Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Future Care Irvington during CMS and state inspections, most recent first.
Call bells were not kept within reach for multiple residents during survey observations. One resident could not locate the call bell because it was wrapped around the bedframe, and several others had call bells on the floor, across an overbed light, or otherwise out of reach. A resident with limited use of one hand asked for the adaptive call bell to be placed near the usable hand. Staff interviews indicated they were expected to ensure call bells were available, but observations showed this was not consistently done.
Delayed reporting and repair of multiple maintenance concerns were found on a unit during survey observation. The surveyor observed exposed lights with a cover on the bathroom floor, holes in walls, damaged floor tiles, exposed wires at outlets, a loose armoire door, and broken bedside table drawers in multiple resident rooms. Staff described a maintenance log and reporting process, and the Maintenance Director stated logs were checked one to two times daily and that unit rounds were being attempted.
An LPN failed to perform hand hygiene or sanitize hands between residents during med pass and used a glucometer on multiple residents without cleaning it between uses. Surveyors also observed a resident’s oxygen tubing on the floor, an uncovered nebulizer mask stored beside open care items and food, and multiple unlabeled basins, bedpans, urinals, and other personal care equipment left on floors and other surfaces throughout the unit.
A resident's privacy was not maintained when a foley catheter bag was observed hanging in the center of the bed and visible from the doorway. An LPN confirmed the facility's practice was to keep foley bags covered with a privacy bag and acknowledged the resident's bag was uncovered.
A resident with a history of schizophrenia and depression had a care plan that listed mood disturbance related to changing health status, depression, and bipolar disorder, but the record contained no documentation supporting bipolar disorder. The DON stated the care plan was created in error and could not explain why it was developed.
A resident with septic leg wounds, non-pressure ulcers, diabetes, hemodialysis, leg pain, and PVD had 12 lower leg wounds on admission, but wound care interventions were not revised despite documentation that the resident could not consistently keep feet elevated or be repositioned every 2 hours. In a separate finding, a resident stated he/she was not involved in the care planning process, and records showed no documentation that the resident was invited to or attended the care plan meeting; the note only indicated the interdisciplinary team reviewed the plan.
Staff failed to follow nursing standards when a nurse removed a resident’s pain patch and placed it on the windowsill instead of discarding it. A GNA confirmed the patch was left there, and the DON and an RN described that removed patches are expected to be discarded and documented on the MAR.
Failure to provide required bathing assistance. A resident assessed as dependent for bathing, dressing, and toileting was documented inconsistently in task records as set up or clean up on several occasions, while other entries showed the resident as dependent for bathing. The DON confirmed the resident was dependent and that any bath would have been completed entirely by staff, but no additional information was provided to show appropriate ADL care was delivered.
A resident’s oxygen therapy was found disconnected from the humidifier bottle, with the tubing end lying on the floor and no date label on the tubing or bottle. An LPN confirmed the missing labeling, and the ADON and DON were notified of the oxygen setup concern.
Inaccurate controlled substance counts were found in 2 of 6 medication carts during a review of narcotic storage and documentation. Discrepancies involved oxycodone, Lyrica, diazepam, and tramadol for several residents. The DON, Administrator, and Regional Clinical Service Manager confirmed that nurses were expected to sign out any controlled substance they administer.
Medication labeling was not maintained correctly in several medication carts. Bulk medications were found with incomplete or missing open dates, and an open insulin pen was not dated when opened. The DON stated that nurses were expected to date medications when opened.
Sugar Substitute Not Provided With Ordered CCHO Diet: A resident on a CCHO diet with dysphagia and fluid restriction was served regular sugar instead of the ordered sugar substitute. The resident stated he/she was diabetic and should not receive regular sugar. The tray card specified sugar substitute, and an LPN confirmed the tray contained sugar while the menu called for sugar substitute; the RD stated CCHO diets typically use sugar substitute, and the DON was informed of the concern.
A GNA failed to follow a resident's care plan requiring two-person assistance for toileting and bed mobility, instead providing care alone. This resulted in the resident falling from bed and sustaining a forehead laceration that required hospital treatment. The deficiency was confirmed through medical record review, staff interviews, and facility investigation.
Call Bells Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure residents had access to their call bells for 7 of 65 residents observed during the surveyor’s initial tour. Resident #7 was observed with the call bell cord and activation pad wrapped around the bedframe at the head of the bed, and the resident stated he/she could not locate the device to use when help was needed. Staff #9 later found the call bell hooked around the left side of the bedframe, out of the resident’s reach, and untangled it to place it under the resident’s right hand. Staff #9 stated the resident had received morning hygiene care and the GNA did not place the call bell within reach afterward. Additional observations showed Resident #18’s call bell on the floor on the right side of the bed, Resident #39’s call bell across the overbed light and not within reach, Resident #133 without an adaptive call bell within reach and asking the surveyor to place it near the resident’s right hand because the resident could not use the left hand, Resident #109’s call bell on the floor, Resident #112’s call bell on the floor on the left side of the bed, and Resident #47’s call bell hanging on the overbed light. During interviews, GNA #13 stated residents are cleaned up, linens changed, and their call bells made sure to be in place before leaving the room, while CMA #14 stated they verify residents have their call bell and bed control when entering the room.
Delayed Reporting and Repair of Multiple Maintenance Concerns
Penalty
Summary
Facility staff failed to report and complete maintenance concerns on Unit 1 South in a timely manner, and the issue was identified during the recertification survey. During observation rounds, the surveyor found multiple maintenance problems throughout the unit, including exposed lights in a bathroom with the light cover on the floor, large holes in the wall behind a resident's bed in Room 103, damaged floor tiles under that bed, marring on a wall behind another resident's bed, an outlet with exposed wires, a hole in a bathroom wall near a commode, a loose and hanging armoire door, broken drawers on a bedside table, another hole in a wall behind a bed, and an electrical outlet with exposed wires in another room. During interviews, GNA #13 stated that maintenance concerns would be reported to the nurse or, if unavailable, to maintenance. CMA #14 stated there was a maintenance log on the unit kept behind the desk on a shelf, where staff document the location, problem, and date. The Maintenance Director stated that maintenance concerns are entered into a log checked one to two times daily, that preventative maintenance is tracked in TELS, and that staff had attempted to begin monthly room checks and weekly Tuesday rounds. The surveyor and Maintenance Director then walked the unit together to view the maintenance concerns observed by the surveyor.
Infection Control Lapses During Medication Pass and Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during medication administration and resident care activities on Unit 1 South. During medication pass, Employee #20 did not wash hands or use hand sanitizer between administering medications to residents #20, #25, #153, and #193, and did not clean the glucometer between residents. The Director of Nursing stated that staff were expected to wash and/or sanitize hands between medication administration to residents and that all equipment used in resident care was to be cleaned between uses. Additional infection control concerns were observed in resident rooms and bathrooms on Unit 1 South. Resident #170’s nasal cannula tubing, including the portion that goes into the nose, was observed on the floor, and the resident’s nebulizer mask was left uncovered on the bedside table next to open peri-care wipes, skin care cream, peri-spray, and an open container of Boost. In multiple rooms, surveyors observed unlabeled basins, bedpans, fracture bedpans, urinals, and kidney basins on floors, on a paper towel dispenser, on a wheelchair cushion, beside a commode, under a sink, and on top of a refrigerator. Resident #49’s oxygen tubing was also observed on the floor beside the bed. A CNA confirmed the findings when asked.
Uncovered Foley Catheter Bag Observed
Penalty
Summary
The facility failed to maintain a resident's privacy by leaving a foley catheter bag uncovered. During an observation of Resident #170, the catheter bag was seen hanging in the center of the bed upon entering the room, and amber-colored urine was visible in the bag from the doorway. An LPN was interviewed about the facility's practice for covering foley catheter bags with a privacy bag and confirmed that the policy was to keep foley bags covered. The LPN acknowledged that Resident #170's catheter bag was not covered with a privacy bag and stated they would cover it.
Incomplete and inaccurate care plan for a resident with mental health history
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to meet the needs of one resident. Review of the resident’s medical record showed a past psychological history that included schizophrenia and depression. The care plan created on 1/13/23 identified mood disturbance related to changing health status, depression, and bipolar disorder, but the surveyor could not find any documentation in the medical record showing that the resident had bipolar disorder. During interview, the DON stated that the care plan was created in error and that the resident did not have bipolar disorder. She also stated that the Unit Manager who created the care plan no longer worked at the facility and she was unable to determine why the care plan had been created.
Care Plan Not Revised for Wound Care Needs and Resident Not Invited to Care Plan Meeting
Penalty
Summary
The facility failed to reassess the effectiveness of wound care interventions and revise the care plan for a resident admitted from the hospital with septic leg wounds, non-pressure ulcers of the lower legs, ongoing hemodialysis, Type II diabetes mellitus, leg pain, and peripheral vascular disease. On observation, the resident had feet ace-wrapped from toe to knee and was sitting in a chair with feet down to the floor, and later remained in the same position without staff available to assist with repositioning or getting into bed. Record review showed the resident had 12 lower leg wounds on admission, with only one wound healed, and wound care plans initiated on 07/14/25 documented that the resident was often unable to keep feet elevated or remained in bed all day and had not been repositioned at least every two hours. The interventions were not revised after these documented challenges, and staff stated that revising care plans was an ongoing process, but the interventions had not been revised as a deficiency concern. The facility also failed to invite a resident to attend and participate in the care plan meeting. The resident stated during interview that he/she had not been involved in the care planning process. Record review showed the resident had multiple admissions and readmissions in 2025, with an admission on 6/20/25 and an MDS admission assessment completed on 6/27/25. Care conference notes and attendance documentation for the care plan meeting following that assessment showed the resident was not on the attendance log, and the care plan note only stated that the interdisciplinary team reviewed the care plan. The social service assistant stated residents are invited with a written invitation and should be added to the attendance log if present, but there was no documentation that this resident was invited or attended the care plan meeting.
Improper Disposal of Removed Pain Patch
Penalty
Summary
Staff failed to practice according to professional nursing standards when a nurse removed a resident’s pain patch and placed it on the windowsill instead of discarding it. During observation on 08/28/25 at 8:37 AM, a pain patch dated 08/26, from the 7:00 AM to 3:00 PM shift, was seen on the windowsill in Resident #18’s room, and GNA #4 confirmed the finding. During later interviews, the DON stated the expectation was for the nurse to discard the pain patch after removal. RN #17 described the process for removing a resident’s pain patch as checking the order, washing hands, applying gloves, removing the patch, cleaning the area with a washcloth, discarding the patch in the wastebasket, and documenting removal on the MAR.
Failure to Provide Required Bathing Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for dependent residents, as evidenced by Resident #77. The resident’s MDS assessment identified the resident as dependent for showering/bathing, upper and lower body dressing, and toileting. However, review of August 2025 bathing/showering task documentation showed that on 8/5/25, 8/11/25, 8/28/25, and 8/31/25 the resident was documented by two different staff members as set up or clean up, while one of those staff members also documented the resident as dependent for bathing on 15 other days that month. During interview, the DON reviewed the documentation and confirmed that the resident was dependent on staff for bathing and that if a bath were completed it would have been completed completely by staff, not as set up. At exit, no additional information was provided to show that appropriate ADL care was provided on those four days.
Oxygen Therapy Not Properly Set Up
Penalty
Summary
The facility failed to ensure oxygen therapy was set up in accordance with professional standards of practice for Resident #122, who was reviewed for respiratory care during the annual survey. During an observation, the surveyor found the oxygen tubing not connected to the humidifier bottle, with the end of the tubing lying on the floor. No date label was observed on either the tubing or the humidifier bottle. An LPN was notified of the disconnected oxygen and confirmed that she did not see labeling; she stated she would provide the resident with new tubing. The Assistant DON was later notified of the missing oxygen label and the administration tubing lying on the floor disconnected, and the DON confirmed awareness of the oxygen tubing and labeling concern.
Inaccurate Controlled Substance Counts in Medication Carts
Penalty
Summary
The facility failed to ensure that narcotic medications were consistently accurate based on review of narcotic counts for 2 of 6 medication carts reviewed for controlled medication storage and documentation. During inspection of the medication storage area, the surveyor found discrepancies in the controlled substance log involving Resident #160's oxycodone, Resident #27's oxycodone and Lyrica, Resident #129's diazepam, and Resident #195's tramadol. The report states that controlled substances are required to be thoroughly tracked and accounted for, including when they are administered to a resident, and that any discrepancy in the count from what is expected must be addressed immediately. The surveyor later spoke with the DON, Administrator, and Regional Clinical Service Manager, who confirmed their expectation that the nurse sign out any controlled substance that is administered.
Medication Labeling Deficiency
Penalty
Summary
Drugs and biologicals were not properly labeled in accordance with accepted professional principles, and controlled drugs were not the issue identified in the report. Based on observation and staff interview, the facility failed to properly label bulk medications with a complete date including month, day, and year, and failed to properly date multi-dose insulin injectable pens when opened. This was observed in 3 of 6 medication carts reviewed, where bulk medication had either an incomplete open date or no date at all, and one open insulin pen was not labeled with the date it was opened. During interview, the DON, Regional Clinical Services Manager, and Administrator were asked about expectations for labeling opened bulk medications and other medications, and the DON stated that nurses were expected to date any medication with the date it was opened.
Sugar Substitute Not Provided With Ordered CCHO Diet
Penalty
Summary
The facility failed to provide sugar substitute as specified by the ordered diet for Resident #86, who was on a Consistent Carbohydrate (CCHO) diet with Dysphagia 3, thin liquids, and a 1350 fluid restriction per day. On 08/29/2025, the surveyor observed the resident’s lunch tray and the resident stated that regular sugar had been served instead of sugar substitute, adding that he/she was diabetic and should not be served regular sugar. The tray card accompanying the meal listed CCHO, Dysphagia 3, Thin, 1350 fluid restriction/day, and sugar substitute under condiments. At 12:37 PM, an LPN confirmed that the tray contained sugar while the menu specified sugar substitute and offered to provide sugar substitute. During interview, the RD stated that a typical CCHO diet would have sugar substitute and provided the Dining Service Menu Guide for the CCHO diet, which stated that the CCHO diet utilized sugar substitute. The DON later confirmed that the RD had informed her of the concern.
Failure to Follow Two-Person Assistance Care Plan Results in Resident Fall and Injury
Penalty
Summary
Facility staff failed to follow a resident's established plan of care, resulting in a fall and injury. Specifically, a Geriatric Nursing Assistant (GNA) provided toileting care to a resident alone, despite the resident's care plan and GNA Kardex indicating a requirement for two-person assistance for both toileting and bed mobility. During this incident, the resident fell from the bed and sustained a laceration to the right side of the forehead, which required hospital evaluation and stitches. The deficiency was confirmed through medical record review, staff interviews, and facility investigation, which included a witness statement from the GNA admitting to not following the two-person assistance protocol. The resident involved had a documented need for two-person assistance for toileting and bed mobility as of a prior care plan update. The incident was reported by the resident's family, and subsequent review of progress notes and interviews with the Director of Nursing and former Administrator confirmed that the care plan was not followed at the time of the fall. The failure to adhere to the resident's care requirements directly led to the resident's injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,916 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westgate Hills Rehab & Healthcare Ctr | 0.6 mi | ★★★★★ | 10 | 0 |
| Carroll Park Healthcare | 1.1 mi | — | 19 | 0 |
| Little Sisters Of The Poor | 1.4 mi | ★★★★★ | 5 | 0 |
| Charlestown Community Inc | 1.4 mi | ★★★★★ | 22 | 0 |
| Ridgeway Rehab Center | 1.5 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Future Care Irvington.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.