Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Maryland Baptist Aged Home during CMS and state inspections, most recent first.
Surveyors identified that staff failed to properly label, date, and track expiration of food items, with several expired or unlabeled products found in kitchen storage areas. Additionally, staff did not consistently maintain the required concentration of Quaternary Ammonium Compounds (QACs) for dish sanitization, with logs showing levels below the manufacturer-recommended range and staff unaware of the correct standards.
The facility did not have an RN on duty for 24 hours on multiple weekends and holidays, as confirmed by staffing records and the Administrator, who stated that RN coverage could not be secured for these periods.
A facility-wide assessment was found to be inaccurate, with errors in reported admission numbers, incomplete information on the facility's ability to care for residents with infectious diseases, and missing details about care for residents with tracheostomies and assistance with showers. The DON and Administrator confirmed inaccuracies and lack of staff competency verification for specialized care.
The facility's leadership failed to ensure effective oversight and implementation of the QAPI program. The QAPI plan lacked a systematic approach for identifying and analyzing problems, and the governing body did not provide adequate oversight. The DON confirmed the absence of governing body involvement, and the CFO was unaware of key issues identified by the QAPI committee, such as staff lacking CPR certification.
Facility staff did not ensure that call devices were installed in shower areas and that strings were attached to call systems in toilet stalls. Observations revealed that both the long and short hall bathrooms lacked call devices in the shower areas, and several toilet stalls were missing the necessary strings for the call systems.
Two residents were not provided with showers or opportunities to get out of bed, despite expressing a desire for these choices. Documentation in the EMR was lacking, and staff confirmed there was no way to record showers, resulting in the residents remaining in bed and not receiving showers since admission.
Staff did not provide a copy of the Notice of Medicare Non-Coverage to a resident's representative before discharge. The form lacked the representative's signature, and there was no verification that the notice was mailed or received, as confirmed by the social worker.
A resident with multiple psychiatric and behavioral diagnoses was administered several psychotropic medications without proper documentation of behavioral and mood monitoring, as required by their care plan. Staff were unable to provide the necessary monitoring records, and a pharmacy consultant's recommendation for a gradual dose reduction of one medication was not addressed. This resulted in a deficiency related to the justification and monitoring of psychotropic medication use.
Staff did not provide a resident's representative with written notification of the reasons for hospital transfers, nor did they supply a copy of the bed-hold policy at the time of hospitalization. Documentation showed only telephone notification, and staff confirmed the bed-hold policy was only given at admission.
A resident was admitted to hospice, representing a significant change in condition, but the required MDS assessment was not completed within the mandated 14-day period. The assessment was started late and remained incomplete beyond the required timeframe, as confirmed by the MDS Coordinator.
Staff did not complete and transmit a resident's MDS assessment within the required 14-day window due to delays in completing specific assessment sections. The MDS Coordinator reported that the DON and Administrator were not made aware of the issue.
Staff did not complete a narcotic count when an RN assumed control of the nursing assignment, as shown by discrepancies in the Controlled Drug Count Verification form and inability of the DON to verify completion. This resulted in a failure to meet professional standards for controlled substance management.
A resident with a left-hand contracture and hemiplegia did not receive the prescribed hand splint as outlined in the care plan, and there was no documentation of supportive device use or recent occupational therapy evaluation, despite ongoing limitations in range of motion.
Staff did not consistently provide activities to two bedbound residents who could not participate in group activities. One resident reported that in-room activities ceased after a staff member left, and activity logs showed no recent sessions for either resident. The Activities Director could not explain the lack of regular activities.
Surveyors found that medications and biologicals were not properly labeled or dated after opening, and expired medications were not removed from medication carts. Examples included undated eye drops, Nystatin powder, Duoderm gel, and blood glucose strips, as well as an expired tube of Nystatin cream, with staff confirming these deficiencies.
A resident with hemiplegia and a left-hand contracture did not receive a required Occupational Therapy evaluation or ongoing interventions after a previous course of therapy ended. The care plan called for supportive devices and splints, but no such interventions were documented or observed, and the resident reported ongoing difficulty with hand movement.
Facility staff did not have an effective system to identify, report, track, investigate, or analyze adverse events, as shown by the lack of documentation and data in the QAPI plan. The DON confirmed that while the team met monthly and discussed staffing concerns, there was no evidence of monitoring or analysis. Additionally, the facility could not provide records regarding the discovery or resolution of issues such as incomplete CPR certification among nursing staff.
Facility staff did not include the Infection Preventionist in QAPI meetings as required, with sign-in sheets lacking their name or signature and no documentation of attendance by phone. The IP could not recall their last participation, and the DON was made aware of the attendance requirement.
The facility did not maintain an adequate emergency water supply and lacked oversight of its internal water system, including failure to test for Legionella and other pathogens. Staff were unaware of their responsibilities regarding water testing and emergency preparedness, and the available water supply was significantly below recommended levels for residents and staff.
Facility staff did not apply for a required waiver for rooms that were less than the minimum square footage, despite being aware of the deficiency. When asked, the DON indicated a waiver existed, but documentation review revealed that no such waiver was available for the undersized rooms. The Administrator stated they were told not to apply for a waiver unless requested by surveyors, resulting in noncompliance.
Deficient Food Labeling and Dish Sanitization Practices Identified
Penalty
Summary
The facility failed to maintain proper labeling, dating, and expiration practices for food items, as well as to ensure correct sanitization procedures in the kitchen. During a kitchen tour, staff were unable to identify correct expiration dates on several food items, including a box of hot sauce with conflicting dates and cereal dispensers with unclear labeling. Expired spices were found, and staff could not consistently identify or date items in the freezer, with some frozen goods and a container of potato salad lacking proper labeling. Unlabeled bags of spreadable butter were also found in a freezer, and staff acknowledged the need for improved labeling practices. Additionally, the facility did not consistently meet the manufacturer-recommended range for Quaternary Ammonium Compounds (QACs) used for dish sanitization. Staff were unsure of the correct QAC concentration range, and logs showed readings below the required 200-400 ppm, with staff not recognizing that 100 ppm was insufficient for proper sanitization. These deficiencies were identified during the initial kitchen visit of the annual recertification survey.
Failure to Provide 24-Hour RN Coverage
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for 24 hours a day over a period of seven consecutive days, as evidenced by staff interviews and review of the PBJ Staffing Data Report. The report identified specific dates on which there were no RNs present for the full 24-hour period, including multiple Saturdays, Sundays, and a holiday. The Administrator confirmed during an interview that there was no RN coverage on these dates, citing an inability to secure RN staff for weekends and holidays, either from facility staff or agency sources. Additionally, review of two weeks of staffing schedules showed a consistent lack of RN coverage on weekends.
Inaccurate Facility Assessment Documentation
Penalty
Summary
A facility-wide assessment failed to accurately reflect the services provided, as discovered during a recertification survey. The assessment incorrectly documented an average of 10 resident admissions during the weekday and did not include the facility's capacity to admit residents with infectious diseases such as COVID-19, MRSA, or Clostridium Difficile. Additionally, the section regarding care for residents with conditions not listed was incomplete, and while the assessment stated the facility could care for residents with a tracheostomy, there were no current residents with this condition. The assessment also omitted showers as a form of assistance provided for activities of daily living. During interviews, the DON acknowledged that it had been some time since nurses participated in a skills lab, and there were no competencies to verify staff training for tracheostomy or gastrostomy tube care. The Administrator confirmed that the reported average of 10 admissions per week was an error.
Failure of Governing Body to Oversee and Implement Effective QAPI Program
Penalty
Summary
The facility's governing body and executive leadership failed to ensure that the Quality Assurance Performance Improvement (QAPI) program effectively identified and prioritized problems related to organizational processes, functions, and services provided to residents. During the recertification survey, it was found that the QAPI plan lacked a systematic approach for identifying, tracking, investigating, and analyzing data. The Director of Nursing (DON) confirmed that there was no oversight of the QAPI processes by the governing body. Additionally, the Administrator stated that the Chief Financial Officer (CFO) provided oversight, but could not confirm the CFO's participation or input in QAPI meetings. Further interviews revealed that the CFO was only kept informed about the QAPI process by the Administrator and DON and occasionally attended morning calls. The CFO was unable to provide details about the most recent QAPI meeting and had not reviewed the QAPI documentation. When asked about specific issues identified by the QAPI committee, such as nursing staff lacking CPR certification, the CFO was unaware of these findings. These actions and inactions demonstrate a lack of effective oversight and engagement by the facility's leadership in the QAPI process.
Missing Call Devices and Strings in Resident Bathrooms and Shower Areas
Penalty
Summary
Facility staff failed to ensure that a functioning call system was available in each resident's bathroom and bathing area. During an annual survey, it was observed that the bathroom on the long hall did not have a call device in the shower area, and the call device in the toilet stall was missing its string. Additionally, the shared bathroom on the short hall was found to be without a call device in the shower area, and two out of three toilet stalls lacked strings attached to the call devices. These deficiencies were confirmed during both the initial and subsequent tours of the facility with facility leadership.
Failure to Support Resident Choice for Showers and Mobility
Penalty
Summary
Facility staff failed to honor and facilitate resident self-determination by not providing opportunities for residents to receive showers or get out of bed, as evidenced by observations and interviews with two residents. One resident reported not getting out of bed despite wanting to, and it was observed that the only available chair in the room was used by the roommate. Both residents were observed in bed over a two-day period, and one resident confirmed not having had a shower since admission in October 2023. A review of the electronic health records and shower schedules revealed no documentation verifying that either resident had received a shower. The scheduled care indicated complete bed baths for both residents on specific days and shifts, but there was no place in the electronic medical record for staff to document showers. Staff confirmed the lack of documentation options, and the Director of Nursing was made aware of the situation, with both residents verifying the lack of showers and opportunities to get out of bed.
Failure to Provide Notice of Medicare Non-Coverage Prior to Discharge
Penalty
Summary
Facility staff failed to provide a copy of the Notice of Medicare Non-Coverage (NOMNC) to a resident's representative prior to the resident's discharge. During the recertification survey, it was found that the NOMNC form for the resident was dated and included a typed note stating that the responsible party was notified by telephone, but there was no signature from the representative to confirm receipt. Additionally, although an envelope addressed to the responsible party was presented, staff could not verify when the letter was mailed or if it was actually received. The social worker confirmed that the facility had not received a signed copy from the responsible party.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications administered to a resident were necessary and justified, as staff did not complete required behavioral and mood monitoring documentation for the conditions these medications were prescribed to treat. A resident with diagnoses including Paranoid Schizophrenia, Major Depressive Disorder, unspecified anxiety disorder, and dementia with behavioral disturbance was receiving multiple psychotropic medications, such as Quetiapine, Valproic acid, Trazodone, and Lorazepam. There was no documented indication for Quetiapine in the physician's order, and no behavior and mood monitoring documentation was found in the resident's medical record, despite care plan interventions requiring behavior monitoring every shift and documentation of behaviors and interventions. During interviews, the DON stated that behavior monitoring was done on paper and kept in the medication administration binder, but staff were unable to produce the behavior monitoring flowsheet when requested, providing only the Treatment Administration Record instead. Additionally, a pharmacy consultant had recommended a gradual dose reduction of Trazodone, but there was no documentation that this recommendation was addressed by the psychiatry provider. These findings indicate a lack of proper documentation and follow-through regarding the use and monitoring of psychotropic medications for the resident.
Failure to Provide Written Notification and Bed-Hold Policy During Resident Hospitalization
Penalty
Summary
Facility staff failed to provide written notification to a resident's representative regarding the reasons for the resident's transfers to the hospital, as required. Medical record review showed that while telephone notifications were documented for two separate hospitalizations, there was no evidence of written communication explaining the reasons for these transfers. Additionally, the facility did not provide a copy of the bed-hold policy to the resident's representative at the time of hospitalization, as confirmed by staff interviews, with the policy only being given upon admission. These deficiencies were identified during a recertification survey through review of both electronic and paper medical records, as well as staff interviews, and were specific to one resident whose records were examined for transfer and discharge practices.
Failure to Complete Timely MDS Assessment After Significant Change
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment within 14 days following a significant change in a resident's condition. Specifically, a resident was admitted to hospice services, which constitutes a significant change requiring an updated MDS assessment. Record review showed that the MDS significant change assessment was initiated ten days after the resident's admission to hospice but remained incomplete more than three weeks after the significant change occurred. During a phone interview, the MDS Coordinator confirmed both the resident's admission to hospice and that the significant change assessment was still in process well past the required timeframe. The Coordinator acknowledged that the MDS assessment should have been updated within 14 days of the significant change, and that the electronic records had not been updated in a timely manner. Facility leadership and relevant staff were informed of these findings during the exit conference.
Failure to Complete and Transmit MDS Assessment Within Required Timeframe
Penalty
Summary
Facility staff failed to complete and transmit a Minimum Data Set (MDS) assessment for one resident within the required 14-day timeframe. Record review showed that the assessment reference date was 04/05/25, but the assessment was not signed until 04/25/25, which exceeded the allowed window for completion and transmission. During an interview, the MDS Coordinator explained that the delay occurred because staff responsible for completing Section E and Section Q did not do so in a timely manner. The MDS Coordinator also stated that neither the Director of Nursing nor the Administrator were informed about the difficulties in obtaining timely completion from staff.
Failure to Complete Narcotic Count During Shift Change
Penalty
Summary
Facility staff failed to complete a narcotic count when a registered nurse assumed control over the nursing assignment, as evidenced by a review of the Controlled Drug Count Verification form. On multiple shifts, the signatures of incoming and outgoing nurses did not match, and it could not be verified that the narcotic count was completed when a different nurse took over the shift. During an interview, the Director of Nursing was unable to confirm that the narcotic count was performed when a nurse assumed control of the assignment, indicating a lapse in following professional standards of practice for controlled substance accountability. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Failure to Apply Prescribed Hand Splint for Resident with Contracture
Penalty
Summary
Facility staff failed to ensure the use of a hand splint for a resident with a left-hand contracture and hemiplegia, as specified in the resident's care plan. The care plan, which was last revised in October 2024, required staff to assist with the application of supportive devices, including splints, and to perform skin checks every shift. However, during multiple observations, the resident was seen without a splint or any supportive device on the affected hand, and there was no documentation of such interventions in the Treatment Administration Record (TAR). Additionally, the resident had not received any occupational therapy screening or evaluation since August 2024, despite ongoing limitations in range of motion as documented in the Minimum Data Set (MDS) assessment. The lack of follow-up therapy and absence of the prescribed supportive device indicate that the facility did not implement the care plan interventions intended to maintain the resident's ability to perform activities of daily living.
Failure to Provide Activities to Bedbound Residents
Penalty
Summary
Facility staff failed to consistently provide activities to residents who were unable to participate in communal activities, as evidenced by record review and interviews. Two residents who were bedbound did not receive regular in-room activities; one resident reported that a staff member previously provided activities in their room, but this stopped when the staff member left. Activity logs for both residents showed no documented activity sessions for several weeks prior to the survey. The Activities Director was unable to explain why these residents were not receiving regular activities.
Improper Medication Labeling and Storage
Penalty
Summary
Surveyors identified that medications and biologicals were not properly labeled or dated once opened, and expired medications were not removed from medication carts. During observation, two eye drop medications for one resident and another eye drop for a second resident were found opened without dates on one medication cart. On another cart, two bottles of Nystatin powder and two tubes of Duoderm Hydroactive gel for a resident were also found without labels or dates. Additionally, a canister of blood glucose strips was found without an opening date. Further review revealed an expired tube of Nystatin cream for another resident still present in the medication cart. These findings were confirmed by staff present during the observations.
Failure to Provide Required Occupational Therapy Evaluation and Interventions
Penalty
Summary
A deficiency was identified when a resident with hemiplegia affecting the left non-dominant side and a left-hand contracture did not receive an Occupational Therapy (OT) evaluation as required. The resident was previously seen by OT from April to August of the prior year for activities of daily living and fall risk, but there was no documentation of any further OT screening or evaluation after that period. The Minimum Data Set (MDS) quarterly assessment indicated a limitation in the range of motion of the upper and lower extremity on one side, and the care plan included interventions such as the use of supportive devices and splints for the left hand contracture. Despite these documented needs, there was no evidence in the medical record or Treatment Administration Record (TAR) of ongoing treatment or intervention for the contracture after August of the previous year. Observations confirmed that the resident was not using a splint or any supportive device on the affected hand, and the resident reported being unable to completely open the hand. The lack of follow-up OT evaluation and absence of prescribed interventions contributed to the facility's failure to provide specialized rehabilitative services as required.
Failure to Implement Effective QAPI System for Adverse Event Monitoring
Penalty
Summary
Facility staff failed to implement an effective system for identifying, reporting, tracking, investigating, and analyzing adverse events, as determined during a recertification survey. The QAPI plan was found to lack a systematic approach for problem identification and data analysis. During interviews, the DON stated that the QAPI team met monthly and focused on staffing concerns, but could not provide documentation or data to demonstrate monitoring or analysis of staffing issues. Additionally, when asked about the process for addressing the lack of CPR certification among nursing staff, the facility was unable to provide documentation regarding when the issue was discovered, how it was being monitored, or what actions were taken to address it. Requested data and records were not available for review in the QAPI documentation.
Infection Preventionist Not Documented as Attending QAPI Meetings
Penalty
Summary
Facility staff failed to include the Infection Preventionist (IP) in the Quality Assurance Performance Improvement (QAPI) meetings as required. Record review of QAPI meeting sign-in sheets for several dates showed that the IP's name or signature was not present. During a telephone interview, the IP confirmed not attending the meetings in person but stated they participated via telephone, although there was no documentation of their attendance either in person or by phone. When asked, the IP could not recall the last time they participated in a meeting. The Director of Nursing was informed of the requirement for the IP to attend QAPI meetings and acknowledged understanding of this requirement.
Failure to Maintain Emergency Water Supply and Water System Oversight
Penalty
Summary
The facility failed to maintain an adequate infection prevention and control program by not ensuring an appropriate emergency water supply and by lacking knowledge and oversight of the building's water system. During interviews, the Director of Maintenance was unaware that the facility was responsible for testing the internal water system for Legionella and other waterborne pathogens, stating that no such testing had been conducted during his two-year tenure. Additionally, he reported that aerators in residents' rooms had not been changed and that plumbing maintenance was only performed in response to emergencies, not as part of routine preventive measures. Observation in the basement revealed only 11 five-gallon containers of water and 4 empty containers, which was significantly below the recommended emergency water supply of one gallon per person per day for three days, given the facility's capacity of 29 residents and 10 staff per day. The Director of Maintenance confirmed that the emergency water supply was used for daily operations and that recent deliveries from the contracted water supplier were insufficient. Staff were unaware of the required emergency water supply amount, and no documentation or diagrams of the water system were available.
Failure to Obtain Waiver for Undersized Resident Rooms
Penalty
Summary
Facility staff failed to apply for a required waiver for resident rooms that were less than the minimum square footage mandated by regulations. During the annual survey, the surveyor inquired about existing waivers at the entrance conference, and the DON stated that a waiver existed for undersized rooms. However, upon review of documentation, it was found that certain rooms did not meet the required square footage, and no waiver was available for these rooms. The Administrator explained that they were instructed not to apply for a waiver unless specifically requested by the survey team, resulting in the waiver not being available prior to the survey and leading to noncompliance.
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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.
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Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fayette Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 23 | 1 |
| Future Care Irvington | 1.6 mi | ★★★★★ | 23 | 0 |
| Carroll Park Healthcare | 1.7 mi | — | 19 | 0 |
| Future Care Sandtown-winchester | 1.8 mi | ★★★★★ | 2 | 0 |
| St. Elizabeth Rehabilitation & Nursing Center | 2 mi | ★★★★★ | 35 | 0 |
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