Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lorien Nsg & Rehab Ctr Belair during CMS and state inspections, most recent first.
Food safety and temperature monitoring were deficient when a Dietary Aide handled food on the serving line while drinking from a personal beverage container, and personal drinks were also observed on the serving line equipment. Surveyors additionally found multiple foods left open to air and unlabeled in the walk-in refrigerator and freezer, and the DC stated hot food temperatures had not been taken or recorded before service that morning.
Failure to Notify Ombudsman of Hospital Transfers: The facility did not have a system in place to notify the local Ombudsman of facility-initiated hospital transfers. Record review showed a resident was transferred to the hospital but was not included on the discharge list, and other discharge lists reviewed contained only residents discharged home, to another facility, to a funeral home, or who had expired. The NHA acknowledged that transfer-to-hospital notifications were not being sent to the local Ombudsman, while discharge notifications were being sent instead.
Late Administration of Physician-Ordered Medications: Staff failed to give ordered meds at scheduled times for two residents during med pass observations, including Metformin, Aspirin EC, Baclofen, and Lyrica being administered late. For another resident reviewed for pain, multiple meds such as Gabapentin, Losartan, Amlodipine, Aspirin, and Bupropion were documented as given late on several occasions, and staff acknowledged that some meds were not liberalized and that the late Gabapentin administration was wrong.
Medication Error Rate Exceeded 5 Percent: Surveyors found that two residents received scheduled meds outside the ordered time range, resulting in a 14.81% med error rate. One resident with Type 2 DM received Metformin and Aspirin late, and another resident received Baclofen and Lyrica late while staff were also passing meds to other residents and obtaining VS. The DON stated that a pink screen on the computer indicated the med was late and staff were not to give it without notifying the MD and obtaining a new order.
Failure to Provide Requested Dental Services: A resident was not seen by the in-house dental service despite repeated family requests during care plan conferences. The family reported bad breath and provided mouth wash for staff use, while the record showed SW notes about needing a dental appt and follow-up on oral care concerns. The DON stated there was no dental policy and later acknowledged that nursing and SW were responsible for follow-up but the team failed to get the resident seen.
Inaccurate and incomplete charting affected multiple residents. One resident’s record stated hospice enrollment and death, but lacked hospice orders, hospice agency documentation, and an MDS change assessment, while other notes reflected palliative care instead. Another resident had a Rocephin order entered with an incorrect indication, and the MAR/nursing note timing did not match the electronic order; staff later confirmed the medication was intended STAT for suspected pneumonia. A third resident’s chart contained inconsistent wound documentation, including physician notes listing wounds as present when wound care records showed they had healed.
A resident’s Foley catheter bag was observed laying directly on the floor during a surveyor tour. An LPN acknowledged the concern, and the facility’s catheter care policy stated the drainage bag and tubing should never touch the floor. The DON later confirmed the bag should be stored off the floor to prevent infection.
A resident who was fully dependent on staff for self-care due to Multiple Sclerosis did not receive necessary ADL care during an evening shift. Despite being cognitively intact and assessed as needing total assistance, the assigned GNA failed to change the resident after a bowel movement, and this lapse was only discovered by the next shift when a strong odor was noted and the resident reported not being cared for.
A resident who was admitted without pressure ulcers developed a Stage III ulcer and a DTI. Despite wound care orders for the right heel and a recommendation for x-rays, staff did not administer the ordered treatments or complete the diagnostic testing before discharge, as confirmed by staff interviews and record review.
The facility failed to maintain proper cold holding temperatures and ensure the cleanliness and proper storage of food items, as observed during a recertification survey. The walk-in refrigerator's temperature exceeded the recommended 41°F on multiple occasions, and there were missing temperature records. Ice build-up was observed on ice cream tubs with damaged lids, and the freezers had significant ice accumulation. Additionally, the dishwashing machine's temperature logs were incomplete, with missing records for several mealtimes, and some rinse temperatures were below the required minimum.
The facility failed to develop comprehensive care plans for residents, including addressing depression and medication use for a resident, ensuring hearing aid accessibility for another, and providing specific care instructions for a nephrostomy tube and post-surgical care for others. These deficiencies were identified during a recertification survey and confirmed by facility staff.
A facility failed to report an allegation of neglect in a timely manner, where a resident was left unattended in bed without a call bell for several hours. The incident was reported to the Nursing Home Administrator but was not communicated to the Office of Healthcare Quality until eight days later, despite the resident expressing distress. Interviews confirmed the delay and acknowledged that intention is not required for reporting such incidents.
A facility failed to document the transfer of a resident, including the reason for discharge, in the medical record. The resident's record lacked a discharge note and details on how or when they left the facility. The Director of Social Services acknowledged the absence of documentation and later provided email evidence of a Notice of Medicare Non-Coverage issued in March, with discharge dates not recorded in the medical record.
A resident was found with their call bell on the floor, out of reach, during a survey. An LPN confirmed the observation and returned the call bell to the resident's bed. The resident's care plan required the call bell to be within reach and encouraged its use for assistance.
The facility failed to manage advance directives properly for three residents. One resident lacked a second certification of incapacity, another had no evidence of being offered an advance directive despite a MOLST form indicating otherwise, and a third resident's advance directive was not obtained until after surveyor inquiry, despite being admitted a month prior.
A facility failed to provide written notification to a resident and their representative about a hospital transfer for symptomatic anemia and GI bleed. The resident was informed verbally, but no written documentation was provided. Staff interviews confirmed that written notifications were not part of the facility's practice, indicating a systemic issue.
The facility failed to provide written notification of the bed-hold policy to two residents or their representatives upon hospital transfer. Despite verbal communication, there was no documentation of the policy being shared. Staff interviews revealed a misunderstanding of the notification process, assuming residents and families were already informed.
A resident's MDS assessments failed to accurately capture diagnoses of adjustment disorder with mixed anxiety and depressed mood or depression, despite being prescribed Sertraline for depression. Facility staff, including an LPN, UM, and MDS Coordinator, confirmed the oversight, revealing a lapse in the process for accurately coding resident diagnoses.
A resident at the facility for short-term rehab fell and sustained a fracture, but the care plan was not updated until weeks later. Interviews with staff revealed confusion over who is responsible for updating care plans. The DON acknowledged the issue, noting that fall risks are assessed and reviewed, but the care plan was not promptly revised.
A resident's hearing aids were not accessible, leading to communication difficulties and frustration. The resident, who was bed-bound, had not worn the aids for weeks and staff failed to assist or document their use. The aids were found locked in a nightstand, contrary to facility policy.
The facility failed to provide proper respiratory care for two residents, as observed during a survey. One resident had undated oxygen tubing and an empty humidifier, with no physician order or care plan for oxygen use. Another resident's oxygen equipment was not dated or maintained according to orders. The facility's policy required daily checks and refills, but these were not consistently followed, leading to deficiencies in care.
A facility failed to ensure pharmacist recommendations were acted upon and documented in a resident's medical record. A pharmacist's recommendation regarding the continued use of omeprazole was not reviewed or signed by the attending physician until prompted by a surveyor, indicating a lapse in addressing medication regimen reviews.
A facility failed to document the necessity for PRN Clonazepam for a resident with panic disorder. The resident received five PRN doses in May without corresponding documentation in the progress notes. Interviews with an LPN and the DON confirmed that the rationale for PRN medication should be documented, but this was not done for the resident's doses.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in care documentation. One resident's records inaccurately reflected participation in activities, while another's showed care activities documented at times when no staff were present. A third resident's medication administration was documented incorrectly. These issues highlight a failure to adhere to professional standards in documentation.
Facility staff failed to perform proper hand hygiene during dressing changes and medication administration, leading to deficiencies in infection prevention and control. An LPN did not sanitize hands between glove changes during a dressing change, and another LPN failed to do so during a nephrostomy tube site dressing change. Additionally, an LPN did not sanitize hands before and after administering an injection. These incidents were observed by surveyors and confirmed by the DON.
The facility failed to provide timely care to a resident, leaving them unattended for hours without access to a call bell, and did not check their tube feeding. Another resident's hand splint care lacked physician orders and documentation. These deficiencies highlight issues in staff communication, oversight, and documentation.
The facility failed to respond to call lights in a timely manner, with residents experiencing wait times ranging from 19 minutes to over an hour. Despite staff education and audits, the issue persisted, affecting residents' dignity and care needs.
The facility failed to protect two residents from mental and physical abuse by a GNA staff member. One resident reported being yelled at and having a call bell thrown at them, while another resident experienced rough handling during care, resulting in pain. The staff member involved had not completed annual abuse training since 2020 and was removed from the facility following the incidents.
A resident reported feeling neglected due to long call light response times, with waits of 30 to 50 minutes over 7 days. The facility's investigation was incomplete, failing to interview all relevant staff and other potentially affected residents. Despite staff education on call bell response times, subsequent audits showed continued delays.
The facility failed to provide adequate incontinent care for two dependent residents. One resident was left unchanged for several hours despite requesting assistance, while another resident's family found them with soiled briefs during visits. Documentation revealed multiple instances of missed care.
A resident admitted for rehab therapy developed a sacral wound that was not properly measured or managed by nursing staff. The wound worsened, leading to infection and the resident's eventual death from sepsis and sacral wound complications.
The facility failed to ensure that a nursing assistant was competent and had the necessary skill set to care for residents. The employee file of a GNA showed no evidence of competence assessment, and the staff member was hired as a nursing assistant in training before receiving her certification.
The facility failed to ensure that a GNA had completed required abuse training and competencies, as her file revealed she had not completed annual abuse training since 2020. The DON and Administrator were unaware of this lapse and were newly acclimating to the facility. The deficiency was identified following allegations of abuse and neglect.
Food Safety and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure food temperatures were taken and recorded before food was served, and surveyors observed multiple food safety issues during the initial kitchen tour. On 01/05/2026 at 7:49 AM, a Dietary Aide was observed assisting with plating food on the serving line while taking a drink from a personal beverage container and placing it back on the shelf on the food serving line equipment. A bottle of drinking water was also observed sitting on the shelf of the food serving line. The Dietary Aide did not respond when asked about training regarding personal items on the serving line, and the person in charge of the kitchen confirmed the concern and removed the beverage from the serving line. Surveyors also observed food left open to air and unlabeled in cold storage areas. In the walk-in refrigerator, beans, two trays of a red gelatin type food, riblet portions, and chicken patties were found on a mobile metal food cart with no covering present. In the walk-in freezer, pepperoni, cornbread, two open bags of a circular round breaded type food, and an angel food type cake with a slice missing were observed left open to air and unlabeled, and a container of ice cream had ice cream on the outside of the lid. When asked about hot food temperatures, the Dietary Coordinator stated the temperatures had not been done that morning and there was no sheet completed for that day. The Dietary Coordinator also stated that both the dietary aide and dietary staff were responsible for taking and recording temperatures, and temperatures were only taken after surveyor intervention.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to ensure a system was in place to notify the local Ombudsman of facility-initiated resident transfers to the hospital. During record review, the surveyor found that Resident #113 had been admitted to the hospital, but the resident was not included on the facility’s discharge list for the transfer. Review of additional discharge lists from October and another month also failed to show any resident transfers to the hospital; instead, the lists included residents who had been discharged home, transferred to another facility, sent to a funeral home, or who had expired. During interview, the NHA and DON were informed that Corporate Office Staff #14 was responsible for emailing weekly transfer/discharge notifications to the local Ombudsman. The NHA acknowledged that Resident #113’s hospital transfer was not included on the discharge lists reviewed and stated that the facility had not been sending transfer-to-hospital notifications to the local Ombudsman. The NHA later confirmed that Corporate Office Staff #14 was sending discharge notifications out of the facility, but not resident transfer notifications to the local Ombudsman.
Late Administration of Physician-Ordered Medications
Penalty
Summary
The facility failed to follow professional standards of practice by not administering physician-ordered medications at their scheduled times and by not ensuring timely medication administration. During a medication administration observation for a resident with Type 2 diabetes mellitus and a history of CVA, an RN administered Metformin 1000 mg and Aspirin EC 81 mg at 10:05 AM even though the computer screen showed scheduled times of 7:30 AM and 8:00 AM. The RN stated the medications were late because he had to administer medications to more than 10 other residents and obtain vital signs first. A second medication administration observation showed another resident’s Baclofen 10 mg and Lyrica 75 mg were scheduled for 8:00 AM, but the Lyrica was administered at 10:15 AM by another nurse who stated she was administering narcotics to residents on the unit hall. The RN and the other nurse administered the resident’s medications outside the scheduled physician-ordered times. The DON stated that when the computer screen highlights pink, it alerts staff that the medication is late, and that staff are not to give the medication but are to notify the physician and obtain a new order. For a resident reviewed for pain, surveyors observed the resident calling out, "Help, I'm in pain." Review of medication administration audit reports showed multiple medications were not administered timely on several dates, including Gabapentin, Losartan, Amlodipine, Aspirin, and Bupropion, with some doses given more than an hour late and one Gabapentin dose documented as not administered until 9:27 PM instead of 8:00 PM. A CMA confirmed medications are documented at the time they are administered, while the UM and DON stated that Gabapentin and other every 8- or 12-hour medications were not liberalized and that the late Gabapentin administration was wrong.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to prevent a medication error rate from exceeding 5 percent, with surveyors determining the rate was 14.81 percent after observing medications being administered outside the scheduled time range. During medication administration observations, staff administered medications late for two of six residents observed, including a resident with Type 2 diabetes mellitus who received Metformin 1000 mg and Aspirin EC 81 mg at 10:05 AM even though the scheduled times were 7:30 AM and 8:00 AM. The resident’s physician orders directed Metformin twice daily before breakfast and dinner and Aspirin once daily for CVA prevention. A second resident received Baclofen 10 mg and Lyrica 75 mg, both scheduled for 8:00 AM, but the Lyrica was administered at 10:15 AM by another nurse while the first nurse was preparing medications. The nurse who administered the late medications stated they were delayed because he had to give medications to more than 10 other residents and obtain vital signs. The DON stated that a pink screen on the computer indicated a medication was late and that staff were not to give the medication and were to notify the physician and obtain a new order.
Failure to Provide Requested Dental Services
Penalty
Summary
The facility failed to ensure that dental services were provided for one resident. The resident’s family member reported that the resident had not been seen by the in-house dental service despite making the request at multiple care plan conferences, and the family did not know when the resident was last seen by the dentist. The family also reported that the resident had bad breath and had brought in mouth wash for staff to use to rinse the resident’s mouth; the surveyor later observed that approximately one-quarter of the bottle remained. The medical record showed that during a care plan meeting, Social Work documented a plan to email Nursing and look into a dental appointment, and later documented that oral care needed follow-up, that the spouse had concerns, and that a dental appointment was needed. During interviews, the NHA and DON stated that the facility did not have a dental policy and that the outside dental service came into the building, but the resident and/or family had to submit a request for services. After the surveyor reviewed the care conference notes showing repeated requests, the DON and DSW acknowledged that nursing and social work were responsible for following up on requests and that the team had failed to do so, resulting in the resident not being seen.
Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for multiple residents. For one resident, the electronic record contained a discharge summary stating the resident was enrolled in hospice, rapidly declined, and expired, but the record did not contain a physician order for hospice care, a hospice plan of care, hospice agency orders, documentation of hospice visitation or services, or an MDS assessment for significant change related to hospice enrollment. Other documentation in the record reflected comfort care and palliative care orders, and staff later stated the resident had not been enrolled in hospice and had instead received palliative care at the family’s request. For another resident, the record contained a physician order for Rocephin with the indication entered as viral infection, even though Rocephin is an antibiotic and the DON acknowledged it does not treat viral infections. The NP later confirmed the medication was intended because the resident had respiratory distress and pneumonia was suspected, and the NP note stated the resident would be treated empirically for concern for pneumonia pending chest x-ray results. The indication entered on the order was inaccurate. The same resident’s record also showed a mismatch between the medication order and the nursing documentation. The electronic order reflected Rocephin to start at 7:00 AM, while a nursing narrative note documented the first dose was set up and administered at 10:28 AM. Further review found a handwritten physician order form showing a verbal order for Rocephin IV daily x5 days STAT, transcribed by UM #15 and signed by the NP, and staff confirmed the medication was intended to be given immediately. In addition, another resident’s record contained inconsistent skin assessment documentation, including a physician progress note describing diabetic wounds of the left second toe and right heel when wound care documentation indicated the wounds had healed and the resident was to be discharged from wound care. The physician later amended multiple progress notes to correct inaccurate wound documentation.
Foley Catheter Bag Left on Floor
Penalty
Summary
The facility failed to maintain appropriate infection control measures for a resident with a Foley catheter. During the initial tour, the surveyor observed the resident’s Foley catheter bag laying directly on the floor. The surveyor then conducted a dual observation with the Unit Manager/LPN, who observed and acknowledged the concern. The facility’s urinary catheter care policy stated that the drainage bag and tubing should never be allowed to touch the floor, and the DON later confirmed that the Foley catheter bag should be stored off the floor to prevent infection.
Failure to Provide Required ADL Care to Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to provide necessary activities of daily living (ADL) care to a resident who was totally dependent on staff for self-care. The resident, admitted in 2017 with a diagnosis including Multiple Sclerosis, was assessed as cognitively intact and fully dependent for self-care according to the most recent MDS assessment. On the evening in question, the resident's nurse identified that the resident needed to be changed after a bowel movement and instructed the assigned geriatric nursing assistant (GNA) to provide care. However, the GNA did not perform the required care, only emptying the resident's urinary catheter and failing to recognize the need for further assistance. The lapse in care was discovered when the next shift's GNA entered the resident's room and noted a strong odor, with the resident reporting that the previous GNA had not provided the necessary care. Facility investigation and interviews confirmed that the resident did not receive the required ADL care during the 3 PM to 11 PM shift. The administrator acknowledged that staff failed to provide the needed care for the resident during this time period.
Failure to Provide Ordered Pressure Ulcer Treatments and Timely Diagnostic Testing
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident who was admitted without any pressure ulcers. The resident developed an open area on the left buttock, which progressed to a Stage III pressure ulcer, and also developed a deep tissue injury (DTI) on the right heel. The wound nurse practitioner ordered specific treatments for the right heel, including cleansing with wound cleanser, application of skin prep twice daily, and use of offloading foam heel boots. Additionally, an x-ray of the left buttock and sacrum was recommended to rule out osseous changes. Despite these orders, a review of the resident's physician orders and treatment administration records revealed that the right heel DTI treatments were neither ordered nor administered from the time of the initial wound nurse practitioner's order through the resident's discharge. Furthermore, the x-ray recommended by the wound nurse practitioner was not completed prior to discharge, with the order for the x-ray not being placed until several days after the recommendation. These failures were confirmed through interviews with facility staff, including the x-ray staff and the Director of Nursing.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility staff failed to maintain proper cold holding temperatures and ensure the cleanliness and proper storage of food items, as observed during a recertification survey. The surveyor noted multiple instances where the walk-in refrigerator's temperature exceeded the recommended 41°F, with specific dates showing temperatures as high as 45°F. Additionally, there were missing temperature records for several days in May 2024. Ice build-up was observed on ice cream tubs with damaged lids, and the freezers had significant ice accumulation. Despite a recent local health inspection that identified similar issues, the facility continued to experience elevated temperatures and missing documentation. The facility also failed to monitor the dishwashing machine's sanitation levels consistently. During a follow-up inspection, it was found that the dishwashing machine's temperature logs were incomplete, with missing records for several mealtimes. On some occasions, the recorded rinse temperatures were below the required minimum of 180°F. The Food Service Director acknowledged the missing documentation and attempted to fill in some temperatures after questioning a dietary worker. These deficiencies indicate a lack of consistent monitoring and documentation of critical food safety and sanitation practices.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and initiate comprehensive person-centered care plans for several residents, as identified during a recertification survey. For Resident #70, the care plan did not address the diagnoses of depression and adjustment disorder with mixed anxiety and depressed mood, nor did it include the use of an antidepressant medication, Sertraline. This oversight was confirmed by both the Licensed Practical Nurse and the Unit Manager, who acknowledged the absence of focus, goals, or interventions related to the antidepressant medication in the care plan. Resident #46 experienced issues with hearing aid accessibility, which was not adequately addressed in their care plan. Despite the resident's admission records indicating the presence of hearing aids, the care plan was incomplete and lacked necessary interventions. The Minimum Data Set nurse confirmed that care planning should have been completed, but it was only initiated after the surveyors began their investigation, more than 14 days post-admission. For Resident #54, the care plan lacked specific instructions for the care of a nephrostomy tube, site, and urine collection bag, despite the resident having returned from the hospital with these needs. The Director of Nursing confirmed the absence of these care instructions. Similarly, Resident #90's care plan did not reflect necessary interventions for post-surgical care following a left hip fracture, including anterior hip precautions and other post-surgical care requirements. The care plan was only revised after surveyor intervention, and even then, it did not comprehensively cover all necessary care interventions.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of neglect and the subsequent investigation to the proper authorities. This deficiency was identified during a recertification survey, where it was found that an incident involving a resident being left lying flat in bed, uncovered, and without a call bell within reach was not reported to the Office of Healthcare Quality until eight days after the occurrence. The incident was initially reported by the Social Worker to the Nursing Home Administrator on the day it occurred, but the facility delayed reporting it to the authorities, despite the resident expressing distress over the situation. During interviews, the facility's Director of Nursing and Administrator confirmed the delay in reporting and acknowledged that the incident did not need to be intentional to warrant reporting. The Geriatric Nursing Assistant assigned to the resident on the day of the incident confirmed that the resident was upset and had been left unattended for several hours. The facility's process for reporting allegations of abuse and neglect was described as immediate, yet this incident was not reported in a timely manner, leading to a deficiency in the facility's compliance with reporting requirements.
Failure to Document Resident Transfer
Penalty
Summary
The facility failed to document the transfer of a resident, identified as Resident #166, in the medical record, including the reason for the transfer. This deficiency was identified during a complaint intake review, medical record review, and staff interview. The resident's closed medical record was reviewed, revealing that there was no discharge note indicating the reason for the discharge or details on how or when the resident left the facility. Additionally, the discharge instructions document in the electronic health record was incomplete, lacking information on who received the instructions. The Director of Social Services, identified as staff #21, was interviewed and acknowledged the absence of documentation regarding the discharge. She could not recall the circumstances surrounding the initiation of the discharge and agreed that documentation should have been recorded. She later provided email documentation indicating that the resident was issued a Notice of Medicare Non-Coverage in March 2023, with a discharge initially set for March 6, 2023, and later extended to March 7, 2023. However, this information was not included in the resident's medical record, highlighting the incomplete discharge documentation.
Resident's Call Bell Out of Reach
Penalty
Summary
The facility failed to ensure that a resident had access to their call bell to request staff assistance. During an initial tour, a surveyor observed the resident lying in bed with the call bell on the floor, out of reach behind the bed. This observation was confirmed by an LPN, who then retrieved the call bell and clipped it to the resident's bed. A review of the resident's medical record revealed a care plan intervention dated March 5, 2024, which specified that the call bell should be kept within reach and that the resident should be encouraged to use it for assistance, along with having commonly used articles within reach.
Deficiencies in Advance Directive Management
Penalty
Summary
The facility failed to ensure proper certification of incapacity for Resident #90, as only one certification was present in the medical record, despite the requirement for two certifications by the attending and a second physician or licensed clinical psychologist. The Maryland Order for Life Sustaining Treatment (MOLST) form indicated that the resident or authorized decision maker had declined to discuss or was unable to make a decision about treatments. The Unit Manager confirmed the absence of the second certification, and the Director of Social Work acknowledged the oversight after surveyor intervention. For Resident #54, there was no evidence of an advance directive or that one had been offered, despite a MOLST form indicating a decision per the resident's advance directives. The social services designee confirmed that advance directive information should be in each resident's chart and that discussions should be documented. However, there was no previous documentation of any discussion with the resident regarding advance directives, and the resident had been at the facility for two years without any evidence of being asked or provided information about advance directives. Resident #112's medical record lacked a copy of the advance directive upon admission. The social worker's notes indicated that the resident had an advance directive and suggested contacting a family member. The Director of Nursing later provided a copy of the advance directive after the surveyor's request, confirming that it was obtained from the resident's family member after the surveyor's inquiry, despite the resident being admitted about a month prior.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and their representative regarding the reason for a transfer to the hospital. This deficiency was identified during a recertification survey for a resident who was hospitalized for symptomatic anemia and a gastrointestinal bleed. The resident confirmed that they were informed verbally about the transfer but did not receive any written documentation. A review of the medical records and interviews with staff, including the Director of Nursing and the Nursing Home Administrator, revealed that there was no evidence of written notification being provided to the resident or their representative. Further interviews with facility staff, including a Licensed Practical Nurse and a Unit Manager, confirmed that it was not the practice to provide written notifications for hospital transfers. Instead, the reasons for transfers were communicated verbally to residents and their representatives, and documented in the transfer sheet sent to the hospital. This practice was consistent among the staff interviewed, indicating a systemic issue in the facility's process for notifying residents and their representatives in writing about hospital transfers.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to notify residents or their representatives in writing about the bed-hold policy upon transfer to an acute care facility. This deficiency was identified during a recertification survey for two residents who were hospitalized. The bed-hold policy outlines the facility's procedure for reserving a resident's bed during their absence for therapeutic leave or hospitalization. However, the facility did not provide written notification of this policy to the residents or their representatives. In the case of one resident, they were transferred to a hospital for symptomatic anemia and a gastrointestinal bleed. Although the resident was verbally informed about the transfer, there was no written documentation provided regarding the bed-hold policy. The Director of Nursing (DON) confirmed the absence of such documentation and acknowledged that the staff failed to complete the relevant section of the change in condition form. Interviews with staff members revealed a lack of understanding and execution of the policy, as they assumed residents and their families were already aware of it. For another resident, who was transferred to the hospital following a fall, neither the resident nor their representative received the bed-hold policy. The documentation indicated that the policy was included in the transfer package given to emergency medical technicians, but not directly to the resident or their family. The DON and Nursing Home Administrator were unable to provide evidence of communication with the resident or their representative regarding the bed-hold policy, highlighting a systemic issue in the facility's notification process.
Inaccurate MDS Coding for Resident's Psychiatric Diagnoses
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident during a recertification survey. The resident, who was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood, was prescribed Sertraline for depression. However, the MDS assessments did not capture the diagnosis of adjustment disorder with mixed anxiety and depressed mood or depression under the psychiatric/mood disorder section, despite the medication being recorded in the medication section. This discrepancy was identified through a review of clinical records, physician orders, and medication administration records. Interviews with facility staff, including a Licensed Practical Nurse (LPN), Unit Manager (UM), MDS Coordinator, and Director of Nursing (DON), confirmed the oversight. The MDS Coordinator acknowledged the error, stating that the expectation was to review active diagnoses within a 60-day period and ensure they were active during the 7-day assessment reference date look-back period. The DON and Nursing Home Administrator were unaware of the omission in the MDS assessments, indicating a lapse in the facility's process for accurately capturing resident diagnoses.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident after the resident sustained an injury from a fall. The resident, who was at the facility for short-term rehabilitation due to a respiratory infection, experienced a fall resulting in a fracture and was subsequently hospitalized. Upon returning to the facility, the resident's care plan, which initially included a goal to prevent falls, was not updated to reflect the new circumstances and necessary interventions until several weeks later. Interviews with nursing staff revealed a lack of clarity and responsibility regarding the updating of care plans. Night shift staff indicated that they do not initiate or update care plans, suggesting that this responsibility lies with supervisors. The Director of Nursing and Nursing Home Administrator acknowledged the issue, noting that fall risks are assessed upon admission and reviewed weekly, but the care plan for this resident was not promptly revised following the fall. The management team, including the Assistant Director of Nursing and the Minimum Data Set coordinator, is responsible for care plan updates, but the process failed in this instance.
Hearing Aid Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's hearing aids were accessible, leading to the resident's inability to hear properly. During an observation, the resident was found not wearing hearing aids and expressed difficulty in hearing conversations, which caused frustration. The resident indicated that the hearing aids were somewhere in the room but was unsure of their exact location and mentioned that staff did not assist in accessing them. The resident had not worn the hearing aids for several weeks, and the Treatment Administration Record (TAR) lacked any instructions or care information regarding the hearing aids. Further investigation revealed that the resident was bed-bound and unable to independently retrieve items from the room. The hearing aids were eventually found locked in the nightstand, which the resident could not reach. The facility's hearing aid policy required staff to assist residents with hearing aids and document their use and care, but this was not followed. The Licensed Practical Nurse (LPN) assigned to the resident was unaware of the resident's hearing impairment, and the Director of Nursing (DON) acknowledged the issue when informed by the surveyor.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents during a recertification survey. For one resident, oxygen tubing was found disconnected and undated, with an empty humidification water bottle. The resident's medical records lacked a physician's order for oxygen and did not include oxygen use in the care plan. The Director of Nursing (DON) later confirmed that the oxygen order was missing when the resident returned from the hospital, and the care plan was not updated to reflect oxygen use until after the surveyor's observation. Another resident was observed with a nasal cannula connected to an empty humidifier bottle, which was dated two weeks prior, and undated oxygen tubing. The Licensed Practical Nurse (LPN) confirmed the discrepancies and adjusted the oxygen flow to the correct setting. The resident's medical records showed an active physician order for oxygen therapy, but the care plan did not include instructions for changing and dating the oxygen equipment weekly, as indicated in the physician's order and Treatment Administration Record (TAR). The facility's policy on oxygen administration required daily equipment checks and refilling of humidifiers when water levels were low. However, the observations revealed that these procedures were not consistently followed, leading to deficiencies in the respiratory care provided to the residents. The DON acknowledged the issues and stated that nurses were responsible for replacing empty humidifiers and that care plans should reflect physician orders, although this was not always the case.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility staff failed to ensure that pharmacist recommendations were acted upon and documented in the resident's medical record, as evidenced during a recertification/complaint survey. Specifically, for one resident, the monthly medication regimen review with consultant pharmacist recommendations to the physician was not readily found in the medical record. The Director of Nursing (DON) confirmed that there were no pharmacist recommendations documented for several months, and although a recommendation was made in January, it was not addressed until prompted by the surveyor. The pharmacist's recommendation involved the continued use of omeprazole, a proton pump inhibitor (PPI), which requires a documented review after 12 weeks of use due to potential risks. The recommendation was not reviewed or signed by the attending physician until the surveyor requested it, indicating a lapse in the facility's process for addressing pharmacist recommendations. The DON acknowledged that the recommendation was missed and had to be addressed retroactively.
Failure to Document PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and document the necessity for the use of PRN (as needed) psychotropic medication for a resident. Specifically, Resident #112 was prescribed Clonazepam for panic disorder, with both routine and PRN doses. During May 2024, the resident received five PRN doses of Clonazepam. However, there was no documentation in the resident's medical records or progress notes to justify the administration of these PRN doses, indicating a lack of proper assessment and documentation of the resident's behavior or condition that warranted the additional medication. Interviews with facility staff, including an LPN and the DON, revealed that the standard procedure was to document the rationale for administering PRN psychotropic medications in the progress notes. The LPN stated that mood and behavior concerns like agitation would prompt the administration of medication, which should be documented accordingly. The DON confirmed that the rationale for PRN medication should be documented, and acknowledged the surveyor's findings that such documentation was missing for Resident #112's PRN Clonazepam doses.
Inaccurate Medical Records and Care Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in care documentation. For one resident, the medical records inaccurately reflected participation in activities, despite observations and staff interviews indicating that the resident was often in bed and not engaged in the documented activities. Staff interviews revealed inconsistencies in the reported activities, with some staff unaware of any activities being offered to the resident in their room. Another resident's medical records showed discrepancies in the documentation of care provided. The records indicated that an LPN documented care activities, such as enteral tube assessments and repositioning, at times when camera footage confirmed no staff were present in the resident's room. The facility's investigation into an incident where the resident was left without access to a call bell and in the same position overnight was deemed inconclusive, but it was confirmed that care was not provided during the night shift. For a third resident, an LPN documented administering an inhaler at a specific time, but later admitted to administering it at a different time. This discrepancy was confirmed during an interview with the DON, who acknowledged the incorrect documentation. These inaccuracies in medical records highlight a failure to adhere to professional standards in maintaining accurate and reliable documentation of resident care.
Deficiencies in Hand Hygiene During Care Procedures
Penalty
Summary
The facility staff failed to ensure proper hand hygiene during dressing changes and medication administration, leading to deficiencies in infection prevention and control. During an observation, an LPN did not perform hand hygiene after removing dirty gloves and before donning clean gloves while changing a resident's left heel ulcer dressing. The LPN acknowledged the oversight and confirmed awareness of the proper procedure. Similarly, another LPN failed to perform hand hygiene between glove changes during a nephrostomy tube site dressing change for a resident, admitting a lack of knowledge about the requirement. Additionally, a third LPN did not sanitize hands before and after administering a subcutaneous anticoagulant injection to a resident. The LPN admitted to not following the handwashing protocol, which was confirmed by the Infection Preventionist. These incidents were observed and reported by surveyors, and the Director of Nursing validated the concerns, highlighting a pattern of non-compliance with hand hygiene protocols among the nursing staff.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide timely and necessary care to Resident #3, as evidenced by two self-reported incidents. The first incident occurred on 5/9/24, when Resident #3 was left lying flat in bed without their call bell in reach for an extended period. The facility's investigation revealed that no staff rounded on the resident for approximately three hours and forty minutes. Despite this, the investigation was deemed inconclusive. Interviews with staff indicated that the resident was upset by the incident, and there was a lack of communication and documentation regarding the resident's needs and care. The second incident involving Resident #3 occurred on the night of 5/11/24 into 5/12/24. The resident was reportedly left in bed from 6 PM to 6:30 AM without access to their call bell and without being repositioned. The facility's investigation confirmed that no staff entered the resident's room during this time, and the resident's tube feeding was not checked. The facility's documentation was incomplete, and there was no process in place to ensure that resident complaints were documented in their medical records. Additionally, the facility failed to have accurate physician orders for Resident #71's hand splint. Although a sign above the resident's bed indicated the use of a hand splint, there were no physician orders or documentation of the resident's use and response to the splint. The Director of Nursing confirmed that there should have been an order and care documentation for the resident's splint care, but it was not present in the medical records.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence by not responding to call lights in a timely manner. Resident #30 reported an allegation of abuse due to long wait times for call light responses, ranging from 30 to 50 minutes over a week. This resident, who had a stroke and required assistance for toileting, expressed concerns about urinary tract infections and skin problems from prolonged exposure to wet briefs. Despite the facility's expectation of a 10-15 minute response time and subsequent staff education, the issue persisted without effective auditing or follow-up to ensure compliance. An anonymous complaint and grievances from two other residents further highlighted the problem. One resident reported call light response times of over an hour, while another, who was on Lasix and experienced urinary urgency, waited between 19 to 50 minutes for assistance. The facility's audits confirmed these extended wait times, but there was a failure to investigate the root causes and implement appropriate corrective actions. The DON and NHA acknowledged the issue but did not take sufficient steps to address it effectively.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from mental and physical abuse. This was evident during the review of two residents. One resident reported that after using the call bell for assistance to use the bathroom, a GNA staff member threw the call bell at them and yelled not to press the button again. The resident, who had mixed incontinence and moderate cognitive impairment, reported feeling fearful and refrained from using the call bell for the remainder of the shift. The resident later stated that they now feel safe and are happy with the care they receive. Another incident involved the same GNA staff member who turned a resident 'roughly' during activities of daily living care, causing the resident to verbalize discomfort. The resident, who had severe cognitive impairment, was assessed for pain in their right arm and shoulder, and an x-ray was ordered. Although the x-ray results were negative, the resident was medicated with Tylenol for pain. The facility's investigation confirmed the staff member's actions, and the staff member was removed from the facility. A review of the staff member's file revealed that they had not completed their annual abuse training since 2020.
Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of neglect reported by a resident who felt neglected due to staff not responding to the call light. The review of the facility's call light audit revealed that the resident had waited 30 to 50 minutes for call light responses over a period of 7 days, during all three shifts. Although the facility staff interviewed the Geriatric Nursing Assistants (GNAs) assigned to the resident during the long call light response times, they did not interview the nurses and other GNAs assigned to the unit to determine their activities during those times. Additionally, the facility failed to interview other residents who might have been affected by the extended wait times. An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) revealed that the facility had not conducted a comprehensive investigation. The DON admitted uncertainty about whether other staff assigned during the extended wait times had been interviewed. Despite the education provided to staff regarding call bell response time expectations, a subsequent audit showed that residents continued to wait 30 to 64 minutes for responses to call bells. The facility did not audit call bell response times following the education to determine its effectiveness.
Failure to Provide Incontinent Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate incontinent care for two dependent residents. Resident #6 complained to the social worker about a GNA who failed to change them after promising to return. The resident was left unchanged from 7 PM until 3 AM the next day, when a nurse finally attended to them. The GNA involved was subsequently taken off the schedule and reported to the Board of Nursing for neglect. Resident #39, admitted for rehab after a hospital stay, was found by family members with soiled briefs during their evening visits. The resident complained that their call bell requests for assistance were ignored. A review of the resident's kardex revealed multiple instances where incontinence care, mobility assistance, and bathing were not documented or provided. The administrator and Director of Nursing were informed of the missing documentation, but they were not working at the facility during that period.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. Resident #39 was admitted for rehab therapy with no initial wounds on their sacrum. However, a new open area was discovered on the sacrum, and nursing staff failed to obtain wound measurements at the time of discovery. The wound worsened, showing signs of infection, including foul-smelling drainage and discoloration, yet measurements were still not recorded. The resident was eventually sent to the hospital due to a change in mental status and lethargy and subsequently died from sepsis and sacral wound complications.
Failure to Ensure Competence of Nursing Assistant
Penalty
Summary
The facility failed to ensure that nursing assistants were competent and had the necessary skill set to care for the residents. This was evident for one nursing assistant staff member. On 4/8/24, the Director of Nursing (DON) and Nursing Home Administrator (NHA) reviewed the employee file of Geriatric Nursing Assistant (GNA) Staff #22 and found no evidence that the facility had determined her level of competence. The DON and NHA confirmed that there was no additional paperwork to demonstrate Staff #22's competence. Further review revealed that Staff #22 was hired in October 2022 as a nursing assistant in training and did not receive her GNA certification until May 2023. The concern was discussed with the DON and NHA on 4/9/24.
Failure to Ensure Abuse Training and Competencies for GNA
Penalty
Summary
The facility failed to ensure that geriatric nursing assistants (GNA) had the required abuse training and competencies to provide safe and proper care to residents. Specifically, the employee file of GNA #17 revealed that she had not completed her annual abuse training since 2020. This deficiency was identified during a review of complaints, facility-reported incidents, interviews, and employee files. The Director of Nursing (DON) and Administrator were unaware of the lapse in training and were newly acclimating to the facility. The employee's file was reviewed following allegations of abuse and neglect, leading to the implementation of education and inservices for other employees related to the findings from the incidents.
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 764 citations issued within 25 miles in the last 12 months — including the 3 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 Bel Air
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sterling Care Bel Air | 3.6 mi | ★★★★★ | 18 | 0 |
| Sterling Care Forest Hill | 4.8 mi | ★★★★★ | 27 | 0 |
| Sterling Care Riverside | 5.1 mi | ★★★★★ | 0 | 0 |
| Lorien Bulle Rock | 8.1 mi | ★★★★★ | 0 | 0 |
| Citizens Care Center | 10.7 mi | ★★★★★ | 15 | 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.