Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Lorien Mays Chapel during CMS and state inspections, most recent first.
Oxygen tubing was not changed or labeled as required for multiple residents. A resident receiving O2 at 2 L/min had unlabeled tubing despite weekly change orders, another resident’s nasal cannula and tubing were hanging from a bed light cord instead of being on the resident and were not dated, and two other residents had oxygen tubing on the floor and not dated while the concentrator remained running. The DON and an LPN confirmed the tubing was expected to be dated and changed per policy and orders.
Failure to provide required beneficiary protection notices to a resident. Record review showed that the facility did not issue the NOMNC or SNF ABN for a resident reviewed on Beneficiary Protection Notification forms. The DON confirmed the notices were not provided and could not explain the omission.
A resident's room on the 3rd floor had many dark marks on the floor in front of the nightstand, and the markings appeared marred into the floor. The issue was observed during a survey tour and later brought to the Administrator's attention.
A resident receiving scheduled Ativan for dementia with agitation had no evidence of a GDR attempt and no adequate clinical documentation supporting continued use. A pharmacy consultant recommended a GDR, but the MD declined it due to concern for decompensation without documenting sufficient rationale, and behavioral monitoring sheets showed no documented behaviors to justify the medication. The resident was also on Cymbalta for depression, which may address anxiety symptoms, and the DON stated the behavior logs might be inaccurate and that the resident yells out.
A resident was transferred to the hospital for expiratory rhonchi, but the facility did not provide written notification to the RP about the transfer and did not give a copy of the bed hold policy. During survey review, the DON could not produce documentation showing that either item had been sent, and stated that both were missed.
Incomplete Respiratory Care Plan: A resident with asthma/COPD and acute bronchitis had oxygen tubing observed on the floor and not labeled with the date and time of administration. An LPN stated the resident receives nebulizer treatments every 6 hours and removes the mask herself when finished, and the DON confirmed the care plan had no respiratory care focus areas.
A resident’s comprehensive care plan was not reviewed and revised after assessment, and the care plan lacked a respiratory focus area despite diagnoses of asthma/COPD and acute bronchitis. The DON reviewed the plan with the surveyor and confirmed that no respiratory care focus was included, even though the resident had attended two care plan meetings since admission.
Failure to Follow Oxygen Orders: A resident’s O2 nasal cannula was found tied to the over-bed light cord instead of on the resident while the concentrator was running at 2 L. Staff confirmed the cannula was not in place and then applied it. The resident’s chart showed an order for continuous O2 at 2 L/min via NC, and the DON stated an older PRN O2 order should have been discontinued.
Staffing ratios and the RN in charge were not posted on the unit white boards used for staffing assignments. Surveyors observed incomplete census and staffing boards on the clinical units, including missing GNA and LPN resident assignment ratios and, at one point, no RN identified on the census board. An LPN stated the boards were to be updated during shift change, but later observations still found no staffing ratios posted on the third-floor unit.
Inaccurate controlled substance documentation and unresolved narcotic count discrepancies were observed on a unit. An LPN signed off on Tramadol and Lorazepam counts that did not match the actual pill counts, and stated that medication administration had not been documented and that he miscounted one of the controlled substances. The DON was present when the discrepancy was identified, and the nurse acknowledged that both nurses missed the Tramadol count issue.
A facility failed to securely store medications and control access to them. An LPN said pharmacy-delivered medications were not stored promptly after delivery, and surveyors observed a brown bag of medications unattended near the nurse's desk and a plastic bottle containing Nystatin powder under a resident's bed.
Food Storage and Dishwashing Sanitation Deficiencies: During a kitchen tour, surveyors found dirty trays and dishes near the dishwasher, missing dishwasher temp log entries, and multiple opened food items in the refrigerator and dry storage without dates. Bread was also being stored in a hallway used for refuse and traffic, while staff moved a mop/bucket and a laundry bin past the food storage area.
A resident’s medical record contained conflicting oxygen orders, including an older PRN O2 order that should have been discontinued and a newer order for continuous 2 L/min O2 via NC. During review, the DON stated the PRN order was an oversight and that the resident should have been on continuous O2.
Unlocked treatment carts were observed on both nursing units, and resident-labeled medications were accessible inside several carts, including hydrocortisone cream, nystatin powder, Orajel, Anasep gel, Silvasorb gel, and Aspercreme. Staff in the area did not question the surveyor’s presence while the carts were being reviewed, and only one of four treatment carts was found locked without surveyor intervention.
The facility failed to secure residents' medical records, as four charts were left unattended on a filing cabinet in a hallway, with physician orders visible to the public. A staff member acknowledged the issue and removed the charts, explaining that new orders were usually flagged and placed for nurse review, leading to the oversight.
The facility failed to properly label and monitor expiration dates for stored food items, as observed during a survey. Expired and undated food items were found in the kitchen and walk-in refrigerator. Staff was unable to clarify expiration dates for these items.
The facility's policy on abuse, neglect, exploitation, and misappropriation was found deficient during a survey, as it lacked accurate reporting timeframes and did not include necessary procedures for investigation. The Administrator confirmed the absence of additional policies and the non-use of occurrence reports, despite the policy's requirements.
The facility did not provide written notification to a resident and their representative regarding the resident's transfer or discharge. A resident was hospitalized on three occasions in 2024, and no written notifications were given. The DON confirmed that the facility only provides verbal or phone notifications, which was identified as a concern.
A facility failed to provide a baseline care plan summary for a resident within the required timeframe, as identified during a survey. The baseline care plan was found to be 78 days overdue, with no documentation in the resident's progress notes. The DON acknowledged the oversight and was unsure why it was missed, noting the resident's admission occurred on a Friday after staff had left for the day.
A resident with a left leg fracture was improperly transferred without a Hoyer lift, as required by their care plan, resulting in pain and a deficiency. The resident was non-weight bearing and required total assist, but the aide transferred them manually, causing their leg to jam and heel to hit the floor.
A facility failed to monitor a resident's medication parameters for Metoprolol Succinate ER, as staff did not document required vital signs despite administering the medication. Interviews revealed that an LPN lacked access to an automated link for inputting values, while an RN confirmed that vital signs should always be recorded. The DON acknowledged the expectation for documentation, even if the medication was not held.
A facility failed to monitor a psychotropic medication for a resident, as a pharmacy recommendation for side effect monitoring of Seroquel was not documented or implemented until identified by a surveyor. The DON confirmed the oversight, and behavior monitoring was being conducted by GNAs, but specific side effect monitoring was not in place until the surveyor's intervention.
A resident received medication not prescribed to them, leading to weakness and body aches. A family member found an unrecognized pill on the resident's bed, which was identified as belonging to the resident's roommate. The nursing supervisor confirmed the error and reported it to the DON and NHA for further investigation.
A facility failed to secure medications properly, leading to a resident ingesting a lancet left in a medicine cup and a medication cart being found unlocked and unattended. The resident was sent to the ER for evaluation, and the facility's staff acknowledged the security lapses.
The facility failed to maintain adequate medical records for two residents. One resident's records lacked a thorough assessment after a gastrostomy tube dislodgement and hospital transfer, while another resident's records did not document a timely pain reassessment after a fall. The DON acknowledged the missing documentation, which led to inaccuracies in the residents' medical records.
The facility failed to maintain accurate infection control signage and up-to-date employee immunization records. Surveyors found inconsistent signage for COVID-19 precautions and missing immunization documentation for several GNAs. The DON acknowledged the discrepancies, and the facility's policy did not include Tdap as a required immunization.
A facility failed to offer a pneumococcal vaccine to a resident, as required by its immunization policy. The resident's medical records lacked documentation of being offered, receiving, or refusing the vaccine. The DON confirmed the oversight during an interview, despite providing evidence of the resident receiving an influenza vaccine.
A facility failed to educate a resident about the COVID-19 vaccine, including its benefits, risks, and side effects, and did not offer the vaccine to the resident. The DON confirmed the lack of documentation and education, which was against the facility's policy that emphasizes the importance of vaccination for LTC residents.
A resident was subjected to verbal and physical abuse by a GNA, who was observed on video screaming and pushing the resident. The facility's investigation confirmed the abuse, leading to the GNA's termination.
The facility failed to review background check results for a GNA, who was employed for a year despite a background check revealing a second-degree assault offense. The Administrator and HR Director were unaware of the results, leading to an audit of other employees' background checks.
The facility failed to report injuries of unknown origin and abuse allegations in a timely manner. A resident sustained head trauma, allegedly from a male aide, but the incident was reported to OHCQ over a month later. Another resident's arm bruise was not reported immediately, and a serious injury was reported 51 hours after x-ray results were received. An abuse allegation was also reported late. The facility's Administrator acknowledged these delays.
A facility failed to protect a resident during an abuse investigation and did not thoroughly investigate the allegation. A resident reported abuse by a male nurse in a blue uniform, matching an LPN's description. Despite this, the facility did not take immediate protective measures, allowing the alleged perpetrator to continue working and conduct an interview with the resident. The investigation file contained inconsistencies, and the facility administrator could not confirm any protective actions taken.
A facility failed to update a resident's care plan after multiple G-tube dislodgements, despite discussing the issue in a care plan meeting. The resident experienced four dislodgements between July and October 2024, with two requiring emergency room transfers. The care plan was not updated until October 2024, as staff typically update plans quarterly or as needed, but the dislodgement issue was overlooked until then.
Oxygen Tubing Not Changed or Dated per Orders and Policy
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed and dated according to physician orders and the facility’s oxygen therapy policy. During observation rounds, Resident #56 was seen receiving O2 at 2 L/min via nasal cannula, but the oxygen tubing was not labeled with a date. The humidifier bottle was labeled with the date 04/01/2026. Review of the medical record showed physician orders that the O2 nasal cannula tubing and humidifier were to be changed every week, and the facility’s DON stated staff were expected to change and date O2 tubing and humidifier bottles at least weekly. Resident #46 was observed with oxygen nasal cannula and tubing tied and hanging from the cord of the over-the-bed light fixture rather than on the resident, while the tubing remained connected to a concentrator running at 2 liters. The tubing was not labeled with a date indicating when it was last changed. Staff #3 verified the condition of the tubing and immediately placed the oxygen on the resident. The resident’s record included an order for continuous oxygen at 2 L/min via nasal cannula and a separate order stating that oxygen tubing and nasal cannula/mask equipment were to be changed weekly and labeled with the date changed. Resident #38 was observed with oxygen tubing not labeled with the date and time of administration, and the tubing was on the floor next to the bed. Resident #5 was also observed with oxygen tubing on the floor and not dated while the oxygen concentrator was still running. In both instances, the assigned LPN stated the residents removed the oxygen themselves or had dropped the tubing, and when asked about dating the tubing, stated it would be changed out and replaced with a new one dated and timed. The facility’s oxygen therapy policy stated that tubing and bottles are labeled with date and that equipment is cleaned and stored in a clean plastic bag with the date.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure that required beneficiary protection notifications were provided to Resident #38. Based on record review and staff interview, the facility did not issue the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, or the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), Form CMS-10055, as applicable. On 04/06/2026, the facility received Beneficiary Protection Notification Review forms for three residents, including Resident #38. When the Director of Nursing returned the forms on 04/08/2026, the review showed that Resident #38 did not receive the required NOMNC or SNF ABN. During an interview later that day, the DON confirmed the notices were not provided and was unable to explain the omission.
Unclean and Poorly Maintained Resident Room Floor
Penalty
Summary
The facility failed to ensure that a resident's environment was clean and well maintained. During an initial tour of the third floor, surveyors observed Resident #101's room and noted many dark marks on the floor in front of the resident's nightstand, with the markings appearing marred into the floor. The concern was brought to the Administrator's attention later that morning, and he stated that maintenance would address the concerns.
Failure to Attempt GDR and Document Ongoing Need for Scheduled Ativan
Penalty
Summary
The facility failed to ensure that a gradual dose reduction (GDR) was attempted for Resident #8’s scheduled antianxiety medication and failed to provide adequate clinical documentation supporting the continued use of the medication. Medical record review showed the resident had been receiving Ativan (lorazepam) three times daily since February 29, 2024, for dementia with agitation. A pharmacy consultant recommendation dated February 9, 2026, suggested a GDR, but the physician declined, stating the resident was at high risk for decompensation. The record did not contain sufficient clinical documentation to support that determination, and there was no evidence that a GDR had ever been attempted. The resident was also receiving Cymbalta (duloxetine) 30 mg at bedtime since January 2024 for depression, which may also address anxiety symptoms, and the dose was decreased to 20 mg on March 17, 2026. Behavioral monitoring sheets from November and December 2025 and January through March 2026 showed no documented behaviors to support the continued need for scheduled Ativan. Physician progress notes also did not document that a GDR was attempted or provide a clear clinical rationale for ongoing use of the medication. During interview, the DON stated the behavioral monitoring sheets might be inaccurate and reported that the resident yells out; when asked whether yelling could reflect an unmet need such as pain given the resident’s cognitive impairment and limited ability to communicate, the DON acknowledged that this was possible.
Failure to Notify Responsible Party of Hospital Transfer and Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification to the resident’s responsible party regarding a hospital transfer and failed to provide a copy of the facility’s bed hold policy. Resident #90 was transferred to the hospital on 1/30/26 for expiratory rhonchi. During survey review, the survey team requested documentation showing that written transfer notification and the bed hold policy had been provided to the responsible party, but the Director of Nursing was unable to produce it. In interview, the DON stated that the bed hold policy was not sent because it was missed, and that written documentation for responsible party notification should also have been sent but was not done.
Incomplete Respiratory Care Plan
Penalty
Summary
The facility failed to develop and implement a complete, comprehensive care plan for Resident #38. During observation on 4/06/2026, the resident’s oxygen tubing was noted to be on the floor next to the bed and was not labeled with the date and time of administration. When the nurse was interviewed, she stated that Resident #38 receives nebulizer treatment every 6 hours for asthma and that the resident takes the mask off herself when finished; she also stated she would change the tubing and get a new one with the date and time on it. On 4/08/2026, the surveyor reviewed the resident’s care plan and interviewed the DON regarding respiratory care. The resident had diagnoses of asthma/COPD and acute bronchitis, but the DON confirmed that she did not see any focus areas in the care plan for respiratory care. The report states that a comprehensive person-centered care plan must include measurable objectives and timeframes to meet the resident’s medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment.
Missing Respiratory Focus in Care Plan
Penalty
Summary
The facility failed to ensure that Resident #38’s comprehensive care plan was reviewed and revised after each assessment. During survey review, the care plan was found to be missing a respiratory focus area even though the resident had diagnoses of asthma/COPD and acute bronchitis. Resident #38 was admitted to the facility and had two care plan meetings since admission, but the respiratory needs were not reflected in the care plan. When the surveyor asked the DON to review the care plan for respiratory care, the DON confirmed that no respiratory focus area was included and stated she was unsure how it was missed.
Failure to Follow Oxygen Orders
Penalty
Summary
The facility failed to follow physician orders for oxygen therapy for one resident who was observed receiving oxygen during the annual survey. During observation rounds, the resident’s oxygen nasal cannula and tubing were found tied and hanging from the cord of the over-bed light fixture rather than being on the resident, while the oxygen concentrator was running at 2 liters. Staff verified the tubing was not on the resident and immediately placed the nasal cannula on the resident, stating the resident should have the oxygen on. The resident’s record showed a physician order dated 02/26/2026 for oxygen at 2 L/min continuously via nasal cannula for oxygen saturation greater than 92% every shift for monitoring. The record also contained a prior order dated 02/10/2025 for oxygen as needed for oxygen saturation below 90% and to titrate oxygen to maintain saturation at 90%. The DON stated the PRN oxygen order should have been discontinued and was an oversight, and confirmed the resident should have been on oxygen 2 L/min by nasal cannula.
Staffing Ratios and RN Assignment Not Posted on Unit White Boards
Penalty
Summary
The facility failed to ensure that staffing ratios and the RN assigned to be in charge of the unit were posted on the white boards used to display staffing assignments on the clinical units. During an observation tour of the second- and third-floor clinical units, the surveyor found that the white boards had not been filled out for the day shift. On the third-floor clinical unit, the white board did not include the staffing ratios for GNA and LPN staff members, and the census board did not identify which RN was in charge of the unit. The surveyor also observed that no RN was identified on the census board at that time. The assigned charge nurse, an LPN, stated that the census and staffing assignment were to be updated during the shift change between 0700 and 0730. The surveyor later informed the administrator and DON that the census boards were not completed prior to 08:15 AM. On subsequent observation tours of the third-floor nursing unit, the surveyor again found that no nursing staffing ratios were posted on the white board used for staff assignments, although on the later observation the census board did display which RN was in charge of the clinical unit.
Inaccurate Controlled Substance Counts and Documentation
Penalty
Summary
The facility failed to ensure the accuracy and timeliness of controlled substance documentation, with unresolved discrepancies in narcotic counts observed during the recertification survey. During an observation of the narcotic count on Unit 2, Staff #24 signed the narcotic count sheet for Tramadol showing 12 tablets, but an actual count found 11 tablets. In the same observation, Lorazepam 0.5 mg was documented at 59 tablets as of 6:00 AM, while 67 tablets were physically present, showing inaccurate documentation and a failure to reconcile controlled substances. During interview, Staff #24 stated he was signing off medications for the prior day because the nurse who administered them had failed to document the administration. He also stated he miscounted the Lorazepam when it was administered and signed it off at 6:00 AM, acknowledging the inaccuracy. When asked about the narcotic count on the prior day, Staff #24 confirmed it had been completed with the off-going nurse, but said both nurses missed the Tramadol discrepancy. The DON, who was present and informed of the findings, instructed Staff #24 to do another narcotic count.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure medications were securely stored and controlled to prevent unauthorized access, and failed to ensure timely storage of medications upon delivery in accordance with accepted professional standards of practice. During observation rounds, a surveyor found a brown bag containing medications with a list of medications stapled to the outside sitting unattended on a bedside table next to the nurse's desk and accessible to unauthorized individuals. An LPN stated that the pharmacy had delivered the medications during the 11:00 PM-7:00 AM shift and that he did not have time to store them where they belong. In a separate observation, Resident #20 was found with a plastic bottle under the bed that contained Nystatin powder, showing that resident medications were not maintained in a secure manner.
Food Storage and Dishwashing Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that dishes were cleaned and stored properly, that dishwasher temperatures were consistently recorded, and that food was dated when opened and stored in a sanitary environment. During the initial kitchen tour, dirty food trays, dirty pitchers, and a dirty bowl were observed on the counter in the area where the dishwashing machine was located. Review of the dishwasher temperature log showed missing entries, with the last recorded temperature entry documented several days earlier, and staff stated that the dishwasher temperatures were supposed to be checked and recorded daily. In the walk-in refrigerator, multiple food items were observed without dates indicating when they were opened, including an opened bottle of ranch dressing, an opened bottle of jelly, a bag of broccoli florets, slices of turkey luncheon meat, a head of lettuce, and a large plastic bin of chicken sitting in water. In the dry storage area, an open bag of sugar was also found without a date. In the hallway used for refuse discard, three bread holders containing loaves and rolls were stored while staff passed by with a mop and bucket and a laundry bin, and the kitchen supervisor stated this was where the bread was usually stored.
Inaccurate Oxygen Orders in Medical Record
Penalty
Summary
Medical records were not maintained in the most accurate form for one resident. Review of the resident’s chart showed a physician order dated 02/26/2026 for oxygen at 2 L/min continuously via nasal cannula for oxygen saturation greater than 92% every shift for monitoring, along with an older physician order dated 02/10/2025 for oxygen PRN when O2 was below 90% for hypoxia, with instructions to titrate oxygen as needed to maintain O2 saturation at 90%. During interview and review of the resident’s oxygen orders, the DON stated the PRN oxygen order should have been discontinued and was an oversight, and that the resident should have been on oxygen 2 L/min by nasal cannula continuously.
Unlocked Treatment Carts Contained Resident-Labeled Medications
Penalty
Summary
The facility failed to maintain a safe and effective system for securing medications stored in designated treatment carts on the nursing units. During the morning tour on 10/7/25, a surveyor observed a treatment cart on the 3rd floor with a silver lock protruding, but the top drawer opened easily. Inside were hydrocortisone cream, bio freeze gel, and nystatin powder labeled with resident names. While the surveyor remained at the cart for about 12 minutes, staff in the area did not question the surveyor’s presence or ask if assistance was needed. A second unlocked treatment cart was observed behind the unit manager on the 3rd floor, and the surveyor reviewed its contents, which included Orajel, Anasep gel, nystatin powder, and Silvasorb gel labeled for individual resident use. On the 2nd floor, another treatment cart outside room 211 was also unlocked and contained Aspercreme, nystatin powder, hydrocortisone cream, and other medications, some identified as house stock and others prescribed for residents. Of the four treatment carts observed in the facility, only one was locked without surveyor intervention, and the DON was informed of the observations later that morning.
Confidentiality Breach of Residents' Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical records, as observed during a recertification/complaint survey on the second floor nursing unit. Four residents' charts were found unattended on top of a wide filing cabinet in the hallway, with physician orders visible to the public. The charts, belonging to Residents #8, #25, #53, and #56, had physician order pages flagged and sticking out, making them easily accessible and visible. Staff #17, when interviewed, acknowledged the issue and removed the charts. She indicated that the person responsible for writing the rehab orders typically flagged new orders and placed them next to the computer station for nurse review, leading to the oversight in securing the charts.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to ensure proper labeling and monitoring of expiration dates for stored food items, as observed during the recertification/complaint survey. During a kitchen tour, surveyors found a 3 lbs can of strawberry topping with an expired 'used by' date, a 6 lbs can of navy beans with an unknown expiration date, and several undated open bags of cinnamon swirl bread with raisins and hamburger buns. Additionally, in the walk-in refrigerator, there were undated open bags of mixed salad, turkey breast deli meat, and a large open plastic container of cherry topping prepared on a specific date but lacking an expiration date. Staff #15 was unable to clarify the expiration dates for these items and mentioned that the undated bread was typically used within the day, with no leftovers usually remaining.
Deficiency in Abuse and Neglect Policy Reporting Timeframes
Penalty
Summary
The facility was found to have a deficiency in its abuse, neglect, exploitation, and misappropriation policy during a recertification/complaint survey. The surveyor identified that the policy lacked the necessary reporting and response timeframes required by regulations. Specifically, the policy contained inaccurate reporting timeframes for allegations of abuse, exploitation, neglect, or unknown injury. It stated that reports should be faxed or emailed within 24 hours to the Office of Health Care Quality, and in cases of reasonable suspicion of a crime, the facility must notify OHCQ and law enforcement agencies. However, the policy did not clearly delineate the required timeframes for reporting allegations of sexual abuse or serious bodily injury, leading to confusion and potential non-compliance. During the survey, the facility's Administrator confirmed that the policy in question was the only one in place and that there were no additional policies or procedures related to the investigation of abuse, neglect, or misappropriation. The Administrator also acknowledged that the facility did not use occurrence reports to document allegations, despite the policy indicating otherwise. The surveyor expressed concerns about these deficiencies, which were acknowledged by the facility's Administrator and Director of Nursing during the exit conference.
Failure to Provide Written Notification for Resident Transfers
Penalty
Summary
The facility failed to provide written notification to a resident and their representative regarding the resident's transfer or discharge and the reasons for the move. This deficiency was identified during a recertification/complaint survey for a resident who was hospitalized on three separate occasions in 2024. The medical records review revealed that there was no written notification provided for the hospitalizations on 1/16/24, 8/25/24, and 10/12/24. During an interview, the Director of Nursing stated that families are notified verbally or by phone, and staff are required to document these notifications. However, she confirmed that the facility does not send written notifications, which was identified as a concern.
Failure to Provide Timely Baseline Care Plan
Penalty
Summary
The facility failed to provide a baseline care plan summary for a resident within the required timeframe. This deficiency was identified during a recertification/complaint survey, where it was found that the baseline care plan for a resident was 78 days overdue. The review of the resident's progress notes did not reveal any documentation related to the baseline care plan. During an interview, the Director of Nursing (DON) acknowledged the absence of the baseline care plan and was unsure why it was missed, noting that the resident was admitted on a Friday after staff had left for the day, and the oversight was not corrected the following Monday.
Failure to Use Assistive Device for Resident Transfer
Penalty
Summary
The facility failed to provide and utilize an assistive device as ordered for a resident during a transfer, leading to a deficiency. On the night of May 6, 2024, a resident who had a left leg fracture and was non-weight bearing due to a fall was supposed to be transferred using a Hoyer lift, as per their care plan and physical therapist evaluation. However, the aide attempted to transfer the resident from the bed to a wheelchair without the Hoyer lift, causing the resident's left leg to jam into the bed and their heel to hit the floor hard, resulting in pain. The Director of Nursing confirmed that the resident was a total assist and should not have been transferred without the Hoyer lift.
Failure to Monitor Medication Parameters
Penalty
Summary
The facility failed to ensure proper monitoring of a medication for a resident, identified as Resident #4, during a recertification/complaint survey. The medical record review revealed that the medication administration record (MAR) for January 2025 documented an order for Metoprolol Succinate ER Tablet 25mg, to be given daily for hypertension, with specific parameters to hold the medication if the pulse was less than 60 or systolic blood pressure was less than 100 mmHg. However, from January 1 to January 16, 2025, the fields for recording blood pressure and pulse were not completed, despite staff signing off on the daily administration of the medication. Interviews with facility staff, including an LPN and an RN, indicated a lack of proper documentation for vital signs associated with the medication order. The LPN mentioned that an automated link for inputting values was not present, while the RN stated that there should always be a box to input vital signs for medications with parameters. The Director of Nursing confirmed the expectation for staff to document vital signs in the medical record, even if the medication was not held. The concern was acknowledged by the Director of Nursing and the Unit Manager.
Failure to Monitor Psychotropic Medication
Penalty
Summary
The facility failed to ensure proper monitoring of a psychotropic medication for a resident, as identified during a recertification/complaint survey. The issue was discovered when a surveyor reviewed the medical record of a resident and found that a recommendation made by the pharmacy in November 2024 for side effect monitoring of Seroquel, an antipsychotic medication, was not documented in the resident's medical record. The Director of Nursing (DON) confirmed that the recommendation was not on the 'no recommendations made' list and was unable to locate the recommendation initially. Upon further investigation, the DON provided the missing recommendation, which indicated the need for side effect monitoring on the medication administration record (MAR). However, it was revealed that no side effect or behavior monitoring was present on the MAR until the surveyor's intervention on January 16, 2025. The DON acknowledged the oversight and confirmed that behavior monitoring was being conducted by Geriatric Nursing Assistants (GNAs), but the specific side effect monitoring was not implemented until the surveyor's findings were shared. The concern was communicated to the Unit Manager and the DON, who both acknowledged the issue.
Medication Error Involving Resident and Roommate
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving a resident who received medication not prescribed to them. A family member of the resident discovered an unrecognized pill on the resident's bed and reported it to the evening shift supervisor. The resident had previously reported feeling weak and experiencing body aches after being given 14 pills, which was inconsistent with their prescribed medication regimen of 3 pills in the morning and 1 at night. Investigation revealed that the pill found belonged to the resident's roommate, who was prescribed multiple medications. The nursing supervisor confirmed the error and reported it to the Director of Nursing and the Nursing Home Administrator for further investigation.
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to properly secure residents' medications, leading to two significant incidents. In the first incident, a nurse left a lancet in a medicine cup with a resident's medications and placed it unsupervised at the bedside. The resident ingested the lancet along with their pills, mistaking it for a medication. This resulted in the resident being sent to the emergency room for evaluation, where a foreign object was confirmed in their gastrointestinal tract via x-ray. Fortunately, the resident did not suffer any adverse effects following the incident. In the second incident, a medication cart on the second floor was found unlocked and unattended during a surveyor's initial tour. The surveyor was able to access the cart's drawers, which contained various resident medications. An LPN confirmed that the facility's expectation was for medication carts to be closed and locked when not in use. The surveyor shared this concern with the facility's Administrator and Director of Nursing, who acknowledged the issue.
Deficiencies in Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain adequate medical records for two residents, leading to deficiencies in documenting the care provided. For one resident, the medical records did not include a thorough assessment following the dislodgement of a gastrostomy tube and subsequent transfer to the emergency room. Additionally, there was no documentation indicating that the resident's representative was notified of the hospital transfer. The Director of Nursing acknowledged that the required SBAR communication tool was not completed in a timely manner, and it was too late to enter a late entry assessment. For another resident, the facility's records failed to document a timely reassessment of pain following the administration of Tylenol after an unwitnessed fall. The resident was found with multiple fractures, and although there was a reassessment conducted, it was not recorded in the medical records. The Director of Nursing confirmed that the reassessment should have been documented within an hour of medication administration, but the records did not reflect this. The lack of documentation meant that the resident's medical records did not accurately reflect all interventions provided during their care.
Inaccurate Infection Control Signage and Incomplete Employee Immunization Records
Penalty
Summary
The facility failed to ensure the accuracy of infection control signage and the up-to-date status of employee immunizations, leading to deficiencies in infection prevention and control. During the survey, it was observed that the signage for infection control precautions was inconsistent and inaccurate. Specifically, rooms with COVID-19 positive residents had varying signage, with some rooms lacking appropriate signage altogether. The Director of Nursing (DON) acknowledged the discrepancies and indicated that the typical Infection Preventionist was on leave, which may have contributed to the oversight. Additionally, the facility did not maintain up-to-date immunization records for its employees. A review of employee files revealed that several Geriatric Nursing Assistants (GNAs) lacked documentation for required immunizations, including Tdap, influenza, and MMR. The facility's policy on employee medical records did not mention Tdap as a required immunization, and the DON was unaware of its necessity until questioned by the survey team. Despite requests for documentation, the facility was unable to provide evidence of the missing immunizations for the employees in question. The surveyor's findings highlighted a lack of adherence to infection control protocols and incomplete employee immunization records, which are critical components of infection prevention and control in the facility. The facility's Administrator and DON were informed of these concerns during the survey and exit conference, acknowledging the issues identified by the survey team.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that each resident was offered a pneumococcal vaccine, as evidenced by the case of Resident #19. During a review of electronic medical records for five residents, it was found that there was no documentation indicating that Resident #19 was offered, received, or refused the pneumococcal vaccine. Although the Director of Nursing (DON) provided evidence that Resident #19 had received an influenza vaccine, there was no documentation for the pneumococcal vaccine. The DON confirmed in an interview that Resident #19 was not offered the pneumococcal vaccine, which is a requirement according to the facility's policy on immunization of residents.
Failure to Educate and Offer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to provide necessary education to a resident regarding the COVID-19 vaccine, including its benefits, risks, and potential side effects. This deficiency was identified during a review of electronic medical records for five residents, where it was found that one resident had not been offered or educated about the COVID-19 vaccination. The Director of Nursing (DON) was unable to provide documentation to show that the resident had been informed about the vaccine, confirming that no such education or offer had been made. The facility's policy on immunization emphasizes the importance of vaccination for long-term care residents due to their higher risk for complications from illnesses like COVID-19. However, the DON admitted that the resident in question was not educated on or offered the COVID-19 vaccine. The facility's expectation is to offer the vaccine and document consent or refusal, but this process was not followed for the resident, leading to the deficiency noted by the surveyors.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving a Geriatric Nursing Assistant (GNA) and a resident. During the facility's recertification/complaint survey, it was found that a nurse aide, GNA #23, was observed on video footage screaming at and calling a resident 'stupid' while pushing the resident back into a wheelchair. This incident was reported in the facility's investigative report MD00204294, which confirmed the abuse through video evidence. The resident involved is a Korean-speaking individual who can understand and respond with limited English. During the initial pool selection, the resident did not express any concerns when asked. However, the investigation revealed that the abuse occurred on a previous date, and the GNA involved was initially suspended and later terminated. The Director of Nursing and the Nursing Home Administrator confirmed that the investigation followed the facility's policy and procedures, including interviews with staff, the resident, and review of camera footage, which substantiated the abuse allegation.
Failure to Review Background Check Results for GNA
Penalty
Summary
The facility failed to ensure a thorough review of background check results during the hiring process for a geriatric nursing assistant (GNA) who had been employed for approximately one year. During a recertification/complaint survey, it was discovered that the employment file for GNA #16 lacked a background check. Upon further investigation, it was revealed that a background check completed on 12/11/23 showed a second-degree assault offense with a guilty disposition and sentencing details. The facility Administrator was initially unaware of these results and could not provide further information about the hiring process for GNA #16. The Human Resources Director confirmed that they were not informed of the background check results by the Human Resources Recruiter, who was no longer in the role. After the surveyor's intervention, the Human Resources Director began an audit to ensure no other employees had similar issues with their background checks. The concern was discussed with the facility's Administrator and Director of Nursing during the exit conference.
Delayed Reporting of Injuries and Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of a serious injury of unknown source and an allegation of abuse, as evidenced by several incidents involving residents. In one case, a resident sustained a blunt force head trauma, allegedly from a male aide, but the facility reported the incident to the Office of Health Care Quality (OHCQ) over a month later. The Nursing Home Administrator (NHA) stated that the injury was believed to be from bedrails, and thus, they did not report it as required. However, the injury was unwitnessed, and the delay in reporting was acknowledged by the NHA. Another incident involved a resident who had a bruise on their arm, which was initially not reported by a GNA who thought it was old. The bruise was later reported to a nurse, and subsequently to the administrator, but the notification to OHCQ was delayed. The LPN involved could not recall the incident, and the NHA was informed of the failure to report in a timely manner. Additionally, a resident's serious injury was not reported to OHCQ until more than 51 hours after the facility received the x-ray results. The facility's Administrator confirmed the late reporting. In another case, an allegation of abuse was made by a resident to a social worker, but the initial report to OHCQ was delayed. The facility's Administrator acknowledged the concern, and no further documentation was provided before the surveyor's exit.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to ensure protective measures were taken for a resident during an investigation of an abuse allegation and did not thoroughly investigate the allegation. A resident reported an allegation of staff-to-resident abuse to an LPN, who documented the complaint and notified the Director of Nursing. The resident identified the alleged perpetrator as a male nurse in a blue uniform, which matched the description of another LPN. Despite this, the facility did not take immediate action to protect the resident, allowing the alleged perpetrator to continue working and even conduct an interview with the resident. The facility's investigation file contained inconsistencies, including two similar statements from the alleged perpetrator with different dates and differing descriptions of the alleged perpetrator. The facility administrator could not confirm any protective measures taken regarding the alleged perpetrator, who was the only male nurse on the unit during the alleged timeframe. The facility's failure to act promptly and thoroughly investigate the allegation resulted in a deficiency identified during the survey.
Failure to Update Care Plan for G-tube Dislodgement
Penalty
Summary
The facility failed to ensure that the care plan for a resident with a gastrostomy tube (G-tube) was reviewed and updated by the interdisciplinary team after a care plan meeting. The resident experienced four separate incidents of G-tube dislodgement between July 2024 and October 2024, with two incidents requiring transfer to the emergency room for further evaluation. Despite the dislodgement being discussed in a care plan meeting in July 2024, the facility did not update the resident's care plan to address the issue and prevent future occurrences until October 2, 2024. Interviews with staff revealed that the responsibility for updating the care plan typically falls on the unit manager or the Director of Nursing, and updates are usually done quarterly with the Minimum Data Set (MDS) assessment or as needed. However, the G-tube dislodgement was not addressed in the care plan until it was realized by a staff member in October 2024.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,539 citations issued within 25 miles in the last 12 months — including the 5 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 Timonium
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maryland Masonic Homes Ltd | 2.5 mi | ★★★★★ | 0 | 0 |
| Broadmead | 3.1 mi | ★★★★★ | 16 | 0 |
| Advanced Rehab At Autumn Lake Healthcare | 3.7 mi | ★★★★★ | 19 | 0 |
| Stella Maris, Inc. | 3.9 mi | ★★★★★ | 0 | 0 |
| Chestnut Grn Hlth Ctr Blakehur | 4.1 mi | ★★★★★ | 13 | 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 July 2026) and official state health department websites.