Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Future Care Capital Region during CMS and state inspections, most recent first.
The facility failed to notify the Ombudsman of resident transfers and discharges to the hospital. Record reviews and interviews showed this occurred for multiple residents with repeated hospitalizations, and there was no documentation in the medical records that the Ombudsman was notified. The LNHA stated the process had not been completed due to a change in Social Services personnel.
The facility had multiple documentation and care failures involving medication ordering, controlled substance administration, insulin pen technique, and respiratory charting. A resident had duplicate oxycodone orders and missing MAR documentation for controlled drug removals, another resident on dialysis had conflicting blood pressure medication instructions that were documented inconsistently, two residents received insulin from multidose pens without the port being cleaned or the needle being primed, and a resident’s chart incorrectly stated mechanical ventilation despite respiratory services confirming the resident was not on a ventilator.
Failure to Provide Proper Respiratory Care and Services: Multiple residents had respiratory equipment or airway devices observed at the bedside without required room signage, and one resident had oxygen equipment in the room without an active order. A resident with an oxygen concentrator had unlabeled tubing and humidifier bottle, while another resident with a tracheostomy and ventilator had no active order for trach care. Records for several ventilator-dependent residents showed orders for emergency oxygen supplies at bedside, but the required signage was not posted.
Food service equipment and monitoring practices were deficient when a beverage dispenser nozzle had black substance on it, an ice scoop was stored improperly on top of the ice machine, blankets were found under a steamer, meal temperature logs did not identify each item temped, and a refrigerator used by residents and visitors had a cracked internal thermometer with conflicting temperature readings.
Improper Sanitizer Levels and Sink Log Documentation: Surveyors found the 3-compartment sink sanitizer was not maintaining the required 200-300 ppm range, with testing showing levels below 200 ppm until chemical was manually added. Review of the chemical sanitizer logs also showed multiple meal services documented at 400-500 ppm, outside the recommended range, with no proper documentation to ensure safe sanitization of kitchen items.
A resident with CHF, severe obesity, DM with renal manifestation, and a right heel wound was found with drainage staining the bed linen and severely overgrown toenails. Staff failed to promptly schedule the ordered in-house podiatry consult, leaving the resident without timely nail care for nearly a month; the podiatrist later found mycotic, elongated, discolored, and incurvated toenails requiring wound care.
Advance Directive Not Obtained or Documented: A resident’s MOLST stated that choices were based on an advance directive, but the document was not found in the chart. Survey review and staff interviews showed social work was responsible for assessing advance directives on admission, yet the record only documented contact with a family member about code status wishes and did not show that the resident’s advance directive was obtained or documented.
Damaged Wall and Doorframe in Resident Room: A resident room had a severely marred and chipped wall next to the bathroom, including the bathroom doorframe. The PCU Nurse Manager stated the damage was caused by the Hoyer lift and shower stretcher, and maintenance staff were later observed repairing the wall.
Background Check Not Completed Before Employee Worked With Residents. The facility failed to ensure a criminal background check was completed before an employee began working with residents. Review of the employee file showed the GNA was hired and worked multiple shifts with residents before the background check was initiated and completed, and the NHA confirmed the first scheduled work day and that current employee files were under review.
A resident receiving hemodialysis had no comprehensive care plan addressing dialysis care, including care coordination with the dialysis center, care of the permacath site, or emergency care. Although the resident had orders for HD 3x/week and for monitoring the right chest permacath site every shift, the care plan did not include a dialysis-related problem, and the RCSM acknowledged the omission.
Care plan timing and accuracy deficiencies were identified for two residents. One resident reported not attending a care plan meeting, and the record contained no documentation that a meeting was held, while the LNHA later stated the facility had no documentation of a care plan being held. Another resident had a current care plan for anticoagulant use and bleeding risk even though the chart showed no current anticoagulant order, only a discontinued Heparin order.
Improper labeling of tube feeding and flush bags was observed for a resident with a G-tube and physician-ordered enteral feedings and water flushes. Staff found one clear liquid flush bag without a label and later a labeled flush bag without a date; the PCU Nurse Manager stated that enteral feeding and water flush bags are to be labeled and dated, and the facility policy stated that fillable enteral bags are changed daily.
A resident with a PICC line did not receive the ordered dressing change on schedule. The dressing was observed dated from the hospital, the TAR showed the weekly change order had started, and the chart lacked documentation explaining why the dressing was not changed. The DON stated the assigned RN or LPN was responsible for completing the dressing change and that the LPN did not communicate to the next shift that it remained undone.
A resident’s oxycodone was not administered consistently with the ordered pain parameters. The resident reported needing to stay on a schedule with pain medication because waiting too long made pain harder to control. Record review showed missed administrations when pain ratings met the PRN criteria and other doses given outside the ordered pain range and time frame; the DON agreed the medication was not given as ordered.
Failure to document controlled pain medication administration: The facility did not accurately document oxycodone administration for two residents. For one resident recovering from surgery, multiple oxycodone removals from facility supply had no matching MAR entries. For another resident with an oxycodone PRN order for pain, numerous doses were removed but not documented as administered on the MAR. Staff described the controlled-substance process, and an RN stated she must have forgotten to sign the medication out after giving it.
A resident recovering from recent surgery had duplicate oxycodone orders in the chart after a new Rx was written for the controlled substance but the earlier order was not discontinued. Staff documented administrations on both orders, including two doses recorded one minute apart on the MAR, showing the resident received the same medication under two active orders.
Unsecured medication carts and an expired IV medication were observed in the PCU medication area. Surveyors found an unattended, unlocked med cart with medications accessible, and also found an expired bag of Ertapenem in the med refrigerator. An LPN later confirmed the cart should have been locked when unattended.
Delayed Lab Result Documentation: A resident receiving IV fluids for hydration had a repeat BMP ordered, but the lab results were not available in the chart when reviewed by the surveyor. The DON later produced the outside lab results after calling the lab company, and the facility record lacked documentation showing the results were received or reviewed.
Menus and diet orders were not consistently followed for two residents. One resident reported missing menu items and meals sometimes arriving in disposable containers; on observation, lunch was initially missing gravy and pureed peach cobbler, which the UM had to retrieve. Another resident with a history of cancer and recent fractures reported persistent hunger and dissatisfaction with a soft bite-size diet, while records showed the diet order was not updated after the resident’s arm restriction was lifted and no dietary reassessment note was found. The resident also did not receive a pre-ordered turkey sandwich and instead was served a different entrée, with very poor meal intake.
A resident with ESRD on dialysis, PVD, and a history of colostomy had a care plan entered that incorrectly listed another resident’s name in the GI status problem statement. The Regional Clinical Services Manager said the care plan content was appropriate for the resident, but the wrong name was used in error.
An LPN administered insulin from multidose pens without cleaning the pen ports, and shared blood pressure equipment was used between two residents without disinfection. In the laundry room, three dryers contained significant debris, the facility lacked washer/dryer manuals and maintenance logs, and staff reported there was no proper sorting process for contaminated laundry or separate handling of heavily soiled items.
A working call system was not accessible or functioning properly for two residents. One resident’s call light was hanging on the bed frame instead of being within reach, and another resident was heard yelling for help while the call bell failed to light in the hallway or sound an audible alert when activated. The ADON stated staff must ensure operational call bells.
Survey Results Binder Not Accessible The facility failed to keep the survey results binder in a place readily accessible to residents, family members, and legal representatives. The surveyor did not see the binder in the front lobby and had to request it at the receptionist desk, where it was stored in a cabinet behind the desk. Review of the binder showed it did not contain the most recent recertification survey, and the Administrator acknowledged it was not current.
Incomplete staffing postings were observed for one unit. The daily staffing and assignment form did not include the facility name or total hours worked per shift, and a lobby posting showed staffing ratios but not the resident census. Record review also found missing nursing hours on multiple shifts for one of four units. The LNHA acknowledged that some posted staffing forms were incomplete and that the lobby report did not meet regulatory requirements for posting nursing staffing hours.
Facility staff failed to provide reasonable accommodations for residents by not ensuring call lights were within reach. During a tour, surveyors observed six residents without accessible call lights, with some cords hanging on the wall or on the floor. The RCSM confirmed the expectation for call lights to be available, highlighting a deficiency in accommodating resident needs.
Surveyors found that the facility failed to properly label enteral feeding supplies for four residents. Observations revealed unlabeled 60-cc enteral feeding syringes and tube feeding bags, despite physician orders and facility protocols requiring daily changes and labeling. This deficiency highlights a lapse in adherence to established tube feeding management procedures.
The facility failed to maintain accurate MOLST documentation for two residents. One resident's MOLST was outdated and did not reflect their severely impaired mental capacity, while another resident's MOLST lacked documentation of a surrogate, despite indicating informed consent by one. Staff confirmed these deficiencies, highlighting lapses in ensuring accurate care preferences and decision-making authorities.
The facility failed to notify the Ombudsman of a resident's hospital transfers, as required. The deficiency was identified during a review of the resident's medical records, revealing that notifications were not completed for two hospital transfers. The Regional Clinical Services Manager confirmed the oversight, and the Nursing Home Administrator acknowledged that notifications had not been made since the previous Administrator's tenure.
The facility failed to provide appropriate respiratory care for two residents. One resident was receiving oxygen therapy without a current physician order, despite it being required by the facility's policy. This oversight occurred after the resident's recent hospitalization. Another resident with a tracheostomy lacked a manual resuscitator bag in their room, contrary to physician orders for emergency supplies. These deficiencies highlight lapses in following prescribed respiratory care protocols.
A facility failed to follow up on a psychiatric consult for a resident, which recommended discontinuing one of two antidepressants. Despite the consult's findings, there was no documentation of follow-up actions by the physician or nursing staff. The DON confirmed the consult was due to the resident's depressive symptoms but acknowledged the lack of follow-up notes.
A facility failed to administer medication as prescribed for a resident. A nurse changed the timing of a seizure medication without consulting the doctor, and no documentation was found regarding this change. The incident was confirmed by the Regional Clinical Services Manager, and the facility's administrator expected the nurse to contact the physician before altering medication times.
The facility was found deficient in sanitary and safe food handling practices during an annual survey. Observations revealed outdated and unlabeled food items in the kitchen and a refrigerator on the VS2 unit. The VS2 Unit Manager admitted that unlabeled food should be discarded, and the Administrator acknowledged the labeling and dating issues.
Facility staff failed to accurately document the Morse Fall Scale (MFS) assessments for a resident, leading to incorrect fall risk assessments due to the omission of past fall history. The DON acknowledged the documentation errors but was unaware of the reasons for the omissions.
Facility staff failed to follow infection control practices by not performing hand hygiene before donning PPE. Despite a visible reminder sign, a nurse and two other staff members were observed removing PPE without sanitizing their hands. A RN confirmed the protocol was to perform hand hygiene first, but this was not adhered to.
The facility failed to notify two residents or their representatives in writing about the bed hold policy during transfers to an acute care facility. In one case, the family was informed by phone, but no documentation of the bed hold policy was found. In another case, documentation provided did not include the bed hold policy, despite claims it was issued.
Two residents experienced deficiencies in care: one did not receive prescribed medication for nausea, and another faced a delay in scheduling an orthopedic consult for spinal stenosis. The medication was available but not documented as administered, and the appointment was scheduled 14 days after the order, contrary to facility expectations.
Failure to Notify Ombudsman of Hospital Transfers and Discharges
Penalty
Summary
The facility failed to provide notification to the Ombudsman of resident transfers and discharges to the hospital. Surveyor record reviews and interviews showed this occurred in 8 of 8 hospitalizations for 4 residents reviewed for the discharge process, including residents who were sent to the hospital multiple times. Resident #9 was noted to have been hospitalized several times in November and December 2025, and the surveyor requested documentation that the Ombudsman had been notified of those transfers. During an interview, the NHA confirmed that the transfers had not been communicated to the Ombudsman for those months and stated that January 2026 notifications would be relayed timely. The local Ombudsman stated she had not been notified of resident transfers and discharges to the hospital, although she had been notified of involuntary discharges. Record reviews for Resident #10 showed hospital discharges on 8/8/2025 and 10/2/2025 with no documentation that the Ombudsman was notified. Resident #14 was transferred to the hospital on [DATE] and 11/3/2025, and Resident #17 was discharged to the hospital on 9/21/2025 and 12/24/2025, with no documentation of Ombudsman notification in either resident's record. The LNHA later provided an email notification to the Ombudsman covering August 2025 through January 2026 and stated the process had not been completed because of a change in Social Services personnel.
Medication, insulin, and respiratory documentation failures
Penalty
Summary
The facility failed to ensure medication ordering and administration records were accurate for a resident receiving oxycodone after recent surgery. Resident #168 had an order for oxycodone 10 mg every 4 hours as needed for pain, and the same order was entered again several days later without discontinuing the earlier order. The resident’s January 2026 MAR showed administrations documented on both orders, including doses recorded one minute apart on the same evening, creating duplicate current orders for the same controlled medication. The facility also failed to accurately document controlled substance administration for the same resident. Review of controlled drug receipt and disposition records showed oxycodone was signed out from facility supply on multiple occasions, but corresponding administrations were not documented on the MAR for several removals. The missing MAR documentation included doses removed on several dates and times, and the DON acknowledged that the controlled substance documentation was a concern. For Resident #15, who received dialysis on Tuesdays, Thursdays, and Saturdays, the facility failed to clarify conflicting blood pressure medication instructions. The record contained an order to hold blood pressure medication prior to dialysis due to hypotension, while the resident also had scheduled hydralazine, nifedipine ER, and carvedilol orders with hold parameters for low blood pressure and pulse. The MAR showed that on some dialysis days the medications were documented as both given and held, and the administration time report showed inconsistencies between the MAR entries and the actual administration times relative to dialysis. The facility also failed to follow expected technique when administering multidose insulin pens to two residents. During observation, an LPN administered lispro insulin to one resident and glargine insulin to another without cleaning the pen port before attaching the needle and without priming the needle before giving the dose. The Infection Preventionist confirmed that the expectation was to clean the port with alcohol and prime the needle with 2 units before dialing the ordered dose. In addition, the facility inaccurately documented respiratory care for Resident #96. Although a ventilator was observed at the bedside and respiratory services stated the resident was not on a ventilator in December 2025, nursing progress notes documented that the resident was on mechanical ventilation during that period. The annual MDS also was not coded to reflect ventilator use, yet later nursing documentation again stated the resident was on mechanical ventilation even though respiratory services confirmed the resident was not on a ventilator.
Failure to Provide Proper Respiratory Care and Services
Penalty
Summary
The facility failed to provide proper respiratory care and services for residents who had ventilators, oxygen equipment, and tracheostomies. During a tour of the PCU Nursing Unit, emergency oxygen tanks were observed attached to the ventilator stands at the bedsides of Residents #1, #7, #96, and #4, but there was no oxygen usage signage posted on their room doors. The medical records for Residents #1, #7, and #96 showed active physician orders for Respiratory Therapy to ensure emergency supplies were at bedside, including a full E cylinder oxygen tank on the ventilator every shift and to ensure the tank was at least 1500 pounds full. On the Arena Way Nursing Unit, Resident #140 was observed sitting in a wheelchair with an oxygen concentrator next to the bed, but the oxygen tubing and humidifier bottle were not labeled and dated, and there was no oxygen usage signage on the room door. Resident #140 stated that he/she did not use oxygen, and the interim Nurse Manager stated that the resident no longer used oxygen and removed the concentrator from the room. The record review showed that Resident #140 did not have an active physician order for oxygen. For Resident #4, the record review showed no active physician order for tracheostomy care, even though the resident had a tracheostomy and was observed with a ventilator attached to the tracheostomy tube.
Food Service Equipment and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to maintain food service equipment in a manner that ensures sanitary food service operations. During kitchen and dining area observations, a multi-nozzle beverage dispenser was seen with black substance on each nozzle, and an ice scoop was stored horizontally on top of the ice machine rather than in a position that would allow proper drainage between uses. In the kitchen service area, four separately folded white blankets were observed resting under the boiler free steamer. The food service temperature logs for prepared meal items also did not identify each item’s temperature that was measured, and the Food Service Director confirmed that each item temped should have been listed next to the recorded temperature. In the Arena Way cafe kitchen service area, a refrigerator for resident and visitor use had an internal thermometer reading 54 degrees Fahrenheit while the external digital display showed 36 degrees Fahrenheit, and the internal thermometer had cracked glass on its face.
Improper Sanitizer Levels and Incomplete Sink Chemical Logs
Penalty
Summary
The facility failed to appropriately document food temperature logs to prevent foodborne illness. During an annual survey, the surveyor observed and reviewed the kitchen and dining areas and found issues with the 3-compartment sink chemical sanitizer system. When the Food Service Director was asked how staff ensured proper chemical sanitization, testing of the sanitizing compartment showed there was not enough chemical detected to sanitize dishes, and repeated testing after pumping the chemical solution still showed levels below 200 ppm. The Food Service Director then manually added chemical solution, which brought the sanitizer level into the required 200-300 ppm range. The surveyor also reviewed the 3 Compartment Sink Chemical Sanitizer logs and found documentation showing sanitizer levels outside the recommended range on multiple meal services in January 2026, including readings of 500 ppm and 400 ppm. The log instructions stated to alert the Food Service Director immediately if bleach sanitizer was not in the recommended range. At the time of the surveyor's discussion with the Food Service Director, the director confirmed the vendor for the sink sanitizer device would be contacted and that staff would be notified to wash kitchen pots, pans, trays, eating/drinking utensils, and cooking utensils in the dishwasher while the 3-compartment sink was inoperable.
Delayed Podiatry Care and Poor Dignity Maintenance
Penalty
Summary
Facility staff failed to ensure Resident #13’s dignity, honor the resident’s rights, and provide necessary in-house podiatry services in a timely manner. On 01/20/2026, the resident was observed with bed linen containing multiple yellow drainage stains from a wound on the right heel and with severely overgrown, thickened toenails on both feet. During interview, the resident stated they were unable to trim their own nails and had informed staff of this need upon admission. Regional Clinical Services Staff #23 was present during the observation and acknowledged the drainage and overgrown toenails, stating she would follow up on the issues. Record review showed the resident was admitted on 12/26/2025 with a history of cardiomyopathy of chronic heart failure, severe obesity, type 2 diabetes mellitus with renal manifestation, and a right heel wound. Admission orders included a podiatry consult as applicable, but staff initially failed to schedule the in-house podiatry visit. The resident was not added to the podiatry schedule until 01/20/2026, nearly one month after admission. Subsequent review showed the podiatrist assessed the resident’s overdue toenails as mycotic, elongated, and discolored, and noted incurvated left great toe and second toenails requiring daily dressing and wound care. Staff later acknowledged the delay in triggering and scheduling podiatry services.
Advance Directive Not Obtained or Documented
Penalty
Summary
The facility failed to obtain and maintain Resident #15’s advance directive in the medical record, even though the resident’s Maryland Order for Life Sustaining Treatment (MOLST) indicated that the resident’s choices were based on an advance directive. During record review, the surveyor could not locate the advance directive referenced by the MOLST in the paper chart or electronic record. Interviews with the NHA and the Director of Social Work showed that social work staff were responsible for assessing whether residents had advance directives on admission, but neither could confirm that Resident #15’s advance directive had been obtained. The electronic record contained a social work note stating the resident could not understand CPR procedures and that staff contacted a family member to obtain code status wishes, but the note did not document that the facility asked whether the resident had an advance directive. The NHA later stated the facility obtained the resident’s HPOA, dated [DATE], and agreed that the HPOA, as a type of advance directive, should have been attempted to be obtained on admission.
Damaged Wall and Doorframe in Resident Room
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident in room [ROOM NUMBER]. During a unit tour on 1/20/2026 at 1:15 PM, the wall next to the bathroom and the bathroom doorframe in that room were observed to be severely marred and chipped. In an interview on 1/28/2026, the PCU Nurse Manager stated that the damage was caused by the Hoyer lift and the shower stretcher and said she would enter the repair in TELS for maintenance. On 1/30/2026 at 9:05 AM, the surveyor and the PCU Nurse Manager observed maintenance staff in the room repairing the wall next to the bathroom.
Background Check Not Completed Before Employee Worked With Residents
Penalty
Summary
The facility failed to have an effective system in place to ensure criminal background checks were completed before allowing an employee to work with residents. Review of the facility’s Abuse Prohibition policy stated that prospective employees would have a background screening completed per Human Resource Policies for applicant screening. Review of GNA #16’s employee file showed the employee was hired on 8/14/24, and timesheet data showed the employee worked with residents on August 14, 15, 16, 19, 20, 21, 23, 25, 26, 27, 28, and 29, 2024, as well as September 2 and 3, 2024. The employee file also contained a criminal background check document that was initiated and completed on 9/25/24. During interview, the NHA confirmed that GNA #16’s first scheduled work day was 8/14/24 and stated that all current employee files were in review.
Missing Dialysis Care Plan
Penalty
Summary
A comprehensive care plan was not developed and implemented for Resident #140 to address hemodialysis needs. Surveyor record review on 1/22/2026 found that the resident had physician orders for hemodialysis three times a week on Monday, Wednesday, and Friday, along with an order to monitor the right chest permacath site every shift, but the care plan did not include a problem related to dialysis care. The missing care plan content specifically involved care coordination, care of the dialysis access site, and emergency care. The facility’s policy and procedure for Hemodialysis and Care of Resident, reviewed by the surveyor on 1/22/2026, addressed care planning and coordination between the facility and the dialysis center, as well as nursing care for residents with dialysis access such as an AV fistula or permacath. During an interview, the Regional Clinical Services Manager reviewed the resident’s care plan and acknowledged that there was no specific care plan problem addressing dialysis care for Resident #140. No additional information was provided by the facility at survey exit.
Care plan timing and accuracy deficiencies
Penalty
Summary
The facility failed to ensure that resident care plans were completed within 7 days of the comprehensive assessment and were prepared, reviewed, and revised by a team of health professionals. For Resident #1, the resident stated in interview that he or she had not attended a care plan meeting and was alert and oriented to person, place, and time. A record review showed the resident had been admitted to the facility, but there was no documentation that a care plan meeting had been held. When the LNHA was asked for documentation, she initially presented a Resident Care Plan Attendance sheet dated 12/23/2026, then later stated that the facility did not have any documentation that a care plan was held for Resident #1. For Resident #140, the record review showed a current care plan for an anticoagulant medication and a related problem of being at risk for bleeding, but there was no current physician order for an anticoagulant medication. The only anticoagulant order in the record was a discontinued Heparin order with a start date of 9/22/2025 for 4 weeks. During interview, the RCSM reviewed the care plan and confirmed that Resident #140 did not have a current physician order for an anticoagulant medication.
Improper Labeling of Tube Feeding and Flush Bags
Penalty
Summary
Proper tube feeding management was not provided for Resident #10, who had a physician order for enteral/tube feedings and water flushes via a gastrostomy tube. During an observation on the PCU unit, the resident was seen in bed in no distress with two fluid bags hanging next to the bed: one labeled as enteral feeding and another containing a clear liquid substance that was not labeled. On follow-up observation, the tube feeding water flush bag was labeled with contents but did not have a date on the label. When asked about labeling expectations, the PCU Nurse Manager stated that enteral feeding bags and water flush bags were to be labeled and dated, and also stated that labels do fall off the bags. The facility policy and procedure for Tube Feeding Protocol indicated that fillable enteral bags are to be changed daily.
PICC Line Dressing Not Changed as Ordered
Penalty
Summary
Appropriate care and services were not provided for a resident with a PICC line. Resident #168 was observed on 1/20/26 with a PICC line in the right upper inner arm, and the dressing covering the line was dated 1/7. The resident stated the dressing had last been changed in the hospital. The surveyor and the resident’s LPN confirmed that the dressing date on the PICC line was 1/7. The unit manager confirmed there was an order for the PICC line dressing to be changed every 7 days on Wednesdays, and the January 2026 TAR showed the dressing change order started on 1/14/26. The TAR indicated the 1/14/26 dressing change was coded as “see progress notes,” but the progress notes contained no written explanation for why the dressing was not changed that day or why 20 days had passed since the last dressing change. The facility policy stated CVAD dressings are to be changed every 5 to 7 days and as needed if compromised. The DON stated the RN or LPN assigned to the resident on the day the dressing was due was responsible for changing it, and that the LPN did not communicate to the next shift that the dressing had not been completed.
Pain Medication Not Given Consistently With Order Parameters
Penalty
Summary
Safe, appropriate pain management was not provided for Resident #168. The resident told the surveyor that he/she had learned to keep a schedule with pain medication because waiting too long made it difficult to bring the pain back down to an acceptable level. The medical record showed an order for oxycodone 10 mg, 1 tablet by mouth every 4 hours as needed for pain rated 5-10, written on 1/10/26 and again on 1/16/26. Review of the January 2026 MAR and pain ratings showed 20 documented administrations of oxycodone from 1/11/26 through 1/21/26. The record showed instances where the resident reported pain ratings that met the order parameters, but no documentation that the medication was administered, including pain rated 0/10 at 7:00 AM with oxycodone pulled but not documented as given, and pain rated 5/10 at 9:50 AM with no documented pain medication administration. The record also showed oxycodone given outside the ordered pain parameters and time frames, including doses on 1/18/26 at 6:25 AM when pain was rated 0/10 and on 1/19/26 at 10:13 PM with pain rated 4/10 and again at 10:14 PM with pain rated 0/10. The DON was shown the medication being given outside the order parameters and agreed it was not given as ordered.
Failure to document controlled pain medication administration
Penalty
Summary
The facility failed to document medication administration according to procedures that ensure accurate disposition of medications. For Resident #168, who reported taking pain medication related to a recent surgery, the record showed an order for oxycodone 10 mg every 4 hours as needed for pain rated 5 to 10. The January 2026 MAR documented 20 administrations of oxycodone from 1/11/26 through 1/21/26, but the controlled drug receipt/record/disposition forms showed 9 oxycodone removals from facility supply with no corresponding MAR documentation for those administrations. The missing documentation included doses removed on 1/11/26, 1/12/26, 1/14/26, 1/16/26, 1/19/26, 1/20/26, and 1/21/26. For Resident #16, the record showed an oxycodone 5 mg order every 6 hours as needed for pain rated 6 to 10. The controlled drug receipt/record/disposition form dated 1/13/26 through 1/28/26 showed 11 oxycodone doses removed that did not have corresponding administration documentation on the January 2026 MAR. These missing entries included doses removed on 1/17/26, 1/19/26, 1/21/26, 1/23/26, 1/24/26, 1/25/26, 1/26/26, 1/27/26, and 1/28/26. During interviews, RN #24 and UM #22 described the process for removing, administering, and documenting controlled medications, and RN #24 later stated that she must have forgotten to sign the medication out on the MAR after giving it.
Duplicate oxycodone orders led to unnecessary medication administration
Penalty
Summary
The facility failed to adequately monitor a resident’s drug regimen, which allowed an unnecessary duplicate order for oxycodone. Resident #168 reported taking pain medications related to a recent surgery. Review of the clinical record showed that on 1/10/26 the resident had an order for oxycodone 10 mg, 1 tablet by mouth every 4 hours as needed for pain rated 5-10, and the same order was written again on 1/16/26 without the earlier order being discontinued, leaving two current orders for the same medication. Review of the January 2026 MAR showed 20 documented administrations of oxycodone from 1/11/26 through 1/21/26. From 1/18/26 through 1/20/26, staff documented giving oxycodone on both orders, and on 1/19/26 one dose was documented at 10:13 PM on the 1/10/26 order and another dose at 10:14 PM on the 1/16/26 order. During interview, the DON stated the second order was written because the pharmacy required a new prescription for the controlled substance, and that the older order should have been discontinued.
Unsecured medication carts and expired IV medication observed
Penalty
Summary
The facility failed to ensure that medications were secured in locked compartments and that an expired medication was not kept in the medication room. During an observation on the PCU unit, the surveyor and the PCU Nursing Manager saw a medication cart unattended and unlocked with the top drawer open outside a resident room. The PCU Manager closed and locked the cart after the observation and stated to RN #9 that the cart had been observed open and should have been locked. In interview, the PCU Manager stated that medication carts were expected to be locked when unattended by nursing staff. During a review of the PCU medication room, the surveyor observed a bag of Ertapenem 500 mg in 55 ml of normal saline in the medication refrigerator that was expired based on the use by/expiration date on the label. The PCU Manager stated she would notify the pharmacy and removed the IV medication from the medication room. On another unit, the surveyor observed a medication cart unattended and pushed into a wall cove near a resident room; the cart appeared unlocked and the surveyor was able to open the top drawer containing medications. An LPN identified herself as responsible for the cart and stated it should have been locked while unattended.
Delayed Lab Result Documentation
Penalty
Summary
The facility failed to obtain laboratory results in a timely manner for Resident #154, who had been receiving IV fluids for hydration. On 1/16/26, a change of condition note documented that lab results were reviewed by the Nurse Practitioner and an order was placed for IV fluids and a repeat BMP on 1/20/26. On 1/20/26, the surveyor observed an LPN remove the resident’s IV site after the resident had completed the ordered IV fluids. When the surveyor reviewed the resident’s record on 1/22/26, there was no lab result documented for the 1/20/26 BMP order. The surveyor also found no notation showing the results had been received or reviewed, and the lab order book had no check mark or entry in the results received section and the doctor reviewed column was blank. During interview, the DON produced the outside lab results and stated she had to call the lab company to have them send the results; she was not sure why the results had not been uploaded into the resident’s medical record.
Menus and Diet Orders Not Followed for Two Residents
Penalty
Summary
Facility staff failed to ensure that food menus were followed and prepared in advance to meet residents’ meal choices. During an interview, Resident #11 reported that food items listed on the meal ticket menu were sometimes not received and that meals were sometimes delivered in disposable containers. On observation, Resident #11’s breakfast was served in a plastic square takeout container, although the meal ticket appeared accurate. Later, Resident #11’s lunch tray was delivered with normal dishware, but two items listed on the meal ticket were missing at the time of delivery: extra gravy and pureed peach cobbler. The unit manager stated she returned to obtain the gravy and did not know why the peach cobbler was missing, noting that the resident’s food was plated on the dining room assembly line. Resident #27, admitted with a history of prostate cancer, bladder cancer, early-stage lung cancer, and status post left arm and left femur fractures, was observed with poor intake and complained of persistent hunger and not receiving enough suitable food. The resident stated that the soft bite-size diet ordered on admission was unappetizing and that the resident wanted more chicken with meals. Record review showed the diet order from 01/05/2026 allowed soft, bite-sized texture with regular bread, but a later meal ticket listed minced or pureed roll/margarine, which contradicted the diet order. After an orthopedic surgeon visit, the resident’s left arm restriction was lifted, but the diet order had not been updated and no dietary reassessment note was found from dietician staff. During lunch service, the resident again did not eat the entrée, reported that the pre-ordered turkey sandwich was not provided, and was served a beef pasta dish instead, resulting in less than 5 percent lunch intake.
Medical Record Inaccuracy Due to Wrong Resident Name in Care Plan
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for accuracy for one resident. During record review, Resident #15 was noted to have a past medical history including end stage renal disease, dependence on dialysis, peripheral vascular disease, and a history of colostomy. The surveyor reviewed the resident’s care plans and found that a care plan entered on 10/2/25 for Resident #15 stated, "Resident #29 has actual alteration in gastrointestinal status related to colostomy," even though Resident #29 was another resident in the facility. In an interview, the Regional Clinical Services Manager stated that the care plan content was appropriate for Resident #15, but the use of the other resident’s name was done in error.
Infection Control Failures in Medication Administration and Laundry Handling
Penalty
Summary
Infection prevention and control practices were not maintained during medication administration observations. On 1/28/26, an LPN prepared and administered lispro insulin from a multidose insulin pen for Resident #138 without cleaning the pen port before attaching the needle. Later that morning, another LPN prepared and administered glargine insulin for Resident #103 and also did not clean the insulin pen port before applying the needle. During the same observation, the LPN moved a portable blood pressure machine from Resident #103’s room into Resident #173’s room and used the same blood pressure cuff on both residents without any disinfecting or cleaning between uses. When interviewed, one LPN stated the pen should have been cleaned before use, and the other stated she should have wiped the blood pressure equipment between residents. The facility also failed to follow infection control protocols in the laundry process and did not maintain laundry dryers in sanitary and hazard-free condition. During observation of the laundry room on 01/29/2026, three dryers were found with significant debris covering the interior drum walls, including melted diapers, gloves, food, and other unidentified objects. Laundry staff stated there was no proper sorting process for laundry, including items marked as contaminated, and that heavily soiled or contaminated linens and pads were not being handled separately. The washer and dryer maintenance logs were missing from the room, and the facility did not have the manufacturer’s instruction manuals for the washer and dryer available for review.
Call System Not Accessible or Functioning for Two Residents
Penalty
Summary
A working call system was not available and accessible in resident bathroom and bathing areas, as evidenced by surveyor observations and staff interviews involving two residents. During a tour of the PCU Nursing Unit, Resident #96 was observed lying in bed with the head of the bed elevated and in no distress, but the call light device was hanging on the bed frame at the head of the bed rather than being accessible to the resident. In a separate observation, Resident #125 was heard yelling for help in the room, and the call bell did not light up in the hallway when activated and did not produce an audible signal to alert staff. The ADON stated that staff must ensure operational call bells and acknowledged that a technical issue was likely, noting that routine checks had not identified a problem before the surveyor’s observation.
Survey Results Binder Not Readily Accessible
Penalty
Summary
The facility failed to ensure that the most recent survey results were kept in a place readily accessible to residents, family members, and legal representatives. On 01/21/2026 at 8:35 AM, the surveyor did not observe a survey results binder in the front lobby and had to request it from the receptionist desk. Guest Services Staff #8 then removed the binder from a cabinet behind the desk and stated that the desk was manned 24/7. When the binder was reviewed at 8:40 AM, it did not contain the most recent recertification survey. The Administrator acknowledged that the survey binder was not current.
Incomplete Staffing Postings
Penalty
Summary
The facility failed to post the facility name and the total hours worked by staff on its Daily Staffing Schedule for one of four units, Vital Strong 1. On 01/30/2026 at 7:45 AM, review of the daily unit staffing and assignment form showed that it did not include the facility name or the total number of hours worked by staff per shift. At 7:52 AM, surveyors observed a laminated report titled Nursing Staff Directly Responsible for Resident Care posted in the lobby that displayed the date, licensed nursing staff ratio, and unlicensed nursing staff ratio written with a dry-erase marker, but the resident census was not posted. Record review at 9:45 AM showed that nursing hours were not listed for one of four units on 12/28/2025 day shift, 01/02/2026 evening shift, and 01/06/2026 night shift. During interview at 10:10 AM, the LNHA acknowledged that some posted assignment and staffing forms were incomplete and confirmed that the lobby report was not a permanent public record, did not include the census, and did not meet regulatory requirements for posting nursing staffing hours.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility staff failed to ensure that residents were provided reasonable accommodations, specifically regarding the accessibility of call lights. During an initial tour of the PPCU-1 unit, surveyors observed that six residents did not have call lights within reach. One resident was in bed with the call light cord hanging on the oxygen gauge on the wall, while two other residents had their call lights on the floor. Additionally, three more residents were observed without an available call light. The Regional Clinical Services Manager (RCSM) confirmed that the expectation was for call lights to be available for residents. This deficiency was identified through observations and interviews, indicating a failure to accommodate the needs and preferences of the residents in terms of call light accessibility.
Failure to Label Enteral Feeding Supplies
Penalty
Summary
The facility failed to adhere to proper tube feeding care and services for four residents, as observed by surveyors. During an initial tour, surveyors noted that three residents had 60-cc enteral feeding syringes at their bedsides that were not labeled with a date. Additionally, the tube feeding bag and tubing in another resident's room were also found to be unlabeled. These observations were made despite existing physician orders that required specific management of enteral feeding supplies, including changing syringes daily and labeling them appropriately. A review of the facility's Nursing Practice Manual revealed that the protocol required gastric syringes to be changed every 24 hours and labeled with the resident's name, date, and room number. Furthermore, the enteral product label was supposed to include the resident's name, room number, date, time, and rate, with the tubing label also requiring a date and time. The facility's failure to comply with these protocols resulted in the deficiency noted by the surveyors.
Deficiencies in MOLST Documentation and Surrogate Identification
Penalty
Summary
The facility failed to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) for two residents. For one resident, the MOLST form was outdated and did not reflect the resident's current mental capacity, which was severely impaired following a hospitalization. The facility did not update the MOLST upon the resident's return, nor did they obtain a proper advance directive to guide care. Interviews with staff confirmed the resident's incapacity to make informed decisions, yet the MOLST remained unchanged. For another resident, the MOLST indicated that a discussion and informed consent had occurred with a surrogate, as per the Health Care Decisions Act. However, the facility failed to identify or document the surrogate in the resident's medical record. When the surveyor requested the MOLST, it was confirmed that no surrogate was listed, and the Social Services Department was reportedly addressing the issue. These deficiencies highlight lapses in ensuring accurate and up-to-date documentation of residents' care preferences and decision-making authorities.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding the transfer of a resident to the hospital. This deficiency was identified during a review of the medical records of a resident who was transferred to the hospital on two occasions. The surveyor discovered that the required notification to the Ombudsman had not been completed for these transfers. During interviews, the Regional Clinical Services Manager confirmed that the notifications had not been made. The Nursing Home Administrator later acknowledged that notifications had not been completed since November, as the former Administrator was responsible for this task.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in their care. For one resident, an oxygen humidifier bottle was observed in their room without a current physician order for oxygen therapy. The resident's care plan included an intervention for oxygen as needed, and the Minimum Data Set (MDS) assessment indicated oxygen therapy as a special respiratory treatment. However, the resident did not have a physician order for oxygen at the time of the survey, which is a requirement according to the facility's oxygen policy. The lack of a physician order was attributed to the resident's recent hospitalization and subsequent return to the facility without the order being renewed. Another resident with a tracheostomy was found to be without a manual resuscitator bag (ambu bag) in their room, which is part of the required emergency supplies. The resident's medical record included physician orders for respiratory therapy to ensure that emergency supplies, including a backup trach, syringe, and manual resuscitator bag, were available at the bedside. The absence of the ambu bag was noted during the initial tour of the unit, indicating a failure to comply with the physician's orders and ensure the resident's safety in case of an emergency.
Lack of Follow-Up After Psychiatric Consult
Penalty
Summary
The facility staff failed to provide follow-up after a psychiatric consult for a resident. A psychiatric consult was ordered and completed, which recommended that the resident did not require two antidepressants based on their current presentation. However, there was no follow-up documentation from the physician or nursing staff regarding the psychiatric consult's recommendations. The Director of Nursing (DON) confirmed that the consult was initiated due to the resident's depressive symptoms following a previous hospital visit, but acknowledged the absence of follow-up notes addressing the psychiatric consult's findings.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as prescribed by the medical provider for one resident. During an interview, the resident's daughter reported that a night nurse changed the time of a seizure medication without consulting the doctor. There was no documentation found in the resident's record regarding the change in medication timing. A review of the Clinical Incident Report revealed that a registered nurse did not administer the medication as ordered and scheduled. The Regional Clinical Services Manager confirmed that the nurse did not document the reason for the time change. The facility's administrator stated that she would expect the nurse to contact the physician before making any changes to the ordered medication times.
Deficiency in Food Handling Practices
Penalty
Summary
The facility failed to ensure sanitary and safe food handling practices, which was identified during an annual survey. Observations in the kitchen revealed outdated food items, including a lemon pie with no open date or year and a container labeled with an open date but no discard date or year. Additionally, containers of teriyaki and soy sauce were not labeled or dated. In a separate refrigerator on the Vital Strong 2 (VS2) unit, an unlabeled and undated container of fruit, a bag with a resident's name and room number but no date, and a grey cooler bag with no name or date were found. The VS2 Unit Manager admitted that unlabeled food should be discarded and expressed uncertainty about how the food was placed there, as the refrigerator is kept locked to prevent unauthorized access. The Administrator acknowledged the labeling and dating issues.
Inaccurate Documentation of Morse Fall Scale Assessments
Penalty
Summary
The facility staff failed to accurately document the Morse Fall Scale (MFS) assessments for a resident, which was evident during a review of the resident's medical record. The resident had a history of falls on multiple occasions, but the MFS assessments did not accurately record this past history, leading to an incorrect assessment of the resident's fall risk. Specifically, the resident's fall risk was inaccurately assessed as moderate and low risk on different occasions due to the omission of past fall history in the MFS assessments. During an interview, the Director of Nursing (DON) acknowledged the incorrect documentation of the MFS post-fall assessments but was unaware of the reasons for the omission of the past history of falls. This deficiency was identified for one resident reviewed for falls, highlighting a lapse in maintaining accurate medical records in accordance with accepted professional standards.
Infection Control Breach: Hand Hygiene Omission
Penalty
Summary
The facility staff failed to adhere to infection control practices before donning personal protective equipment (PPE) during an annual survey. Observations revealed that a Licensed Practical Nurse and two other staff members removed PPE from a cart without performing hand hygiene, despite a visible sign reminding them to sanitize their hands before taking a gown. During an interview, a Registered Nurse confirmed that the protocol required staff to perform hand hygiene before removing PPE, yet the observed staff did not follow this procedure.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify residents or their representatives in writing about the bed hold policy when residents were transferred to an acute care facility. This deficiency was identified for two residents who were reviewed for hospitalization. In the case of the first resident, the family was informed of the transfer to the hospital via phone, but there was no documentation of the bed hold policy in the resident's chart or electronic system. The Unit Nurse Manager confirmed that the bed hold policy was not provided to the resident or the family, and this issue was raised as a concern by the Regional Clinical Services Manager. For the second resident, a closed record review revealed that the resident was transferred out with an order from a Nursing Practitioner, but there was no documented notification to the family, nor was there a bed hold policy in place. Although the Regional Clinical Services Manager provided hard copies of documents to support that the bed hold policy was issued, these documents only included an Emergency Department transfer form and a notice of facility-initiated transfer form, with no bed hold policy found. The lack of documentation of the bed hold policy was noted as a concern during further interviews.
Medication Administration and Appointment Scheduling Deficiencies
Penalty
Summary
The facility staff failed to administer medication to a resident who had been evaluated by a medical provider for nausea. Despite the medication being available in the facility's Pyxis MedStation, there was no documentation confirming that the medication was given. The Director of Nursing (DON) was unable to provide records showing the medication was administered and confirmed that staff could not recall if the medication was given. Additionally, the facility did not schedule an outside medical appointment in a timely manner for another resident diagnosed with spinal stenosis who complained of back pain. Although pain medications were administered, an orthopedic consult was ordered but not scheduled until 14 days later, with the appointment set for over a month after the order. The DON could not identify the reason for the delay, which was not in line with the facility's usual practice.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Landover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Largo Nursing And Rehabiliation Center | 2.5 mi | ★★★★★ | 37 | 0 |
| Villa Rosa Nursing And Rehabilitation, Llc | 3 mi | ★★★★★ | 37 | 0 |
| Forestville Rehabilitation And Wellness Center | 4.1 mi | ★★★★★ | 44 | 0 |
| Deanwood Rehabilitation And Wellness Center | 4.2 mi | ★★★★★ | 13 | 1 |
| Doctors Community Rehabilitation And Patient Care | 5.3 mi | ★★★★★ | 16 | 0 |
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