Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Haven Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
Unsafe and Poorly Maintained Resident Environment: Surveyors observed widespread disrepair and poor housekeeping throughout resident rooms, hallways, and common areas, including ripped and mismatched flooring, cracked ceiling tiles, chipped and peeling paint, broken blinds, stained furniture, damaged doors, cloudy windows, missing molding, exposed wiring, and unclean sink and bathroom areas. A resident reported the room conditions had been present for a long time, and facility leadership acknowledged the concerns during the survey.
Unsanitary kitchen conditions and improper food storage monitoring were observed throughout the facility. Surveyors found debris, food crumbs, chipped and dirty refrigerator surfaces, unlabeled and out-of-date food items, and a leaking pipe over food service equipment. Nourishment refrigerators also had inconsistent or incomplete temp logs, incorrect temperature ranges listed on medication storage forms, frost and liquid buildup, and staff gave conflicting answers about acceptable temp limits and reporting procedures.
The facility failed to complete and accurately reflect its Facility Assessment for physical environment and physical plant needs. The Maintenance Director and Administrator both stated there was no preventive maintenance program, even though the Facility Assessment listed a routine PM schedule on a daily, weekly, and monthly basis without evidence it was being completed. The assessment also did not include an evaluation of building maintenance capital improvements or structures.
Unsafe linen handling and an incomplete water management program were identified. A staff member transported clean blankets on an uncovered cart, with two blankets dragging on the floor, and the facility’s in-service stated clean linen must be covered and only clean linen placed in linen carts. Surveyors also found the Water Management Plan was not facility-specific, used generic flow diagrams, and had not been updated after Legionella was detected in multiple water samples; the infection control log also showed a rise in pneumonia episodes and staff could not provide evidence of updated prevention and control measures.
The facility failed to keep laundry equipment and an AED in safe operating condition. A family reported that resident clothing had to be taken home when a washer was broken and said they were not informed that laundry services could still be provided or when they resumed. Surveyors found multiple washers and dryers out of service for extended periods, with staff reporting some units had been down for years and no clear repair timeline. Surveyors also found an AED with a cracked cabinet window, a non-ready indicator, a beeping alarm, and pads that needed replacement; maintenance staff could not explain the AED status.
Call bell systems were not functioning properly in multiple resident rooms and hallway indicators. At one station, a resident’s call bell produced an audible alarm at the nurses’ station but did not display the correct room number or light the room indicator, and staff said the issue had been ongoing for months. At another station, a room call bell did not activate the hallway system, and several hallway indicator lights were missing caps or bulbs, with the Administrator stating the facility did not have a PM program.
Exterior Environment Not Maintained in Safe and Sanitary Condition: The surveyor observed multiple exterior maintenance and housekeeping issues, including weeds, missing and misplaced bricks, damaged fencing with broken and sharp-edged sections, debris, a broken glass window with tape, lifted and missing roof shingles, soiled windows, cobwebs, broken blinds, a missing window screen, and dirty surfaces around the entrance and carport area. The Administrator and DOR acknowledged the concerns, and the Administrator stated there was no preventative maintenance program.
A hallway handrail next to a resident room was observed with a sharp edge and a protruding metal screw, and the cap was found on the opposite railing. The handrail was also loose and movable. An LPN acknowledged the concern, and a maintenance assistant stated the handrails had recently been fixed but broke.
Failure to Honor Resident Bathing Preferences: A resident reported being denied showers and receiving only bed baths, with staff telling them there was no shower chair large enough and the bathing area was too small. Records showed only bed baths were documented, the ADL care plan listed no bath/shower preference, and the shower schedule included set shower days. Staff stated the resident was always bathed in bed and never offered or taken for a shower, despite a bariatric shower chair and shower area being available elsewhere on the unit.
Failure to notify the MD of Legionella water test results and increased pneumonia cases. Two residents had positive CXR findings for PNA, and the facility did not document informing the MD of the Legionella analytical water results or the additional pneumonia cases. The MD stated he was unaware of the water findings and the increased cases, and said a different clinical approach would have been taken if he had known.
Failure to keep resident records private and confidential occurred when a publicly accessible website posted testimonials with full names, photos, and medical diagnosis information for three residents. The DON could not produce consents for two residents, and the only consent provided for a third resident was incomplete and covered only photo use. All three residents were cognitively intact, and interviews showed they were unaware their information had been posted; two residents said they did not want it shared.
Failure to Timely Report Allegation of Verbal Abuse: A resident reported that two females verbally abused him/her by telling him/her to “shut the f*** up,” and the allegation was documented in a physician note. Surveyors found the facility did not self-report the abuse allegation to the state agency until after surveyor intervention, and interviews showed administration and SSAD had conflicting accounts about whether the report had been communicated to the Administrator.
Failure to Provide Transfer and Bed Hold Notices: The facility did not document that a resident’s representative received written transfer notices or the bed hold policy when the resident was sent to the hospital on multiple occasions. The record also lacked proof that the local ombudsman was notified of the facility-initiated transfers. Social services staff stated the notices were typically prepared and sent by email or certified mail, but the required documentation was not available for the earlier transfers.
A resident with dementia and ADL dependence was shaved by staff against family/POA preferences on more than one occasion. Although the care plan addressed ADL support and cognitive loss, it was not updated with the resident’s specific shaving preferences, and family members reported the concern had been discussed at multiple care plan meetings.
Delayed Care Plan Meeting After Quarterly Assessment: The facility failed to hold or document a timely care conference for a resident after a quarterly MDS assessment. The last documented care conference was more than 90 days earlier, and the record contained no evidence that the IDT met during the assessment timeframe. The Social Services Director confirmed the missing documentation.
Incorrect PASRR Completion and Missed Level II Referral: A resident with bipolar disorder, dementia, depression, PTSD, and a history of psychiatric hospitalizations was admitted after Geri psych stabilization, but the PASRR was completed inaccurately. The SSA marked key mental health screening items as “No,” left a follow-up question unanswered, and completed the form in a way that indicated a Level II referral was needed, yet AERS was not contacted.
A resident was observed eating lunch without staff assistance, licking food from the plate and pudding container until a GNA placed a utensil in the resident’s hand, after which the resident could feed themself. Another resident reported never being allowed to shower and said staff only gave bed baths, citing lack of a suitable shower chair and a too-small bathing area; records showed only bed baths were documented and staff said the resident had not been offered showers on scheduled shower days.
A resident’s toilet was observed leaking water from the base, leaving a large puddle on the bathroom floor and making the floor slippery when walked on. The DON was later informed of the condition and acknowledged the issue.
Bedrail Use Without Required Assessment and Consent: The facility failed to complete required bedrail assessments and obtain consent before using bedrails for two residents. One resident was observed with quarter rails in place and the record showed an order and ongoing documentation of rail use, but no bedrail assessment, consent, or device assessment was found. Another resident was observed with raised bedrails for bed mobility, and the DON stated bedrail assessments had not been completed for residents using rails for mobility.
Medication administration was not given in accordance with physician orders for two residents, resulting in a 7.69% error rate. One resident received Topamax crushed even though the order specified no crush and to give it whole, and another resident received Ferrous Sulfate 325 mg without food despite an order to give it with meals. An LPN stated the meal trays were on their way, but the resident was not served until later.
Unsecured Medication Cart Exposed Medications and PHI: Surveyors observed an unlocked medication cart unattended in a hallway, and the drawers could be opened to reveal medications and resident PHI. No staff were present in the area when the cart was found, and surveyors had to locate staff before the unit nurse was notified to secure it.
Delayed routine dental care: A resident with missing teeth, retained roots, crowns, and heavy plaque/food debris buildup was observed with discolored natural teeth and could not recall the last dental visit. Record review showed the resident’s last dental exam was over a year earlier, despite recommendations for periodic oral exams, prophylactic care, and fluoride varnish. The resident missed the recommended follow-up dental visits, and the SS director could not explain why the appointments were not tracked or completed on the next available visit.
A resident with MS who was non-ambulatory and mostly dependent stated they did not know what would be on meal trays and had no monthly menu or alternative options available at the bedside or posted nearby. An LPN said no menus were available on the unit, while observations found empty or incomplete menu display boards and an outdated menu posted in one area. The Dietary Director and Activities Director described menu posting and reading practices, but the observed units did not have current menus accessible to the resident.
Inaccurate Advance Directive Documentation: A resident’s chart contained 2 unvoided MOLST forms at the same time, along with incapacity certifications and a guardianship order. One MOLST was documented as signed by the resident and another by the guardian, and the newer form was incomplete. The Social Services Director stated the older MOLST should be in effect, while the DON confirmed nursing staff use the hard chart MOLST to determine code status in an emergency.
Failure to Inspect and Assess Bedrails: Two residents were observed with raised bedrails in use for bed mobility, including one resident whose head and shoulder were resting on a side rail. Record review showed an order for quarter rails and documentation that the rails were in place, but there was no documented device assessment to confirm the rails were secure, properly installed, maintained, or assessed for entrapment risk. The DON stated the facility had not been completing bedrail assessments, and the Director of Maintenance stated beds were not checked for bed safety.
Multiple-resident bedrooms did not meet the required 80 square feet per resident. The NHA and DON stated there was no room-size waiver, and the Administrator said rooms 1, 5, 6, and 9 had not been modified. Surveyors measured these rooms with space per resident ranging from 70.75 to 73.66 square feet, and a prior CMS-2567 had already cited the facility for the same issue.
A facility failed to ensure resident rooms had working privacy curtains to provide visual privacy for each resident. Surveyors observed one bed area with a missing privacy curtain and another with a curtain that would not pull fully across because the track was jammed; the NHA and Maintenance Director both acknowledged the issues.
Missing Daily Nurse Staffing Postings: Surveyors found that current nurse staffing assignments and ratios were not posted daily in clear, visible locations on multiple units. On one unit, poster boards were tucked away at the nurse station and staff said they had been down for painting, while other units had no current staffing ratio posting or displayed an outdated posting from the prior day.
Survey Binder Missing Most Recent Survey Results: The facility failed to keep the most recent complaint survey and revisit survey results accessible in the Survey Binder for residents, family members, and legal representatives. The binder in the reception area contained older complaint and annual survey results instead, and the DON stated she was not aware that complaint or revisit survey results needed to be included.
Staff failed to provide required two-person assistance during bed positioning for a resident with complex medical needs, resulting in a fall and fracture. Another resident was allowed to keep and self-administer multiple medications at the bedside, despite facility policy and concerns about unsafe use, after staff did not provide the requested medications.
The facility did not conduct initial or ongoing competency assessments for nurse aides, as evidenced by the lack of skills assessments in an aide's file and confirmed by the administrator and DON. Interviews revealed that there was no formal process or skills lab in place to verify staff competency, and competency evaluations were not routinely performed.
Administration did not conduct annual performance reviews or provide regular in-service education for nurse aides, as confirmed by file reviews and staff interviews during an investigation into staff-to-resident abuse. The DON acknowledged that no yearly evaluations had been performed for nursing staff since assuming her role.
Surveyors observed multiple failures in food storage and kitchen sanitation, including grease buildup, debris, unsealed food containers, dirty equipment, and inadequate cleaning schedules. The kitchen and storage areas were found with dirt, dust, food particles, and mice traps, with several areas not being cleaned as required by professional standards.
Staff failed to properly dispose of garbage and refuse, with observations including littered cigarette butts, broken furniture, unsecured gates, piles of debris, and open dumpsters with scattered trash and pallets.
Administration failed to ensure systems for staff performance evaluation and required education, with only one annual evaluation in seven years for a GNA and insufficient training on cognitive impairment. Policies and procedures were not accessible to direct care staff, with only one nursing manual available and confusion among staff about their location. The facility also did not maintain an effective pest control program, as evidenced by ongoing pest complaints, unsanitary conditions, and unaddressed recommendations from the pest control company.
The facility did not ensure that its QAA committee included the Medical Director and an Infection Preventionist, as required. Attendance records showed repeated absences of these key members from QAPI meetings, and there was a lack of documentation for some scheduled meetings. The current Infection Preventionist attended some meetings only as an MDS nurse, not in the required role.
Surveyors found that the facility failed to maintain a safe and homelike environment, with observations of dust-covered vents and heaters, damaged doors and walls, cracked flooring, and missing closet and bathroom doors in resident rooms. The sole maintenance staff member reported the absence of a preventative maintenance program and insufficient time to address cleaning and repairs.
The facility did not maintain an effective pest control program, resulting in ongoing infestations of mice and cockroaches throughout the building. Multiple complaints and observations confirmed pest activity in resident rooms, the kitchen, and common areas, with unsanitary conditions and structural issues contributing to the problem. Pest control recommendations for improved sanitation and building maintenance were not implemented, and communication lapses among staff further hindered effective pest management.
A surveyor observed that food delivered to a resident was not at appropriate temperatures, with hot items such as an egg omelet and sausage measuring below standard serving temperatures. The Certified Dietary Manager confirmed the findings after testing a tray from the meal cart, and the Administrator was notified of the issue.
Staff did not timely report an allegation of abuse involving a resident's claim of stolen marijuana, and documentation was lacking for the reporting of a resident-to-resident altercation that resulted in injury. Required notifications to the state agency and documentation of incident reporting were not completed as mandated.
Facility staff failed to properly investigate allegations of misappropriation of property and abuse involving three residents. In one case, a resident's report of stolen property was not formally investigated. In two other cases, allegations of staff-to-resident abuse were not thoroughly investigated, with incomplete documentation, lack of witness statements, and failure to remove the accused staff from resident contact during the investigation.
Facility staff did not create or implement comprehensive, person-centered care plans for two residents, resulting in unmet needs related to medical appointments and management of a recurrent rash. One resident's care plan failed to address their preferences and behaviors regarding outside medical consults, while another resident's care plan did not provide specific approaches for a persistent skin condition, despite repeated specialist involvement and ongoing symptoms.
A resident with severe cognitive impairment and documented preferences for specific activities did not receive an individualized activities program. The care plan was not tailored to the resident's needs, lacked measurable goals, and there was minimal documentation of activity participation or one-to-one engagement by staff. Observations and records showed the resident was not regularly involved in activities, and staff interviews confirmed gaps in documentation and care planning.
A resident with a recurrent leg rash and multiple chronic conditions did not have a cancelled dermatology appointment rescheduled as ordered by the physician. The lapse occurred due to a lack of communication between nursing and the staff responsible for scheduling, resulting in the resident not receiving timely follow-up care for the ongoing rash.
Staff did not follow physician orders or develop individualized interventions for a resident at risk for pressure ulcers, including missing required Braden Scale assessments and failing to specify or document turning, repositioning, and use of prescribed treatments. The resident subsequently developed a sacral wound, and documentation of preventive care remained inconsistent even after new interventions were ordered.
A resident with dementia and behavioral disturbances received a PRN order for Lorazepam that was not limited to 14 days and lacked a documented rationale for continuation beyond this period. The medication was administered without evidence that non-pharmacological interventions were attempted first, and required documentation was missing.
A resident was found with several medications, including medicated spray, topical cream, and various liquid medications, left unsecured on an over-the-bed table. The resident reported keeping these medications at the bedside due to staff refusal to retrieve them, and that a family member had supplied the medications. The DON confirmed the medications were not properly stored and had not been reported by staff. The attending physician was aware of the situation but proper storage was not maintained.
The facility did not conduct or document a comprehensive facility-wide assessment, resulting in missing and outdated information about resident census, staff levels, and resource needs. The assessment lacked a full evaluation of resident diagnoses, acuity, and care requirements, and did not address staff competencies, facility resources, or contracted services. The Nursing Home Administrator acknowledged these deficiencies during the survey.
Surveyors identified that the facility did not maintain an accurate inventory of a resident's personal belongings, including high-value items and their disposition after discharge, and failed to ensure consistent and complete documentation of end-of-life choices for another resident. Conflicting information was found between the EMR, paper records, and care plans regarding code status, and two active MOLST forms with different directives were present in the medical record.
A resident with a history of sexually inappropriate behavior was involved in multiple incidents of abuse and misappropriation of property. Despite being witnessed by staff, the facility failed to investigate or report these incidents to the State agency. The resident's behavior care plan noted various problematic behaviors, which were not adequately addressed, leading to further occurrences of abuse involving vulnerable residents.
Unsafe and Poorly Maintained Resident Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment throughout resident rooms, hallways, and common areas. Surveyors observed numerous examples of disrepair and poor upkeep, including ripped and mismatched flooring, cloudy and unclean windows, chipped and peeling paint, broken blinds, damaged doors, cracked ceiling tiles, lifted ceiling tiles, exposed wall mesh, missing molding, and stained or worn furnishings. Several resident rooms also had unclean privacy curtains, damaged window coverings, cracked window glass, and areas of exposed or unfinished wall and flooring materials. In multiple resident rooms, surveyors observed conditions that showed ongoing disrepair, including broken or bent blinds, damaged door coverings, cracked or lifted flooring, missing or damaged hardware, stained bathroom surfaces, missing caulk around commodes, and ceiling tiles with stains or holes. One resident room had an air conditioning unit and window area taped and boarded in place, with weeds visible through the window space and gray buildup in the vent. Another resident room had a cracked window pane, lifted flooring tiles, a loose light fixture with a short cord, and no privacy curtains for two residents in the room. A resident interviewed by the surveyor stated that the conditions in the room had been present for a long time. Common areas and hallways were also observed to be in poor condition, including stained and worn chairs, a soiled couch, red stains on the floor, unpainted spackled wall areas, damaged handrails, exposed electrical panels, missing outlet covers, cracked walls, damaged molding, and ceiling tiles with stains, cracks, or lifting. Surveyors also observed dirty sink areas, broken or missing hardware, worn signage, and areas of exposed wiring or sharp metal surfaces. Facility leadership and maintenance staff acknowledged the surveyors' concerns during the tours and observations.
Unsanitary kitchen conditions and improper monitoring of food storage temperatures
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices in the kitchen and nourishment areas. During the initial kitchen tour, the reach-in refrigerator was observed with black debris and food crumbs in the bottom, missing paint on the racks, brown debris on the interior walls, and handles missing coverings that exposed sharp edges. An unlabeled container of salad with a condiment packet resting on the lettuce was also observed inside the refrigerator. In the walk-in refrigerator, the exterior thermometer was broken and reading below -40 degrees, a Worcestershire sauce container had dark rings and white debris on the outside, and an air filter above the ice chest had a thick layer of gray fuzzy debris. The surveyor also observed lunchmeat and cheese sandwiches marked with a use-by date of 9/03, a container of hard boiled eggs with speckled debris on the outside, and two unlabeled saran-wrapped packages containing hot dogs and French fry wedges. Additional observations showed unsanitary conditions on the food service line and surrounding equipment. Brown and black debris and food crumbs were present on shelving below the steam table, with tan crusted food debris on the surface below the food service line. A plumbing pipe below the three-compartment sink was dripping into a plastic hot food cover filled with clear liquid. Gray fuzzy matter was observed on piping extending over and near the food service line, and gray and black debris was present on a vent near the food serving line. On a later tour, debris was still present on the vent near the food serving line, and the walk-in refrigerator continued to show a dirty floor with black and brown matter, thick food debris, trash, chipped paint on the walls, black and brown matter where the walls met the ceiling, and a crack in the ceiling with black speckled matter present. The facility also failed to properly monitor nourishment refrigerator temperatures and to ensure labeling, dating, and expiration monitoring of food products. In multiple nourishment rooms, the temperature logs in use were labeled as medication storage logs with handwritten nourishment headings, and the temperature ranges listed on the logs allowed refrigerator temperatures up to 46F. Staff gave inconsistent answers about the acceptable temperature range and about who was responsible for monitoring and reporting out-of-range temperatures. One nourishment refrigerator had no temperature log present, while others had incomplete logs or two different logs with different ranges in use at the same time. Surveyors observed frost buildup with brown staining, brown liquid inside a nourishment refrigerator, and yogurt stored in these refrigerators. In one nourishment refrigerator, milk with an expiration date of 9/12/25 was still present on the shelf, and the dietary director stated it was out of date and needed to be discarded.
Facility Assessment Missing Preventive Maintenance and Building Evaluation
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that evaluated the resources needed to care for residents competently during day-to-day operations and emergencies. During observational rounds and an interview with the Maintenance Director, the surveyor asked whether there was a preventive maintenance plan for replacement or repair of resident beds, resident furniture, electrical switches and outlets, painting of facility walls, wall and ceiling conditions, floor conditions, shower functionality, building foundation condition, resident call bell functionality, and monitoring of overall facility decline. The Maintenance Director stated that there was no such plan. During a later interview with the Administrator, with the Maintenance Director present, the Administrator also stated that the facility did not have a preventative maintenance program. Review of the Facility Assessment showed the facility listed a Routine Preventive Maintenance Schedule on a daily, weekly, and monthly basis, but the facility could not provide evidence that it was being completed. The Facility Assessment also did not include an evaluation of building maintenance capital improvements or structures.
Unsafe Linen Handling and Incomplete Water Management Program
Penalty
Summary
The facility failed to ensure clean linen was handled and transported in a safe and sanitary manner. During observation, a staffing coordinator was seen pulling a 2-shelf cart with clean blankets piled on the top and bottom shelves, uncovered, and 2 brown blankets on the bottom shelf were dragging on the floor as the cart was moved onto the basement elevator. When asked whether the blankets were clean and whether they should be covered, the staffing coordinator acknowledged they were clean and stated, "I know, I know. She's getting me a bag." Another staff member then provided a large clear plastic bag and removed the 2 brown blankets that had been dragging on the floor from the cart. The surveyor later discussed the concern with the NHA, and the facility reviewed an in-service summary and attendance form on clean linen transportation. The in-service stated that clean linen must be transported in linen carts with covers in place, that only clean linen should be in linen carts, and that no personal items should be in linen carts. Nursing staff had signed the form. The facility also failed to establish and maintain an infection prevention and control program related to its Water Management Plan. The Infection Control Log showed 3 episodes of pneumonia for 7/1/25-7/31/25 and a potential spike of 6 episodes of pneumonia for 8/1/25-8/31/25. Water testing results dated 7/17/25 showed Legionella detected in 3 of 7 sample areas, including the 1st floor kitchen sink hot water at 12 CFU/ml, the 2nd floor main shower room cold water at 18 CFU/ml, and the 1st floor kitchen sink cold water at >300 CFU/ml. The Water Management Plan reviewed by surveyors contained facility information, a team roster, a water safety assessment dated 11/20/21, generic flow diagrams that were not specific to the facility, and no updated facility-specific flow diagrams. Staff stated the assessment had not been reviewed or updated after the positive water test results, and the facility was unable to provide evidence of adequate prevention and control measures after the water testing issue was identified.
Laundry Equipment and AED Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain laundry equipment in safe operating condition. During record review and interviews related to a complaint, a family member reported that the washing machine was broken and the resident’s clothes had to be taken home to be washed. The family also stated they were told the machines were down but were not informed that the facility could still wash resident clothing, and they were never told when laundry services resumed. During observations in the Laundry Room, 1 of 4 washers and 4 of 5 dryers were out of service. Staff reported that one washer had been out of service for over 3 years, another washer had been down for 5 days in May 2025, and that when only 2 washers were working the facility used an off-site laundry plan. Staff also stated that 3 of the 5 dryers had been out of service for over 3 years and were being used for spare parts, and that another dryer had been out of service since July 2025 with no date for return to service. Staff said resident clothing could still be cleaned, but there may have been delays. The facility also failed to maintain patient care equipment in safe operating condition for 1 of 4 AEDs. Surveyors found an AED in a locked wall container with a cracked, sharp-edged window, no visible expiration date, and a red indicator with a black X instead of the ready green light. The AED was not ready to use, and when removed from the case it made a beeping noise. The chest pads needed replacement, and maintenance staff were unable to explain the AED status or how to determine whether it was ready for use.
Call Bell Systems Failed to Identify Resident Rooms
Penalty
Summary
The facility failed to ensure that resident call systems were functioning properly in multiple resident rooms and bathing areas. Surveyors observed that at Station 4, when Resident #107 in room [ROOM NUMBER] pressed the call bell, the nursing station call system produced an audible beeping noise but did not illuminate a room number, and no light above the resident room illuminated to identify the room needing assistance. GNA #23 stated that the resident had pressed the call bell and that the light above the room and at the nursing station had not been working properly for months, with the light working on and off and maintenance having been made aware. During further testing at Station 4, surveyors pressed call bells for other rooms and observed that some rooms illuminated correctly, while the call system displayed room [ROOM NUMBER] even though there was no such room on the Station 4 nursing station call system. Maintenance Director #18 and the NHA were informed of the concern and confirmed the surveyors’ findings that the call bell in room [ROOM NUMBER] caused the wrong room number to appear on the call system. Maintenance Assistant #7 stated that the light above the door had been fixed, and staff stated they would address the room [ROOM NUMBER] issue. At Station 1, surveyors observed that the call bell near room #4 did not light the hallway call system when pressed. They also observed room [ROOM NUMBER] with a call bell indicator light above the doorway that had no cover, with the bulb protruding from the mounted system. On the second floor of Station 1, several call bell indicator lights were missing plastic caps and failed to identify which room was calling for assistance, including room [ROOM NUMBER], whose call light indicator had no cap and no bulb present. During interview, the Administrator stated the facility did not have a preventative maintenance program, and the Administrator and Director of Maintenance acknowledged the environmental concerns.
Exterior Environment Not Maintained in Safe and Sanitary Condition
Penalty
Summary
The facility failed to ensure the exterior environment was maintained in a safe and sanitary condition. During the exterior tour, the surveyor observed a white painted wooden board affixed to the front entrance with visible black nails and weeds sticking out from the side of the board, uneven depressed areas of missing and misplaced bricks at the main parking lot entrance with weeds present, and movable bricks leading up to the concrete sidewalk near the front doors. Weeds were also observed along the front sidewalk, sections of fencing along the front of the facility were in disrepair with broken railings and railings falling out of place, mismatched fence caps, one broken cap with sharp edges protruding upward, matter on the white fencing, and a broken white fencing post sticking out of the ground. A fence post was also observed falling onto the ground next to tattered job fair signage. Additional exterior observations included dry brown plant matter protruding from the gutter above the facility signage, a broken glass window with tape on it, weeds protruding from shrubs in front of resident room windows, lifted and missing shingles on the roof with hanging shingles, exposed black roofing material and wood, visibly soiled and cloudy resident and community area windows, dried brown vines on the exterior wall, cobwebs on the second-floor window area near the vending machine, broken blinds, a window screen on the ground below a window with no screen present, a gray film on the carport area with cracked and chipping paint and rust-colored spots on columns, and plastic covers below resident windows with a thick layer of brown debris, a dirty brief on the ground, and broken railing pieces and debris beneath a resident window. The Administrator and Director of Maintenance acknowledged the concerns during the tour, and the Administrator stated there was no preventative maintenance program.
Loose Hallway Handrail With Protruding Screw
Penalty
Summary
A handrail in the hallway next to room [ROOM NUMBER] on Station 3 was observed with a sharp edge and a metal screw protruding from the wall. The cap to the handrail was sitting on the opposite railing across the hall, and further inspection showed the handrail was loose and movable. During interview, the Unit Manager/LPN acknowledged the surveyor’s concern and stated that maintenance should be contacted because the handrails had recently been replaced. A Maintenance Assistant later stated that the handrails had just been fixed, but they broke.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to ensure resident self-determination for bathing preferences, including the method and timing of bathing, for one resident. The resident stated they were never allowed to shower and were always given a bed bath. When asked what happens when they request a shower, the resident reported being told there was no shower chair large enough and that the bathing area was too small. The resident also stated they had never been taken to the shower and that bed baths were often provided with sink water that was cold or not warm enough. Record review showed that for the period reviewed, only complete or partial bed baths were documented as completed or offered, with only one refusal of a bed bath noted. The care plan for ADLs, initiated in 2019, indicated no preference between bath and shower and had no updates reflecting a desire to shower. The shower schedule listed Monday and Thursday as shower days for the resident. During observation and interviews, staff stated the resident was always bathed in bed and never offered or taken for a shower. Staff also stated the resident could not fit in the regular shower chair or room, while a bariatric shower chair and shower area were shown elsewhere on the unit; staff explained the bariatric chair is used by turning it sideways to enter the shower area after the resident is hoyered or assisted into it. Staff further stated the resident had a history of refusing showers when previously on another unit.
Failure to Notify Medical Director of Legionella Water Results and Increased Pneumonia Cases
Penalty
Summary
The facility failed to notify the Medical Director of recent testing results when there was a need to alter treatment or testing significantly for two residents. During review of the Infection Control Log, the surveyor found a rise in pneumonia cases in August 2025, with six episodes reported after three episodes in July 2025. The Water Management plan also showed Legionella Analytical water test results from samples collected on 7/1/25 and reported on 7/17/25, with Total Legionella detected in three of seven sample areas, including the 1st Floor Kitchen Sink (Hot), 2nd Floor Main Shower Room (Cold), and 1st Floor Kitchen Sink (Cold) at >300 CFU/ml. During email review with the Baltimore County Health Department, the Public Health Investigator asked for respiratory panel results, chest x-rays, and confirmation of Legionella urine antigen testing for residents with positive chest x-rays. The ADON/Infection Preventionist replied that two residents had positive chest x-rays for pneumonia but no symptoms that warranted Legionella urine antigen testing, and stated they were being monitored and would be reported to the MD/NP if symptoms developed. However, there was no discussion in the email exchange of the facility's Legionella water test results, and no follow-up emails were provided for additional pneumonia cases after the email period ended. In interview, the Medical Director stated he was not aware of the Legionella water test results or the additional pneumonia cases, and said a different clinical approach would have been taken if he had known. The NHA stated the Medical Director was likely informed at a Risk meeting, but later confirmed there were no minutes from the last Risk meeting and no documentation to support that the Medical Director was notified of the water test results.
Failure to Keep Resident Information Private
Penalty
Summary
The facility failed to keep resident personal and medical records private and confidential when its publicly accessible website displayed testimonials that included the full names, photos, and medical diagnosis information for three residents. Survey review on 09/12/25 found the website foresthavennursingcenter.com contained this information for Residents #20, #45, and #65. The surveyor showed the website to the DON and requested consent documentation for use of the residents’ information, and review of the electronic medical record showed all three residents had BIMS scores of 15, indicating they were cognitively intact. At 10:45 AM, the DON could not produce consents for Residents #45 and #65. A consent for Resident #20 was provided, but it was incomplete and only verbally consented to by the resident’s responsible party; the language only granted permission for the resident’s photo to be used on the website. During interviews, Residents #20, #45, and #65 stated they were unaware their information was on the website and did not recall consenting to it. When asked if they were agreeable to having their information posted, Residents #45 and #65 said they were not okay with it and wanted the information removed, while Resident #20 stated they had no issue with it.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident who told the physician that two females verbally abused him/her by saying, “shut the f*** up.” The resident also stated that he/she wanted to go home and felt safe in the facility. The allegation was documented in the physician’s progress note on 6/18/25, but the facility did not self-report the verbal abuse allegation to the Office of Health Care Quality until after surveyor intervention. During surveyor interviews, the Administrator initially stated they needed to check on whether a self-report had been made, and later stated that administration did not know about the allegation. Social Services Assistant Director #2 confirmed that the resident had previously reported an allegation of abuse, including verbal abuse, and stated that it was definitely reported to the Administrator. The Administrator also stated that the physician did not notify administration because the physician was the abuse coordinator, and acknowledged the concern when the surveyor identified that the allegation had not been timely reported.
Failure to Provide Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to provide written notification of transfer and the bed hold policy to the resident representative when Resident #15 was transferred to the hospital on 6/23/2025, 7/28/2025, and 9/5/2025. Record review found no documentation in the electronic or paper medical record showing that the resident representative received the required written notice for any of these hospital transfers. The survey also found no documentation that the local ombudsman was notified of the facility-initiated transfers on 6/25/2025, 7/28/2025, or 9/5/2025. During interview, Social Services Director #1 and Social Services Assistant Director #2 stated that the social work department completed the Bed Hold Policy form and Notice of Discharge or Transfer form and sent them to resident representatives by email or certified mail, with copies kept in the medical record. However, the surveyor was unable to verify that these notices were sent for the earlier hospital transfers involving Resident #15. Social Services Director #1 later stated that she was unaware the resident had left the building for the 9/5/2025 hospital transfer until after the fact, and the required forms and email receipts for that transfer were only reviewed on 9/10/2025.
Care Plan Not Updated for Resident Shaving Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, including the resident’s right to refuse treatment. Record review showed the resident had care plan interventions for ADL functional status/rehabilitation potential and cognitive loss/dementia, noting the resident required assistance with ADLs due to cognitive deficit and was unable to make daily decisions without cues or supervision because of dementia. However, the care plan dated 05/28/25 was not updated with resident-specific preferences related to shaving, despite repeated family concerns. During record review and interviews, it was found that the resident’s face and beard were shaved against the family/POA preferences on more than one occasion. A progress note dated 05/03/2025 documented that the resident was shaved by an aide, and the daughter stated that her mother did not want the resident shaved by staff. On 09/15/2025, the daughter and wife/POA stated the resident had been shaved against preferences since around June 2024, and the wife/POA reported the issue had been discussed multiple times at care plan meetings. Surveyors also observed signage posted on the resident’s closet dated November 2024 requesting that the resident not be shaved.
Delayed Care Plan Meeting After Quarterly Assessment
Penalty
Summary
The facility failed to facilitate timely care plan meetings after a resident's quarterly assessment, affecting 1 of 4 residents reviewed for care planning during the annual survey. Care plans are used to summarize a resident's health conditions, specific care needs, and current treatments, and are developed, reviewed, and/or revised by the interdisciplinary team after completion of a comprehensive MDS assessment. Care conference meetings were reported by Social Services Director #1 to be held at admission, quarterly, for a significant change, or as requested by the resident or resident representative, and are usually held during the timeframe of the MDS assessment. For Resident #14, the last documented care conference was on 5/15/2025, and the next care conference was due on 8/27/2025. The resident had a quarterly MDS assessment completed on 8/5/2025, but review of the medical record did not reveal documentation of a care conference meeting during the timeframe of that quarterly assessment. During interview, Social Services Director #1 confirmed the surveyor's concern that the last care conference was greater than 90 days earlier and that there was no documentation to verify a care conference meeting had occurred since 5/15/2025. By survey team exit on 9/15/2025, no documentation of a care conference meeting since 5/15/2025 had been provided.
Incorrect PASRR Completion and Missed Level II Referral
Penalty
Summary
The facility failed to complete a resident’s PASRR form according to professional standards of practice. During record review, the resident was found to have diagnoses including bipolar disorder, dementia, depression, and PTSD, and a physician note documented multiple prior inpatient mental health hospitalizations, including one in 9/2022 and a placement at a Geri psych facility for stabilization before admission to the nursing facility on 8/29/2023. The PASRR form completed on admission by the Social Service Assistant answered “No” to Section C #3, which asked whether the individual had psychiatric treatment more intensive than outpatient care more than once in the past 2 years or inpatient hospitalization, despite the resident’s documented psychiatric hospitalizations. The follow-up question in Section C asking whether the individual was considered to have a serious mental illness was left unanswered, and Section D was completed with all “No” responses, indicating the resident should have been referred to Adult Evaluation & Review Services for a Level II evaluation. The Social Service Assistant did not follow up with the local AERS office, and the Social Service Director later confirmed the PASRR was filled out incorrectly and that AERS was not notified of the positive PASRR Level I.
Failure to Assist with Eating and Provide Showering Services
Penalty
Summary
The facility failed to ensure Resident #117 received the assistance needed for eating. During observation, the resident was seated in a wheelchair in the hallway at an overbed tray table with lunch in front of them and was seen licking carrots from the plate and pudding from the container with their tongue to get the food into their mouth. No staff were observed assisting or supervising the resident at that time. When the surveyor located GNA #37, the staff member stated the resident could feed themself if the utensil was placed in their hand, and after the surveyor raised the concern, the GNA placed the utensil in the resident’s hand and the resident then began feeding themself. The resident’s care plan stated they required assistance with ADL care and eating, with assistance and periodic reassessment for changes in cognition, and the active order dated 11/4/2024 specified eating with assist of 1. The facility also failed to ensure Resident #114 received the necessary services for personal hygiene. The resident stated they were never allowed to shower and were always given bed baths, reporting staff told them there was no shower chair large enough and the bathing area was too small. The resident also stated they had only been bathed in bed and that the sink water was often cold or not warm enough. Record review showed that on the Matrix POC for 8/10/25 through 9/9/25, only complete or partial bed baths were documented as completed or offered, with only one refusal of a bed bath noted. The ADL care plan, initiated on 8/25/19, indicated no preference between bath and shower and had no updates reflecting a desire to shower, while the shower schedule listed Monday and Thursday shower days. Staff interviews indicated the resident had not been offered or taken for a shower on those assigned days.
Leaking Toilet and Slippery Bathroom Floor
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for Resident #110. During observation rounds, the resident’s toilet was found leaking water from the base, with a large puddle of water surrounding the toilet on the bathroom floor. The bathroom floor was also observed to be slippery when walked on. Later, the Director of Nursing was informed of the leaking toilet and the water on the floor, and acknowledged that maintenance would repair the toilet and the puddle would be mopped from the floor.
Bedrail Use Without Required Assessment and Consent
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the safe use of bedrails, failed to obtain consent from the resident or resident representative before bedrail use, and failed to complete a device assessment for bedrails. This was identified for 2 residents reviewed for accidents. Bedrails, also referred to as side rails, were described as adjustable bars attached to the bed and used for mobility, fall prevention, or security, with noted risks including suffocation, entrapment, and psychological risks. Resident #15 was observed sleeping in bed with the head of the bed elevated about 30 degrees and quarter bedrails raised on both sides; the resident was also seen leaning with the head and shoulder resting on the right-side bedrail. The medical record showed an active physician order for quarter rails for turning and positioning and documentation that quarter rails were in place from February through September 2025, but the record did not contain a bedrail assessment, resident or representative consent, or a device assessment. Resident #65 was observed lying in bed with bedrails raised on the upper sides of the bed and stated the rails were being used to assist with bed mobility. The DON stated the facility had not completed bedrail assessments for residents using bedrails for mobility, and a completed bedrail assessment for Resident #65 was later presented that had been created the same day it was reviewed.
Medication Administration Not Given Per Physician Orders
Penalty
Summary
Medication administration was not carried out in accordance with physician orders for 2 of 26 opportunities reviewed, resulting in a medication error rate of 7.69%. During the morning medication pass on 09/09/25, Resident #21 was given Topamax in crushed form by Staff #14, even though the electronic medical record showed an order for headache that specified the medication was not to be crushed and was to be given whole. During the morning medication pass on 09/10/25, Resident #128 was given Ferrous Sulfate 325 mg without food, although the physician's order indicated it was to be administered with meals. When Staff #15 was asked about the timing, they stated the food trays were on their way, and the surveyor observed that the resident was not served until 8:52AM.
Unsecured Medication Cart Exposed Medications and PHI
Penalty
Summary
Medications and resident information were left unsecured when an unlocked medication cart was observed unattended in the hallway during the facility's recertification survey. Surveyors were able to open the cart drawers and found medications along with resident information containing protected health information (PHI). No staff were present in the area at the time of the observation, and two surveyors walked the length of the unit before locating Staff #25 and alerting them to the situation. The unit nurse was then sent to secure the cart, and the Nursing Home Administrator was informed later that day.
Delayed Routine Dental Care
Penalty
Summary
The facility failed to ensure a resident who required routine dental services received necessary dental care in a timely manner. Resident #15 was observed in bed with the head of the bed raised about 30 degrees, and the Surveyor noted brownish yellow discoloration of the resident’s natural teeth. The resident was unable to state when they had last been seen by a dentist. The resident had an active physician’s order for a dental consult as needed, but the record did not show when the resident was last seen by a dentist at the time of the survey review. A dental note later reviewed by the Surveyor showed the resident was last seen by the dentist on 7/2/2024. At that visit, the resident had numerous missing teeth, retained roots, crowns, heavy soft plaque/food debris buildup, and was identified as high risk for dental caries. The dental recommendations included an annual exam, a prophylactic exam at 6 months, and fluoride varnish, with the next periodic oral exam due on 1/2/2025 and the next annual exam due on 7/2/2025. Social Service Director #1 confirmed the resident did not receive the recommended follow-up dental visits on those dates and stated the dental group was backed up with routine services; the director could not explain why the missed appointments were not followed up or why the resident was not seen on the next available appointment.
Failure to Provide Accessible Menus and Dietary Choices
Penalty
Summary
The facility failed to ensure residents’ right to make personal dietary choices for Resident #112, who has a history of Multiple Sclerosis and is non-ambulatory and mostly dependent. During observation and interview, the resident stated never knowing what was coming on the food tray at any meal and said there was no monthly menu or alternative options available at the bedside or posted on the poster board. The resident also stated that meal alternatives were not often requested anymore and that they usually just accepted what was given. On follow-up, an LPN stated that no menus were provided to residents or available on the unit for staff to inform residents of daily menu items. The Dietary Director stated staff should have a copy available at the nurse’s station or make their own copy of the Always Available list, and that menus were posted on the units in glass display boxes, but observations showed the display boards were empty, partially missing menu pages, or contained an outdated menu from Spring/Summer 2023. The Activities Director stated the quarterly menu was read daily to residents in the common dining room and that menus could be provided if requested, but also stated they did not update the display glass box with menus.
Inaccurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for one resident reviewed for advance directives. The resident’s chart contained 2 certifications of incapacity, a guardianship order, and 2 Maryland Orders for Life Sustaining Treatment (MOLST) forms that were both present in the hard chart at the same time and neither had been voided at the time of surveyor review. One MOLST was documented as certified by the resident on 6/7/2025, and the other was documented as certified by the resident’s guardian on 3/16/2023. The surveyor observed that the 6/7/2025 MOLST had an incomplete second page, with sections 2 through 9 left blank. During interview, an LPN acknowledged the concern and stated it would be addressed. The Social Services Director stated the 2025 MOLST was from the hospital and that the 2023 MOLST was the one that should be in effect, and also stated the MOLST was left in the chart for the physician to void. The surveyor then observed the Social Services Director obtain the physician’s voiding of the second MOLST. The DON later stated that social services reviews documents after hospital readmission and that nursing staff refer to the hard chart MOLST to determine code status in an emergency.
Failure to Inspect and Assess Bedrails
Penalty
Summary
The facility failed to ensure regular inspections of bedrails being used by residents. During a tour of Station 4, Resident #15 was observed sleeping in bed with the head of the bed raised about 30 degrees and quarter bedrails raised at the top of the bed on both sides; the resident’s head was leaning on the right-side bedrail. Later, the resident was again observed lying in bed with the head of the bed elevated about 30 degrees and quarter bedrails raised on both sides, with the resident leaning to the right side and resting the head and shoulder on the right-side bedrail. Record review for Resident #15 showed a physician’s order for quarter rails for turning and positioning every shift, and treatment administration records documented that quarter rails were in place from February 2025 through September 2025. However, the medical record did not contain documentation of any device assessment to ensure the quarter bedrails were secure, properly installed and maintained, and limited entrapment risk. Resident #65 was also observed lying in bed with bedrails raised on the upper sides of the bed and stated the bedrails were in place to assist with bed mobility. The DON stated the facility had not completed any bedrail assessments for residents using bedrails for mobility, and the Director of Maintenance stated they do not check the beds for bed safety.
Multiple-Resident Bedrooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to have multiple-resident bedrooms that measure at least 80 square feet per resident. During interviews, the Nursing Home Administrator and the DON stated that the facility did not have a waiver related to room sizes, and the Administrator also stated that rooms 1, 5, 6, and 9 had not been modified to ensure compliance with the required square footage per resident. Review of the prior CMS-2567 from the 8/2/2022 recertification survey showed the facility had previously been cited for multiple-resident bedrooms measuring less than 80 square feet per resident. During observation rounds with the Maintenance Director, surveyors measured four rooms that did not meet the required space per resident. Room 1 measured 283 square feet for four residents' beds, which equaled 70.75 square feet per resident. Room 5 measured 221 square feet for three residents' beds, which equaled 73.66 square feet per resident. Room 6 measured 214 square feet for three residents' beds, which equaled 71.33 square feet per resident. Room 9 measured 216 square feet for three residents' beds, which equaled 72.33 square feet per resident.
Lack of Visual Privacy in Resident Rooms
Penalty
Summary
Resident rooms were not equipped to provide visual privacy for each resident. During observation rounds with the Nursing Home Administrator and the Maintenance Director, surveyors found a missing privacy curtain for bed A in one room. When interviewed immediately afterward, the Nursing Home Administrator agreed that the privacy curtain was not present. Later the same day, surveyors observed a privacy curtain for bed A in another room that did not pull across completely. During the interview that followed, the Maintenance Director agreed that the curtain did not fully close and stated that the track for the privacy curtain was jammed.
Missing Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the current nurse staffing assignments and ratios for each shift were posted daily in a clear and visible place on each nursing unit. During the recertification survey, surveyors observed that Unit Station 2B did not have current staffing assignments and ratios posted in a prominent location readily accessible to residents, staff, and visitors, and instead observed poster boards tucked in the nurse station area. When interviewed, GNA staff stated the poster boards had been down because of painting and that staffing sheets were kept at the nurse's station on the back wall, which was not visible from the main hall for residents or visitors to see. Surveyors also observed missing or outdated staffing postings on other units. Station 3 did not have the current nurse staffing ratio posted on the hallway dry erase board, Station 2A displayed the prior day's staffing posting instead of the current shift staffing, and Station 4 was observed multiple times without the required staffing ratio posting. On a later follow-up observation, Station 2B was again observed without the staffing ratio posting before poster boards were seen on the walls with current staffing assignments.
Survey Binder Missing Most Recent Survey Results
Penalty
Summary
The facility failed to have the most recent survey results posted and accessible to residents, family members, and legal representatives in the Survey Binder located in the reception area. On 9/10/2025, the Surveyor observed the Survey Binder on a console table next to the Receptionist desk, and later reviewed its contents. The binder did not include the results of the most recent complaint survey conducted on 4/21/2025-4/25/2025 and 4/28/2025-5/1/2025, or the on-site revisit survey conducted on 7/31/2025, 8/1/2025, and 8/4/2025. Instead, the binder contained survey results from a complaint survey dated 5/30/2024 and an annual survey dated 8/2/2022. During an interview on 9/11/2025, the DON confirmed that the most recent survey results were not in the Survey Binder and stated she was not aware that complaint or revisit survey results needed to be accessible to residents and visitors in the binder.
Failure to Provide Adequate Supervision and Safe Medication Management
Penalty
Summary
Facility staff failed to provide adequate supervision and safe care during activities of daily living for a resident with significant medical needs, including respiratory failure, heart failure, a vertebral fracture, hospice care, and dementia. The resident required extensive assistance from two staff members for repositioning in bed, as documented in the MDS assessment. However, a Geriatric Nursing Assistant provided care alone and left the resident unattended on her side in bed to retrieve supplies. During this absence, the resident fell from the bed and sustained a fracture to the left superior pubic ramus. The incident was confirmed by facility records and staff interviews, and the administrator acknowledged that staff did not follow the facility's ADL policy for supervision. Additionally, another resident was found to have multiple medications, including medicated spray, Desitin, Pepto Bismol, and cough syrup, stored openly at the bedside. The resident reported keeping these medications because staff would not provide them, and a family member supplied them. Facility policy prohibits residents from having medications at the bedside, and the DON was unaware of the situation until it was observed. Social Services staff and the attending physician confirmed that the resident had a history of keeping medications in the room and that self-administration was considered unsafe due to concerns about overuse. Despite these concerns, staff continued to allow the resident to keep and self-administer the medications.
Failure to Ensure Staff Competency Assessments
Penalty
Summary
Facility staff failed to ensure that nurse aides demonstrated competency in the skills and techniques necessary to care for residents' needs. During the investigation of an abuse allegation involving a resident, a review of a Geriatric Nursing Assistant's (GNA) employee file revealed that, although a general orientation checklist was present, there was no evidence of initial or ongoing skills assessments to confirm competency. The administrator confirmed that no such skills assessments existed for this staff member. Interviews with the Director of Nursing (DON) and the Human Resources director further revealed that the facility did not have a formal process for evaluating staff skills competency. The DON, who had recently assumed the position, stated that there was no formal method in place for verifying nurse and GNA competencies, and that the facility did not have a skills lab. The DON also indicated that, aside from pharmacy-conducted medication pass observations for nurses, no formal competency evaluations were conducted.
Failure to Complete Annual Performance Reviews and In-Service Education for Nurse Aides
Penalty
Summary
The facility administration failed to complete annual performance reviews for every nurse aide and did not provide regular in-service education based on the outcomes of such reviews. During the investigation of an allegation of staff-to-resident abuse, it was found that a Geriatric Nursing Assistant (GNA) had only one annual performance evaluation on file since being hired, with no subsequent yearly evaluations available. The Director of Nursing (DON) confirmed that annual performance evaluations for nursing staff had not been conducted since she assumed her position, and the Human Resources director corroborated this information. These findings were based on employee file reviews and staff interviews.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Facility staff failed to store, prepare, and serve food in accordance with professional standards of food service safety, as evidenced by multiple observations during two separate kitchen tours. Surveyors found grease layered on tiles, debris such as paper and plastic under and behind kitchen items, dust and dirt on floors, and mouse traps set throughout the kitchen. The prep supply area was dirty, insulation was coming off pipes under the sink, and food items like bread and elbow noodles were found on carts and the floor. An open bag of flour was left unsealed, and the clean food cart storage area had water-stained ceiling tiles, dirty floors, a large hole in the wall, and missing floor tiles. The cleaning schedule provided by the Dietary Manager did not include the dry storage area or specify that all floors should be mopped and trash cleaned up. Further observations included dirty mouse traps with food particles, sticky floors, vents and pipes with grease and dust buildup, and a refrigerator with a damaged seal. The bulletin board and air conditioning unit were dirty, and rolls of foil and plastic wrap were stored inappropriately. The stove, mixer, and meat slicer were left uncovered or uncleaned, and open containers of sugar were not properly sealed. Food carts, the fire suppression system, and the metal connection box had accumulations of dirt, food crumbs, and mice droppings. Hand sinks were blocked or dirty, and the hand sanitizer dispenser was unclean. The Administrator was made aware of these findings and had no additional comments.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Facility staff failed to properly dispose of garbage and refuse, as observed during tours of the smoking and dumpster areas. Specific findings included cigarette butts littering the ground, broken pallets and chairs placed next to the building, unsecured gates that could be opened by residents, and piles of plywood, broken air conditioners, buckets, and trash in various locations. Additional observations included food serving carts in disrepair, a commercial hair drying unit leaning on metal doors, multiple air conditioners and food carts stored in the yard, ladders against the wall, an open shed filled with debris, and various pieces of trash and old furniture scattered around. In the dumpster area, dumpsters were found with open side doors, a pile of pallets, and milk containers scattered around, all contributing to improper refuse disposal.
Deficiencies in Staff Evaluation, Policy Accessibility, and Pest Control
Penalty
Summary
Facility administration failed to establish and ensure systems for evaluating staff performance and providing required education based on performance reviews and facility assessment. Review of an employee file for a GNA revealed only one annual performance evaluation over seven years of employment, and insufficient annual training on cognitive impairment and mental illness. Interviews with the DON and HR Director confirmed that annual performance evaluations were not conducted for nursing staff, and there was no formal process for ongoing competency verification or structured training needs assessment. Staff interviews indicated that policies and procedures were not readily available or accessible to all staff. Multiple staff members believed that policy binders were located in the nurse's station, but upon inspection, only a wound care policy binder was found. Other staff referenced policies being kept in various locations or with department heads, but the DON confirmed that direct care staff did not have access to policies and procedures on the units, and only one nursing manual was available in the facility. The facility also lacked an effective pest control program. Complaints and observations revealed ongoing issues with mice and cockroaches, unsanitary kitchen conditions, and structural deficiencies such as gaps and holes allowing pest entry. Pest control company recommendations for maintaining sanitation and building repairs were not implemented, and documentation showed only monthly pest control visits despite claims of increased frequency. Maintenance staff were not receiving pest control reports, and structural recommendations were not followed up, contributing to persistent pest issues.
Failure to Maintain Required QAA Committee Membership and Meeting Attendance
Penalty
Summary
Facility staff failed to maintain a Quality Assessment and Assurance (QAA) committee that included the required members, specifically the Medical Director and an Infection Preventionist. Review of QAPI (Quality Assurance Performance Improvement) committee meeting attendance sheets from April 2024 through April 2025 revealed that the Infection Preventionist was absent from multiple meetings, including several quarterly meetings, and the Medical Director was also absent from several meetings. Additionally, there was no evidence that meetings were held in certain months, as no sign-in sheets or documentation were available for those periods. Further review indicated that although the current Infection Preventionist had recently assumed the role, neither the current nor former Infection Preventionists attended the required meetings in that capacity. The staff member who is now the Infection Preventionist was present at some meetings, but only in the role of an MDS nurse, not as the Infection Preventionist. The absence of these key committee members was confirmed through record review and staff interviews.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe and homelike environment for residents. On the second floor, hallway heaters and vents were found covered with dust, and in one resident's room, the bathroom door had scuff marks and peeling veneer near the doorknob. The sink in the same room was dripping water, the flooring was cracked in two places, and the wall outside the bathroom was damaged and unpainted. The heating vent under the sink was also caked with dust. In another room, there were gaps where pipes entered the wall, and the vent under the window, as well as hallway vents, were heavily dust-laden. Additionally, one resident's room was missing doors on both the closet and bathroom. During an interview, the Maintenance Assistant stated that the facility did not have a preventative maintenance program to ensure resident rooms were maintained in a safe and homelike manner. He indicated that maintenance was only performed when issues were reported by nursing staff and that he was the sole maintenance worker since February, which prevented him from keeping up with cleaning and repairs. The new Maintenance Director later acknowledged these concerns.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in ongoing issues with mice, cockroaches, and other pests throughout the building. Multiple complaints were received regarding mice infestations, rodent droppings in resident rooms and the kitchen, and sightings of pests by visitors and residents. Observations confirmed the presence of pests and pest evidence in various areas, including a large hole in a wall near food storage, cockroaches in resident rooms and bathrooms, and mouse traps placed in response to sightings. The kitchen was found to be unsanitary, with layers of grease and dirt, and pest control recommendations for improved sanitation and building maintenance were not implemented. Outdoor areas, such as the resident smoking area and dumpster area, were cluttered with debris and had open containers, further contributing to pest problems. A review of the pest control policy revealed missing implementation details and lack of a designated pest management coordinator. Pest control logs showed regular pest sightings, and receipts from the pest control company documented ongoing recommendations for structural repairs and increased sanitation, which were not followed. Interviews with maintenance staff indicated a lack of communication and follow-up on pest control reports and recommendations. The administrator reported treating areas based on pest logs and claimed to increase pest control visits when needed, but documentation did not support this. The facility's failure to address structural issues, maintain cleanliness, and implement pest control recommendations led to persistent pest infestations affecting the entire facility.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. During a lunch tray line observation, a surveyor and the Certified Dietary Manager (CDM) monitored the process of food delivery, including the use of a test tray. The food cart was parked in a hallway while nursing staff distributed trays to residents' rooms. When the CDM measured the temperatures of the test tray items, the egg omelet with cheese registered at 98°F, sausage at 90°F, and milk at 42°F. The CDM confirmed these temperatures, which did not meet the required standards for hot food service. The Administrator was informed of the food temperature concern.
Failure to Timely Report Allegations of Abuse and Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to report an allegation of abuse in a timely manner to the State Agency. In one instance, a resident became agitated and accused staff of stealing marijuana, which is not permitted in the facility. The nurse documented the resident's allegation in the medical record, the 24-hour report, and verbally reported it to the oncoming nurse and the nursing supervisor. However, the allegation was not reported to administration or the State Agency, and the Clinical Services Director later confirmed that the incident was not reported as required. In a separate incident, one resident struck another on the head with a cane, resulting in a laceration. The facility's investigation did not include documentation of when the incident was reported to the Office of Health Care Quality (OHCQ) or when the final report was sent. The Nursing Home Administrator was unable to provide documentation of the reporting, as email confirmations had been deleted and were unavailable for review by the surveyor.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
Facility staff failed to investigate an allegation of misappropriation of property for one resident who reported that their marijuana was stolen. The resident, who had previously expressed frustration about not being allowed to use marijuana for pain management, reported the alleged theft to nursing staff, who documented the complaint in the medical record and 24-hour report, and informed the oncoming nurse and supervisor. However, no formal investigation was conducted by administration or clinical leadership after the allegation was made. In a separate incident, the facility did not conduct a thorough investigation into an allegation that a Geriatric Nursing Assistant (GNA) threw cookies at a resident, striking them on the nose. The facility's documentation lacked statements from staff or residents regarding the alleged event, and the GNA in question was not removed from resident contact during the investigation period, despite working multiple shifts on the unit where the resident resided. The investigation relied on limited and, in one case, outdated staff statements, and did not include comprehensive interviews or evidence collection. Additionally, the facility failed to conduct a complete investigation into an allegation of abuse involving another resident with a mental health disorder and dementia. The investigation file did not contain a statement from the resident or from all potential witnesses, and although the accused GNA denied contact with the resident, there was no further inquiry into their assignment or possible interaction. The DON and Administrator acknowledged that an interview with the resident had occurred but could not provide documentation of it, and the investigation file was incomplete.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in unmet needs related to medical appointments and skin care. For one resident, the medical record showed multiple physician orders for dental, cardiology, neurosurgery, and neurology consults, but there was no evidence that these appointments were attended. The resident often scheduled and canceled appointments independently, and staff did not maintain documentation of when or where the resident went for these appointments. Interviews with the Administrator and Transportation/Scheduler confirmed that the facility was not consistently involved in arranging or tracking the resident's outside medical visits, and the care plan did not address the resident's preferences or behaviors regarding appointment scheduling and attendance. Another resident experienced a recurrent rash on the lower legs, with documentation of ongoing symptoms and repeated courses of topical treatment. The resident was seen by both dermatology and rheumatology, and follow-up appointments were ordered, but the care plan addressing skin integrity was generic and not tailored to the resident's persistent and recurring condition. The care plan lacked specific, measurable actions or approaches to address the ongoing rash, despite repeated documentation of the issue and multiple specialist referrals. In both cases, the facility's care planning process did not adequately address the residents' individual needs, preferences, or the complexity of their medical situations. The deficiencies were identified through medical record review and staff interviews, which revealed gaps in documentation, lack of comprehensive planning, and insufficient coordination of care for residents with ongoing or complex health concerns.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
Facility staff failed to provide an activities program that met the needs and preferences of a resident with severe cognitive impairment. The resident, who had a diagnosis of dementia with behavioral disturbance and a BIMS score indicating severe cognitive impairment, had documented preferences for activities such as reading, listening to music, being around animals, keeping up with the news, participating in group activities, going outside, and engaging in religious practices. Despite these documented preferences, the care plan for activities was not individualized and lacked measurable goals and specific approaches tailored to the resident's needs. Observations during the survey revealed that the resident was either in their room or ambulating in the hallway and was never observed participating in any activities or receiving one-to-one engagement from staff. Review of activity participation logs showed that activities were only provided on a few days each month, with no documentation of daily or individualized activities, and no records of participation for two consecutive months. The care plan inaccurately stated that the resident was independent in meeting their activity needs, despite evidence of cognitive impairment and the need for staff engagement. Interviews with the Activity Director confirmed that one-to-one visits and group activity invitations were supposed to be documented, but there was a lack of documentation to support that these interventions occurred regularly. The absence of a resident-centered care plan and insufficient documentation of activity participation led to the finding that the facility did not meet regulatory requirements for providing an activities program that addresses the unique needs and preferences of the resident.
Failure to Reschedule Dermatology Appointment as Ordered
Penalty
Summary
Facility staff failed to follow physician orders for a resident who had a recurrent rash on the lower legs. The resident, who had diagnoses including dementia, hypertension, and hypothyroidism, had been prescribed the same ointment multiple times and was under the care of both rheumatology and dermatology for the rash. Medical records showed that the resident was seen by rheumatology and dermatology as ordered, but a dermatology appointment scheduled for February was cancelled due to an elevator malfunction at the hospital. Although there was a physician order to reschedule the dermatology appointment, there was no documentation that the follow-up appointment was ever scheduled. Interviews revealed that the staff member responsible for scheduling appointments and transportation was not notified by nursing to reschedule the dermatology appointment. The attending physician confirmed that the expectation was for the appointment to be rescheduled if missed, and was unaware that it had not been done. The deficiency was identified when it was found that the resident continued to have a rash and lacked current treatment or follow-up with dermatology as ordered.
Failure to Implement and Document Individualized Pressure Ulcer Prevention Measures
Penalty
Summary
Facility staff failed to implement appropriate individualized interventions for a resident identified as at risk for developing pressure ulcers. Upon admission, the resident was noted to have redness to the groin and buttock, but the documentation did not specify the size or whether the redness was blanchable. Physician orders included daily and weekly skin checks, weekly Braden Scale assessments for four weeks, and application of a moisture barrier cream. However, staff did not complete the required weekly Braden Scale assessments as ordered, and the interim plan of care did not specify individualized interventions to address the resident's skin integrity risk. The comprehensive care plan also lacked specific measures for turning and repositioning, use of prescribed moisture barrier cream, and the pressure-reducing device, despite the resident's dependence on staff for mobility and hygiene. The resident later developed an open area on the sacrum, which was first identified as unstageable, prompting new interventions such as an alternating pressure mattress, urinary catheter, and scheduled turning and repositioning. Documentation revealed that staff did not consistently record turning and repositioning assistance both before and after these interventions were added to the care plan. Interviews with the attending physician and DON confirmed that appropriate interventions were not in place or documented prior to the development of the pressure ulcer, and that staff failed to follow physician orders and facility protocols for residents at risk of pressure ulcers.
Failure to Limit and Document PRN Psychotropic Medication Orders
Penalty
Summary
Facility staff failed to ensure compliance with regulations regarding the use of as needed (PRN) psychotropic medications for a resident with dementia and behavioral disturbances. A physician order for Lorazepam, to be administered prior to blood draws, was written as a PRN order without a 14-day limitation or a specified duration and discontinuation date. The medical record did not contain documentation from the physician providing a rationale for continuing the PRN order beyond 14 days, as required by regulation. Additionally, review of the medication administration record showed that Lorazepam was administered to the resident, but there was no documentation indicating that non-pharmacological interventions were attempted prior to giving the medication. These findings were confirmed during interviews with the Director of Nursing and the Nursing Home Administrator, who acknowledged the lack of appropriate documentation and understanding of the requirements for PRN psychotropic medication orders.
Medications Improperly Stored at Bedside
Penalty
Summary
Facility staff failed to ensure that all medications and biologicals were stored in locked, temperature-controlled compartments as required. During an observation, a resident was found with multiple medications, including medicated spray, Desitin, Pepto Bismol, liquid pectate, severe congestion liquid medication, and cough syrup, left out in the open on the over-the-bed table in the resident's room. The resident stated that these medications were kept at the bedside because staff refused to retrieve them, and that a family member had purchased and brought the medications to the facility. The DON confirmed the presence of these medications during a follow-up observation and noted that staff had not reported this situation. The attending physician was aware of the medications at the bedside and had discussed the issue with the resident and administration multiple times, but proper storage was not ensured. These findings were reviewed with the Nursing Home Administrator and Clinical Services Director.
Failure to Conduct and Document Comprehensive Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive and accurate facility-wide assessment to determine the resources necessary to care for residents competently during both routine operations and emergencies. During a complaint survey, the facility provided a binder labeled as the facility assessment, but review of its contents revealed significant omissions and outdated information. The facility profile lacked current data, such as the average resident census and accurate staff information, and did not include the average number of staff on nights. Additionally, the profile listed contact information for previous administrators and maintenance directors, indicating it was not up to date. Further review showed that the assessment did not adequately evaluate the resident population's needs, including an analysis of diseases, conditions, physical and cognitive abilities, and overall acuity. The comorbidity report was limited to 50 residents and did not provide a comprehensive assessment of the entire population. The assessment also failed to address the specific care requirements for residents, such as the types of diseases and disabilities present, and did not evaluate the staff competencies necessary to meet these needs. There was no documentation of staff education, training, or health information technology resources relevant to the resident population. The facility assessment was also missing evaluations of the facility's physical resources, such as buildings, vehicles, equipment, and contracted services. There was no evidence of an assessment of ethnic, cultural, or religious factors that could affect care, nor was there documentation of an evaluation of the number of staff required to meet resident needs. The list of contracted providers did not include an evaluation of how these services would meet regulatory, operational, or training requirements. These deficiencies were acknowledged by the Nursing Home Administrator during the survey.
Failure to Maintain Accurate Resident Property Inventory and End-of-Life Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete inventory of a resident's personal belongings, as well as failed to document the disposition of those belongings upon the resident's discharge. One resident's medical record did not contain an inventory of personal items, including a motorized wheelchair and marijuana, despite staff acknowledging the presence and storage of these items. There was no documentation regarding the final disposition of these belongings after the resident was transferred to the hospital, and the facility was unable to provide a policy specific to the inventory of residents' belongings beyond a general admission policy. Additionally, the facility did not ensure accurate and complete documentation of residents' end-of-life choices. For another resident, the electronic medical record (EMR) indicated a code status of 'Full Code,' while the paper record contained an active MOLST form indicating 'Do Not Resuscitate/Do Not Intubate' (DNR/DNI) status. Staff interviews revealed reliance on both the EMR and paper chart for code status, but discrepancies existed between the two sources. The resident's care plan and a nurse practitioner's note also contained conflicting information regarding code status, and two active MOLST forms with different directives were found in the medical record. These deficiencies were evident during a complaint survey and were confirmed through record review, staff interviews, and observation. The lack of a consistent process for documenting and updating both personal property inventories and end-of-life directives led to incomplete and conflicting records for the residents involved.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving a resident with a history of sexually inappropriate behavior. This resident, diagnosed with dementia and other mental health issues, was involved in several incidents of sexual abuse and misappropriation of property. On one occasion, the resident was found inappropriately touching another resident, who was unable to consent due to their condition. Despite the severity of these incidents, the facility did not conduct investigations or notify the State agency as required. The resident's behavior care plan noted various problematic behaviors, including sexual inappropriateness, which were not adequately addressed by the facility. The resident was observed engaging in inappropriate sexual conduct with multiple residents, including a bed-bound and demented resident, and another resident who was quadriplegic and dependent on staff for care. These incidents were witnessed by staff members, yet the facility failed to take appropriate action to prevent further occurrences or to report the incidents to the appropriate authorities. Additionally, the facility did not investigate or report an incident where the resident took personal items from another resident, causing distress. The lack of timely and appropriate response to these incidents highlights a significant deficiency in the facility's ability to protect residents from abuse and to comply with regulatory requirements for reporting and investigating allegations of abuse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,895 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Catonsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Catonsville | 0.2 mi | ★★★★★ | 41 | 0 |
| Frederick Villa Healthcare | 0.9 mi | ★★★★★ | 62 | 0 |
| Ridgeway Rehab Center | 0.9 mi | ★★★★★ | 28 | 0 |
| Autumn Lake Healthcare At Summit Park | 1 mi | ★★★★★ | 26 | 0 |
| St. Joseph's Nursing Home | 1.4 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.