Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Larkin Chase Center during CMS and state inspections, most recent first.
A resident with multiple cardiac and neurologic comorbidities developed acute respiratory distress, prompting an NP to order STAT labs and a chest x-ray to evaluate for pneumonia and other causes of clinical decline. The lab vendor later reported critical and abnormal results, including severe hypernatremia and markedly elevated WBC, to evening nursing staff, but the provider was not notified at that time despite facility policy requiring immediate physician notification for significant changes and critical values. The NP did not review the STAT lab results until the next day, at which point IV fluids were started and the attending physician was consulted, leading to an order to transfer the resident to the ED. EMS found the resident hypotensive with agonal respirations, and despite CPR in the hospital, the resident was pronounced dead. Surveyors cited Immediate Jeopardy under F580 for failure to promptly notify the provider of critical lab values after a change in condition.
A resident with multiple cardiac and neurologic comorbidities developed acute respiratory distress, prompting an NP to order a STAT chest x-ray and STAT labs (CMP, magnesium, CBC with differential) to rule out pneumonia and other causes. The STAT chest x-ray was never completed, and although the lab vendor obtained blood and later phoned in critical results including severe hypernatremia, elevated BUN, high magnesium, and markedly elevated WBC, the provider was not notified that evening. The NP was unaware the x-ray had not been done and that critical labs had been reported, and stated she would have sent the resident to the hospital if notified. The DON, Medical Director, and Administrator all described expectations for immediate provider notification of changes in condition, critical labs, and unfulfilled orders, but these expectations were not met in this case, leading to an F684 Immediate Jeopardy citation for failure to provide appropriate and timely care according to orders and resident condition.
Surveyors found that the facility failed to timely obtain, transcribe, and implement wound care orders for two residents with in-house acquired pressure ulcers, and did not consistently assess or document these wounds. One resident developed a Stage 2 pressure ulcer on the posterior lower leg that was identified and measured by the skin team, but no wound care order was entered until nearly two weeks later, just before discharge. Another resident with hemiplegia had moisture-associated skin damage and a sacral wound for which a wound physician ordered specific treatment that was never transcribed to the order recap or TAR, and nursing documentation repeatedly conflicted with the physician’s Stage 3 pressure ulcer staging and measurements. For this second resident, wound treatment orders lapsed and changed over time without clear continuity, the emergency contact was not informed of the wound until much later, and the RD was never notified of the new pressure ulcer despite facility policy requiring IDT notification and coordinated wound treatment.
The facility failed to obtain informed consent before administering psychotropic medications to two residents. One resident with anxiety and insomnia, who was cognitively intact per BIMS, received daily clonazepam for anxiety, and another resident with major depressive disorder and insomnia, with moderate cognitive impairment, received escitalopram via G‑tube for depression. In both cases, care plans identified risk related to psychotropic drug use, orders and MARs showed the medications were administered as prescribed, but the psychotropic medication disclosure/consent forms in their records were blank. Nursing staff, the DON, and the Administrator all acknowledged that psychotropic medications require consent prior to use under federal guidelines.
The facility failed to follow its abuse reporting policy when an allegation of sexual abuse involving a resident with muscle weakness and intact cognition was not reported to the state survey agency within the required two-hour timeframe. Policy required immediate entry of abuse allegations into the PCC risk management system and reporting of abuse, including sexual abuse, within two hours of the allegation. The DON informed the Administrator of the allegation after a housekeeper reported seeing another housekeeper hug and kiss the resident, but the incident was not reported to the state agency until more than two hours later, contrary to facility policy and the Administrator’s stated expectation for immediate reporting.
The facility failed to follow its abuse prohibition policy by not interviewing the CNAs assigned to a resident after the resident, who had muscle weakness and intact cognition, alleged neglect and rough care during the night shift. Although the resident reported being left in bed without a bath or assistance, experiencing rough care from a female aide, and having the call light turned off, the investigation only included statements from two RNs and one CNA who was not among the staff assigned during the reported shifts. Staffing records showed specific CNAs were assigned to the resident during the timeframe of the alleged incident, but these primary care staff were not interviewed, despite the DON’s acknowledgment that such interviews are typically part of an abuse investigation.
The facility failed to accurately code the MDS for a resident with documented Stage 3 pressure ulcers. Although the resident had a history of hemiplegia with moderate cognitive impairment and was care planned as at risk for skin breakdown with existing pressure ulcers on the sacral/right gluteal area, left heel, and left lateral ankle, the quarterly MDS indicated no risk for pressure ulcers and no unhealed pressure ulcers. Progress notes from a wound physician and an evening nursing supervisor documented unhealed and in-house acquired Stage 3 pressure ulcers on the sacrum and left gluteus during the MDS look-back period. In interviews, the DON confirmed the ulcers should have been coded, the MDS Coordinator admitted she missed coding the Stage 3 ulcer, and the Administrator stated he would expect a Stage 3 pressure ulcer to be reflected on the MDS.
Staff failed to protect resident PHI when an LPN left an EHR screen visible on a hallway medication cart during medication administration. The cart was positioned between resident rooms for several minutes with the EHR open and displaying information for multiple residents while visitors and staff walked past. The LPN later locked the cart but did not close or conceal the EHR, and subsequently acknowledged leaving resident information visible. The DON reported that staff are expected to protect residents’ personal health information and ensure EHR screens are not visible to passersby.
A medication cart was observed unlocked and unattended in a hallway between resident rooms while visitors and staff passed by. Facility policy required that only authorized staff access medication carts and that carts remain locked when not in use or not attended by authorized personnel. An LPN later returned to the cart, locked it, and admitted leaving it unlocked and unattended despite knowing it should be locked when not in direct line of sight. The DON confirmed that nurses are expected to keep medication carts locked when not directly observing them.
Failure to Notify Provider of Critical Lab Results Following Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a provider of critical and abnormal laboratory values for one resident who was being evaluated for a change in condition. The resident had a history of atherosclerotic heart disease, paroxysmal atrial fibrillation, encephalopathy, vascular dementia, traumatic subdural hemorrhage, hypertension, and cognitive communication deficit, and had a BIMS score of 11 indicating moderate cognitive impairment. On the day of the incident, a nurse practitioner (NP) was requested to evaluate the resident for acute respiratory distress, noting difficulty breathing with use of accessory muscles, lung crackles, and oxygen saturation of 93–96% on room air. In response, the NP ordered STAT laboratory tests, including a comprehensive metabolic panel, magnesium level, and CBC with differential, as well as a STAT chest x-ray, to rule out pneumonia and assess for other underlying causes of the resident’s clinical decline. The laboratory vendor received the STAT lab order late that morning, collected the blood specimen in the afternoon, and later that evening reported the results to the facility. The lab results showed a critically high sodium level of 161 mmol/L, elevated BUN of 55 mg/dL, elevated magnesium of 2.9 mg/dL, and a markedly elevated WBC count of 29.68 x10^3/uL. The laboratory vendor representative stated that the critical and abnormal values were reported by phone to the Evening Nursing Supervisor at 8:57 PM. The Evening Nursing Supervisor acknowledged recalling a call about the resident’s critical and abnormal lab values but stated she did not think she was the person the lab had called. Despite the facility’s policy requiring immediate notification of the physician and resident representative when there is a significant change in condition or clinical complication, the provider was not informed of these critical results on the evening they were received. The NP later documented, on the following day, that the STAT lab results obtained the prior day were reviewed at that time and showed significant abnormalities, including severe hypernatremia, elevated BUN consistent with acute kidney injury, and markedly elevated WBC concerning for dehydration, possible infection, and renal impairment. After this delayed review, the resident was started on IV fluids and the NP discussed the resident’s condition and abnormal labs with the attending physician, who agreed the resident required transfer to the hospital for further evaluation and management at a higher level of care. Emergency medical services were called due to decreased oxygen saturation, and upon arrival at the hospital the resident was noted to be hypotensive with agonal respirations, progressed to pulselessness, underwent CPR, and was pronounced dead. The surveyors determined that the facility’s noncompliance with the requirement to immediately inform the physician of significant changes and critical lab values caused, or was likely to cause, serious injury, harm, impairment, or death, and cited Immediate Jeopardy under F580, Notification of Changes.
Failure to Complete STAT Diagnostics and Notify Provider of Critical Labs After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a STAT chest x-ray was completed as ordered and to promptly notify a provider of critical and abnormal laboratory values for a resident who experienced a change in condition. The resident had a medical history including atherosclerotic heart disease, paroxysmal atrial fibrillation, encephalopathy, vascular dementia, traumatic subdural hemorrhage, hypertension, and cognitive communication deficit, and had a BIMS score of 11 indicating moderate cognitive impairment. On the day of the change in condition, a nurse practitioner (NP) was requested to evaluate the resident for acute respiratory distress and documented that the resident had difficulty breathing with use of accessory muscles, lung crackles, and oxygen saturation of 93–96% on room air. In response, the NP ordered a STAT chest x-ray and STAT laboratory tests, including a CMP, magnesium level, and CBC with differential, to rule out pneumonia and assess for other possible underlying causes. Physician orders were entered for the STAT chest x-ray and STAT laboratory tests within minutes of the NP’s assessment. The medical record, however, contained no evidence that the STAT chest x-ray ordered that day was ever completed. The x-ray vendor later reported receiving an x-ray order on a subsequent day and stated that when the technician arrived, the resident had already been sent to the emergency room, and that no STAT chest x-ray order had been received on the earlier date when the NP initially ordered it. The DON stated there was no written policy providing guidance on STAT orders, but there was a mutual expectation that STAT orders should be completed within four hours, and the x-ray vendor representative stated the vendor had eight hours to complete a STAT x-ray. The laboratory vendor reported receiving the STAT lab order late that morning, collecting the blood specimen in the afternoon, and communicating the critical and abnormal results to the Evening Nursing Supervisor later that evening. The lab results showed a critically high sodium level of 161 mmol/L, elevated BUN of 55 mg/dL, elevated magnesium of 2.9 mg/dL, and a markedly elevated WBC count of 29.68 x10^3/µL. The Evening Nursing Supervisor recalled receiving a call about the critical and abnormal lab values but stated she did not think she was the person the lab had called. The NP stated she was not aware the chest x-ray had not been completed and that the facility should have contacted the provider when the critical lab results were received; she further stated that had she been notified that evening, she would have sent the resident to the hospital. The DON confirmed that nurses were responsible for following up on STAT orders, notifying the provider if labs or x-rays were not completed, and reporting all critical lab values immediately, and acknowledged she was unaware that the resident’s critical lab results had not been reported to the provider. The Medical Director and Administrator both stated their expectation that providers be notified immediately of any change in condition, all critical lab results, or if an order could not be carried out. The resident was ultimately transferred to the hospital the following day after the NP reviewed the lab results and clinical status and obtained an order for transfer due to critical lab values and elevated WBC count. Upon arrival at the hospital, the resident was noted by EMS and emergency department documentation to be hypotensive with agonal respirations. EMS initiated intraosseous access, fluids, and bagging, and the resident lost pulses, prompting CPR initiation. The emergency department record indicated the resident remained pulseless and in asystole despite multiple rounds of CPR and medications, and resuscitation efforts were terminated with a recorded time of death. The surveyors determined that the facility’s noncompliance with requirements for quality of care, specifically the failure to complete the ordered STAT chest x-ray and to promptly notify the provider of critical and abnormal laboratory values, caused or was likely to cause serious injury, harm, impairment, or death, and cited the facility at F684, Quality of Care, at an Immediate Jeopardy level.
Failure to Implement and Coordinate Pressure Ulcer Care and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to prevent new ulcers from developing for two residents. For one resident with a history of left femur fracture, right lower leg fracture, and orthopedic aftercare, the admission MDS showed intact cognition and no unhealed pressure ulcers, though the resident was at risk for pressure injury due to decreased mobility. A care plan focus area was initiated for risk of skin breakdown. On 03/06/2026, the Skin Health Team Lead (SHTL) documented a newly identified in-house acquired Stage 2 pressure ulcer on the resident’s right posterior lower leg, measuring 8.93 cm by 5.43 cm, which later increased in size by 03/12/2026. Despite this, there was no corresponding wound care order in the medical record until 03/18/2026, with treatment starting 03/19/2026, one day before discharge home. The SHTL stated wound care was performed daily but confirmed that wound care orders were not implemented until 03/18/2026 and could not explain the lack of earlier orders. For the second resident, admitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, the quarterly MDS indicated moderate cognitive impairment and no unhealed pressure ulcers, and not at risk for pressure ulcers, although the care plan documented risk for skin breakdown related to incontinence, limited mobility, and a pressure ulcer on the right gluteus/sacral area, left heel, and left lateral ankle. The care plan directed weekly wound assessments with measurements and descriptions. On 01/06/2026, an eINTERACT SBAR note by the Evening Nursing Supervisor documented moisture-associated skin damage (MASD) on the left gluteal area and a wound physician’s order to cleanse with wound cleanser, pat dry, apply medical honey plus calcium alginate, and cover with a dry dressing. However, there was no evidence on the Order Recap Report or the TAR that this order was transcribed or implemented. Subsequent Skin Issues notes and wound physician progress notes showed inconsistent characterization and staging of the resident’s sacral/left gluteal wound, with nursing documentation describing MASD and unstageable pressure ulcers with varying measurements, while the wound physician consistently documented a Stage 3 pressure ulcer with different measurements and noted the wound as deteriorating at one point. The facility’s documentation for the second resident also showed gaps and inconsistencies in wound treatment orders over time. An order dated 01/25/2026 directed daily cleansing of the left gluteal wound with wound cleanser, hydrogel, and gauze/foam dressing, but this order ended on 02/09/2026. A later order dated 03/26/2026 for sacral wound care with wound cleanser, plurogel, calcium alginate, and foam dressing every day and as needed was discontinued on 04/03/2026, and replaced with a one-time and every day shift order for cleansing and calcium alginate with foam dressing. The Lead Registered Dietician (RD) reported she was not familiar with this resident and, upon review of the record, stated it did not appear that any new nutritional orders were implemented when the wounds developed and that she would have expected to be notified of the new wounds. The resident’s emergency contact stated they were unaware of the sacral wound since January and believed the wound had just developed based on a recent call. The DON acknowledged that skin meetings did not include a deep dive into whether wound orders were appropriate or implemented, could not explain why the staff did not document the pressure ulcer as Stage 3 as the wound physician did, and could not state why orders to treat the pressure ulcer were missed, while the Administrator stated that residents’ wounds must be monitored and documented appropriately. The facility’s own policy, NSG236 Skin Integrity and Wound Management, required notification of interdisciplinary team members for a comprehensive approach to care, including prevention and wound treatments, and implementation of special wound care treatments and techniques as indicated and ordered. In both residents’ cases, the survey findings showed failures to ensure timely and appropriate wound care orders were obtained, transcribed, and implemented after in-house acquired pressure ulcers were identified, failures to notify the Lead RD of new pressure ulcers, and inconsistencies in assessment and documentation of the pressure ulcer’s stage and characteristics. These actions and inactions directly conflicted with the facility’s stated policy requirements.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to two residents. For one resident with anxiety disorder and primary insomnia, the admission MDS showed a BIMS score of 15, indicating intact cognition, and documented antianxiety medication use. The resident’s care plan, initiated shortly after admission, identified risk for complications related to psychotropic drugs and included an intervention to provide informed consent to the resident or healthcare decision maker. Physician orders and MARs showed clonazepam 0.5 mg was ordered and administered daily for anxiety over a two‑month period. However, the Psychotropic Medication Administration Disclosure form in the resident’s medical record was blank. Nursing staff interviewed acknowledged that psychotropic medications required consent prior to use and could not recall reviewing the psychotropic consent with the resident, and facility leadership confirmed that consent had not been obtained. For a second resident with major depressive disorder and primary insomnia, a quarterly MDS documented moderate cognitive impairment with a BIMS score of 11 and antidepressant use. The resident’s care plan, initiated after admission and later revised, also identified risk for complications related to psychotropic drugs. The Order Recap Report showed an order for escitalopram 20 mg via gastrostomy tube at bedtime for depression, and the MAR confirmed the medication was administered as ordered. As with the first resident, the Psychotropic Medication Administration Disclosure form in this resident’s record was blank. During interviews, the DON confirmed that consent for psychotropic medications had not been obtained when the medication was started, and the Administrator stated that psychotropic medications required consent prior to use according to federal guidelines.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the state survey agency for one resident. Facility policy titled “Abuse Prohibition,” revised 11/14/2025, required that upon receiving information about suspected or alleged abuse, the Administrator or designee must enter the allegation into the PCC Risk Management Portal and report allegations involving abuse, including sexual abuse, no later than two hours after the allegation is made. Resident #5, admitted on 12/04/2025, had a medical history including muscle weakness and a quarterly MDS with an ARD of 02/09/2026 showing a BIMS score of 13, indicating intact cognition. On 03/19/2026 at 9:30 AM, the DON notified the Administrator of an allegation of sexual abuse involving Resident #5, after Housekeeper #2 reported seeing Housekeeper #1 enter the resident’s room and hug and kiss the resident. The Facility Reported Incident Initial Report Form documented that this allegation was reported to the state survey agency at 12:13 PM, which exceeded the facility’s policy requirement to report such allegations within two hours. During an interview, the Administrator stated his expectation was that any allegation of abuse must be reported immediately. This sequence of events, including the time the allegation was received and the time it was reported to the state survey agency, demonstrated that the facility did not adhere to its own policy for timely reporting of abuse allegations.
Failure to Interview Assigned Staff After Resident’s Allegation of Neglect
Penalty
Summary
The facility failed to ensure that staff assigned to care for a resident were interviewed after the resident voiced an allegation of neglect. Facility policy "OPS300 Abuse Prohibition" required that an investigation be initiated within 24 hours of an allegation of abuse, focusing on whether abuse or neglect occurred, causative factors, and interventions to prevent further injury, and that the investigation be thoroughly documented with witnessed interviews. Resident #1, who had a diagnosis of muscle weakness and an intact cognition as evidenced by a BIMS score of 15 on a quarterly MDS, reported on two occasions that they were left in bed without a bath or assistance, that a female GNA was rough when providing care, and that their call light was turned off during the 11:00 PM to 7:00 AM shift. The facility’s investigation file contained statements from two RNs and one GNA (GNA #5), but did not include interviews with the GNAs who were actually assigned to the resident during the relevant shifts. Staffing assignments showed that GNA #10 was assigned to the resident on two consecutive nights during the 11:00 PM to 7:00 AM shift, and GNA #13 was assigned on the following night during the same shift, which matched the timeframe identified by the resident. During interviews, the resident confirmed the incident occurred on the night shift but could not recall the employee’s name. The DON stated that during an investigation the facility typically interviewed the primary care staff assigned to the resident at a minimum, and the Administrator stated that abuse investigations should be thoroughly investigated to determine the thoroughness of the investigation, underscoring that the assigned staff were not interviewed as required by policy.
Inaccurate MDS Coding for Resident With Stage 3 Pressure Ulcers
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident with pressure ulcers/injuries. The quarterly MDS with an Assessment Reference Date of 02/17/2026 documented that the resident was not at risk for developing pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. This coding was completed despite existing documentation in the resident’s medical record and care plan indicating the presence of pressure ulcers. The facility reported that it followed the CMS LTC Facility RAI 3.0 User’s Manual for MDS completion, which requires coding of any pressure ulcer/injury present during the 7‑day look‑back period. The resident, admitted on 08/05/2025, had a medical history including hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage affecting the left non-dominant side and had a BIMS score of 10, indicating moderate cognitive impairment. The resident’s care plan, initiated on 08/07/2025, identified them as at risk for skin breakdown related to incontinence, limited mobility, and existing pressure ulcers on the right gluteus/sacral area, left heel, and left lateral ankle. Progress notes dated 01/28/2026 by the wound physician documented an unhealed Stage 3 pressure ulcer on the sacrum, and notes dated 02/12/2026 by the evening nursing supervisor documented an in-house acquired Stage 3 pressure ulcer on the left gluteus. During interviews, the DON confirmed the pressure ulcer should have been coded on the MDS, and the MDS Coordinator acknowledged she missed coding the Stage 3 pressure ulcer, while the Administrator stated that a Stage 3 pressure ulcer should be reflected on the MDS.
Failure to Protect Resident PHI on Medication Cart EHR Screen
Penalty
Summary
The facility failed to protect residents’ private and confidential information during medication administration when an electronic health record (EHR) was left visible on a medication cart in a hallway. On 2/19/26, a medication cart was observed positioned between specified resident rooms from 9:55 a.m. to 9:59 a.m., with the EHR screen displaying resident information for 14 of 73 residents. During this time, several visitors and staff members walked past the cart in the hallway while the EHR remained open and visible. The LPN responsible for the cart exited a resident room, approached the cart, and locked it but did not close or obscure the EHR screen containing resident information. In an interview immediately afterward, the LPN acknowledged being responsible for the cart and confirmed that the EHR with resident information had been left visible. In a separate interview, the DON stated that the facility’s expectation is that nursing staff protect residents’ personal health information and ensure the EHR is not visible to passersby. No additional resident-specific medical histories or clinical conditions related to the affected residents were provided in the report.
Unattended Unlocked Medication Cart Left Accessible in Hallway
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments when not in use, as required by facility policy and professional standards. The written policy on medication storage stated that only licensed nurses, pharmacy staff, and other authorized personnel may access medication carts, and that medication rooms, cabinets, and supplies must remain locked when not in use or attended by authorized staff. During observation, a medication cart was seen positioned between resident rooms, unlocked and unattended for approximately four minutes while several visitors and staff walked past it in the hallway. The LPN responsible for the cart later returned, locked the cart, and acknowledged having left it unlocked and unattended despite knowing it should be locked when not in direct line of sight. The DON confirmed that the facility’s expectation is that nurses keep medication carts locked when they are not directly observing them. No specific residents, their medical histories, or conditions at the time of the deficiency were identified in the report, and the deficiency centered on the unsecured medication cart and staff noncompliance with the established medication storage policy.
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 1,593 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bowie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Rosa Nursing And Rehabilitation, Llc | 4.4 mi | ★★★★★ | 37 | 0 |
| Autumn Lake Healthcare At Crofton | 5.4 mi | ★★★★★ | 24 | 0 |
| Largo Nursing And Rehabiliation Center | 5.9 mi | ★★★★★ | 37 | 0 |
| Future Care Capital Region | 6.6 mi | ★★★★★ | 31 | 0 |
| Doctors Community Rehabilitation And Patient Care | 6.8 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Larkin Chase Center.
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.