documentation reported that they did not consistently chart insulin administration at the time it was given. One RN stated that she administers insulin on time but does not always sign it off as she gives it, acknowledging she knows better than to do that. Another RN reported that he sometimes writes administration times on paper and enters them into the electronic MAR later, and stated that he did not actually administer two doses of the same insulin together as the documentation suggested, indicating that the time stamps reflected delayed documentation rather than the actual time of administration.
Unverified LPN Licensure and Compact Status
Penalty
Summary
The facility failed to employ LPNs in accordance with Maryland State law after surveyors determined that two of four employees reviewed for licensure, LPN #8 and LPN #14, did not have verified authority to practice as LPNs in Maryland. The deficiency was identified during review of Complaint #2625762, employee files, facility documentation, and staff interviews. Surveyors found that the facility had continued to employ both nurses after the issue had first been identified during a prior recertification survey on 4/3/24. For LPN #8, surveyors reviewed the personnel file and found that the individual did not have Maryland LPN licensure. The Maryland Board of Nursing did not recognize the license because the nursing program attended was not recognized and approved by the Board. The personnel file showed a Virginia state identification card and a Maryland primary address, and the Nursing Home Administrator stated that LPN #8 did not have a primary residence in Virginia. During interview, LPN #8 stated that he/she had worked at the facility since May 2022 as an LPN and believed Maryland residence did not require a Maryland LPN license. Surveyors also reviewed the facility’s prior statement of deficiencies and plan of correction from the 4/3/24 survey, which had already identified LPN #8 as a staff member under the citation for not employing licensed staff according to Maryland State law. During the current survey, the facility’s licensure audit also identified LPN #14 as holding a Virginia LPN license without verified compact status documentation. In interview, LPN #14 stated that he/she was an MDS Coordinator, lived in Maryland most of the week, filed taxes in Maryland, and voted in Maryland, while the NHA confirmed that the required compact status documentation had not yet been received.
Residents Lacked Access to Call Bells
Penalty
Summary
Staff failed to ensure that residents had access to their call bells when assistance was needed on Patuxent Hall. During observation rounds, multiple residents were found without reachable call bells: one resident’s call bell was clipped onto the cord on the wall while in bed, another had the call bell hanging from the cord on the wall, two residents had call bells on the floor near or under the bed, one resident’s call bell was on the bedside table but out of reach, one resident did not have access to the call bell, and another resident’s call bell was clipped to the cord hanging from the wall. The surveyor later reported to the Administrator that multiple residents on Patuxent Hall did not have access to their call bells. When interviewed, a GNA stated that during morning rounds staff make sure each resident has their call bell.
Improper Linen Handling and Infection Prevention Practices
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not store and process linen properly and did not maintain effective infection prevention practices. During a tour of the laundry area, clean linen was observed uncovered in the laundry room and in the hallway outside the laundry area, and multiple soiled tiles were present in the laundry storage room. The surveyor observed particles from the tile on the clean laundry. The Environmental Services Manager stated that clean and dirty laundry should not be in the same room and that clean laundry should be covered, and the Laundry Aid stated they were multitasking and about to put the laundry away. During a tour of the third floor, the surveyor observed a trash bin on top of a chest of drawers and several used, wet, white washcloths hanging on a bar in the ensuite bathroom of a room with a shared bathroom for up to 6 female residents. The Nursing Home Administrator stated the trash should have been on the floor and the used washcloths were to be placed in the soiled linen bin. The Infection Preventionist stated that the washcloths were to be put out for laundry the same day and that staff are to conduct frequent rounding to residents' rooms to collect soiled or used linens to be laundered.
Clothing and pillows not maintained in resident rooms
Penalty
Summary
The facility failed to maintain a comfortable, clean, and homelike environment for residents on Patuxent Hall, as evidenced by observations of clothing left out of storage and residents without pillows. During surveyor rounds, one resident had clothes on top of a tall grey basket and a soiled gown plus a blue article of clothing on the bathroom floor, another resident had two pairs of black sweatpants and a grey sweatshirt on the floor beside the bed, and a large clear plastic bag with clothing was observed on the floor in one room. Two residents were observed in bed without pillows, and a large black garbage bag was also observed on the floor in another room. The deficiency affected 5 of 33 residents on the unit. When the findings were reported, an ADON stated that residents’ clothing should be in the closet and extra clothing could be taken to storage, and an LPN stated that every resident should have a pillow and that there were plenty of pillows in Central Supply.
Missing Person-Centered Care Plans for Residents with Vision Needs
Penalty
Summary
Facility staff failed to generate person-centered care plans for a resident with dementia, two residents with visual disturbances, and a resident who needed to wear a helmet to protect the brain while out of bed. During record review and interviews, the surveyor found this deficient practice in 2 of 5 resident records reviewed for care plans during the recertification survey. Resident #12 reported blurred vision during an interview, and the resident’s diagnoses included a history of Primary Open Angled Glaucoma. Review of the care plans showed no care plan had been initiated for vision. In an interview, the DON stated that Health Drive comes to the facility and residents needing vision or dental services are scheduled for appointments, but the resident still did not have a vision care plan. Resident #91’s EMR showed a last eye exam by Health Drive with a recommendation for new glasses, and the resident had a diagnosis of blindness in one eye; however, no care plan for impaired vision had been initiated. The Administrator stated residents are usually seen yearly and an appointment would be made with Health Drive for Resident #91. When interviewed, Resident #91 stated they were blind in the right eye, had blurred vision in the left eye due to a cataract, and never received the recommended glasses.
Failure to Hold Quarterly Care Plan Meetings
Penalty
Summary
Facility staff failed to complete quarterly care plan meetings for Resident #96. During the survey, the Social Services Director explained that care plan meetings for LTC residents are scheduled twice weekly, held quarterly and annually, and include the resident’s representative and relevant departments, with additional meetings held upon request or for significant change. However, review of Resident #96’s electronic health record showed no documented care plan meeting notes from 03/20/23 through 07/24/25. When the Administrator was asked to verify whether the resident had any care plan meetings, the regional Director of Clinical Services confirmed that the resident did not have any care plan meetings.
Failure to Document Hospice Orders and Monitor Psychotropic Medication
Penalty
Summary
Resident #43 received hospice care for 12 days without a physician order. The resident’s hospice consent was signed on 03/14/25, and an order for hospice care was not written until 03/26/25. LPN #31 stated the hospice nurse came to the facility twice a week, but a review of the paper chart found no hospice notes in Resident #43’s medical record. During interview, the DON stated the resident was already admitted to hospice, that hospice had its own physician in house, and that hospice orders were written by hospice and run by the in-house physician; however, there was no documentation to verify communication with the hospice nurse and no order written before the resident received hospice care. Resident #10 was prescribed Risperidone 1 mg PO in the evening for schizophrenia, then later discontinued and changed to Risperdal 0.5 mg PO daily for psychosis. Review of the EHR showed the resident was not being monitored for extrapyramidal side effects or behavioral monitoring. The Regional Director of Clinical Services confirmed that Resident #10 was not being monitored for extrapyramidal side effects and that staff were not receiving behavioral monitoring.
Failure to Provide Regular Podiatry Care
Penalty
Summary
Facility staff failed to ensure that a dependent resident’s personal hygiene needs were adequately met by providing regular podiatry services for toenail trimming. Resident #119 reported that their toenails were extremely long and uncomfortable, stated they had not seen a podiatrist in a while, and said the podiatrist had tried to break the toenails off instead of trimming them. The resident said they told that podiatrist they did not want to see him again and wanted another podiatrist, but their toenails had not been cut since then and remained very long. The resident also stated they were diabetic and knew they should take care of their feet. The medical record review found only one podiatry consult note and a doctor’s order for podiatry consults as needed, and the ADON stated they could not find additional consult documentation in the hard copy chart.
Failure to Ensure Vision Care and Recommended Glasses
Penalty
Summary
Facility staff failed to ensure residents with impaired vision received vision care and a recommended assistive device. During interview, Resident #12 stated their vision was blurred, and the resident’s diagnoses included a history of Primary Open Angled Glaucoma. The DON stated the facility uses Health Drive to provide vision services and keeps a list of residents needing care for scheduling, but Resident #12 was identified as having glaucoma with blurred vision during the survey interview. A review of Resident #91’s EMR showed the last eye exam by Health Drive was on 07/24/24 and recommended new glasses. The resident’s diagnoses included blindness in one eye, dated 11/01/24. The Administrator stated the resident was supposed to receive glasses last year and that an appointment would be made with Health Drive. When interviewed, Resident #91 stated they were blind in the right eye, had blurred vision in the left eye due to a cataract, and never received the recommended glasses. An LPN stated they did not recall seeing the resident wear glasses.
Failure to Document Nephrostomy Drainage Bag Care
Penalty
Summary
The facility failed to ensure that nephrostomy drainage bag care was provided for Resident #4, who had a nephrostomy. During interview, the resident stated that staff did not empty or change the nephrostomy drainage bag and that the resident had to care for it personally, with family providing the bags. A record review showed that the Task Administration Record did not document any emptying or changing of the resident's urostomy bag. The DON stated that the urostomy bag was being changed, but staff were not documenting it, and acknowledged that without documentation the facility could not verify that the care had been done.
Improper Handling of Fallen Tray During Breakfast Service
Penalty
Summary
The facility failed to maintain proper infection control procedures while serving breakfast. During observation, a Dietary Aide knocked a tray onto the floor, then picked up the tray along with the silverware, napkin, and beverages from the floor and placed those items back on the tray. The aide then positioned the fallen tray beside the clean trays on the serving line, and breakfast service continued while clean trays were slid down the service line over the area where the dirty tray had been. A Dietary Manager was informed that the tray had fallen and that the items had been picked up from the floor and placed on the clean serving area; the manager stopped the serving process, removed the trays, and sanitized the countertop before service resumed. The Dietary Manager and District Manager for Health Care Service later confirmed that picking up a tray that had fallen on the floor and continuing to serve was against protocol and presented an infection control risk.
Facility Failed to Maintain Multiple Areas in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the building and resident areas in a safe operating condition, as evidenced by multiple maintenance and environmental issues identified during survey observations. In a resident room, the front of the heating/AC unit was on the floor, and in a shared bathroom there were holes in the bathroom door. In another resident room, the electrical outlet plate behind Bed-A was not secured to the wall, the armoire wood was dry rotted, and damaged drywall with exposed corner bead was observed in the bathroom. The sink in that bathroom was not secured to the wall. In another room, the armoire had missing wood trim. The surveyor also observed damaged tile near the drain in the Central Spa Room on Patuxent Hall. Additional concerns were identified in the laundry area and linen storage room. During the tour of the laundry area, the surveyor observed damaged drywall behind the sink, holes in the wall, the eyewash station was not installed, damaged pipe insulation, and damaged floor tiles. In the room where linen was stored, there were at least four heavily soiled ceiling tiles and soiled pipe insulation. During interview, the Maintenance Director stated that staff use TELS and word of mouth to notify maintenance of problems, and that there is a preventative maintenance schedule with weekly and monthly tasks and two technicians assigned to floors.
Unsanitary fly strips observed in resident rooms
Penalty
Summary
The facility failed to maintain a sanitary environment in 2 of 2 resident rooms observed during the annual recertification survey. In one room, a fly strip containing several dead flies and other insects was hanging from a cork bulletin board directly above Resident #64's bed while the resident was lying asleep beneath it. When interviewed, an LPN identified the item as a fly strip/trap placed because the resident had previously complained about flies in the room and confirmed that dead flies and bugs were stuck on it, acknowledging that having the fly trap with dead insects in the resident's room was unsanitary. In a separate room, a fly strip was observed attached to the cork bulletin board above Resident #72's head, with dead flies noted on the strip, and the resident reported having an issue with bugs in the room.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility staff failed to ensure that residents received showers at least twice a week, as required. This deficiency was identified through interviews with residents and staff, as well as clinical record reviews. Resident #81 reported not having had a shower in three days and only receiving bed baths in February and March. The Unit Manager acknowledged the issue but had not taken action. Resident #111 also reported not receiving showers, and although a nurse claimed the resident was scheduled for showers, there was no documentation to support this. Resident #116 stated they had only one shower in the last 30 days, and their clinical records confirmed the lack of showers. The Unit Manager incorrectly assumed the resident was independent and chose not to shower, despite no documentation of refusal in the clinical records. Resident #28 reported receiving only two showers since admission a year ago. Clinical records showed the resident received bed baths but not showers, except for one tub bath. The resident's assigned GNA confirmed the lack of routine showers, and there was no documentation of the resident refusing showers. The Nursing Home Administrator and Regional Director of Operations confirmed that residents should receive showers twice a week and that GNAs are expected to document this on the ADL flow sheet. However, this expectation was not met, leading to the deficiency.
Failure to Ensure Accuracy of MOLST and Maintain Advance Directives
Penalty
Summary
The facility failed to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) and to maintain proper advance directives in the residents' medical records. This deficiency was evident for seven out of nine residents reviewed. For instance, Resident #27's legal contact person could not recall if a completed MOLST or advance directive was provided upon admission. The facility's internal face sheet section was used instead, leading to an error in the MOLST form, which incorrectly stated that the resident was mentally competent and had given informed consent. Additionally, the Social Worker admitted that the MOLST and advance directive were not obtained during the admission period, and a blank form was only sent out after the surveyor's intervention. Similarly, Resident #64 had resided at the facility for over 11 months without proper documentation of a MOLST or advance directive. The Social Worker confirmed that these documents were not completed and relied on the internal face sheet section instead. Resident #61's clinical record also lacked an advance directive, and the Social Worker admitted that they do not routinely ask residents if they want to complete one. Resident #111's record showed no advance directive, and although the resident was aware of it, there was no evidence that the facility staff offered assistance in its completion. These findings were communicated to the Administrator and the Regional Director of Clinical Operations, who acknowledged the issues but did not provide immediate corrective actions.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This deficiency was evident for three residents. Resident #97 reported never being invited to a care plan meeting. The Social Worker Assistant, responsible for planning these meetings, admitted to not being up-to-date on conducting care plan meetings and could not provide any progress notes for Resident #97's care plan meetings. The Social Worker overseeing the assistant was unaware of the backlog and confirmed the deficiency upon review. Resident #33 did not recall having a care plan meeting, and record reviews confirmed that no care plan meetings had been documented since January 2022. The Social Worker confirmed that the last care plan meeting for this resident was in 2020. Resident #81 also reported not having had a care plan meeting since admission and had not seen the Social Worker. The requested care plan attendance sheets were not provided before the exit conference, further indicating a lapse in the facility's care planning process.
Failure to Safeguard Resident Information and Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain medical records in accordance with acceptable professional standards and practices by not safeguarding resident-identifiable information and keeping accurate documentation. An unattended medication cart with a computer displaying a resident's medication profile was observed, exposing sensitive information to the public. The involved staff acknowledged the issue but did not take appropriate measures to prevent it from happening again. Inaccurate documentation was also found in the medical records of several residents. One resident's record incorrectly noted that they were escorted to dialysis, which the interim Director of Nursing confirmed was an error. Another resident's Treatment Administration Record showed a dressing change as completed when it had not been done, and the resident confirmed that they no longer had a toe wound. Additionally, another resident's progress notes inaccurately documented the presence of medical devices and medications, which staff attributed to errors in the electronic medical record system. Furthermore, a resident did not receive four prescribed medications because they were not available in the medication cart, yet the LPN documented that the medications were administered. The LPN later admitted that the medications were not obtained, and the Nursing Home Administrator and Director of Nursing were informed of the discrepancy. The medications were eventually located and administered, but the initial failure to provide them and the inaccurate documentation were significant issues.
Infection Control and PPE Availability Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitization of medical equipment between residents and did not maintain the availability of gowns for Enhanced Barrier Precautions (EBP). During a medication administration observation, a Certified Medication Aide (CMA) used a blood pressure monitor with a wrist cuff on two different residents without sanitizing the equipment between uses. The CMA acknowledged the failure to sanitize the equipment and stated that the facility's expectations were to sanitize all shared medical equipment after each use and between each resident. The Director of Nursing (DON) confirmed that it is expected of all nursing staff to sanitize medical equipment between residents with sanitizing wipes. Additionally, the facility did not ensure that gowns were available for staff use as required by EBP signage posted on certain rooms. Observations revealed that rooms with EBP signs did not have gowns stocked in the wall caddies or on a cart outside the rooms. Interviews with staff indicated a lack of awareness and proper procedure for obtaining gowns. The Unit Manager, Regional Director of Clinical Operations, and Infection Control Nurse were shown the deficiency, and supplies were subsequently obtained and stocked. The Infection Control Nurse confirmed that staff are expected to wear gloves and gowns for direct resident care under EBP, and the DON acknowledged the issue with gown availability and stated that efforts were being made to educate staff and maintain supplies.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to have an effective system in place to ensure that residents and their representatives are notified in writing of the bed hold policy upon transfer to the hospital. This deficiency was identified for four residents during the annual survey. For Resident #16, there was no documentation that the bed hold was offered upon transfer to the hospital, and interviews with LPNs revealed that they did not offer or document the bed hold policy. The Nursing Home Administrator confirmed the expectation for staff to offer and document bed holds but could not locate any evidence of this for Resident #16's transfer on 3/6/24. For Resident #63, the medical record review showed no documentation that the bed hold policy was provided upon transfer to the hospital. Interviews with RN #4 and the Director of Nursing revealed that the bed hold policy is reviewed only during the admissions process and not provided in writing at the time of transfer. The Social Worker and Administrator confirmed that the nursing staff should offer a written copy of the bed hold policy when the resident is transferred out of the facility, but this was not done for Resident #63. Similarly, Resident #109's medical record lacked documentation of the bed hold policy being provided upon transfer to the hospital. Interviews with RN #4, the Director of Nursing, and the Social Worker indicated that the bed hold policy is not reviewed or provided in writing at the time of transfer. The Administrator confirmed that the policy should be offered in writing but was not done for Resident #109. For Resident #117, there was no documentation that the bed hold policy was provided at the time of transfer to the hospital, and the Administrator and Regional Clinical Director did not dispute the findings or provide any evidence of notification.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately document resident assessments on the Minimum Data Set (MDS) for four out of six residents reviewed. Resident #16 had a diagnosis of End Stage Renal Disease and was dependent on dialysis, but the MDS assessment did not indicate that the resident received dialysis. Resident #28's MDS assessment incorrectly documented that the resident did not use tobacco, despite multiple smoking assessments indicating nicotine use. Resident #24's MDS assessment did not reflect active diagnoses of depression and anxiety disorder, although the resident was receiving antianxiety and antidepressant medications. Resident #13, who had bilateral above-knee amputations, was incorrectly coded as requiring maximal assistance for putting on/off footwear, despite not having prostheses. These inaccuracies were confirmed through medical record reviews and staff interviews. The Nursing Home Administrator and Lead MDS Coordinator acknowledged the errors upon review. The discrepancies in the MDS assessments indicate a failure in accurately documenting the residents' health status and functional capabilities, which is essential for providing appropriate care and treatment.
Failure to Provide Proper Wound Care
Penalty
Summary
The facility failed to provide wound care treatments according to professional standards for four residents. Resident #101's significant other was performing wound care without supervision from the facility's wound nurse, who had not been present for several weeks. The care plan required daily evaluation of the wounds, but no documentation of wound assessments was found after the wound nurse left. The facility's staff confirmed that the nurses were expected to provide wound care, but there was a lack of documentation and assessment in the medical records. Resident #21 had an order for daily assessment of a left ankle wound, but the Treatment Administration Record (TAR) showed inconsistent and inaccurate documentation. The resident reported pain and signs of infection, but the TAR did not reflect these observations accurately. The Regional Director of Clinical Operations acknowledged the concern but did not provide additional information. Resident #332 had a right hand wound that was not documented in the medical record, and no wound care order was found. The wound Nurse Practitioner confirmed that there should have been an order for the wound care. Additionally, Resident #74 had multiple instances of undocumented wound care dressing changes, with the Director of Nursing acknowledging the missing documentation and stating that staff would be educated on wound care requirements.
Failure to Maintain Confidentiality of Resident Records
Penalty
Summary
The facility staff failed to ensure the privacy and confidentiality of residents' personal and medical information. During a review of clinical records, it was discovered that a discharge summary and Preadmission Screening and Resident Review (PASRR) form for one resident were incorrectly placed in another resident's clinical record. This error was identified for one resident out of a sample of 48 residents. The Administrator confirmed that the personal information should not have been in the other resident's record during an interview.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by two separate incidents involving two residents. In the first incident, a resident alleged that a Registered Nurse (RN) used profane language and was dismissive when the resident complained about a cold room. The RN admitted to using profanity and being dismissive, but the Nursing Home Administrator (NHA) concluded that the allegation was unsubstantiated due to a perceived lack of intent. The resident did not recall the incident but described the staff as rude. The RN received abuse training following the incident. In the second incident, an anonymous caller informed the Administrator about a video circulating online that showed a staff member verbally abusing a resident. Although no staff members witnessed the abuse, the video was verified, and the staff member involved was terminated. The resident involved did not feel disrespected, and staff education on abuse was conducted. The Director of Nursing (DON) confirmed that another resident had recorded and posted the video, which was later taken down.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility staff failed to ensure the dignity of the residents as evidenced by two specific incidents. First, on 3/18/24, a Geriatric Nursing Assistant (GNA) on the 3rd floor nursing unit was observed without a name tag. When questioned, the GNA acknowledged that the expectation was to wear a name tag at all times and subsequently wrote her name on a piece of tape and placed it on her uniform. Similarly, on 3/20/24, a Registered Nurse (RN) was observed without a name tag after exiting a resident's room. The RN confirmed that the expectation was to wear a name tag at all times. Second, on 3/19/24, another GNA was observed using a personal cell phone while assisting a resident with their lunch. This GNA was also not wearing a name tag and admitted that the facility's policy prohibited cell phone use in resident rooms and required name tags to be worn at all times.
Failure to Safeguard Resident's Personal Property
Penalty
Summary
The facility failed to ensure that personal property was not lost for Resident #28. During an initial tour, Resident #28 reported missing clothes and stated that he/she had informed multiple staff members, including nurses, the Social Service Director, and the Nursing Home Administrator (NHA), about the issue. Despite these reports, no grievance forms were found for Resident #28 regarding the missing items. The surveyor's review of the resident's physical chart also revealed the absence of a personal inventory sheet. Interviews with staff confirmed that the inventory sheet should be in the physical chart, but it was not located. The Social Service Director acknowledged awareness of the missing items and mentioned that the Housekeeping Supervisor was searching for them. However, the NHA was initially unaware of the issue and had not completed a grievance form until prompted by the surveyor. The Housekeeping Supervisor later provided a list of missing items and suggested that the resident's clothes might have been mistakenly donated. The NHA eventually completed a grievance form for the missing items, but this was done only after the surveyor's intervention. The deficiency was further highlighted by the facility's inability to locate Resident #28's personal inventory sheet and the lack of timely grievance documentation. The Housekeeping Supervisor's belief that the resident's clothes were mistakenly donated underscores a lapse in the facility's procedures for handling personal property. The NHA's delayed response and lack of initial awareness of the issue indicate a breakdown in communication and follow-up within the facility. This series of actions and inactions led to the failure to safeguard Resident #28's personal property, resulting in the resident's ongoing distress and inconvenience.
Failure to Timely Report Suspected Abuse Resulting in Serious Bodily Injury
Penalty
Summary
The facility failed to report a reasonable suspicion of abuse resulting in serious bodily injury within the required 2-hour timeframe to the State Agency. This deficiency was identified in the case of a resident who complained of right hip pain on 12/4/23 at 10:49 PM, after returning to their room in a wheelchair. The resident informed the nurse that they had fallen three days prior but had not reported it. An x-ray ordered on 12/5/23 confirmed a right hip intertrochanteric fracture, and the resident was subsequently transferred to a community hospital for urgent surgery on 12/6/23. The initial self-report of the incident was not sent to the State Agency until 12/6/23 at 5:45 PM, which was 2 days and 7 hours after the facility staff became aware of the reasonable suspicion of serious bodily injury. The Administrator confirmed that the facility staff were aware of the incident on 12/4/23 at 10:49 PM, but the delay in reporting violated the requirement to report such incidents within 2 hours. This failure to timely report the incident was evident during the review of the facility's self-report file and interviews with the staff and Administrator.
Failure to Provide Written Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide written notice with the reason for transfer to residents and failed to notify the Ombudsman of residents that transferred. This deficiency was identified in three residents who were hospitalized. Resident #332 was transferred to the hospital in early February 2024, but there was no written notice provided to the resident, and the transfer was not included in the list sent to the Ombudsman. The Nursing Home Administrator acknowledged that only discharges, not transfers, were sent to the Ombudsman for the month of February 2024. Resident #63 was transferred to the hospital due to abdominal pain and vomiting, but there was no documentation that the resident or their representative received written notice of the transfer. Similarly, Resident #109 was transferred to the hospital due to the facility not having appropriate respiratory equipment, but there was no written notice provided to the resident or their representative. Interviews with staff revealed that verbal notifications were given, but written notices were not provided, and no evidence of written notices was presented during the exit conference.
Failure to Develop Baseline Care Plan for Newly Admitted Residents
Penalty
Summary
The facility failed to develop and provide a baseline care plan for two newly admitted residents within 48 hours of their admission. For Resident #125, admitted in late January 2024, the medical record review revealed no baseline care plan note. Although a nursing evaluation was completed on 1/24/24, it did not indicate that care planning was discussed with the resident or that the resident received a summary. The evaluation also lacked documentation of the therapy services planned, the resident's goals, and a summary of medications with dietary instructions. When the surveyor requested the baseline care plan, the Nursing Home Administrator stated that nursing handles baseline care planning in their initial assessment but did not provide additional information by the time of the surveyor's exit.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement appropriate care plans for three residents, leading to deficiencies in their care. Resident #28 was identified as a smoker, with multiple smoking assessments and a smoking contract in place. However, the resident's care plan did not include any information related to smoking until after the surveyors' visit. The surveyors found cigarette butts and an empty cigarette pack in the resident's room, despite the resident denying smoking. Additionally, the resident was observed smoking without an oxygen tank, which was not addressed in the care plan. The Nursing Home Administrator confirmed the absence of a smoking care plan for Resident #28 during the surveyors' visit. Similarly, Resident #125, who had expressed a goal to be discharged to the community, did not have a care plan addressing discharge planning, despite being admitted to the facility in late January 2024. The Nursing Home Administrator acknowledged the lack of a discharge care plan for this resident during the interview with the surveyors. Resident #111's care plan indicated that the resident was independent with bathroom Activities of Daily Living (ADL), yet the staff were using incontinence briefs on the resident. The resident was not on a toileting program to address incontinence, which was inconsistent with the care plan. The Administrator acknowledged the discrepancy and expressed concern over the findings. These deficiencies highlight the facility's failure to develop and implement comprehensive care plans that address the specific needs of the residents, leading to inadequate care and oversight.
Failure to Cut Resident's Toenails
Penalty
Summary
The facility staff failed to ensure that a resident's toenails were cut. This was evident for one resident who had a long toenail on the big toe of the right foot, measuring about one inch above the toe. The resident reported that no one had cut the toenails even after the dressings on the feet were changed. The long toenail was observed again four days later, indicating that the issue had not been addressed. The Regional Clinical Director confirmed that the resident had a podiatry appointment the previous week.
Inadequate Activities Program for Residents
Penalty
Summary
The facility failed to have an activities program designed to meet the interests and needs of residents based on their comprehensive assessment and care plan. This deficiency was evident in two residents reviewed for activities during the survey. Resident #7, who has a medical history including paranoid schizophrenia, major depressive disorder, adjustment insomnia, and mild cognitive impairment, expressed preferences for group activities, keeping up with the news, going outside, participating in religious practices, and doing favorite activities. Despite these preferences, the care plans and documented activities did not align with Resident #7's expressed interests. Observations showed Resident #7 frequently lying in bed, and the activity logs indicated minimal engagement, primarily involving snack delivery and occasional light conversation, failing to meet the resident's stated needs for meaningful activities and social interaction. Similarly, Resident #79 reported that the facility's activities were limited to snacks, music, and conversation, which was corroborated by the activity logs. The logs showed minimal and repetitive activities such as coloring material drop-offs and supply deliveries being counted as activities. The Administrator and Regional Clinical Director acknowledged the lack of adequate activities when shown the documentation. This indicates a systemic issue in the facility's activities program, failing to provide residents with engaging and meaningful activities as per their preferences and care plans.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of 5% or less during a re-certification survey. During an observation of medication administration, a Certified Medication Aide (CMA) did not administer Vitamin D to a resident as ordered and incorrectly documented it as given. Additionally, the CMA administered Levothyroxine to another resident after breakfast, contrary to the order specifying it should be given before breakfast. The CMA confirmed these errors during an interview. The surveyor informed the Nursing Home Administrator (NHA) and Director of Nursing (DON) that the medication administration observation resulted in an error rate of 8%.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to maintain a safe and effective system for securing medication and treatment carts on the nursing units. During a random tour of the 1st floor nursing station, a surveyor observed an unlocked medication cart containing medications labeled with residents' names and room numbers. The LPN responsible for the cart confirmed it was his responsibility and acknowledged that the facility's expectation was for the cart to be locked when unattended. Similarly, an unlocked treatment cart was observed on the 1st floor, containing various medical supplies. The LPN responsible for this cart also confirmed it should have been locked when unattended. On a subsequent tour of the 3rd floor nursing unit, another unlocked treatment cart was observed, containing medical supplies such as scissors, ointments, bandages, and dressings. The RN responsible for this cart confirmed it was his responsibility and that it should have been locked. Interviews with the NHA and DON revealed that the facility's expectation was for all medication and treatment carts to be locked when unattended. The NHA mentioned that an in-service had been conducted to address the issue of unlocked carts, but it was unclear how new and agency night shift employees were provided with this education.
Failure to Assist Resident in Obtaining Necessary Dental Care
Penalty
Summary
The facility staff failed to assist Resident #13 in making necessary appointments for dental care or treatment. During an observation and interview, the resident, who had only three teeth left and reported gum pain, revealed that no further dental appointments were made after a dentist recommended extractions during an on-site visit. The resident's medical record showed a history of tobacco use, bilateral above-knee amputations, dementia, and anxiety. Despite the dentist's recommendation for extractions during a visit on 4/3/23, no extractions were performed during subsequent visits on 6/23/23 and 7/5/23, and no further appointments were scheduled. The Administrator acknowledged the failure to assist the resident in obtaining the necessary dental care and treatments.
Failure to Employ Licensed Practical Nurse in Accordance with State Laws
Penalty
Summary
The facility failed to employ a Licensed Practical Nurse (LPN) in accordance with Maryland State laws. During a review of Staff #13's employee file, it was found that the LPN had an active Virginia Practical Nurse License but lacked necessary documentation such as education transcripts, hire application, evaluations, or disciplinary actions. The Nursing Home Administrator (NHA) confirmed that the LPN was hired while residing in Virginia but currently resides in Maryland, as indicated on her I-9 form. The NHA acknowledged awareness of the requirement for nurses to have an active license in the state of their primary residence and stated that Staff #13 has been informed to apply for a Maryland State Board of Nursing license.
Failure to Secure Bed Mattresses
Penalty
Summary
The facility failed to ensure that residents' bed mattresses were properly secured to the bed frames, leading to safety concerns. This deficiency was observed in two residents. Resident #97's mattress was repeatedly found slid over, exposing approximately 4 inches of the bed frame on multiple occasions. Despite the Maintenance Director's acknowledgment of the issue and a promise to inspect the bed, the problem persisted. Resident #97 had a history of falling and required supervision or assistance while moving in bed, as documented in the medical record and Minimum Data Set (MDS) assessment. The last bed inspection for Resident #97's room was completed in May 2023, indicating a lack of regular inspections. Similarly, Resident #85's mattress was observed slid down, exposing the top right corner of the bed frame. Resident #85, who had bilateral amputation and required assistance with transfers and moving in bed, reported using the bed frame to help move around. The Maintenance Director acknowledged the safety concern and promised to inspect the bed. The last bed inspection for Resident #85's room was also dated May 2023. The deficiency highlights the facility's failure to conduct regular and thorough inspections of bed frames and mattresses, leading to potential safety risks for the residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of insects in a resident's room. During a medication administration observation, multiple gnats were observed swarming inside the room. The Director of Nursing (DON) was called to the room and confirmed the infestation, noting that the privacy curtain was covered in gnats. The DON took pictures and reported the issue to the Nursing Home Administrator (NHA). The NHA was initially unaware of the infestation and stated she would investigate. A review of pest logs revealed that the facility had received extermination treatments for gnats.
Failure to Monitor and Document Required In-Service Training for Nurse Aide Staff
Penalty
Summary
The facility failed to monitor staff to ensure required in-service training for nurse aide staff was completed. This deficiency was identified during an employee record review and interviews, specifically for Geriatric Nursing Assistant (GNA) Staff #48. The surveyor noted that the employee file for Staff #48, who was hired on 10/16/2023, lacked documentation of required education. Despite the facility's use of Relias, a computer-based training program, and On Shift, a messaging system, there was no evidence that Staff #48 had completed the necessary in-service training. The staff educator, who had been in the position for two months, confirmed that it was her responsibility to track in-service and education for nursing staff but could not provide the required documentation for Staff #48. Further interviews with the Human Resources Director and the Corporate Human Resource Business Partner revealed that all completed education should be part of the employee's file. However, the only training documentation provided for Staff #48 included modules completed in 2019 and 2020, with only one training completed in 2024. The Nursing Home Administrator confirmed that Staff #48 had been hired in a different position in October 2023 and had previously worked in a different role in 2019. Despite efforts to locate additional education records, none were found, confirming the deficiency in monitoring and documenting required in-service training for nurse aide staff.
Failure to Inform Resident's Representative of Care Plan Changes
Penalty
Summary
The facility failed to honor the rights delegated to a resident's representative by not informing them of changes to the plan of care. Resident #77 was admitted in early August 2023 and was evaluated by two providers in September 2023, who had conflicting assessments regarding the resident's ability to appoint a healthcare representative. Despite the evaluations indicating the resident's incapacity to make informed decisions, the social history assessment completed in October 2023 incorrectly indicated that Resident #77 had decision-making capacity and did not list a healthcare proxy or agent. This discrepancy led to confusion about who should be contacted for decisions regarding the resident's care. Further review of Resident #77's medical records revealed multiple instances where changes in the resident's condition were documented, but the notifications were inconsistently made to either the resident or the ex-spouse, who was listed as an emergency contact. Interviews with staff indicated a lack of clarity and proper documentation regarding the resident's representative. The Nursing Home Administrator acknowledged the oversight and stated that a surrogate form should have been filled out to indicate the decision-maker for the resident, which was not done by the social services staff.
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Illustrative
What surveyors actually found near you
We read the 1,740 citations issued within 25 miles in the last 12 months — including the 7 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roland Park Place | 0.9 mi | ★★★★★ | 0 | 0 |
| Transitional Care Services At Mercy Medical Center | 1.3 mi | ★★★★★ | 5 | 0 |
| Maryland Baptist Aged Home | 1.4 mi | ★★★★★ | 0 | 0 |
| Future Care Sandtown-winchester | 1.4 mi | ★★★★★ | 2 | 0 |
| Future Care Charles Village | 2.1 mi | ★★★★★ | 30 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.