Frederick Crossing Of Journey
Inspection history, citations, penalties and survey trends for this long-term care facility in Frederick, Maryland.
- Location
- 30 North Place, Frederick, Maryland 21701
- CMS Provider Number
- 215184
- Inspections on file
- 20
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Frederick Crossing Of Journey during CMS and state inspections, most recent first.
A resident alleged being hit on the head by staff after using the call bell and was later found sitting on the floor of the room. The facility generated an internal incident report and conducted an investigation, but the resident’s medical record contained no documentation of the abuse allegation, no notation of an unwitnessed fall or being found on the floor, and no related assessments or interventions. A skin assessment completed the next day showed no tissue injury but did not state why it was performed, and the incident report was kept outside the medical record as a privileged document.
The facility did not ensure that controlled drug counts were accurately maintained and properly signed by two staff members at each shift change. Errors included pre-signing, missing signatures, and signatures being crossed out, with staff and management confirming these documentation lapses during interviews.
Surveyors found that 4 out of 6 coffee mugs on a coffee cart contained a chalky, grayish-brown residue inside, which was easily removed by wiping. The kitchen cook and administrator confirmed the mugs were not clean, and the Certified Dietary Manager indicated that new staff may not have mastered the cleaning process.
A resident suffered bruises and bloody skin tears after a GNA mishandled them while attempting to place them in a wheelchair. The incident was witnessed by the resident's roommate, who confirmed the GNA's actions. Despite having a clear background and abuse training, the GNA refused to provide a statement and reacted inappropriately when questioned by an LPN. The facility's investigation verified the abuse allegation.
The facility staff failed to properly store, label, and date food items in the kitchen's walk-in refrigerator and dry storage room. Observations revealed unlabeled opened containers of food and expired beverages in the refrigerator, and undated canned goods and opened bread in the dry storage. These deficiencies were confirmed by the Dietary Manager and acknowledged by the NHA.
The facility failed to ensure clean drinkware for residents, compromising infection control. Surveyors observed plastic mugs with a chalky film, confirmed by a Dietary Aide and an RN. The Nursing Home Administrator was informed of the issue.
A facility failed to obtain a signature or document refusal for the Notice of Medicare Non-Coverage (NOMNC) for a resident discharged from Medicare Part A services with benefit days remaining. The NOMNC, which informs residents of their rights and protections, was not signed, and there was no documentation of who conducted the notification or if the representative refused to sign. The social services director's documentation was found to be inaccurate, as there was no evidence that the NOMNC was mailed to the resident's representative.
The facility failed to report maintenance issues in resident rooms, resulting in unaddressed deficiencies such as a frayed fall mat, unpainted scrapes, and spackling. The maintenance director was unaware of these issues due to a lack of communication from staff.
A resident with severe cognitive impairment and multiple diagnoses, including depression, was receiving psychotropic medication without a comprehensive care plan. The facility's care plan lacked measurable goals and non-pharmaceutical interventions, focusing only on potential drug-related complications. This deficiency was acknowledged by the DON and Corporate RN during a surveyor discussion.
A facility failed to ensure a resident's representative participated in the care planning process. Despite the resident's severe cognitive impairment and reliance on their daughter as a decision-maker, no formal care plan meeting was held after the MDS assessment. Staff confirmed updates were given, but there was no documentation of a care conference or rescheduling efforts.
A staff member in an LTC facility violated medication administration policy by borrowing Miralax powder from another resident's supply due to a shortage. The facility's policy prohibits administering medications supplied for one resident to another. The staff member claimed the medication was a house-stock item awaiting restocking. The DON expected the staff to restock rather than borrow.
A resident was discharged from a facility without confirmed arrangements for necessary home health services, including IV antibiotics and wound care. The social worker failed to ensure that the referrals were received and services were confirmed with the home health agencies. After discharge, it was discovered that the initial agency did not provide the required services, prompting the social worker to arrange new providers.
A facility failed to implement physician-ordered pressure injury prevention therapies for a resident with a recently healed pressure injury. Despite orders to wear protector boots and float heels, observations showed the resident's heels resting against bed linens without protectors. Staff interviews revealed the resident often refused the booties, and there was miscommunication about replacement booties. The facility's policy required documentation of compliance, but the resident's refusal was not documented in the medical record.
A resident with physical and cognitive limitations was not provided with prescribed bilateral wrist/hand splints to maintain range of motion and prevent contractures. Despite physician orders and documentation indicating the splints were applied, multiple observations showed the resident without them, with hands closed in a fist. The Occupational Therapist confirmed the splints' purpose, and the Nurse Manager acknowledged the discrepancy between records and observations.
The facility failed to provide adequate pain management for two residents by not including pain scale parameters in medication orders and not documenting comprehensive pain assessments. One resident's orders for Acetaminophen and Oxycodone lacked specific pain scale guidance, and another resident's record did not document pain assessment details before administering medication. The DON and clinical services staff acknowledged these deficiencies.
The facility failed to ensure that two staff members completed the controlled drug count at each shift change, as required by policy. A nurse pre-signed the Shift Count sheet, indicating no actual count occurred, and another shift lacked the required signatures. The DON was informed of these deficiencies.
The facility failed to secure medications and needles, as observed in unlocked emergency carts in residents' hallways. An emergency cart in the South Unit was found with open drawers containing epinephrine and a glucagon syringe, while another cart in the North Unit had unsecured needles. The DON confirmed the carts were unlocked and acknowledged the lack of a policy for securing them.
A resident with physical and cognitive limitations was observed not wearing prescribed wrist/hand splints, despite documentation indicating otherwise. The resident's TAR inaccurately recorded splint application during day shifts, which was confirmed by the South Unit Nurse Manager. The discrepancy was discussed with the DON, but no further information was provided.
The facility failed to provide written notification of hospital transfers for two residents, as identified during a recertification survey. In both cases, the residents' representatives were notified via phone, but no written documentation was provided. Interviews with staff confirmed this deficiency, highlighting a lapse in the facility's notification process.
The facility failed to provide written notification of its bed hold policy to residents or their representatives upon transfer to a hospital. This deficiency was identified for a resident with moderate cognitive impairment and another resident during a complaint review. Staff confirmed that the policy was discussed verbally but not provided in writing, leading to the deficiency.
A facility failed to document the specific reasons for administering a PRN antianxiety medication and did not implement non-pharmacological interventions before its use. A resident received the medication multiple times, with post-medication assessments indicating ineffectiveness, yet there was no documentation of attempted non-pharmacological interventions or monitoring of behaviors and side effects. The DON confirmed these concerns during an interview.
Failure to Document Abuse Allegation and Fall Event in Medical Record
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for a resident who alleged physical abuse and was found on the floor. According to the facility’s own incident reporting and investigation for a facility-reported incident, the resident alleged that a staff member answered the call bell and hit the resident on the head. Witness statements obtained during the facility’s investigation indicated that the resident was later found sitting on the floor of the room at approximately 11:40 PM. The allegation was reported to the State Agency and local police, and the facility conducted an investigation and submitted a follow-up report, but they were unable to verify that the resident was struck on the head as alleged. When surveyors reviewed the resident’s medical record, there was no documentation of the resident’s allegation of physical abuse, no notation that the resident had an unwitnessed fall or was found sitting on the floor, and no related assessments or interventions documented in response to these events. An incident report dated the same night indicated the resident was observed sitting on the floor next to the bed, but this document was labeled as privileged, confidential, and not part of the medical record. A skin assessment completed the following day documented no current tissue injury and no skin issues, but did not indicate the reason the assessment was performed. Thus, the medical record lacked required entries regarding the allegation of abuse, the fall event, and any clinical assessments or interventions associated with those events.
Failure to Maintain Accurate Controlled Drug Count Documentation
Penalty
Summary
The facility failed to ensure that controlled drug counts were properly maintained and signed by two staff members at each change of shift, as required. During a review of four drug control books, it was found that two of them contained documentation errors, including pre-signing of shift counts, missing signatures, and signatures that were crossed out. In one instance, a shift count was signed for a future shift before it occurred, and in another, a nurse crossed out her signature after realizing a mistake. Additionally, there were cases where the required signatures for both the outgoing and incoming nurses were missing, and no credible evidence was provided that the count had been performed as required. Interviews with nursing staff and nurse managers confirmed these documentation errors and lapses in procedure. The Director of Nursing acknowledged that pre-signing and incomplete documentation of controlled drug counts had been identified in previous audits and remained an ongoing concern. The findings indicate that the facility did not consistently follow its own procedures for controlled substance accountability, as evidenced by the incomplete and inaccurate shift count records.
Unclean Drinkware Found on Coffee Cart
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary environment to prevent the development and transmission of communicable diseases and infections by not ensuring that residents' drinkware was clean. During an inspection of the coffee serving cart, 4 out of 6 coffee mugs were found to have a chalky, grayish-brown material inside, which was easily removed by gentle rubbing. The kitchen cook initially reported that the cups were clean and ready for use, but upon further inspection, confirmed the presence of the residue. The administrator also confirmed the observation of the unclean mugs. The Certified Dietary Manager acknowledged awareness of the issue and attributed it to new employees not mastering the cleaning process.
Resident Abuse Incident by GNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Geriatric Nursing Assistant (GNA) who physically mishandled a resident. The incident occurred when the GNA attempted to place the resident into a wheelchair, during which the GNA grabbed and wrestled with the resident, resulting in bruises and bloody skin tears on the resident's hands. The incident was witnessed by the resident's roommate, who confirmed that the GNA pushed and pulled the resident into a chair, causing the injuries. The facility's investigation revealed that the GNA had an active license and a clear background check at the time of hire, and had received abuse training earlier in the year. Despite this, the GNA refused to provide a statement about the incident and reacted inappropriately when questioned by a Licensed Practical Nurse (LPN). The facility's final report to the Office of Health Care Quality (OHCQ) confirmed that the abuse allegation was verified through evidence collected during the investigation and interviews with the victim and a witness.
Removal Plan
- Abuse education was provided to all employees
- Resident skin assessments and resident interviews were done
- The employee was immediately terminated
- The GNA was reported to the nursing registry
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility staff failed to properly store, label, and date food items in the kitchen's walk-in refrigerator and dry storage room, as observed during a survey. In the walk-in refrigerator, several opened containers, including a 46-ounce container of thickened Ready Care lemon water, an 8-quart container of applesauce, and a fruit cocktail, were not labeled with the date they were opened. Additionally, a container of gravy was labeled with the wrong date, and two containers of Thick and Easy beverages were found to be expired. These observations were confirmed by the Dietary Manager, Staff #10, who was present during the inspection. In the dry storage room, multiple items were not dated when received, including a 6-pound 9-ounce container of mandarin oranges, three 6.75-pound cans of chili con carne, a 6.6-pound can of sliced white potatoes, six 8-pound cans of concord grape jelly, and two 6.56-pound cans of carrots. Additionally, an opened bag of hamburger buns and an opened bag of hot dog buns were not dated when opened. These findings were also confirmed by Staff #10. The Nursing Home Administrator was informed of these concerns and acknowledged them.
Infection Control Deficiency Due to Unclean Drinkware
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment, which is essential for preventing the development and transmission of communicable diseases and infections. During an observation by two surveyors, it was noted that 11 plastic mugs, designated for resident use, were placed upside down on a tray on a food cart. Upon inspection, two of these mugs had a chalky white/gray film inside, which could be easily removed with gentle finger rubbing. This observation was confirmed by Staff #12, a Dietary Aide, who then removed the soiled mugs. Later, another observation in the South Wing hallway revealed a similar issue with a food cart near resident rooms. Two trays of upside-down plastic mugs were found, and two of the mugs on one tray also had a chalky white/gray film inside. This was confirmed by Staff #11, an RN and South Wing Unit Manager, who removed the soiled mugs and stated they would inform the kitchen of the concern. The Nursing Home Administrator was made aware of these infection control concerns and acknowledged the issue.
Failure to Obtain Signature on NOMNC for Resident
Penalty
Summary
The facility failed to obtain a signature or document refusal to sign the Notice of Medicare Non-Coverage (NOMNC) for a resident who was discharged from Medicare Part A services but had benefit days remaining. This deficiency was identified for one resident who intended to remain at the nursing facility receiving non-skilled care. The NOMNC is a critical document that informs residents of their rights and protections related to financial liability and appeals when being discharged from Medicare services. The facility is required to issue this notice at least two calendar days before the last day of Medicare coverage, allowing the resident or their representative to appeal the decision to terminate paid coverage. In this case, the review of the resident's Beneficiary Notification checklist showed that the NOMNC was dated but not signed, with a statement indicating it was reviewed with the resident's brother via telephone. However, there was no documentation of who conducted the notification or whether the representative refused to sign. A progress note by the social services director claimed that the brother signed the documents, but the NOMNC lacked a signature. An interview with the social services director revealed that the NOMNC was usually mailed to representatives who could not come to the facility, but there was no evidence that this was done for the resident in question. The director admitted that his documentation regarding the signed NOMNC and its distribution was inaccurate.
Failure to Report Maintenance Issues in Resident Rooms
Penalty
Summary
The facility failed to ensure that staff reported areas in need of repair in residents' rooms to the maintenance department, leading to deficiencies in maintaining a safe, clean, and homelike environment. On multiple occasions, surveyors observed issues such as a frayed fall mat and a pillow on the floor in a bathroom, unpainted scrapes on a wall, and unpainted spackling in another bathroom. These observations were made over several days, indicating that the issues were not addressed promptly. The maintenance director confirmed that he was unaware of these issues as they had not been reported through the facility's electronic system for tracking maintenance concerns. Despite checking the system twice daily, the maintenance director had not identified any problems in the affected rooms. The lack of communication between staff and maintenance led to the persistence of these deficiencies, as the maintenance director stated that he could not fix issues he was not informed about.
Failure to Develop Comprehensive Care Plan for Resident on Psychotropic Medication
Penalty
Summary
The facility staff failed to develop and implement a comprehensive, resident-centered care plan for a resident receiving psychotropic medications. The resident, who was admitted to the facility following an acute hospital stay, had severe cognitive impairment and diagnoses including dementia, depression, and adjustment disorder with mixed anxiety and depressed mood. The resident was prescribed Fluoxetine, an antidepressant, which was administered daily. However, the care plan only addressed the resident's response to potential drug-related complications and did not include measurable goals or non-pharmaceutical interventions targeting the resident's symptoms for antidepressant use. The deficiency was identified during a review of the resident's medical records and care plans, which revealed a lack of a comprehensive care plan with specific, measurable goals. The care plan included interventions such as administering medications, observing for side effects, and encouraging the resident to express feelings, but it did not adequately address the resident's targeted symptoms or include non-pharmaceutical interventions. The concerns were acknowledged by the Director of Nurses and the Corporate Registered Nurse during a discussion with surveyors.
Failure to Ensure Resident Representative Participation in Care Planning
Penalty
Summary
The facility failed to ensure the participation of a resident's representative in the care planning process, which was evident for one resident reviewed for care planning. The Minimum Data Set (MDS) assessment, which is crucial for developing a care plan, was completed for the resident, but the facility did not hold a care plan meeting with the resident's representative. The resident, who had severe cognitive impairment, relied on their daughter as the decision-maker. Despite the care plan conference summary report indicating that the representative was unable to participate initially and that a meeting would be rescheduled, there was no evidence that such a meeting was ever rescheduled or held. Interviews with facility staff revealed that while updates were provided to the resident's representative, a formal care conference meeting did not occur. The social services director and a social service designee confirmed that the care conference was conducted over the phone due to the representative's inability to attend physically. However, there was no documentation to support that this phone meeting took place or that any rescheduling efforts were made, as initially noted in the care conference summary report.
Medication Administration Policy Violation
Penalty
Summary
The facility staff failed to adhere to professional standards of practice during medication administration. During an observation, a staff member prepared medications for a resident and, upon discovering a shortage of Miralax powder, borrowed the medication from another resident's supply. This action was contrary to the facility's policy, which explicitly states that medications supplied for one resident should never be administered to another. The staff member later claimed that the borrowed medication was a house-stock item, but acknowledged that the supply was depleted and awaited restocking. The Director of Nursing confirmed that the staff responsible for restocking was absent, but expected the staff member to obtain the key and restock the medication rather than borrowing from another resident's supply.
Inadequate Discharge Planning for Resident
Penalty
Summary
The facility failed to ensure appropriate discharge plans for a resident who was admitted after hospitalization for an infection and required IV antibiotics, wound care, PT, and OT. A care plan was initiated to discharge the resident home with home health care services. However, the discharge planning process was inadequate as the social worker did not confirm arrangements with the home health providers before the resident's discharge. The discharge planning review document lacked contact information for the agencies involved, and the social worker only faxed referrals without confirming receipt or services with the agencies. After the resident's discharge, it was discovered that the IV antibiotic provider no longer offered the required services, and the home health agency had not received the referral. The social worker attempted to rectify the situation by contacting new agencies to arrange for the necessary services. The deficiency was identified when the resident's family reported the lack of follow-up from the agencies, and the social worker confirmed the absence of documentation indicating discussions with the initial agencies.
Failure to Implement Pressure Injury Prevention Therapies
Penalty
Summary
The facility failed to implement physician-ordered pressure injury prevention therapies for Resident #77, who had a recently healed pressure injury on the heel. Physician orders required the resident to wear protector boots while in bed and to float heels every shift to prevent skin breakdown. However, multiple observations during the survey revealed that the resident was not wearing heel protectors, and the heels were resting against the bed linens. Interviews with staff indicated that the resident often refused to wear the booties, and there was a miscommunication regarding the availability and use of replacement booties when the original ones were sent to the laundry. The facility's policy on pressure injury prevention required documentation of compliance with interventions in the medical record. However, a review of Resident #77's progress notes failed to show documentation of the resident's refusal to wear the heel protector booties. Interviews with the physician and nursing staff confirmed the lack of documentation and miscommunication regarding the use of heel protectors. The Director of Nursing and the president of Clinical Services acknowledged the concerns raised during the survey, but no additional information was provided before the survey concluded.
Failure to Apply Prescribed Splints for Resident's Range of Motion Maintenance
Penalty
Summary
The facility staff failed to provide appropriate treatment to maintain a resident's range of motion, as evidenced by the lack of application of prescribed bilateral wrist/hand splints for a resident with physical and cognitive limitations. The resident, who was totally dependent on staff for activities of daily living, had a physician's order for wearing the splints to prevent further contractures and protect the hands from injury. Despite this order, multiple observations over several days revealed that the resident was not wearing the splints, and their hands were consistently observed to be closed in a fist. The Occupational Therapist confirmed the purpose of the splints was to maintain hand alignment and prevent worsening of finger contractures. However, the South Unit Nurse Manager acknowledged the inconsistency between the treatment administration record, which documented that the splints were applied, and the surveyor's observations. The nurse manager confirmed the concerns regarding the non-application of the splints during the observed periods.
Deficiency in Pain Management Documentation and Parameters
Penalty
Summary
The facility failed to ensure proper pain management for two residents by not including pain scale parameters in as-needed pain medication orders and not documenting comprehensive pain assessments. For one resident, the medication orders for Acetaminophen and Oxycodone lacked specific pain scale parameters to guide administration. The resident was observed in pain after a dressing change, and the LPN indicated that the resident requested Oxycodone when their pain level was 6, despite the absence of a formal pain scale in the orders. The Director of Nursing and the Senior President of Clinical Services acknowledged the omission of pain scale parameters in the Oxycodone order. Another resident was observed expressing severe back pain, yet their medical record did not document a pain assessment, including the location and type of pain, before administering pain medication. The resident's medication administration record showed pain medication was given, but follow-up pain scales were recorded as 0 without prior documentation of non-pharmacological interventions. The LPN reported implementing non-pharmacological interventions only if the resident continued to complain after receiving medication. The regional director of clinical services confirmed that nurses were expected to document pain assessments and non-pharmacological interventions before administering as-needed pain medications.
Failure to Complete Controlled Drug Count at Shift Change
Penalty
Summary
The facility failed to ensure that two staff members completed the controlled drug count at the change of each shift, as required by their Controlled Substance Storage policy. This deficiency was identified during a review of the facility's drug control books, where it was found that one out of three books did not have the required documentation. Specifically, the Shift Count documentation for the Section 1 North medication cart showed that a shift count was completed and signed by the Coming On Duty Nurse and the Going Off Duty Nurse. However, further review revealed that the Going Off Duty Nurse had pre-signed the document, indicating that no actual count had occurred at that time. During an interview, the nurse confirmed that pre-signing the Shift Count sheet was her standard practice, as she had been instructed to do so. The unit nurse manager intervened during the interview to correct this practice, instructing the nurse to sign the Shift Count at the time of the count. Additionally, a review of the Shift Count documentation for another shift failed to reveal a signature for the offgoing nurse, further indicating that the required procedure was not followed. The Director of Nursing was informed of these findings, highlighting the issue of staff pre-signing the shift count documentation.
Unsecured Emergency Carts with Medications and Needles
Penalty
Summary
The facility failed to ensure the security of medications and needles, as evidenced by observations of unlocked emergency carts in residents' hallways. During a survey, it was observed that the lower drawer of an emergency cart located in the South Unit near the nurse's station was slightly open and not locked. The top drawer of the same cart was also found open, containing an amp of epinephrine and a glucagon syringe. A similar observation was made on the North Unit, where another emergency cart was found unlocked with unsecured needles in the third drawer. The Director of Nursing confirmed the observations, acknowledging that the emergency carts were unlocked and the medications unsecured. A nurse reported that the emergency cart is not kept locked and is stocked by the night shift. The Director of Nursing also admitted that the facility lacked a policy regarding the security of emergency carts, which contributed to the deficiency observed during the survey.
Inaccurate Documentation of Splint Application
Penalty
Summary
The facility failed to ensure that staff documented only the interventions that were completed, specifically regarding the application of wrist/hand splints for a resident with physical and cognitive limitations. The resident was dependent on staff for activities of daily living and had an order to wear bilateral wrist/hand splints for up to six hours daily to reduce the risk of further contracture, with skin integrity checks required pre- and post-wear. However, multiple observations over several days revealed that the resident was not wearing the splints as ordered, and their hands were consistently observed to be closed in a fist. Despite these observations, the treatment administration record (TAR) inaccurately documented that the splints were applied during the day shifts on two specific days. The South Unit Nurse Manager confirmed the discrepancy between the TAR and the actual observations, acknowledging that the splints were not applied as documented. The Director of Nursing was informed of these concerns, but no additional information was provided before the survey concluded.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of transfer to residents and/or their representatives upon transfer to the hospital. This deficiency was identified during a recertification survey for one resident and one complaint. In the case of Resident #59, the medical record review showed that the resident experienced difficulty breathing and was sent to the emergency room on the attending provider's order. Although the resident's representative was notified via phone, there was no evidence of written notification regarding the transfer and its reason. Interviews with staff, including a unit manager and the nursing home administrator, confirmed that notifications were made via phone calls and not in writing. Similarly, for Resident #301, the clinical record review revealed a transfer to the emergency room, but no written notice of transfer was found in the medical record. An interview with the Director of Nursing confirmed the absence of such documentation, acknowledging this as a deficiency. The lack of written notification in both cases highlights a failure in the facility's process for informing residents and their representatives about hospital transfers.
Failure to Provide Written Bed Hold Policy Notice
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of the facility's bed hold policy upon transfer to an acute care facility. This deficiency was identified during a recertification survey for one resident and one complaint. Specifically, Resident #59, who had been living in the facility since November 2022 and had moderate cognitive impairment, was transferred to the hospital due to difficulty breathing. The facility did not provide a written copy of the bed hold policy to the resident's representative, as confirmed by a unit manager and the director of nursing. The staff indicated that the policy was discussed verbally but not provided in written form upon transfer. Additionally, a review of another resident's clinical record revealed a similar deficiency. The resident was transferred to the emergency room, and there was no evidence that a written bed hold policy notice was provided to the resident or their representative. The Director of Nursing confirmed the absence of the document in the resident's medical record, acknowledging this as a deficiency. The facility's practice of discussing the policy verbally without providing written documentation upon transfer led to these findings.
Failure to Document PRN Psychotropic Medication Use and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to document the specific reason for administering a psychotropic medication prescribed as needed (PRN) and did not implement non-pharmacological interventions before administering the medication. This deficiency was identified during a recertification survey for a complaint involving a resident who was allegedly chemically restrained with an antianxiety medication. The attending provider had ordered the medication to be administered every 12 hours PRN for agitation/anxiety, but the medical records did not specify the behaviors that warranted the medication's use. The medication administration record (MAR) for the resident showed that the antianxiety medication was administered on several occasions, with post-medication assessments indicating that the medication was ineffective. Despite this, there was no documentation of non-pharmacological interventions attempted before administering the medication, nor were there records of interventions implemented following the ineffective assessments. Additionally, there was a lack of ongoing monitoring of the resident's behaviors and side effects related to the medication use. The director of nursing confirmed these concerns during an interview.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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