Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Nursing & Rehab Ctr - Elkridge during CMS and state inspections, most recent first.
Residents sitting together were not served meals at the same time during lunch, with some residents receiving food minutes after others at the same table. In addition, an LPN was observed standing while feeding one resident and assisting another resident with drinking, reflecting a failure to maintain dignity during dining and feeding assistance.
Missing Required Training for Newly Hired GNAs: Facility staff failed to ensure newly hired GNAs had documentation of required orientation topics. Surveyors reviewed five GNA training files and found missing records for abuse, neglect, exploitation, QAPI, infection control, compliance and ethics, and dementia. The DON acknowledged one GNA’s training documents could not be found, and additional files for other newly hired GNAs also lacked evidence of required training.
Missing QAPI Training Documentation for Multiple GNAs: The facility failed to maintain documentation showing that multiple GNAs received QAPI training. Employee file review found QAPI training for some GNAs, but several files lacked evidence of the required training. The DON acknowledged the missing documentation and stated the facility had staffing changes and the prior staff trainer was no longer employed.
The facility failed to ensure GNAs received required annual in-service training. Record review showed that four GNA employee files lacked evidence of annual in-service training, and the DON stated that the ADON was responsible for conducting the annual training and that it should be completed annually. The DON later confirmed the facility failed to maintain documentation of annual GNA in-service training for 2025.
A resident’s family member reported that a GNA told her that residents and their representatives were not allowed to speak directly with state surveyors who were on site. Instead of bringing the family member to a surveyor, the GNA provided contact information for the state oversight agency to file a complaint. The family member subsequently filed a complaint, and record review confirmed the complaint submission, demonstrating that the resident’s representative was discouraged from and not permitted to communicate directly with surveyors.
A resident with hemiplegia, muscle weakness, impaired coordination, and documented need for one-person assistance with transfers and partial to moderate assistance for toilet transfers experienced prolonged delays in call bell response when requesting toileting help. The resident reported long waits, attempted to toilet without assistance, and had multiple falls. Review of call bell logs showed several response times exceeding the facility’s stated 20-minute expectation, including one response over 24 minutes. A GNA reported inadequate staffing to meet care needs, and the resident’s family reported new episodes of incontinence since admission, which they associated with prolonged call bell response times.
The facility failed to provide written notification of transfer or discharge for two residents who were sent to the hospital. Record review showed the residents' representatives were notified by phone call, but no written notice was found in either medical record. During interview, the DON stated the facility only notifies representatives of transfers or discharges via phone call.
A resident’s care plan was not revised after an active NO CPR/DNI order was entered. The code status focus still reflected ATTEMPT CPR and had not been updated to match the resident’s current resuscitation wishes, and the DON stated the care plan should have been revised.
Failure to provide and document individualized activities: A resident who rated music and religious services as very important was observed in bed with no music or activity occurring, and the relative reported the resident was not involved in activities. The Activities Director stated the resident received room visits, music, and bedside religious activities, but there was no activity log or documentation system to track what was provided.
A resident receiving tube feeding and ordered water flushes was observed with the feeding container, tubing, and water flush canister left unlabeled and undated, while the tube feeding continued at 60 mL/hr. The resident’s record showed NPO status with Diabetasource AC via pump and scheduled water flushes for hydration. Follow-up observations found the same missing identifying information, and no flush syringe was seen at the bedside.
MOLST Information in EHR and Hard Chart Did Not Match: A resident’s EHR documented a NO CPR/DNI code status, but the hard chart contained a MOLST form showing attempt CPR, creating a mismatch between the resident’s electronic record and paper chart. Staff interviews confirmed that current MOLST forms were kept in hard charts, and the DON and SSD were notified of the discrepancy.
A facility failed to ensure a newly hired GNA had documented training on abuse, neglect, and exploitation. Review of the employee file showed no evidence of abuse training, and the DON later confirmed the facility did not maintain documentation of the required training for that employee.
Missing compliance and ethics training documentation was identified during the annual survey after review of employee files. A GNA hired in March 2024 had no evidence of 2025 training, and two additional GNAs also lacked documentation of the required training. The DON acknowledged that the facility failed to maintain the training records for these three GNAs.
Facility staff did not conduct an investigation after a resident's family reported missing personal items, including a puzzle and an electronic sound amplifier device. The resident's medical record lacked an inventory sheet for these items, and the DON confirmed that no investigation was performed.
Nursing staff did not document ADL care for a resident on three separate shifts, as confirmed by the DON during a complaint survey. This lack of documentation was identified after a family complaint regarding care and the development of a preventable wound.
A resident with left-sided hemiparesis, requiring total care, fell from bed during ADL care due to inadequate assistance, resulting in a humeral neck fracture and hematoma. Despite care plans indicating the need for two-person assistance, a GNA attempted care alone, leading to the incident. Subsequent evaluations revealed the extent of injuries, and staff interviews confirmed the resident's dependency on two-person support for ADL care.
A resident with one-sided impairment and dependent on staff for toileting reported long wait times for call bell responses over a weekend. The facility's policy requires call bells to be answered within 20 minutes, but logs showed delays of 28 and 55 minutes. The Second Floor Supervisor confirmed the expectation for timely responses but could not explain the delays.
A resident with a history of ischemic CVA and requiring total care experienced a medical event involving excessive sweating and a distended abdomen. The physician was notified, and an x-ray was ordered, but the Responsible Party (RP) was not informed until after the resident's passing. The delay in notification was acknowledged by the DON, who confirmed that the RP should have been updated on changes in the plan of care.
A facility failed to thoroughly investigate a missing credit card incident reported by a resident. The investigative file lacked documentation of staff and resident interviews or evidence from the bank about fraudulent use. The DON confirmed no additional documentation was available, indicating an incomplete investigation.
A facility failed to document staff training on the application of a sling for a resident with a humeral fracture. Despite the family's concerns and the DON's acknowledgment of the need for training, there was no evidence of an in-service being conducted. Interviews revealed inconsistencies and lack of documentation regarding the training, contributing to the deficiency identified by the surveyor.
A resident experienced a delay in receiving necessary x-ray services after an incident where their legs slid out of bed, resulting in a bruise. Despite orders for x-rays of the left rib, humerus, and shoulder, the facility failed to obtain the services in a timely manner, leading to the resident being transferred to the hospital for evaluation. The facility has since changed its radiology service provider.
A facility failed to involve a resident's guardian in the initial care planning process, violating the resident's rights. The resident, with a history of schizophrenia, epilepsy, and edema, was incorrectly designated as their own representative. The baseline care plan lacked a written summary and signatures from the resident or their representative. Despite a hospital discharge summary indicating updated decision-making capacity, this information was not in the facility's records. The Social Work Director acknowledged speaking with the guardian, but the Nursing Home Administrator noted that staff should have been aware of the guardianship status.
The facility failed to assist two residents in formulating or obtaining advance directives, as revealed during an annual survey. Both residents lacked documentation indicating whether they had advance directives or were offered assistance in creating one. The social director confirmed the oversight, acknowledging that the residents were not provided with the opportunity to formulate advance directives.
A facility failed to complete a Significant Change in Status MDS within 14 days for a resident enrolled in hospice care. The resident was admitted to hospice, but the MDS did not reflect this change, as confirmed by the MDS Coordinator during a survey review.
The facility staff inaccurately coded the MDS assessments for two residents. One resident was incorrectly marked as having natural teeth, while another resident's Foley catheter was not documented, leading to inaccurate coding of urinary incontinence. The errors were acknowledged by the MDS Coordinator.
A facility failed to complete a comprehensive baseline care plan for a resident with a history of disorientation, malnutrition, and diabetes. The care plan lacked specific details in dietary and therapy sections, and there was no documentation of the resident's dietary preferences or goals. Interviews revealed that multiple disciplines did not document initial goals or care plans, leaving the resident uninformed about the services to be provided.
A facility failed to conduct timely care plan meetings for a resident following quarterly assessments, as required for effective care planning. Despite an audit identifying missing meetings for multiple residents, documentation for the resident in question remained incomplete, indicating a lapse in the facility's care planning process.
The facility failed to document and provide activities that meet the needs of two residents, as observed during an annual survey. One resident was unable to recall any activities and had no documentation of participation for several months, while another resident reported not being offered activities despite expressing interest. The Activities Director cited staffing shortages and admitted to incomplete assessments and documentation, leading to a deficiency in meeting the residents' needs for socialization and engagement.
A facility failed to have physician orders for a resident's foley catheter care, despite the resident's history of sepsis, UTIs, and obstructive uropathy. The absence of orders led to no documented foley care in the Treatment Administration Record. The DON confirmed the oversight, noting that without an order, the task was not assigned.
A resident with a stage 2 pressure ulcer on the heels was not consistently provided with protective boots as ordered, despite having a care plan indicating the need for pressure relief interventions. Observations showed the resident without boots in bed, and the TAR lacked documentation for these interventions. An LPN and the DON confirmed the boots should have been applied, highlighting a deficiency in pressure ulcer care.
A resident experienced issues with bowel regularity, and the facility failed to follow its bowel protocol. Despite having an order for MiraLax to treat constipation, it was not administered, and bowel movements were not documented on several days. The facility's protocol required specific steps to address constipation, which were not followed, leading to the deficiency.
The facility failed to ensure timely certification for nurse aides in training (NAITs), as three NAITs did not obtain Geriatric Nursing Assistant (GNA) licensure within the required timeframe. One NAIT was reassigned until licensure was obtained, another continued working until resignation, and a third was employed beyond the permissible period without proper enrollment records. The HR Director acknowledged the issue and confirmed discrepancies in employment status.
The facility failed to maintain professional standards in food service safety, with multiple instances of unlabeled and improperly stored food items observed. Unlabeled spices, cheese, meat, and eggs were found, along with missing dishwasher temperature log entries and improperly stored wet bowls. Further inspections revealed continued issues with unlabeled and undated food items, indicating non-compliance with food safety standards.
The facility failed to maintain medical records according to professional standards, as evidenced by incomplete documentation for two residents. One resident's COVID-19 test result lacked a date, and another resident's MOLST form was incomplete, with discrepancies in the code status between the electronic medical record and the care plan.
A facility failed to maintain infection control practices, including a foley catheter drainage bag left on the floor, discrepancies in PICC dressing change documentation, and a GNA handling soiled linen without gloves or hand sanitization.
Dining and Feeding Assistance Dignity Concerns
Penalty
Summary
The facility failed to maintain residents’ dignity while dining by not serving meals at the same time to residents sitting together. During lunch service in the common dining room, 8 residents were seated together at one table and 2 residents were seated together at another table, but meals were not delivered to all residents at the same time. Three residents at the table of 8 had meals in front of them while the others were still waiting, and one resident at the table of 2 had a meal before the other resident received theirs 6 minutes later. The last resident at the table of 8 did not receive a meal until 23 minutes after the first 3 residents at that table were observed with meals. The facility also failed to maintain dignity during feeding assistance. An LPN was observed standing while feeding Resident #64 and then, while still standing, turning to Resident #21, picking up a cup, and assisting the resident with drinking. The report states that these observations involved 2 residents observed with feeding assistance and that the concern was addressed with the DON and NHA later that day.
Missing Required Training for Newly Hired GNAs
Penalty
Summary
Facility staff failed to ensure that newly hired geriatric nursing assistants (GNAs) had the required knowledge to provide resident care. During the annual survey, the surveyor reviewed five GNA training files and found missing required training documentation for resident abuse, neglect, exploitation, QAPI, infection control, compliance and ethics, and dementia. The deficiency was identified after review of the newly hired GNA #16 file, which did not contain the required training records. The DON stated that newly hired GNAs complete two days of office orientation followed by two to three days of training on the nursing unit, and she acknowledged that the missing training documents for GNA #16 could not be located. The HR Director stated that newly hired GNAs complete two days of in-office orientation using Health Academy modules, with the remainder of training conducted on the nursing unit. Review of additional training files for GNAs hired between October 2025 and January 2026 showed missing documentation for required topics in multiple files, including infection control, QAPI, compliance and ethics, and dementia. The facility's assessment staff orientation training included abuse, neglect, exploitation, dementia, and infection control.
Missing QAPI Training Documentation for Multiple GNAs
Penalty
Summary
The facility failed to ensure staff received Quality Assurance and Performance Improvement (QAPI) training for new and existing staff. During review of employee files, QAPI training was documented for GNA #17, GNA #15, and GNA #25, but the files for GNA #14 and GNA #16 did not contain evidence of QAPI training. The DON stated that newly hired GNAs complete two days of in-office onboarding orientation followed by two to three days of training on the nursing unit, but acknowledged that the facility did not maintain documentation of QAPI training for GNA #14 and GNA #16. The DON also stated the facility experienced staffing changes in 2025 and that the employee previously responsible for staff training was no longer employed. Further review of training files for GNA #26, GNA #27, GNA #29, GNA #30, and GNA #31 showed that all except GNA #26 were missing documentation of QAPI training in the employee training file.
Missing Annual In-Service Training Documentation for GNAs
Penalty
Summary
The facility failed to ensure Geriatric Nursing Assistants (GNAs) received required annual in-service training. During the annual survey, administrative record review showed that the employee files for GNA #17, GNA #15, GNA #14, and GNA #25 did not contain evidence of annual in-service training. In an interview, the DON stated that the ADON was responsible for conducting the annual GNA in-service training and confirmed that the training should be completed annually. The surveyor requested documentation of completed in-service training for 2025, and later the DON stated that the facility failed to maintain documentation of annual in-service training for GNAs in 2025.
Resident Representative Discouraged From Speaking Directly With State Surveyors
Penalty
Summary
The facility failed to permit a resident’s representative to speak directly with state surveyors during a recertification survey. During an interview, the family member of Resident #14 reported that a Geriatric Nursing Assistant (GNA #23) told her that residents and their representatives were not allowed to speak directly with state surveyors who were on site. Instead of facilitating contact with the surveyors, GNA #23 provided the family member with contact information for the Office of Health Care Quality (OHCQ) to file a complaint. Complaint record review confirmed that the family member subsequently filed a complaint with OHCQ. This conduct resulted in the resident’s representative being discouraged from and not permitted to communicate directly with the state surveyors who were present in the facility. No additional medical history or clinical condition for the resident was provided in the report.
Failure to Provide Timely Assistance With Toileting and Call Bell Response
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), specifically toileting, to a resident who required staff help. The resident, admitted in January 2026 with hemiplegia and hemiparesis affecting the left non-dominant side, muscle weakness, difficulty walking, and lack of coordination, reported long wait times for staff to respond to the call bell when needing restroom assistance. Due to these delays, the resident stated they attempted to use the restroom without assistance and fell on multiple occasions. Record review showed the resident had unwitnessed falls in January and February 2026, and the baseline care plan from January 2026 documented a need for one-person assistance with transfers. An MDS from January 2026 indicated upper and lower extremity impairment and a need for partial to moderate assistance with toilet transfers. The care plan documented a fall on 01/21/2026 and included a goal initiated on 01/22/2026 for the resident to use the call bell and wait for staff assistance. During an interview, the Administrator stated that staff are expected to respond to call bells immediately, but no longer than 20 minutes. Review of the call bell response log for the resident’s room between January and February 2026 revealed multiple instances where response times exceeded 20 minutes. On 02/09/2026, the call bell was activated at 6:59 PM and staff responded 24.31 minutes later. A GNA reported that the facility was not adequately staffed to meet residents’ care needs. The resident’s family member reported that the resident, who was continent of bowel and bladder at admission, had episodes of incontinence attributed to prolonged call bell response times. These findings were reviewed with the Administrator on 02/11/2026.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to notify residents and their representatives in writing of transfers or discharges for 2 residents reviewed for hospitalization. Record review showed that Resident #5 was transferred to the hospital on 1/11/2026 and Resident #1 was transferred to the hospital on a date documented in the progress notes. Further review of both residents' transfer notes showed that their representatives were notified by phone call, but no written notification of transfer was found in either resident's medical record. During interview, the DON stated that the facility currently only notifies representatives of transfers or discharges via phone call.
Care Plan Not Updated for Current Code Status
Penalty
Summary
The facility failed to revise Resident #33’s care plan to reflect a change in code status after an active order was entered for NO CPR, OPTION A-2, and DO NOT INTUBATE (DNI). The resident’s current care plan focus for code status still stated, “I want my resuscitation status to be ATTEMPT CPR (including any and all medical efforts that are indicated during arrest),” and it had not been updated to match the resident’s current resuscitation wishes. The care plan had been initiated on the earlier date with no revision noted, and the DON acknowledged that the care plan should have been revised to reflect the resident’s current CPR status.
Failure to Provide and Document Individualized Activities
Penalty
Summary
The facility failed to provide and document individualized activities in accordance with Resident #9’s assessed preferences. The resident’s relative stated that Resident #9 was not involved in any activities. During observation, Resident #9 was seen in bed with no music on and no activity occurring in the room. The resident’s most current MDS and CAAs were reviewed, including Sections C, F, and GG related to cognitive patterns, preferences for customary routine and activities, and functional abilities and goals. Review of the resident’s MDS Section F showed that the resident rated listening to music as very important and also rated participating in religious services or practices as very important. The Activities Director stated that the resident received room visits because he/she did not come out of the room, that the resident was offered the Daily Chronicle and asked about attending activities, and that staff would make the resident comfortable in bed, play continuous music, and perform nail care. The Activities Director also stated the resident was supposed to listen to music three or more times per week and that religious activities were provided at bedside, but there was no documentation or activity log available to reflect provision of music or religious activities. The Activities Director further stated there was currently no documentation system in place to track activity provision, and the NHA acknowledged the absence of documentation and activity tracking as a concern.
Unlabeled Tube Feeding and Flush Supplies
Penalty
Summary
The facility failed to ensure that enteral nutrition and hydration canisters were labeled and dated for Resident #7, who was receiving tube feeding and was NPO. On 02/05/2026, the resident was observed receiving tube feeding at 60 mL/hr, and the tube feeding container and attached tubing were not labeled with the resident’s name, the date, or the start time. The manufacturer’s label on the container was present but remained blank, and the water canister used for flushes was also not labeled or dated. A clinical record review showed physician orders for Diabetasource AC via feeding pump at 60 mL/hr for 20 hours per day, with total nutrient volume of 1200 mL, and water flushes of 240 mL every 4 hours for hydration. Follow-up observations on 02/09/2026 and 02/10/2026 showed the tube feeding continued to run at 60 mL/hr, while the feeding container, tubing, and water flush canister still lacked identifying information. A syringe for water flushes was not observed at the bedside or in the resident’s room during these observations. An LPN stated that feed and water flushes are required to be labeled and dated with the resident’s name and the time initiated, and the DON stated that enteral containers should be labeled with the date and shift they are changed and that a syringe for flushing should be maintained at the patient’s side.
MOLST Information in EHR and Hard Chart Did Not Match
Penalty
Summary
Resident #33’s medical record was not maintained in the most accurate form because the electronic medical record and the hard chart did not match regarding code status. The resident had an active order for NO CPR, OPTION A-2, DO NOT INTUBATE (DNI), and social work progress notes in the EHR stated that the resident had MOLST code status of NO CPR A2 and that a MOLST on file indicated NO CPR/DNI. However, the EHR also contained two copies of voided MOLSTs and no active MOLST was identified in the EHR. When the hard chart was reviewed, it contained a MOLST form dated [DATE] that indicated attempt CPR was selected under CPR (Resuscitation) Status, which did not match the EHR documentation. Staff interviews confirmed that up-to-date MOLST forms were kept in hard charts, and the DON and SSD were made aware that the resident’s EHR and hard chart MOLST information did not match. A later review of the hard chart found an updated MOLST form completed by the facility’s Medical Director, and the DON stated the issue had been corrected with an updated MOLST form.
Missing Abuse Training Documentation for Newly Hired GNA
Penalty
Summary
The facility failed to ensure staff received training on abuse, neglect, and exploitation for 1 of 5 employee files reviewed during the annual survey. On 02/10/2026 at 10:45 AM, review of GNA #16’s employee file showed a hire date of October 2025, but the file did not contain evidence of abuse training. During an interview the same day, the DON stated that newly hired GNAs complete two days of in-office orientation followed by two to three days of training on the nursing unit. After the surveyor noted the missing education and requested the training files, the DON later confirmed at 2:43 PM that the facility had failed to maintain documentation of abuse training for GNA #16. The Administrator was informed of the finding on 02/11/2026.
Missing Compliance and Ethics Training Documentation
Penalty
Summary
The facility failed to ensure staff received required compliance and ethics training, as shown by administrative record review and staff interview during the annual survey. On 02/10/2026 at 10:45 AM, review of GNA #17’s employee file showed a hire date of March 2024 but no evidence of compliance and ethics training completed in 2025. The surveyor then reviewed four additional employee files and found that compliance and ethics training was also missing for GNA #14 and GNA #16. During an interview later that day, the DON was informed that documentation of 2025 compliance and ethics training was missing from these three GNA files, and at 2:43 PM the DON acknowledged that the facility failed to maintain documentation of the training for GNA #17, GNA #14, and GNA #16.
Failure to Investigate Missing Personal Items Complaint
Penalty
Summary
Facility staff failed to thoroughly investigate a complaint regarding missing personal items belonging to a resident. The resident's family reported that an adult puzzle and an electronic sound amplifier device were missing from the resident's room. Upon review, there was no evidence in the resident's medical record of an inventory sheet listing these items. Additionally, the Director of Nursing confirmed that no investigation into the missing items had been conducted, despite the complaint being reported and the items being identified as missing during a room search.
Failure to Document ADL Care in Resident Medical Record
Penalty
Summary
Facility nursing staff failed to accurately document activities of daily living (ADL) care in the medical record for a resident on three separate shifts. Specifically, there was no documentation of ADL care provided on the day shift of 1/15/25, the evening shift of 1/20/25, and the night shift of 1/23/25. This deficiency was identified during a complaint survey following a family report that the resident did not receive necessary ADL care, which allegedly contributed to the development of a preventable wound. The Director of Nursing (DON) confirmed during an interview that the nursing staff did not document the required ADL care for the resident on the specified dates.
Failure to Provide Adequate Assistance Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adequately assess and assist a dependent resident during Activities of Daily Living (ADL) care, resulting in a fall from bed and actual harm to the resident. The resident, who was admitted in early 2023, had left-sided hemiparesis and required total care, being unable to participate in medical decision-making. The care plan initially required 1-2 staff for bed mobility, but was revised to require 2 staff by July 2023. Despite this, a Geriatric Nursing Assistant (GNA) attempted to perform care alone, leading to the resident's fall. The incident occurred when the GNA was providing afternoon care and attempted to roll the resident onto their side, causing the resident's legs to slide out of bed while the upper torso remained in bed. Although initially no injuries were noted, subsequent medical evaluations revealed a humeral neck fracture and a muscular hematoma, necessitating a blood transfusion due to anemia. The resident's care plan and assessments consistently indicated the need for extensive assistance and two-person support for bed mobility, which was not adhered to during the incident. Interviews with staff, including the GNA involved and the LPN responsible for care planning, confirmed that the resident required a two-person assist for all ADL care. The facility's investigation report highlighted that the Nursing Assistant in Training (NAT) involved in the incident had received training on safe resident lifting and transfers, which emphasized the need for two staff members for repositioning in bed. The Director of Nursing (DON) acknowledged the discrepancy in the care plan and confirmed that it was adjusted post-incident to reflect the need for two-person assistance for all ADL care.
Delayed Call Bell Response for Dependent Resident
Penalty
Summary
The facility failed to answer call bells in a timely manner to attend to the needs of dependent residents, specifically for one resident on the Second Floor Nursing Unit. During an interview, the resident reported that over the weekend, they used the call bell to request assistance to the bathroom, but it took a long time for the staff to respond. The resident expressed difficulty in waiting for assistance when needing to use the bathroom. A review of the resident's electronic medical record revealed that the resident has an impairment on one side and is dependent on staff for toileting and transferring needs. The surveyor requested and reviewed the call light response time log for the resident, which confirmed that on a specific date, the call light was on for 28 minutes and later for 55 minutes and 51 seconds. The facility's Call Light Policy states that call lights should not be ignored, and the Routine Resident Checks policy specifies that call bells should be answered within 20 minutes. The Second Floor Supervisor confirmed the expectation for call lights to be answered within 20 minutes and acknowledged the delay in response time but was unable to determine the reason for the prolonged wait.
Failure to Timely Notify Responsible Party of Treatment Changes
Penalty
Summary
The facility failed to inform the Responsible Party (RP) of Resident #70 about the need to alter treatment in a timely manner. Resident #70, who had a history of ischemic CerebroVascular Accident (CVA) with left-sided hemiparesis and required total care, was admitted to the facility in early 2023. On a particular day, the resident was noted to have excessive sweating and a distended abdomen with hypoactive bowel sounds. The physician was notified, and an abdominal x-ray was ordered. However, the RP, identified as the resident's granddaughter, was not informed of these developments until later in the afternoon. The delay in notifying the RP was documented by LPN #28, who noted that the call to the RP was delayed due to pending abdominal x-ray results. Despite the physician being updated and an x-ray being ordered, the RP was not informed of the morning events until after Resident #70 had passed away at 3:10 PM. The Director of Nursing (DON) confirmed that the RP should have been notified of changes in the plan of care and acknowledged the delay in notification as documented by the LPN.
Incomplete Investigation of Missing Credit Card
Penalty
Summary
The facility failed to maintain documentation that a Facility Reported Incident (FRI) was thoroughly investigated for one resident out of thirteen during the annual survey. The deficiency was identified when a resident reported a missing credit card months prior, and the surveyor found that the facility's investigative file lacked comprehensive documentation. The file contained initial and follow-up report forms submitted to the Office of Health Care Quality, but there were no records of interviews with facility staff, other residents, or evidence from the bank regarding fraudulent use of the credit card. The Director of Nursing confirmed that no additional documentation was available, indicating an incomplete investigation into the reported incident.
Failure to Document Staff Training on Sling Application
Penalty
Summary
The facility failed to provide necessary education for the application of a sling device after a knowledge deficit was identified among staff. This deficiency was observed in the case of a resident who had been admitted to the facility in early 2023. The resident had suffered a fall resulting in a mildly impacted humeral neck fracture and a left pectoral muscular hematoma, requiring nonoperative management with a sling. Despite the physician's note indicating the family's concern about staff's ability to manage the sling and the Director of Nursing's (DON) acknowledgment of the need for an in-service training, there was no documentation to confirm that such training was conducted. Interviews with the DON and the Occupational Therapist (OT) revealed inconsistencies and lack of documentation regarding the in-service training. The OT recalled conducting an in-service on the standard sling but could not confirm the attendance or documentation of the training. The DON was unable to provide any evidence of the training being completed, and no documentation was found in the medical record or elsewhere to indicate that staff had been adequately trained to manage the resident's sling. This lack of documentation and follow-through on training contributed to the deficiency identified by the surveyor.
Failure to Provide Timely Radiology Services
Penalty
Summary
The facility failed to provide timely radiology services for Resident #70, who was admitted in early 2023. On July 15, 2023, a Licensed Practical Nurse (LPN) documented an incident where the resident's legs slid out of bed while a Geriatric Nursing Assistant (GNA) was providing care, resulting in a bruise. The LPN communicated this observation to a provider on July 17, 2023, who requested lab tests and clarification of the fall. On July 18, 2023, the Nurse Supervisor sought further clarification and inquired about the need for an x-ray. The resident's physician and Medical Director ordered x-rays for the left rib, humerus, and shoulder later that day. Despite the order, the x-ray was not completed at the facility. On July 19, 2023, the Medical Director noted that staff had been unable to obtain an estimated time of arrival from the radiology service. Due to the resident's pain and the possibility of a fracture, the resident was transferred to the hospital's emergency room for evaluation. The Director of Nursing confirmed that the x-ray order was placed on July 18, 2023, and was scheduled for completion on July 19, 2023, but the radiology company did not fulfill the order. The facility has since changed its radiology service provider.
Failure to Involve Guardian in Care Planning
Penalty
Summary
The facility failed to involve a resident's guardian in the initial care planning process, which is a violation of the resident's rights. The deficiency was identified during a review of the medical records and interviews conducted by the surveyor. Resident #162 was admitted to the facility with a history of schizophrenia, epilepsy, and edema. The baseline care plan incorrectly designated the resident as their own representative, and there was no written summary or signatures from the resident or their representative on the care plan. The Social Work Director and Nurse Supervisor signed the document, but the guardian's involvement was not documented. Further investigation revealed that a hospital discharge summary indicated the resident's capacity to make care decisions was updated prior to admission, but this information was not included in the facility's records. During interviews, the Social Work Director acknowledged speaking with the resident's guardian and requesting guardianship paperwork, but the Nursing Home Administrator stated that admissions and nursing staff should have been aware of the guardianship status. The incorrect assessment of the responsible party led to the failure to involve the guardian in the care planning process.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to assist residents in formulating or obtaining an advance directive, as evidenced by the cases of two residents during an annual survey. Resident #54 was admitted in late August 2024, and a social worker assessment was completed on August 22, 2024. However, the assessment did not indicate whether the resident had an advance directive or if they were offered assistance in formulating one. During an interview, the social director confirmed that the necessary documentation was missing, and the resident was not offered help in creating an advance directive. Similarly, Resident #162, admitted in early September 2024, also lacked documentation regarding advance directives. A social worker assessment completed on September 6, 2024, failed to show whether the resident had an advance directive or was offered assistance in formulating one. The social director acknowledged the oversight during an interview, confirming that the resident was not provided with the opportunity to create an advance directive. These findings highlight the facility's failure to comply with regulations regarding residents' rights to formulate advance directives.
Failure to Complete Significant Change MDS for Hospice Enrollment
Penalty
Summary
The facility failed to accurately assess and complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days of a resident's enrollment into a hospice program. This deficiency was identified during an annual survey for one resident who was investigated for hospice care. The MDS is a comprehensive assessment tool used to evaluate a resident's functional, medical, psychosocial, and cognitive status to develop a personalized care plan. A Significant Change in Status MDS is required when a resident enrolls in a hospice program, which provides specialized care for individuals with a life expectancy of six months or less. The surveyor discovered that the resident was admitted to a hospice program on June 7, 2024, as indicated by a physician's order. However, during a review of the Significant Change in Status MDS with an assessment reference date of June 17, 2024, it was found that the enrollment into the hospice program was not addressed in the assessment. MDS Coordinator #5 confirmed that the resident's enrollment in hospice should have triggered a Significant Change in Status MDS, which was not completed as required. This oversight was confirmed during an interview with the MDS Coordinator and a review of the assessment documentation.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility staff failed to accurately code the Minimum Data Set (MDS) assessments for two residents during the annual survey. For one resident, the MDS assessment incorrectly indicated that the resident was not edentulous, despite observations confirming the resident had no natural teeth. The MDS Coordinator acknowledged the error during an interview and confirmed that the coding was incorrect. For another resident, the MDS assessment failed to document the presence of an indwelling Foley catheter, despite the resident's medical history and care plan indicating its use due to obstructive uropathy. The MDS Coordinator admitted to missing this detail, as he primarily relied on physician orders and nursing assessments, which did not include an order for the Foley catheter. This oversight led to the resident being inaccurately coded as always having urinary incontinence.
Failure to Complete Baseline Care Plan for Resident
Penalty
Summary
The facility failed to adequately include and review all initial healthcare information and goals in the baseline care plan for a resident. Upon admission in early July 2024, the resident had a medical history of disorientation, protein-calorie malnutrition, and diabetes. Despite being alert and oriented to self, the resident was not oriented to place or time. The baseline care plan, completed shortly after admission, lacked specific details in several sections, including dietary and therapy orders, functional goals, and therapy services. Additionally, there was no documentation of the resident's dietary preferences, risks, or goals, and the section for the resident or representative's signature was left blank. Interviews with the Social Work Director and the Nursing Home Administrator revealed that the responsibility for completing the baseline care plan was divided among different disciplines. However, several disciplines failed to document initial goals or the care to be provided, leaving the resident uninformed about the plans and services to be rendered. The lack of a comprehensive baseline care plan and the absence of a care plan meeting contributed to the deficiency identified by the surveyor.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to facilitate timely care plan meetings for a resident following their quarterly assessments, which is a requirement to ensure the resident and their representative can participate in the care planning process. This deficiency was identified during an annual survey, where it was found that care plan meetings were not held after several MDS assessments, including quarterly and annual assessments. Specifically, for one resident, care plan meetings were documented on only a few occasions, despite multiple assessments being conducted over the period. The Social Services Director confirmed the absence of timely care plan meetings and acknowledged that an audit had previously identified this issue for multiple residents. Despite the audit and efforts to rectify the situation, documentation for the resident in question was still lacking. The deficiency highlights a failure in the facility's process to ensure regular and documented care plan meetings, which are crucial for evaluating the effectiveness of the resident's care.
Deficiency in Meeting Residents' Activity Needs
Penalty
Summary
The facility failed to evaluate and document activities that meet the needs of residents, as evidenced by the cases of two residents during an annual survey. Resident #38 was observed in bed with outdated activity calendars and was unable to recall any activities provided by the facility. The resident's care plan indicated a need for assistance with activities and a preference for group activities, but there was no documentation of participation in activities for several months. The Activities Director acknowledged the lack of documentation due to staffing shortages and confirmed that no records showed the resident's engagement in activities. Resident #54 reported not being offered activities and expressed interest in participating. The resident's medical record showed an admission in late August 2024, but there was no documentation of activities being offered or provided. The MDS assessment indicated preferences for reading materials, music, and group activities, among others. However, the Activities Director admitted that no Home and Lifestyle Assessment was completed, and there was minimal documentation of activities offered, with only a beverage and nail care recorded for September 2024. The surveyor's investigation revealed significant gaps in the documentation and provision of activities for both residents, highlighting a deficiency in meeting the residents' needs for socialization and engagement. The lack of documentation and assessment of residents' preferences contributed to the failure to provide appropriate activities, as required by the residents' care plans and preferences.
Lack of Physician Orders for Foley Catheter Care
Penalty
Summary
The facility failed to have physician orders written to ensure proper care and treatments were in place for a resident with a foley catheter. This deficiency was identified during a survey when reviewing the medical records of a resident who was readmitted to the facility after a hospital stay. The resident had a history of sepsis due to MRSA, urinary tract infections, and obstructive uropathy, which necessitated the use of a foley catheter. Despite the presence of a care plan for bladder elimination issues, there were no physician orders documented for the foley catheter or its care. The surveyor's review of the Treatment Administration Record (TAR) for September 2024 revealed no documentation of foley care. During an interview, the Director of Nursing confirmed the absence of orders for the foley catheter and acknowledged that without an order, the task was not assigned to the TAR. This oversight resulted in the lack of documented care for the resident's foley catheter, highlighting a gap in the facility's process for ensuring necessary medical orders and care documentation.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate services to promote the healing of a pressure ulcer. This deficiency was identified for one resident who was observed multiple times without protective boots while in bed, despite having orders to elevate and float heels and apply off-loading boots for pressure relief. The resident had a care plan indicating a risk for pressure ulcers, which was later revised to include a stage 2 pressure ulcer on the heels. However, the protective boots were not consistently applied as required. The surveyor noted that the Treatment Administration Record (TAR) for the resident did not include documentation for pressure relief interventions. During an interview, an LPN confirmed that the resident should have been wearing the boots while in bed and acknowledged the presence of wounds on the resident's feet. The Director of Nursing also confirmed that the boots should have been applied according to the orders and that any refusal by the resident should have been documented. This lack of adherence to the care plan and physician orders contributed to the deficiency in pressure ulcer care.
Failure to Follow Bowel Protocol for Resident
Penalty
Summary
The facility failed to provide appropriate treatment for constipation and maintain bowel continence for a resident. The resident, who was readmitted to the facility after a hospital stay, reported issues with bowel regularity. The medical record review revealed that the resident had an order for MiraLax to be administered as needed for constipation, but it was not given despite several days without a documented bowel movement. The facility's bowel protocol, which included steps to address constipation, was not followed. The surveyor noted that the resident's bowel movements were not recorded on multiple days, and the prescribed MiraLax was not administered according to the protocol. The facility's protocol required an abdominal assessment and the administration of prune juice and MiraLax if no bowel movement occurred within specified timeframes. However, these steps were not taken, leading to the deficiency. The Director of Nursing was informed of the concern that the bowel protocol was not adhered to for the resident.
Failure to Ensure Timely Certification for NAITs
Penalty
Summary
The facility failed to ensure that nurse aides in training (NAITs) obtained appropriate certification within the required timeframe, as evidenced by the cases of three NAITs. NAIT #24 was hired during the pandemic waiver period and was required to obtain Geriatric Nursing Assistant (GNA) licensure by the end of the waiver period. However, the licensure was not obtained in time, leading to her reassignment to the Assisted Living side of the facility until she obtained her licensure. NAIT #25 also did not obtain licensure within the required timeframe and continued to work as a NAIT until her resignation. The Human Resources (HR) Director acknowledged the issue and stated that a process is now in place to track educational progress for all NAITs. Additionally, NAIT #26 was hired as a dietary aide and there were no records indicating her enrollment in a nurse-in-training program. Despite completing her training and obtaining certification, she was employed as a NAIT beyond the permissible period and was incorrectly coded as a GNA for her last two days of employment. The HR Director confirmed these discrepancies, indicating a failure in the facility's process to ensure timely certification and proper employment status for NAITs.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. During an initial kitchen tour, several items, including bottles of Oregano, Italian Seasoning, and Old Bay, were found unlabeled regarding their opening and discard dates. Additionally, unlabeled cheese, a meat patty, a bag of meat, and an opened scrambled egg carton were identified. The Dietary Team Lead acknowledged that labeling might have been missed. A dishwasher temperature log was found with missing entries, and wet bowls were improperly stored upright, preventing proper drainage. Further observations revealed ongoing issues with food labeling and storage. On a subsequent visit, a refrigerator on the second floor contained an open pudding container and other resident food items that were unlabeled and undated. The process for labeling food was unclear among staff, as indicated by the responses from a Unit Secretary and a Registered Nurse. During a kitchen revisit, a container of egg salad was found past its labeled expiration date, and jars of mayonnaise and mustard were without labels or dates, indicating continued non-compliance with food safety standards.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards, as evidenced by deficiencies found in the records of two residents. For one resident, the surveyor discovered incomplete documentation related to a COVID-19 test. The paper medical record contained a point-of-care COVID antigen test result that was positive, but the form lacked a date indicating when the test was performed. This incomplete documentation was brought to the attention of the Director of Nursing. Another deficiency was identified in the medical records of a second resident, where the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form was incomplete. Although the first page of the MOLST form was filled out, signed, and dated with a Do Not Intubate (DNI) code status, the second page was incomplete. Additionally, there was a discrepancy in the resident's electronic medical record, which showed a care plan with a code status of Do Not Resuscitate, Intubate (DNR A-1), conflicting with the physician's order of DNI A-2. This inconsistency was confirmed by the Assistant Director of Nursing.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain infection prevention practices, as evidenced by several observations. In one instance, a resident's foley catheter drainage bag was observed lying on the floor, which could increase the risk of infection. Despite being informed by a Geriatric Nursing Assistant (GNA) that the clip was broken, the Licensed Practical Nurse (LPN) did not address the issue promptly, leaving the bag on the floor for approximately an hour. This delay in response was acknowledged by the Director of Nursing (DON) during a review of the concern. Another deficiency was noted when a Registered Nurse was observed changing a resident's Peripherally Inserted Central Catheter (PICC) dressing. The dressing was labeled with a date that did not match the documented change date in the Medication Administration Record (MAR). The DON confirmed that the dressing had not been changed as documented, due to the resident being at therapy, and acknowledged that the documentation was completed prior to the actual dressing change. Additionally, a GNA was observed handling soiled linen without gloves and subsequently touching a clean linen cart without sanitizing hands, which was later acknowledged by the GNA as a lapse in infection control practice.
What surveyors are citing around you — mapped
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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 2,350 citations issued within 25 miles in the last 12 months — including the 12 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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Elkridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Residences At Vantage Point | 5.4 mi | ★★★★★ | 17 | 0 |
| St. Joseph's Nursing Home | 5.9 mi | ★★★★★ | 17 | 0 |
| Lorien Health Systems - Columbia | 6.1 mi | ★★★★★ | 37 | 0 |
| Autumn Lake Healthcare At Summit Park | 6.5 mi | ★★★★★ | 26 | 0 |
| Autumn Lake Healthcare At Catonsville | 7 mi | ★★★★★ | 41 | 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.