Above average — CMS composite of the measures below.
A standard survey is most likely before around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Future Care Charles Village during CMS and state inspections, most recent first.
Incomplete Abuse Investigation: A facility failed to complete a thorough abuse investigation for a resident because staff who worked during the time of the alleged incident were not interviewed. The investigation lacked statements from three GNAs who worked the relevant shifts, even though the Administrator stated the facility’s process was to interview staff based on the timing of the concern and to review all staff who worked with the resident during the relevant period.
A resident had a change in mental status that led to transfer to the hospital for observation and treatment. The record showed the son was notified, but the daughter was listed as the first contact/resident representative and there was no documentation explaining why she was not contacted. The RN later stated that an attempt was made to reach the first contact, no message was left, and the attempt was not documented.
Kitchen sanitation and equipment maintenance deficiencies: During an initial kitchen tour, the surveyor found multiple unsanitary conditions and equipment problems, including an obstructed/nonfunctional hand sink, rusted and dirty dishwasher equipment, leaking sink drain lines, overfilled grease traps, missing or damaged tiles, unclean food prep and tray line equipment, improper food storage, and unclean walk-in refrigeration areas. A later tour also found inadequate hood airflow, and surveyors observed the ware washing area blocked by contractor work with grease/sewage water on the floor and a foul odor throughout the kitchen.
Unsafe and Poorly Maintained Resident Environment: Surveyors observed multiple resident rooms and a shower room with stained ceiling tiles, a loose baseboard, broken dresser drawers, a damaged sink surface, dust-like debris, a soiled privacy curtain, and a commode shower chair with a spotty brown substance. Residents also reported inadequate or hard-to-use overbed lighting, including a pull string that was difficult to operate or nearly absent, and one resident said the only available light for reading was inadequate.
Hot foods were not consistently maintained above the required temperature and several residents reported cold, unpalatable meals. Surveyors observed a steam table at 110 degrees F and later confirmed a middle steam table was turned off, while plated food on a test tray reached the unit at 127-129 degrees F. Residents reported cold breakfast, cold coffee, cold eggs, and other meals lacking flavor or seasoning.
Infection control and hand hygiene failures were identified across multiple areas of the facility. Staff were observed filling residents’ water cups from a hand sink faucet, several commodes were found rusted, damaged, and difficult to sanitize, and residents were observed eating without hand hygiene or access to ABHR. Surveyors also observed kitchen contamination concerns during grease trap and drain line work while food service was in progress, along with unwrapped IV poles stored in clean areas and utility spaces with leaking sinks, missing ceiling tiles, and damaged cabinets.
Kitchen equipment was not maintained in proper operating condition. The hand sink in the ware washing area was obstructed and then confirmed inoperable with no water flow, the high-temp dishwasher was found turned off with a missing grease trap cover, and temp logs had not been completed for several meal periods. When the dishwasher was later started, rinse temps varied widely, dishwater leaked from the unit, and steam escaped throughout the kitchen. An Ecolab tech stated the booster heater, door gaskets, and curtains needed replacement, and the middle 3-well steam table was also observed turned off.
Inoperable and poorly maintained ventilation systems were observed in multiple areas of the facility. Surveyors noted water-damaged ceiling tiles, dusty vent covers, and HVAC condensation buildup near the nurse's station and in resident areas, while a dishwasher in the kitchen released significant steam and vapors because its end curtains needed replacement. The exhaust systems in all 3 portable oxygen cylinder tank storage closets were also confirmed inoperable.
A resident with a physician's order for topical ointment to be applied to the right hip for pain had 11 consecutive entries over three days documented by multiple staff indicating application to both hips, contrary to the order. Facility leadership confirmed staff selected the wrong indication in the electronic medical record system.
A resident with sepsis, chronic DVT, and type II DM had an MDS coded to show 1 day of insulin injections in section N0350, but the MAR and physician orders did not show any insulin order. The MDS Coordinator later found the only documented injection was Trulicity, not insulin, and confirmed a modified MDS was submitted to change the insulin count to 0.
Failure to Revise Care Plan for Discontinued Antipsychotic Medication: A resident’s care plan continued to address antipsychotic drug use even after Seroquel was discontinued due to non-use. The resident did not attend care plan meetings and was alert and oriented, while record review and DON interview confirmed the care plan had not been updated to reflect the medication change.
Activities Not Provided to Meet Resident Needs and Preferences: Residents were observed in crowded activity spaces, with some unable to participate because of limited room. A resident reported that activities were only held on the first floor, that no activities were available on the second and third floors, and that the offerings did not match their interests. Staff confirmed that activities were held only in the first-floor dining/activities room, with the schedule running from late morning into mid-afternoon, while the DON and clinical services nurse acknowledged the limited space for all residents to participate.
Ordered splints were not actually in place for a resident even though the nurse documented they had been applied. The facility also delayed hospital transfer for one resident who fell and later was found to have a hip fracture, and delayed calling 911 for another resident who had severe abdominal pain, vomiting, and repeatedly requested transport; that resident was later diagnosed with a bowel obstruction and required surgery.
Missing Oxygen Signage for a Resident Using Oxygen A resident with an order for O2 via NC at 3 L/min for SOB was observed with an oxygen concentrator in use in the room, but no oxygen sign was posted on the room door. The UM stated that an oxygen sign should be posted when oxygen is in use and acknowledged the missing signage.
A resident ordered on a regular diet with level 2 mildly thick liquids, no straws, and no ice was repeatedly observed without a hydration cup at the bedside or in the dining area. The resident requested water and stated being thirsty, and the Regional DON confirmed the resident had ordered thickened liquids but no hydration cup was present by the bedside table.
Inaccessible Restroom Call Bell Cords: The facility failed to provide accessible call bell systems in resident restrooms. Surveyors observed that restroom call bell cords in 3 of 3 reviewed systems were wrapped around toilet handrails, making them inaccessible to a resident on the restroom floor; an additional restroom call bell cord was later observed in the same condition. The Regional Director of Operations was notified and confirmed the cords would be extended to the restroom floors.
The facility staff failed to consistently document psychotropic medication side effects and behaviors for a resident and did not document resident consent prior to the installation of side rails for three residents. The DON confirmed the lack of documentation and the absence of a separate consent form for side rails.
The facility staff failed to send a copy of a resident's transfer to the hospital to the Ombudsman. A review revealed the resident was transferred to the emergency department, but the resident was not included in the admission/discharge list sent to the Ombudsman. The Regional Nursing Director acknowledged the oversight.
The facility staff failed to create patient-centered care plans for three residents, including one with oxygen therapy needs, one with significant weight loss, and one with dementia. The deficiencies were confirmed by the DON and other staff members during interviews.
The facility staff failed to provide a summary of a resident's stay and a copy of the most recent comprehensive assessment to a resident who initiated a discharge. The standard discharge process included providing discharge instructions, prescriptions, and a medication list, but did not ensure the inclusion of a summary of the resident's stay or the most recent comprehensive assessment.
The facility failed to ensure that residents requiring assistance with ADLs such as bathing and showering were provided these services. Three residents did not receive scheduled showers, and documentation was inconsistent. Staff interviews revealed confusion and gaps in the documentation process, and the facility lacked a comprehensive ADL policy.
The facility staff failed to prevent new pressure ulcers in two residents. One resident developed a left heel wound and a right upper buttock deep tissue injury after readmission, while another resident developed a new open wound on the left lower buttock. The facility lacked documentation to show that the second resident had refused to be turned prior to the wound's development.
The facility failed to complete annual performance reviews for an LPN and a GNA. The LPN had multiple disciplinary issues without a performance evaluation, and the GNA did not receive a required review after three months of employment. These deficiencies were confirmed by the DON and discussed with the administration team.
The facility failed to store medications and biologicals at the proper temperature, with a refrigerator thermometer reading 58 degrees F, above the required range of 36-46 degrees F. Staff confirmed the issue, and the facility's policy mandates proper temperature monitoring.
The facility failed to follow a resident's food intolerance list and honor requested double-portion meals. Despite the resident's repeated complaints about receiving inappropriate food items and insufficient portions, the facility did not make the necessary adjustments. The resident continued to receive items that could aggravate their condition, such as orange juice and acidic foods.
The facility failed to store food in accordance with professional standards, as observed by a surveyor. A bucket with labeled food items was found on the floor, and a stack of fresh bread trays was placed in a high foot traffic area, with the last tray nearly touching the floor. The Kitchen Director acknowledged the issue.
The facility staff failed to maintain infection control practices as evidenced by a resident's uncovered oxygen tubing and five used, unlabeled urinals left in a bathroom cabinet. The oxygen tubing and sterile water were not labeled or dated, and these findings were confirmed by GNAs. The DON stated that urinals should be labeled and changed when soiled, and oxygen tubing should be dated and changed weekly or when soiled.
The facility failed to ensure effective pest control as flying gnats were observed throughout the building. Residents reported ongoing issues with gnats during a council meeting, despite previous control efforts. The administration acknowledged the problem and provided maintenance logs showing recent treatments for fruit flies.
Incomplete Abuse Investigation
Penalty
Summary
Facility staff failed to complete a thorough investigation of an allegation of abuse involving Resident #8. During record review, the surveyor found that the facility’s investigation did not include staffing sheets as part of the original documentation, and when the staffing sheets were later reviewed, there were no interviews or statements from three GNAs who worked on the unit during the time of the alleged incident. The missing staff interviews involved GNAs who worked the relevant shifts on Unit 3 during the period surrounding the allegation. The surveyor reviewed the facility’s investigation on 05/18/26 and confirmed that the entire investigation had been received before the documents were reviewed. During an interview, the Administrator stated that residents who could answer questions were interviewed, residents unable to answer had a head-to-toe assessment completed, and staff who worked with the resident were interviewed based on the timing of the concern. The Administrator was informed that three GNAs who worked during the time of the alleged incident were not interviewed, despite the facility’s stated process of interviewing staff who worked with the resident during the relevant time frame.
Failure to Document Contact Attempt After Change in Condition
Penalty
Summary
The facility failed to accurately document contact attempts for notification of a change in condition with a resident representative for one resident reviewed during a complaint investigation. The resident had a documented change in mental status on 12/13/25, which led to transfer to the local hospital for observation and treatment. The medical record showed that the resident's son was notified of the change in condition and transfer, but the resident's daughter was listed as the first contact/resident representative in the record. Further review of the medical record found no documentation explaining why the first contact/resident representative was not contacted after the change in condition. During interview, the RN who authored the change in condition documentation stated that he/she attempted to contact the first contact, was unable to reach her, and then contacted the second contact on the list. The RN also admitted that no message was left for the first contact and that the attempt to contact her was not documented.
Kitchen sanitation and equipment maintenance deficiencies
Penalty
Summary
The facility failed to maintain food service equipment and kitchen areas in sanitary condition during the initial kitchen tour with the Dietary Director. The hand sink in the ware washing area was obstructed and nonfunctional, the hand sink was attached to an unsealed plywood wall, and the high-temperature dishwasher was visibly stained and rusted. The dishwasher drainpipes discharged directly into the floor sink without an air gap, the food waste grinder was clogging the above-ground grease trap interceptors, and the two grease trap interceptors were overfilled and corroded. The 3-compartment sink gooseneck faucet was leaking, one drain line was leaking gray water onto the floor, and required temperature and sanitizing logs were missing for several days. Multiple tiles were missing or damaged around the underground grease trap interceptor, the wet vacuum was unclean, and several food service areas, including the tray line, cookline, food prep sink area, ice machine area, and walk-in refrigerator/freezer, were observed to be unclean or in disrepair. Additional observations included a chef’s knife stored between the hot and cold lever handles of the in-counter prep sink, a leaking drain line beneath that sink, grease buildup on the stove overshelf, unclean walls behind and beneath cooking equipment, a burned-out hood light, and a reach-in refrigerator that was partially blocked by a storage rack and had a damaged door gasket. The food prep sink drainpipes were unclean and missing a floor drain cover, the deli slicer was unclean, the ice machine drain line discharged directly into the floor sink without an air gap, and the ice machine deflector shield and scoop holder were unclean. In the walk-in refrigerator/freezer area, a toaster oven was placed on top of a microwave near the walk-in door, the walk-in gasket was missing, shelving and surfaces were unclean, compressor fans and covers were unclean, and dunnage racks were lined with torn cardboard boxes with dirt and debris buildup. During the second tour with the Maintenance Director and Regional Director of Operations, the surveyor also reviewed backflow prevention devices on waterlines for equipment such as the ice machine, coffee maker, juice machine, and mop sink, and observed that the canopy hood ventilation system was not sufficiently pulling air underneath the cookline when smoke was used to demonstrate airflow. On 9/30/2025 at 1:10 AM, surveyors observed the ware washing area was inaccessible during lunch preparation and service because a contractor was replacing two above-ground grease trap interceptors and the dishwasher drainpipes. The ware washing area floors were soiled with grease and sewage water that employees tracked throughout the kitchen, and a foul sewage odor permeated the kitchen. The contractor was instructed to stop remaining dishwasher pumping repairs to prevent potential cross-contamination.
Unsafe and Poorly Maintained Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, homelike environment for residents, as surveyor observations identified multiple rooms and a shower room with items not in good repair or not clean. During the tour, the surveyor observed stained ceiling tiles in several resident rooms, a loose baseboard in a bathroom under the sink, and a bedside dresser with three broken drawers that were not affixed to the dresser tracks. The Regional Director of Operations acknowledged the observed repairs were needed and stated there was a plan going forward with the construction department of Future Care. The Licensed Nursing Home Administrator later stated that the facility was getting new ceiling tiles. The surveyor also observed environmental concerns affecting lighting and cleanliness. One resident stated that the wall-mounted overbed light was the only available light source for reading and provided inadequate lighting, while another resident reported the pull string for the overbed light was difficult to operate and required staff assistance each time lighting needed adjustment. A third resident stated the pull string was absent, and the surveyor observed the chain extended only one inch from the light panel. In addition, the surveyor observed scattered gray granular dust-like debris on a bathroom vanity, a hole in the sink surface, a brown stain on a ceiling tile above a resident’s bed, a large brown stain on a shower room ceiling tile, a soiled privacy curtain, black substance along the base of a window, and a commode shower chair with a spotty brown substance on it.
Hot Foods Served Below Required Temperature and Meals Reported as Cold
Penalty
Summary
The facility failed to ensure resident meals were palatable and that hot foods were maintained above 135 degrees Fahrenheit. During interviews, Resident #11 reported that meals were served last of the three units and were regularly cold by the time they were received. Resident #9 stated that breakfast was often cold and would have preferred it to be hotter. Resident #87 reported that the food served was cold and lacked flavor, Resident #13 said the food was cold and unseasoned, and Resident #10 stated that chicken strips served for lunch were cold and without dipping sauce. Resident #2 also reported that breakfast was not always hot, that portions were small, and later stated breakfast had been late and ice cold, with cold coffee and eggs that could not be eaten cold. During tray line observations, surveyors saw breakfast items on a middle 3-well steam table containing unshelled hard-boiled eggs and scrambled eggs. After breakfast service, the water temperature of that steam table measured 110 degrees Fahrenheit, and the Certified Dietary Manager stated the unit temperature levels had been reduced while another steam table was visibly steaming. On a later observation, the Certified Dietary Manager confirmed that the middle 3-well steam table was turned off. Food temperatures on the first steam table were 179 degrees Fahrenheit for grits and scrambled eggs and 176 degrees Fahrenheit for a biscuit sausage sandwich, but when the last test tray reached the first-floor unit, the plated food temperatures had dropped to 128 degrees Fahrenheit for scrambled eggs, 127 degrees Fahrenheit for gravy, and 129 degrees Fahrenheit for the biscuit sausage sandwich. The HACCP plan stated that potentially hazardous foods were to be hot-held above 135 degrees Fahrenheit prior to serving.
Infection Control and Hand Hygiene Failures
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment to minimize or eliminate the spread of potential cross-contamination and failed to implement proper hand hygiene practices in 5 of 5 infection control areas reviewed during the annual survey. Surveyors observed Staff #11 filling residents’ water cups from the hand sink faucet in the second-floor nourishment room, and the staff member stated this was routine practice. Later, the Regional Clinical Services Nurse stated staff had received in-service training on the proper procedure for filling water cups from an appropriate area in the second-floor nourishment room, and Staff #22 stated the first-floor unit receives water pitchers from the kitchen to fill residents’ water cups. Surveyors also observed multiple over-the-toilet commodes and a bedside commode with rusted, damaged, and unclean parts, including bolts and joints that could come into contact with residents’ hands. These conditions were noted in several resident rooms, and the rusted areas were described as difficult to sanitize between uses. The Regional Director of Operations later confirmed that the rusted and/or damaged commodes had been replaced throughout the facility, but a subsequent observation still found an over-the-toilet commode that was rusted and damaged. Hand hygiene concerns were also identified with residents. Resident #37 reported missing breakfast and lunch due to a lack of hand hygiene before eating and pointed out an empty bottle of ABHR on the bedside tray table. Surveyors observed breakfast being served on the first-floor unit and verified staff used ABHR when exiting residents’ rooms, but they could not verify that residents’ hands were washed or cleaned before food service. Another resident was observed eating in the dining/activities room and stated they had not washed their hands before eating. The Administrator and Regional Clinical Services Nurse later confirmed the facility would provide sanitizing wet naps or other hand sanitizing supplies for residents to use before eating.
Kitchen Equipment Not Maintained in Working Order
Penalty
Summary
Essential kitchen equipment was not maintained in proper operating condition during the annual survey. In the ware washing area, the hand sink was obstructed by an open box of trash bags with two bags draped over the sink and extending to the kitchen floor, and when the surveyor requested that the faucet be turned on, the Certified Dietary Manager confirmed that the hand sink was inoperable with no water flowing from the faucet. The Champion high-temperature dishwasher was also observed turned off, and one of the two above-ground grease trap interceptor covers was missing, allowing visual inspection of the grease level. A review of the dishwasher log sheet showed that wash and rinse temperatures for breakfast, lunch, and dinner had not been documented since 9/24/2025, and the CDM confirmed the dishwasher had been used over the weekend but staff had neglected to log the temperatures. During the kitchen tour, the surveyor observed that the grease level in one of the above-ground grease trap interceptors attached to the dishwasher was elevated. The Maintenance Director and Regional Director of Operations confirmed that the dishwasher had been turned on and immediately shut off when the grease trap began to fill to capacity. Later, when the dishwasher was started again, the final rinse temperatures varied between 184 degrees Fahrenheit and 138 degrees Fahrenheit, dishwater leaked from the lower edges of the side double doors onto the kitchen floor, and a significant amount of steam and vapors escaped from both ends of the unit throughout the kitchen. An Ecolab technician stated that the booster heater, door gaskets, and curtains from both ends required replacement for the unit to operate according to the manufacturer's specifications. The middle 3-well steam table was also observed turned off, and the CDM stated that a new unit had been ordered and would be installed as soon as possible.
Inoperable and poorly maintained ventilation systems
Penalty
Summary
The facility failed to maintain clean and effective ventilation systems, with observations showing impaired airflow in multiple areas. During the initial tour, the surveyor noted multiple water-damaged ceiling tiles in several resident rooms and restrooms, along with a heavily dusted ceiling vent cover and water-damaged ceiling tiles above the first-floor nurse's station. The Maintenance Director stated the water damage was due to condensation buildup on HVAC duct systems and said maintenance staff were replacing ceiling tiles throughout the facility, while he and the Regional Director of Operations agreed the root causes of the HVAC condensation buildup needed to be addressed. In the kitchen, the Certified Dietary Manager started the Champion high-temperature dishwasher and observed a significant amount of steam and vapors escaping from both ends of the unit and dissipating throughout the kitchen. An Ecolab technician later stated the curtains at both ends of the dishwasher, which are needed for inserting soiled dishracks and retrieving clean ones, required replacement for the unit to operate according to the manufacturer's specifications. In addition, when the surveyor checked the portable oxygen cylinder tank storage closets, the Maintenance Director confirmed that the exhaust systems in all three closets were inoperable after the surveyor observed a water-damaged ceiling tile adjacent to a vent cover in one of the closets.
Incorrect Documentation of Topical Ointment Administration
Penalty
Summary
The facility failed to ensure that a resident's Treatment Administration Record (TAR) was documented in accordance with physician's orders. Specifically, a physician had ordered a topical ointment to be applied to the resident's right hip four times daily for pain. However, review of the Medication Administration Record (MAR) and TAR showed that three staff members documented 11 consecutive entries over a three-day period indicating the ointment was applied to both hips, rather than only the right hip as ordered. This inconsistency was identified during record review and confirmed by facility leadership, who verified that staff had selected the incorrect indication from the dropdown menu in the electronic medical record system.
Inaccurate MDS Coding for Insulin Administration
Penalty
Summary
Facility staff failed to code a resident’s status accurately on the MDS assessment. Resident #5 was admitted with diagnoses including sepsis, chronic deep vein thrombosis, and type II diabetes. Review of the resident’s MDS assessment showed section N0350 for insulin coded as 1 day of insulin injections received, but review of the physician orders and August 2025 MAR did not reveal any insulin orders for the resident. During interview, the MDS Coordinator reviewed the electronic record and could not locate an insulin order or documentation supporting insulin administration. The coordinator found that one injection documented in the MAR was Trulicity, which is a GLP-1 receptor agonist and not insulin. In a follow-up interview, the MDS Coordinator confirmed that a modified assessment was submitted that changed the number of insulin injections to 0.
Failure to Revise Care Plan for Discontinued Antipsychotic Medication
Penalty
Summary
The facility failed to revise Resident #14’s care plan in a timely manner for antipsychotic drug use. Resident #14 was interviewed and stated that they did not attend care plan meetings and did not want to attend them; the resident was alert and oriented to person, place, and time at the time of the interview. Record review showed that antipsychotic drug use had been addressed on Resident #14’s care plan, with a revision date of 7/31/2024. The physician orders showed that Seroquel, an antipsychotic medication, was discontinued on 2/27/2025 due to non-use, but the resident’s current care plan still continued to address antipsychotic drug use. During interview, the DON reviewed the current care plan and physician orders and acknowledged that the care plan had not been revised when the Seroquel was discontinued.
Activities Not Provided to Meet Resident Needs and Preferences
Penalty
Summary
The facility failed to provide activities to meet residents’ needs and preferences. During observations, 14 residents were seen in the first-floor dining/activities room, with eight in wheelchairs and six in Geri chairs; two residents had fully extended recliner seats positioned to elevate their legs. When the surveyor attempted to speak with Resident #13, five other residents had to rearrange their chairs to allow the resident to exit from the corner of the limited-space room. On another observation, five residents were in the second-floor dining/activities room, with three seated in front of a large-screen TV and two staring out the windows. Later, 16 residents were observed in the first-floor dining/activities room, and two residents were seated in wheelchairs just outside the room in front of the employee bathroom door while other residents participated in coloring activities at the table; due to the limited space, those two residents could not participate in the activities. Resident #119 stated that there were no activities to participate in on the second and third floor dining/activities rooms and that all monthly scheduled activities on the calendar were held only in the first-floor dining/activities room. The resident also reported that the facility did not provide activities that met their interests and that it was difficult to get down to the first floor to participate in activities that ran from 10:00 AM to 2:30 PM. Staff #3 and Staff #18 confirmed that activities were only held in the first-floor dining/activities room, with the first activity starting at 10:00 AM and the last ending at 3:30 PM. The Regional DON and Regional Clinical Services Nurse acknowledged that the room had limited space for all residents to participate in activities.
Failure to Apply Ordered Splints and Delays in Hospital Transfer After Injury and Abdominal Pain
Penalty
Summary
Ordered splints were not in place for a resident who was observed lying in bed without any noticeable splints or braces. The Medication Administration Record showed that the nurse had signed off that the splints had been applied, but they had not been applied. The Director of Nursing was notified of the observation. The facility also failed to obtain timely higher-level care for two residents. One paraplegic resident fell while left unsupervised on the toilet, was assessed by the nurse, and an X-ray was ordered at 11:00 pm but not written as STAT. The X-ray was not completed until the next afternoon, the fracture result was not available until later that day, and the resident was not transferred to the hospital until 6:33 pm, about 21 hours after the injury, where emergency surgery was performed for a broken hip. Another resident had abdominal pain, vomited, and repeatedly requested that staff call 911 and send her to the hospital, but staff continued to check on her instead. A nursing assessment was completed and the DON later stated staff were providing care, but there was no progress note beyond the initial assessment and no pain medication given beyond the standing acetaminophen order. The resident was not transported until the roommate called 911, and the hospital determined she had a bowel obstruction caused by adhesions and performed surgery to remove it.
Missing Oxygen Signage for Resident Using Oxygen
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident who had a physician order for oxygen via nasal cannula at 3 liters per minute every shift for shortness of breath. During a tour of Unit 3, the resident was observed in bed with an oxygen concentrator in use in the room, but there was no oxygen signage posted on the room door. The facility’s Respiratory Therapy: Oxygen Therapy Policy and Procedure stated that oxygen will be delivered in a safe manner. When asked about the expectation for oxygen signage, the Unit Manager stated that an oxygen sign should be posted on the resident’s room door when oxygen was in use and acknowledged that the sign was not posted for this resident.
Failure to Provide Ordered Thickened Hydration
Penalty
Summary
The facility failed to provide sufficient physician-ordered thickened drinks to meet Resident #13’s hydration needs and preferences. The resident was on a regular diet with level 2 mildly thick liquids, with no straws and no ice, effective 9/8/2025. During multiple observations, the resident was seen in the dining/activities room and later with a therapist, and no hydration cup was present at the table, bedside tray table, or dresser drawer. When the surveyor escorted the resident to the room and asked about hydration, the resident requested a cup of water and later stated being thirsty. The Regional DON confirmed that the resident was prescribed thickened liquids but did not have a hydration cup by the bedside table.
Inaccessible Restroom Call Bell Cords
Penalty
Summary
The facility failed to provide a working call bell system that was accessible to residents in the restrooms. During the annual survey, the surveyor observed that restroom call bell cords in 3 of 3 reviewed restroom call bell systems were wrapped around toilet handrails, making them inaccessible to residents if they were on the restroom floors. This was observed in rooms [ROOM NUMBERS] on 9/29/2025, and an additional restroom call bell cord in room [ROOM NUMBER] was later observed on 10/6/2025 in the same inaccessible condition. The Regional Director of Operations was informed of the findings on 10/3/2025 and confirmed that the call bell cord would be extended to the restroom floors to ensure resident accessibility.
Failure to Document Psychotropic Medication Side Effects and Siderail Consent
Penalty
Summary
The facility staff failed to consistently document whether a resident was experiencing psychotropic medication side effects or behaviors. This was evidenced in the behavioral records of one resident, where multiple dates in November, December, and January showed no documentation for signs and symptoms of depression, inappropriate behaviors towards female staff, or psychotropic medication side effects. The Director of Nursing (DON) confirmed the lack of documentation during a review with the surveyor and acknowledged that the nursing team reviews orders and attempts to ensure they are carried out, but documentation was still incomplete on the specified dates. Additionally, the facility staff failed to document in the progress notes the consent of the resident or the resident representative prior to the installation of side rails. This was evident for three residents reviewed for siderail consent. The DON and staff confirmed that the facility does not have a separate consent form for side rails and that the clinical staff are expected to document the date and time of consent in the progress notes. However, the surveyor found no documentation in the electronic medical records for the consent prior to the installation of side rails. Late entry progress notes were found for the residents, but these were dated after the installation of the side rails, indicating a failure to obtain and document consent in a timely manner as per the facility's policy.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility staff failed to send a copy of a resident's transfer to the hospital to the Ombudsman. This deficiency was evident in one of two resident records reviewed for transfer/discharge paperwork during the survey. Specifically, on 01/10/24, a review of a resident's electronic medical record revealed the resident was transferred to the emergency department on 10/20/23. On 01/23/24, the surveyor requested a copy of the resident's transfer notice sent to the responsible party and verification that a copy was sent to the Ombudsman. On 01/24/24, the surveyor received a copy of the October 2023 admission/discharge list that was emailed to the Ombudsman on 11/01/23, but the resident was not included on the list. During an interview on 01/24/24, the Regional Nursing Director acknowledged that the staff did not perform the quick editing, and when the Administrator pulled the report, the resident was not on the list, which was realized on 01/23/24.
Failure to Initiate Comprehensive Care Plans
Penalty
Summary
The facility staff failed to initiate patient-centered care plans for three residents, leading to deficiencies in their care. Resident #20 had an order for oxygen therapy, but no specific care plan was created to address this need. The Director of Nursing (DON) confirmed the absence of a patient-specific care plan for oxygen therapy during an interview. Similarly, Resident #32 experienced significant weight loss, yet no care plan was developed to address this issue. Both the DON and the dietician confirmed the lack of a care plan for weight loss during their respective interviews with the surveyor. Additionally, Resident #12, who had a diagnosis of dementia, did not have a care plan addressing this condition. The resident's electronic medical record and care plan meeting notes revealed that dementia was not discussed or included in the care plan. The DON and the social worker confirmed that the interdisciplinary team had not created a dementia care plan for Resident #12. These deficiencies were discussed with the DON, two regional RNs, and the administrator during the exit conference.
Failure to Provide Comprehensive Discharge Documentation
Penalty
Summary
The facility staff failed to provide a summary of a resident's stay and a copy of the most recent comprehensive assessment to a resident who initiated a discharge. This deficiency was identified during a review of Resident #241's electronic medical record, which revealed that the resident was discharged without receiving these critical documents. Interviews with the Director of Social Services and the Director of Nursing confirmed that the standard discharge process included providing discharge instructions, prescriptions, and a medication list, but did not ensure the inclusion of a summary of the resident's stay or the most recent comprehensive assessment. The surveyor's review of the discharge documentation for Resident #241 showed that while the resident received a post-discharge plan of care, prescriptions, and other necessary paperwork, there was no documentation to support that the resident received a summary of their stay or a comprehensive assessment. The Director of Social Services admitted that this information was not provided and suggested it could be obtained from the hospital, indicating a gap in the facility's discharge procedures. The Director of Nursing also confirmed that the discharge documentation typically provided did not include these essential documents, highlighting a systemic issue in the facility's discharge process.
Failure to Provide Scheduled Showers and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents requiring assistance with activities of daily living (ADLs) such as bathing and showering were provided these services. This deficiency was identified for three residents. Resident #82 had not been provided a shower since admission, despite expressing a preference for daily showers. The resident's Kardex indicated a schedule for showers twice a week, but this was not adhered to. Resident #32 reported receiving assistance with a shower only once a week, contrary to the expected twice-weekly schedule. Documentation for Resident #32 showed multiple instances where personal hygiene and shower assistance were not recorded or marked as not applicable. Similarly, Resident #38's records indicated missed documentation for personal hygiene and shower assistance on specific dates. Interviews with staff revealed inconsistencies and confusion regarding the documentation and provision of showers. Staff #31 mentioned that handwritten shower logs were used alongside electronic medical records, but there were gaps in documentation. Staff #5 and Staff #3 acknowledged the confusion and stated that GNAs were expected to document refusals and inform LPNs or RNs. However, the facility did not have a comprehensive ADL policy, only individual policies addressing specific aspects of personal care. The lack of consistent documentation and adherence to scheduled showers led to the deficiency, as confirmed during the exit interview with the administrator and Staff #5.
Failure to Prevent New Pressure Ulcers
Penalty
Summary
The facility staff failed to prevent new pressure ulcers from developing in two residents. Resident #242 was readmitted with an intact skin condition but developed two new wounds: a left heel wound and a right upper buttock deep tissue injury. The Director of Nursing confirmed that these wounds were not present upon readmission. Additionally, there were allegations that the resident was left in urine and not turned or repositioned every two hours, which could have contributed to the development of these pressure ulcers. Resident #92, who was admitted with chronic respiratory failure and incontinence, was identified as being at risk for pressure ulcers. Despite this, the resident developed a new open wound on the left lower buttock. The Unit Manager confirmed that the wound developed while the resident was in the facility and mentioned that the resident often refused to be turned. However, there was no documentation to support that the resident had refused to be turned prior to the wound's development. The Director of Nursing was made aware of this concern.
Failure to Complete Annual Staff Performance Reviews
Penalty
Summary
The facility failed to ensure annual staff performance reviews were completed as required, specifically for one Licensed Practical Nurse (LPN) and one Geriatric Nurse Aide (GNA). The LPN, hired in 2021, had no documentation of a performance evaluation in their file. Additionally, the LPN had multiple disciplinary notices for not following proper infection control procedures, failing to complete scheduled evaluations, and being insubordinate to a Nurse Practitioner. Despite these issues, no performance evaluation was conducted, as confirmed by the Director of Nursing (DON) and the Regional Nurse (RN) Staff. Similarly, the facility did not complete an annual performance review for a GNA who began working in June 2023. The DON confirmed that if the performance evaluation was not in the employee's file, it had not been completed. The DON also acknowledged that the GNA should have had a performance review after three months, which was not done. These deficiencies were discussed with the administration team during the exit interview.
Improper Medication Storage Temperature
Penalty
Summary
The facility failed to properly store medications and biologicals under proper temperature controls according to professional standards. During observation rounds of the facility's 2nd floor medication storage room, the refrigerator storing medications and biologicals was found to have a thermometer reading of 58 degrees F, which is above the required temperature range of 36 degrees F to 46 degrees F. Staff confirmed the temperature reading and acknowledged that the refrigerator was too hot. The facility's policy for medication storage mandates that medications requiring refrigeration must be kept in a secure refrigerator with a thermometer for temperature monitoring. This deficiency was discussed with the administrative staff during the exit conference.
Failure to Follow Food Intolerance List and Honor Meal Requests
Penalty
Summary
The facility failed to follow a resident's food intolerance list and honor requested double-portion meals. This was evident for one resident who had a history of gastro-esophageal reflux disease (GERD) and was on a modified diet. Despite the resident's repeated complaints about receiving inappropriate food items and insufficient portions, the facility did not make the necessary adjustments. The resident was observed in a weakened state, expressing the need for more food to regain strength, and continued to receive items that could aggravate their condition, such as orange juice and acidic foods. The resident's concerns were communicated to the dietician and kitchen manager, but no improvements were documented. The resident continued to receive inappropriate food items, such as broccoli and berries, which were not suitable for their condition. The facility's kitchen manager stated that larger portion meals required an order from the resident's attending physician, but no such order was documented. The lack of response to the resident's dietary needs and preferences led to ongoing dissatisfaction and potential health risks for the resident.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service, which could potentially lead to contamination. During a tour of the kitchen, a surveyor observed a bucket with labeled food items and dates sitting on the floor. Additionally, a stack of fresh bread in eight large trays was found in a high foot traffic area, with the last tray less than one inch from the floor. The Kitchen Director acknowledged the situation and stated that she was about to move the bread.
Infection Control Deficiencies
Penalty
Summary
The facility staff failed to maintain infection control practices as evidenced by a resident's oxygen tubing being uncovered and draped over the oxygen concentrator, and five used, unlabeled, and undated urinals being left in the bathroom cabinet. During observation rounds, the surveyor noted that the oxygen tubing and sterile water connected to the oxygen concentrator were not labeled or dated. Additionally, five used urinals were found under the bathroom sink in another room. These findings were confirmed by the respective Geriatric Nursing Assistants (GNAs) present during the observations. The Director of Nursing stated that the expectation is for urinals to be labeled with the resident's room number, bed, and the date it was provided, and that oxygen tubing and sterile water should be dated and changed weekly or when soiled.
Failure to Ensure Effective Pest Control
Penalty
Summary
The facility failed to ensure effective pest control as flying gnats were observed throughout the building. During the survey, multiple observations of gnat sightings were made, including in one of the facility's rooms on the first day of the survey. During a resident council meeting, residents were seen swatting at gnats and expressed that the problem had been ongoing despite previous control efforts. The Regional Director of Operations and the Director of Nursing acknowledged the issue and stated that the building is treated weekly for pest concerns. Maintenance logs indicated that the facility was last treated for fruit flies on the second floor and in the kitchen area on two separate occasions. The administration team was made aware of the residents' concerns during the survey exit meeting.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,346 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Future Care Homewood | 0.3 mi | ★★★★★ | 15 | 0 |
| Future Care Sandtown-winchester | 1 mi | ★★★★★ | 2 | 0 |
| The Nursing And Rehab Center At Stadium Place | 1.2 mi | ★★★★★ | 8 | 0 |
| Keswick Multi-care Center | 1.6 mi | ★★★★★ | 23 | 0 |
| Transitional Care Services At Mercy Medical Center | 1.6 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.