Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Moran Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow its Legionella remediation plan and local health department guidance after positive water testing in resident rooms. Staff reported that resident room showers were not to be used and were not routinely flushed, but surveyors found several showers still operational and flushing logs were incomplete. The IP stated residents with respiratory symptoms were not tested for Legionella unless they had a pneumonia diagnosis, despite guidance for enhanced surveillance. Surveyors also found no designated handwashing sinks in the soiled laundry rooms, improper use of the utility sink for multiple tasks, and a damaged hopper labeled out of order.
Kitchen Food Service Equipment and Surface Sanitation Deficiencies: During the annual survey kitchen tour, the surveyor and CDM observed missing cove base tiles, unclean food carts, hot plate warmers, and dish tray racks, and damaged drywall under the dish machine with dirt, dust, and food spills. The high-temp conveyor dish machine had steam and vapor escaping, with mold-like buildup on nearby walls and caulked edges, while the kitchen was warm and humid with stagnant air and unclean wall-mounted fans. The walk-in cooler floor panels and thresh board plates were also lifted and warped, creating gaps with debris buildup.
A resident with aphasia and use of a communication board had activated the call light when an NA entered the room without knocking, announcing herself, or asking permission, even though the door was open. The NA said she did not knock because the door was open and noted she should have announced herself. Records showed the resident was alert and oriented and usually understood by others.
A cognitively intact resident with severely impaired vision and a need for help with transfers and toileting was verbally abused by a CNA during toileting care. Staff overheard the CNA shouting, using foul language, and slamming the bathroom door while the resident called for help. The resident later reported being told, "F you," and said the incident left him/her tearful, anxious, and concerned about safety.
Incomplete Documentation for PRN Compounded Psychotropic Medication: A resident with schizophrenia, MDD, aphasia, and post-CVA deficits received a PRN compounded topical psychotropic medication for agitation, but the order lacked dosage details, non-pharmacological interventions, and monitoring parameters. eMAR and nursing notes showed multiple administrations without documented nursing assessments, attempted non-pharmacological measures, or follow-up on effectiveness/adverse effects, and the NHA and DON acknowledged the documentation concerns.
Failure to Provide Scheduled Showers: A resident who required staff assistance with ADLs did not receive the scheduled number of showers. The resident was observed in a room with a strong urine-like odor and stated receiving only one shower per week, while the MDS and unit shower schedule showed 2 showers per week were expected. Shower documentation showed repeated missed showers over several months, and staff stated refusals should have been documented, but no documentation confirmed the resident received all scheduled showers or refused them.
Failure to Document and Report Resident Bruising: Staff failed to accurately complete skin assessments and document significant bruising for a resident who was observed with a left elbow bruise and reported being hurt during care and transfers. The resident’s private duty assistant provided a photo of marked ecchymosis and stated the resident was frequently bruised during bathing and repositioning, yet weekly and daily skin assessments documented no bruising. The DON confirmed there was no record supporting that staff identified or recorded the elbow injury.
Failure to complete annual GNA evaluations and required training: Record review showed that two GNAs had performance evaluations that were more than one year old, and one GNA had not completed required abuse, QAPI, or compliance training for over a year. HR stated that training was assigned from corporate classes and that the DON was responsible for evaluations, while the NHA confirmed awareness that one GNA was behind on annual evaluations and training.
The facility failed to ensure provider documentation supported pharmacist MRR responses for two residents. One resident had a pharmacist recommendation to stop an antiulcer medication and omega-3 fish oil, but the attending provider’s notes did not show review of the MRR or a rationale for declining it. Another resident with dementia and anxiety had psychotropic meds including Buspirone, Depakote, Rexulti, and Trazodone; the chart lacked a documented clinical rationale for continuing the regimen without GDR, despite pharmacy requests and provider declination of changes.
Unlabeled medications were found in a med cart drawer, including a cup of about 5 meds identified by an LPN as belonging to a resident who had refused them, and two additional cups with opened capsule shells and a brownish liquid were discarded. The MAR showed conflicting documentation for the resident's med pass and refused oral meds. Surveyors also found multiple OTC meds stored in an unlocked cabinet in the ADON's office, with the office door unlocked and the cabinet able to be opened without a key.
Failure to Maintain QAPI Oversight for Water Management and Legionella Mitigation: The facility did not effectively incorporate its Legionella concerns into QAPI, and staff gave inconsistent accounts of water flushing and documentation practices. Maintenance and EVS staff reported incomplete or unclear flushing logs, no comprehensive list of active or shut-off showers, and inconsistent flushing of resident room showers, while surveyors observed showers in varying conditions and residents said they used hallway bathing rooms instead of room showers. The IP also stated the facility only tested residents diagnosed with pneumonia for Legionella, despite guidance to test residents with respiratory illness symptoms.
Improper Airflow in Soiled Laundry Rooms: During the annual survey, a strong odor was noted in the soiled laundry rooms because the mechanically operated ventilation systems serving the two soiled laundry rooms did not have negative pressure airflow. On a follow-up tour, a window in one soiled laundry room was open to provide air circulation, and the Maintenance Director stated the roof exhaust fans would be reassessed.
Incomplete GNA Annual Training and Performance Evaluations: The facility failed to ensure that two GNAs had current annual performance evaluations and received required annual education. One GNA completed only 9.5 hours of training in the past year, and both GNAs lacked training assignments based on performance needs because their evaluations were overdue. Interviews confirmed the facility knew one GNA was behind on required courses and annual training.
A resident with diabetes, total incontinence, a colostomy, and risk for recurrent UTIs received incontinence care that did not follow facility policy or infection control standards. A GNA performed perineal care while repeatedly touching dirty linen, furniture, and clean linens with the same gloves, used wet towels taken from a trash bin to clean the genital area, placed used towels on clean surfaces, and continued care between the buttocks and down the legs without changing gloves. The GNA also applied prescription zinc cream and then touched room surfaces with contaminated gloves, removed PPE and exited without hand hygiene, and later re-entered, donned gloves, and washed the resident’s face without first washing hands, despite expectations from the LPN nurse manager and DON that staff follow proper front-to-back wiping, glove changes, hand hygiene, and enhanced barrier precautions.
The facility failed to follow infection prevention and control practices during incontinence care, medication administration, and catheterization. A resident with incontinence and a colostomy received perineal care from a GNA who used the same gloves for dirty and clean tasks, handled clean linens and environmental surfaces with contaminated gloves, reused wet towels taken from the trash on the genital area, placed used towels on clean surfaces, and left and re-entered the room without performing hand hygiene. Another resident with multiple chronic conditions received 11 medications from an LPN who did not perform hand hygiene before room entry, before donning gloves, between tasks, or after glove removal; when a glove tore during insulin preparation, the LPN continued with one bare hand and administered the insulin injection without subsequent handwashing. A third resident with progressive MS, paraplegia, neurogenic bladder, and recurrent UTIs reported that an RN performing straight catheterization poked near the anus while seeking the urethra, inserted the catheter into the vagina despite the resident’s objections, then into the urethra causing pain, pressed on the abdomen despite the resident’s discomfort, and later retrieved the catheter from the trash, all contrary to the facility’s stated expectations for sterile catheterization technique and infection control.
A resident with a history of drug abuse and multiple medical conditions was found unresponsive and tested positive for fentanyl, which was not prescribed. Despite this incident and documented history, the care plan was not updated to address substance abuse risks or the recent event, contrary to facility policy and staff acknowledgment.
Staff did not wear required gowns or consistently change gloves during incontinence care for a resident with a urinary catheter, despite facility policy and visible signage indicating Enhanced Barrier Precautions. Gloves were used to handle both soiled and clean items without proper hand hygiene, and staff expressed uncertainty about PPE requirements. Facility leadership confirmed the expectation for gown and glove use, but monitoring responsibilities were unclear.
A facility failed to maintain licensed nurse coverage during a night shift, as two agency LPNs left the building simultaneously to get food, leaving residents without supervision. This resulted in missed medication administration and left only GNAs to care for the residents. The incident was confirmed by geotracking data and interviews with staff and residents.
The facility failed to report abuse allegations within the required time frame for three residents. Incidents included a GNA forcefully pushing a resident, delayed reporting of an abuse incident by a resident with intact cognition, and rough handling by a GNA. Reports to the Office of Health Care Quality were made late, exceeding the mandated two-hour reporting requirement.
The facility failed to conduct thorough investigations of abuse allegations involving three residents. In one case, a GNA continued working after an abuse allegation was made, and there was no documentation of interviews with other residents. Another incident involved a GNA forcefully pushing a resident, with no interviews or abuse training conducted afterward. In a third case, investigation documentation lacked signatures and failed to document interviews with other residents.
The facility failed to ensure 24-hour supervision by licensed nursing staff and proper medication administration. A resident did not receive timely medication, and another was found deceased after not receiving necessary assessments and medications. Two agency LPNs left the facility unattended, resulting in missed medication passes. Additionally, a resident's blood sugar checks were not properly documented, indicating they were likely not performed.
The facility did not offer the current COVID-19 vaccine or document education or refusal for several residents, as confirmed by record review and staff interviews. Immunization records lacked evidence of vaccine offers, education, or refusals, and staff stated that the COVID-19 vaccine would be offered at the same time as the flu vaccine in the future.
A facility failed to protect residents from verbal and physical abuse by a GNA, as reported by multiple residents. One resident felt the GNA was rough and inattentive, while others described similar experiences, including rough handling and lack of attentiveness. The incident was reported, but the night shift LPN did not recognize it as abuse, highlighting a deficiency in resident care.
A resident's MDS assessment was inaccurately coded, failing to reflect a fall that occurred in February 2024. The RN Assessment Coordinator admitted to missing the fall during the assessment period review. The DON was informed of the error, highlighting a deficiency in the facility's assessment process.
A resident with a history of pressure ulcers and dementia, requiring two staff for bed mobility, was bathed by a single GNA, leading to a fall and injuries. Despite the care plan's requirements, the GNA routinely bathed the resident alone, and another GNA confirmed similar practices. The DON stated staff should follow the care plan and check the resident profile for assistance needs.
A facility failed to follow physician orders and lacked a comprehensive policy for chest tube care, resulting in undocumented drainage and site care for a resident. Interviews revealed reliance on a nursing manual without specific guidance, and the need for physician contact for site care orders was acknowledged.
Surveyors found a ceiling tile in a 3rd floor shower/bathroom covered with a black and fuzzy white substance, indicating a failure to maintain a clean and sanitary environment. The issue was confirmed by nursing and administrative staff, with conflicting reports about whether the tile had been replaced after a recent pipe repair. The Maintenance Director was not previously informed of the current condition.
The facility did not ensure that the walk-in refrigerator door in the kitchen would routinely close, as observed during multiple staff entries and exits. The Certified Dietary Manager confirmed the door had ongoing issues, requiring staff to monitor it closely and check temperatures more frequently. The deficiency was confirmed through direct observation and staff interviews.
Failure to Follow Legionella Controls and Infection Control Practices
Penalty
Summary
The facility failed to follow its Legionella corrective action plan and Maryland Department of Health guidance related to water management and resident surveillance. Resident room showers were reported by staff to be out of use because of water issues and safety concerns, yet surveyors found that multiple resident room showers were still operational. The Maintenance Director stated that showers were not routinely flushed, were only flushed if drains produced an odor, and initially said there was no official log documenting flushing. Later, logs were produced, but they were incomplete and did not identify dates, room numbers, staff, or daily flushing as required by the facility’s written remediation plan. Facility records showed positive hot water Legionella test results in two separate resident rooms, and the local health department directed the facility to complete remediation activities including flushing affected lines, replacing fixtures as needed, retesting, and daily flushing of room water lines. Additional guidance from the local health department directed enhanced surveillance for residents with respiratory symptoms, including evaluation for pneumonia, chest x-rays, immediate reporting of new pneumonia cases, Legionella diagnostic testing, and maintenance of respiratory illness line lists. The Infection Preventionist acknowledged that residents were only tested for Legionella after a confirmed pneumonia diagnosis and not when they presented with respiratory symptoms. Review of the respiratory illness line listing showed multiple residents with respiratory symptoms in March 2026, including shortness of breath, wheezing, runny nose, chills, and rhonchi, but only residents diagnosed with pneumonia were tested for Legionella. The facility also failed to maintain infection control practices during observations of laundry and utility areas. Surveyors found that neither of the two soiled laundry rooms had a designated handwashing sink. The only utility sink in the laundry machine room was being used as an eye washing station, a soaking station for soiled laundry, and a handwashing sink. In the third-floor soiled utility room, the hopper was visibly damaged and labeled out of order. During follow-up observation, the Infection Preventionist and Environmental Services Director acknowledged that designated handwashing sinks were required in the soiled laundry rooms, that PPE would be provided in those rooms, and that the nonfunctional hopper would be replaced.
Kitchen Food Service Equipment and Surface Sanitation Deficiencies
Penalty
Summary
Food service equipment and kitchen surfaces were not maintained in a sanitary condition during the annual survey kitchen tour. On 05/12/2026 at 9:25 AM, the surveyor toured the kitchen with the Certified Dietary Manager (CDM) and observed multiple cove base tiles missing throughout the kitchen areas, creating gaps and holes along the walls. Food carts, hot plate warmers, and dish tray rolling racks were unclean and heavily soiled with dust, dirt, debris, and accumulated food spills. The drywall underneath the dish machine, measuring about 24 inches by 36 inches, was in disrepair with significant chipping and peeling paint and had accumulated dirt, dust, and food spills. The surveyor also observed steam, vapor, and heat escaping from the high-temperature conveyor dish machine, with significant buildup of mold-like substances on the surrounding walls and caulked edges. The kitchen environment was warm and humid with stagnant air, and the canopy hood ventilation system and the local exhaust system in the designated wash-down area appeared insufficient. Wall-mounted fans were unclean with excessive buildup of dust, dirt, and debris. In addition, the stainless-steel floor panels and thresh board plates in the walk-in coolers were lifted, buckled, and warped, creating gaps for buildup of dust, dirt, and food spills. At 2:05 PM, a follow-up tour of the kitchen was conducted with the Maintenance Director and CDM to review the findings.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not knocking and requesting permission before entering the resident’s room. During an observation, the resident had activated the call light for help, and a nursing assistant entered the room while the surveyor was present without knocking, announcing herself, or asking permission to enter, even though the door was already open. The nursing assistant stated that she did not knock because the door was open and added that she should have announced herself even though the resident could not answer. Record review showed the resident was alert and oriented but had difficulty communicating due to a history of aphasia; the resident used a communication board and signs/gestures, made himself/herself understood, and was usually understood by others.
Resident subjected to verbal abuse during toileting assistance
Penalty
Summary
The facility failed to keep a cognitively intact resident free from abuse when a nursing assistant shouted at the resident, used foul language, and slammed the bathroom door while providing toileting assistance. The resident had severely impaired vision and required help with transfers and toileting. During the incident, the resident had activated the call light and was yelling for help, and the exchange was overheard by a nurse and a medicine aide. Facility investigation statements described the nursing assistant yelling that she had 30 other residents to care for, entering the resident’s room, and engaging in loud back-and-forth yelling with curse words heard by staff. The nurse and medicine aide both reported hearing a loud door slam and additional yelling. The resident later stated that the staff member told him/her, "F you," and that the resident was concerned about safety if the staff member returned to work. The incident was not reported to administration until several hours after it occurred. The facility investigation ultimately verified verbal abuse, and the resident was described as tearful and anxious after the event, stating that his/her feelings were hurt and that the resident spent time thinking about what happened. The report also noted that the alleged abuser remained in resident care until the end of the scheduled shift.
Incomplete Documentation for PRN Compounded Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving a PRN compounded psychotropic medication had adequate clinical documentation to support its administration, including evidence of non-pharmacological interventions before use, monitoring for effectiveness and adverse effects, and complete medication order information. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, paranoid schizophrenia, major depressive disorder, aphasia, psychomotor deficit following cerebral infarction, and a history of falls. The physician order for the compounded topical medication containing Ativan (lorazepam), Benadryl (diphenhydramine), and Haldol (haloperidol) to be applied to the palm side of the wrist twice daily as needed for increased agitation did not include documented dosages, non-pharmacological interventions to attempt before administration, or monitoring parameters for effectiveness or adverse effects. Review of the eMAR and nursing progress notes showed multiple administrations of the compounded psychotropic medication without supporting nursing documentation. On several occasions, the medication was given without documented nursing assessments, non-pharmacological interventions attempted prior to administration, or follow-up documentation of effectiveness. On 5/13/26, the eMAR reflected two administrations close together, with follow-up documentation entered later, but there were no nursing progress notes documenting the resident assessment, what prompted administration, whether any non-pharmacological interventions were attempted, clarification of the administration time discrepancy, or assessment of medication effectiveness. During interview, the Nursing Home Administrator and DON acknowledged concerns regarding the lack of documentation related to administration and monitoring of the compounded psychotropic medication.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident who required staff assistance with ADLs received the scheduled showers. Resident #20 was observed sitting in a chair by the bedside, and the room had a strong urine-like odor. During interview, the resident stated that he/she received only one shower per week. The MDS assessment indicated that the resident required staff assistance with showering, and the unit shower schedule showed the resident was scheduled for 2 showers per week, or 8 per month. Review of the nursing assistant's shower documentation showed that Resident #20 did not receive the scheduled number of showers over multiple months: 4 showers in March instead of 8, 7 showers in April instead of 9, and 1 shower by 5/12/26 instead of 3. A nursing assistant stated that refusals were expected to be documented and reported to nurses, and the unit manager stated that every resident was expected to receive 2 showers per week and that refusals were to be documented. The record review and interviews did not provide documentation confirming that Resident #20 received all scheduled showers or refused any.
Failure to Document and Report Resident Bruising
Penalty
Summary
The facility failed to ensure that skin assessments were completed accurately and that significant bruising was identified and documented for Resident #53, who was investigated for potential abuse. During an initial interview, the resident was observed with a bruise on the left elbow and stated that staff were rushed and often hurt them when they were moved. The resident’s private duty assistant showed a photograph of significant ecchymosis on the elbow and stated it was taken after an incident in which the resident was injured while a nurse and another GNA were providing care. The assistant also stated the resident was frequently bruised during bathing and repositioning. Record review showed that weekly skin assessments for April documented the resident’s skin as warm, dry, normal color, with no petechiae, normal turgor, and no skin alterations, with no documentation of bruising. The resident’s care plan directed staff to inspect skin during bathing and personal care, complete weekly wound observations, use draw sheets or similar devices for positioning and turning, apply a protective foam dressing to the left elbow, monitor and report changes in skin status, perform skin inspections every shift, and use caution during transfers and bed mobility. Despite these directions, the GNA daily skin assessments also failed to document the left elbow bruise. When interviewed, the NHA, DON, and RCD denied knowledge of the incident, and the DON confirmed there was no documentation supporting that staff identified or recorded the bruising on either daily or weekly skin assessments.
Failure to Complete Annual GNA Evaluations and Required Training
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received annual performance evaluations and the federally required 12 hours of annual education and in-service training. Record review showed that the most recent performance evaluation for GNA #17 was completed on 7/12/24 and the most recent performance evaluation for GNA #18 was completed on 10/9/24, with both evaluations more than one year old at the time of survey review. The deficiency was identified for 2 of 2 GNAs reviewed for annual performance evaluations. Further record review showed that GNA #18 had not completed abuse, QAPI, or compliance training for more than one year. Because a performance evaluation had not been completed, the GNA had not received training assignments based on identified performance needs. During interview, HR #19 stated she was responsible for assigning predetermined corporate classes and for sending reports to supervisors when staff were behind on training, and she showed an Education Station board listing staff completion percentages, including GNA #18 at 33.33% complete. HR #19 also stated the DON was responsible for performance evaluations and was unable to provide evidence that GNA #18 had completed QAPI training. The NHA confirmed awareness that GNA #18 was behind on required training and that the facility had identified it was behind on annual GNA performance evaluations.
Lack of Provider Documentation for Pharmacist Recommendations and Psychotropic GDR Rationale
Penalty
Summary
The facility failed to ensure that the attending provider documented review of the pharmacist’s monthly drug regimen review and the rationale for declining the pharmacist’s recommendations. For Resident #5, a pharmacy medication regimen review completed on 11/28/25 recommended discontinuing an antiulcer medication and an omega-3 fish oil medication, and the Physician/Director of Nursing response on the review stated “Decline.” Although the resident was seen by the attending physician on 12/7/25 and again on 12/15/25, neither note documented that the provider reviewed the pharmacist’s recommendations or explained why they were declined. The DON stated she received the MRR reports by email, typically reviewed them with attending providers by phone, and then documented the provider response herself, but the resident’s electronic medical record did not contain supporting documentation of provider review or rationale. For Resident #31, who had diagnoses including dementia and anxiety disorder, the medical record showed active orders for Buspirone HCl 7.5 mg, Depakote 125 mg, Rexulti 0.5 mg, and Trazodone 100 mg. Pharmacy consultant documentation dated 12/31/25 requested provider documentation regarding gradual dose reduction for these psychotropic medications, but the record only contained a provider declination stating “no changes at this time.” The chart lacked a documented clinical rationale supporting continuation of the psychotropic regimen without GDR, and psychiatric provider documentation dated 1/6/26, 3/12/26, and 5/11/26 also failed to show a rationale for continuing the medications without gradual dose reduction. The DON reviewed the documentation with the surveyor and acknowledged the lack of a documented rationale from the prescribing provider.
Unlabeled medications and unsecured OTC storage
Penalty
Summary
Medications were not labeled in accordance with accepted professional principles and were not all stored in locked compartments. During observation of the 3rd floor medication storage room, two cups were found sitting on top of the medication cart, one containing opened capsule shells and the other containing a brownish liquid identified by the nurse as med pass nutritional supplement; both cups were discarded. After the medication cart was unlocked, a medicine cup containing about 5 medications was found in the top drawer with no label identifying the medications or the resident they were for. The nurse stated the medications were for Resident #20, who had refused them, and then discarded them. The MAR for Resident #20 showed the nurse documented med pass as administered at 9:00 AM and also documented at 9:57 AM that the resident refused seven oral medications due at 9:00 AM. Medication storage was also found unsecured outside the medication cart. Documentation provided by the facility indicated medications were stored in a nursing supply room on the first floor, but the corporate nurse and NHA were not aware of this. Observation of the ADON's office on the 3rd floor showed the office door was unlocked and a metal cabinet containing multiple OTC medications was not secured with a key; the latch could be opened by hand and the cabinet was opened without a key. The cabinet contained aspirin, Senna, liquid iron, Pepcid, cough drops, milk of magnesia, and suppositories. The facility list also showed more than 20 residents on the 3rd floor had a diagnosis of dementia.
Failure to Maintain QAPI Oversight for Water Management and Legionella Mitigation
Penalty
Summary
The facility failed to implement and maintain an effective QAPI program for its water management and Legionella mitigation processes. Surveyors found that the facility had prior Legionella concerns, but the issue had not been formally incorporated into the QAPI program before the annual recertification survey. Staff #11, the Regional Director of Clinical Operations, stated that the Legionella concerns should have been addressed through QAPI, but could not confirm or provide evidence that this had occurred. Interviews with maintenance, environmental services, housekeeping, infection prevention, and administrative staff showed inconsistent and incomplete water management practices. Staff #14 stated that maintenance requests were primarily verbal, only limited staff used the electronic tracking system, routine shower flushing was not consistently performed or documented, and no routine flushing log was maintained for resident room showers. Staff #14 also stated that showers in resident rooms were generally not utilized, some showers containing stored resident belongings would not be flushed, and there was no comprehensive log identifying which showers were active or shut off. Staff #15 was uncertain about water flushing logs, while Staff #16 stated that staff were expected to run water in rooms daily for approximately 10 minutes and that logs were submitted monthly, although not all resident room showers were flushed and some showers were non-functional. Surveyors observed inconsistent conditions in resident room showers, including some showers running, others off, and dust accumulation on fixtures, and residents stated they received showers in hallway bathing rooms rather than in their resident rooms. The Infection Preventionist stated that the facility only tested residents diagnosed with pneumonia for Legionella, despite guidance directing testing of residents with respiratory illness symptoms. The NHA and DON confirmed concerns with water management and Legionella mitigation, and the facility had not implemented a formal testing protocol or an ongoing data collection process for respiratory illness surveillance or Legionella mitigation efforts before the survey.
Improper Airflow in Soiled Laundry Rooms
Penalty
Summary
The facility failed to ensure proper airflow in the soiled laundry rooms. During the annual survey, a tour of the clean and soiled laundry rooms was conducted with the Healthcare Services Group Environmental Services Director, and a strong odor was noted in the soiled laundry rooms because the mechanically operated ventilation systems serving the two soiled laundry rooms did not have negative pressure airflow. During a follow-up tour with the Maintenance Director, a window in one of the soiled laundry rooms was observed open to provide air circulation. The Maintenance Director stated that the roof exhaust fans would be reassessed to ensure proper airflow from the mechanically operated ventilation systems.
Incomplete GNA Annual Training and Performance Evaluations
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received education based on annual performance evaluations and failed to ensure that GNAs received the federally required 12 hours of annual education and in-service training. Record review showed that GNA #17’s most recent performance evaluation was completed on 7/12/24 and GNA #18’s most recent performance evaluation was completed on 10/9/24, and both evaluations were more than one year old at the time of review. Because annual performance evaluations had not been completed, the GNAs had not received training assignments based on identified performance needs. The surveyor also reviewed GNA #18’s education record and found that only 9.5 hours of training had been completed over the past year. During interview, the Human Resources and Payroll Associate stated that staff are assigned classes predetermined by corporate and that reports are sent to supervisors when staff are behind on training, with delinquent staff posted on an Education Station bulletin board. The bulletin board showed GNA #18 at 33.33% completion of required courses, and the HR associate confirmed that GNA #18 was behind on annual training. The Nursing Home Administrator also confirmed awareness that GNA #18 was behind on required training and that the facility had identified it was behind on annual GNA performance evaluations.
Failure to Provide Clean and Safe Incontinence Care and Follow Infection Control Practices
Penalty
Summary
The deficiency involves failure to provide clean and safe incontinence and perineal care in accordance with facility policy and infection control practices for one resident. Facility policy required staff to perform hand hygiene, gather necessary supplies before care, use gloves and other PPE per standard precautions, and clean the perineal area from front to back using clean sections of the washcloth, followed by rinsing and drying. The resident involved had type 2 diabetes, needed help with personal care, was always incontinent, had a colostomy, and was at risk for repeated urinary tract infections. The care plan documented scheduled bathing and that the resident required substantial to maximal assistance with perineal hygiene. During an observed incontinence care episode, a GNA touched the bedside table, resident’s blanket, dirty linen, closet handles, and clean linen without changing gloves. The GNA handled clean towels, clean sheets, and the faucet with the same gloves used for dirty items and was unsure whether the resident remained on enhanced barrier precautions, despite the resident being on such precautions due to a colostomy. The GNA used wet towels removed from the trash bin to clean the resident’s genital area and placed used towels on clean surfaces, including a clean sheet next to the resident. The GNA continued wiping between the buttocks and washing the thighs and knees without changing gloves, and after applying prescription zinc cream, touched the bedside table with contaminated gloves. The GNA then removed gloves and gown, discarded them, left the room without performing hand hygiene, and later re-entered the room, donned gloves, and washed the resident’s face without prior handwashing. Interviews with the nurse manager and DON confirmed that staff were expected to know and follow proper incontinence care steps, including front-to-back wiping, glove changes between dirty and clean tasks, hand hygiene, and adherence to clean-to-dirty procedures.
Failure to Follow Infection Control Practices During Incontinence Care, Medication Administration, and Catheterization
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control practices, including hand hygiene, glove use, separation of clean and dirty items, safe medication administration, and safe catheterization technique. For a resident with type 2 diabetes, incontinence, a colostomy, and a history of recurrent UTIs, a GNA provided incontinence care without changing gloves between dirty and clean tasks and without maintaining separation between contaminated and clean surfaces. During a partial bed bath, the GNA touched the bedside table, resident’s blanket, dirty linen, closet handles, and clean linen with the same pair of gloves. The GNA handled clean towels, clean sheets, and the faucet with gloves that had already been used on dirty items, and used wet towels taken from the trash bin to clean the resident’s genital area, then placed used towels on clean surfaces, including a clean sheet next to the resident. After applying prescription zinc cream, the GNA touched the bedside table with contaminated gloves, then removed gloves and gown, discarded them, and exited the room without performing hand hygiene, later re-entering the room and donning gloves without prior handwashing to wash the resident’s face. For another resident with spinal stenosis, bilateral lower-extremity weakness, vertigo, muscle weakness, neuropathy, and a bone disorder, an LPN failed to perform hand hygiene during medication administration. The LPN did not sanitize hands before entering the room or before donning gloves and administered 11 medications without performing hand hygiene between tasks. While preparing and administering insulin, the LPN’s right glove ripped, and the LPN continued the procedure with only the left hand gloved. Using a bare hand, the LPN wiped the injection site with alcohol and administered the insulin injection, then did not wash or sanitize hands after removing the remaining glove. These actions were inconsistent with the facility’s hand hygiene policy, which required handwashing or sanitizing before resident contact, before donning gloves, after glove removal, and after contact with potentially contaminated items. For a resident with active progressive multiple sclerosis, paraplegia, a history of recurrent UTIs, neurogenic bladder, and complete urinary incontinence, the facility’s practices around straight catheterization raised infection control and procedural concerns. Documentation showed repeated catheterizations for urine samples and a resident report that fecal matter was seen on the tip of a catheter used for urine collection. In a grievance and related complaint, the resident reported that during a straight catheterization, an RN touched the wrong area and poked near the anus while trying to locate the urethral opening, inserted the catheter into the vagina despite the resident shouting that it was the wrong place, then inserted the catheter into the urinary tract, causing pain. The resident also reported that the RN pressed on the abdomen to obtain more urine despite the resident stating it hurt, and that the catheter came out and the procedure was ended. The resident, who was alert and oriented with a BIMS score of 15, consistently described these events to facility staff. The DON acknowledged that catheterization is a sterile procedure and that the expectation was to keep the procedure as clean and sterile as possible with clean gloves and careful technique, and also acknowledged awareness that the RN later returned to the resident’s room to retrieve the catheter from the trash, which was not consistent with the DON’s expectations for handling the procedure and related supplies. Interviews with facility leadership and the infection preventionist confirmed that staff were expected to follow specific infection control practices that were not observed in these cases. The nurse manager stated that staff were expected to wipe front-to-back, change gloves between dirty and clean tasks, wash hands, and gather all supplies before starting care, and confirmed that the resident with a colostomy was on enhanced barrier precautions. The infection preventionist described prior in-services on perineal care, hand sanitizing, working from outer to inner areas, changing gloves after dirty care and between new briefs, and performing hand hygiene before and after glove use, as well as expectations for hand hygiene during medication passes. The DON stated that catheterization was a sterile procedure and that the facility expected clean gloves and careful technique. Despite these stated expectations and policies, the observed care and documented events for the three residents showed failures to adhere to infection prevention and control practices during incontinence care, medication administration, and catheterization.
Failure to Revise Care Plan After Resident Drug Abuse Incident
Penalty
Summary
The facility failed to revise the care plan for a resident with a known history of drug abuse after an incident in which the resident was found unresponsive and tested positive for fentanyl, a medication not prescribed to them. The resident had multiple medical diagnoses, including hemiplegia, hepatic encephalopathy, dysphagia, aphasia, and vascular dementia, and was assessed as having moderate cognitive impairment and short-term memory problems. Despite documentation in the resident's medical records and emergency room notes indicating a history of drug abuse and a previous overdose, the care plan was not updated to reflect these significant risk factors or the recent incident involving fentanyl. Interviews with facility staff, including the MDS Coordinator, ADON, and DON, confirmed that the resident's care plan was not revised to address the history of drug abuse or the fentanyl incident. The facility's own policy required the interdisciplinary team to review and revise care plans after each assessment and when a resident's clinical status or condition changes. However, the care plan review conducted after the incident did not include any updates related to the resident's substance abuse history or the unresponsive episode, despite clear evidence and staff acknowledgment that these issues should have been addressed.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinence Care
Penalty
Summary
Staff failed to follow the facility's infection prevention and control program by not donning all required personal protective equipment (PPE) and not adhering to hand hygiene protocols during incontinence care for a resident with an indwelling urinary catheter. Facility policy required Enhanced Barrier Precautions (EBP), including the use of gloves and gowns, for residents with catheters during high-contact care activities. Despite visible signage and available gowns outside the resident's room, staff only donned gloves and did not wear gowns while providing care. During the observed care, two staff members assisted the resident, who had a history of infection and required assistance with personal care. Both staff members performed incontinence care without changing gloves between dirty and clean tasks, and handled personal items and clean clothing with soiled gloves. Hand hygiene was not performed at appropriate intervals, and gloves were only changed after multiple care steps had been completed. The staff members acknowledged during interviews that they should have worn gowns and changed gloves more frequently, but cited uncertainty and nervousness as reasons for their actions. Interviews with facility leadership, including the QA/Infection Prevention Nurse, ADON, DON, and Administrator, confirmed that the expectation was for staff to wear gowns and gloves for residents on EBP and to change gloves when soiled or before handling clean items. Monitoring of staff compliance was described as a responsibility of the QA/IP Nurse and nursing leadership, but there was uncertainty about who specifically monitored incontinence care. The deficiency was identified through direct observation, interviews, and review of facility policy.
Lack of Licensed Nurse Coverage During Night Shift
Penalty
Summary
The facility failed to ensure licensed nurse coverage was present throughout the entire night shift on February 21, 2025. This deficiency was identified during a survey following a complaint from a resident who felt unsafe due to the absence of licensed nurses. The resident reported that agency staff left the building unattended to get food, resulting in missed medication administration. The staffing schedule confirmed that two agency LPNs were the only licensed nurses on duty that night, and both left the facility simultaneously, leaving the residents and GNAs without supervision. Interviews and record reviews revealed that the agency LPNs left the facility for approximately 1-2 hours during their shift, which was corroborated by geotracking data. The absence of licensed nurses during this time meant that the facility's residents were left without proper supervision and care, as only four GNAs were present. The facility administrator confirmed the incident, acknowledging that the LPNs took an excessively long break and left the facility without a designated charge nurse in place.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse within the mandated time frame for three residents. In the first case, a Geriatric Nursing Assistant (GNA) was observed forcefully pushing a resident into a wheelchair, witnessed by the facility social worker. The incident occurred in the dining room and was reported to the Office of Health Care Quality more than four hours later, which was acknowledged as a deficiency by the Nursing Home Administrator (NHA). In the second case, a resident with intact cognition reported an abuse incident to a GNA, which was then communicated to the NHA. However, the initial report to the State Agency was delayed, being sent over nine hours after the incident was first reported to the facility staff. In the third case, a resident's representative informed a nurse about an abuse allegation involving rough handling by a GNA. The nurse notified the Director of Nursing and the NHA, but the report to the Office of HealthCare Quality was not made until the following day, exceeding the two-hour reporting requirement. The facility's policy requires immediate reporting, but the surveyor found that the staff did not adhere to this policy, resulting in late reporting of the abuse allegations.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to ensure thorough investigations of abuse allegations for three residents. In the first case, a resident's representative reported that a Geriatric Nursing Assistant (GNA) was rough and slapped the resident's hand. Despite the facility's policy to suspend the accused staff during investigations, the GNA continued to work until the following day. Additionally, there was no documentation of interviews with other residents or the representative to verify the allegation. In the second case, a GNA was observed forcefully pushing a resident into a wheelchair. The facility's investigation did not include interviews with other residents who were present during the incident, nor did it assess if other residents had experienced similar abuse. Furthermore, there was no evidence of abuse training provided to staff following the incident. The third case involved a resident who confirmed an abuse incident that occurred previously. The investigation documentation lacked signatures from interviewed residents and the staff conducting the interviews. The Director of Nursing and the Nursing Home Administrator were unsure if other residents were interviewed, and the Registered Nurse responsible for the documentation admitted to failing to document interviews with other residents assigned to the alleged perpetrator.
Failure in Supervision and Medication Administration
Penalty
Summary
The facility staff failed to ensure 24-hour supervision by licensed nursing staff and proper medication administration for residents. Resident #68, admitted for alcohol dependence and other health issues, had medications administered late by an agency LPN. Similarly, Resident #409, admitted for potential hospice care, did not receive necessary assessments and medications, including morphine for pain management. The resident was found unresponsive and later pronounced deceased. It was reported that agency LPNs left the facility unattended during their shift, leaving residents without proper care and supervision. An anonymous complaint and interviews revealed that two agency LPNs left the facility during their shift to purchase food, leaving the facility without licensed nursing coverage. This resulted in missed medication passes and lack of supervision for the residents. The facility's staffing schedule confirmed the absence of licensed nurses during this period, and the DON and NHA acknowledged the incident. The facility did not report the incident to the state agency or the Maryland Board of Nursing, and no investigation was conducted to verify the events with the GNAs present that night. Additionally, Resident #8, who had been residing in the facility since 2022 and required insulin for diabetes management, had an order for weekly blood sugar checks that were not properly documented. The eMAR indicated that the checks were marked as done, but no actual blood sugar values were recorded. Interviews with the LPN assigned to the resident and the DON confirmed the lack of documentation, indicating that the blood sugar checks were likely not performed as ordered.
Failure to Offer or Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to offer the current COVID-19 vaccination or provide documentation of vaccine education or refusal for four out of five residents reviewed for immunization status. Medical record reviews on 3/04/25 revealed no evidence that these residents had been offered or educated about the current COVID-19 vaccine, nor was there documentation of any refusals. During interviews, the Infection Preventionist confirmed that these residents had not received the COVID vaccine, had not been educated about it, and that there was no documentation of refusal. The Infection Preventionist also stated that the facility planned to offer the COVID vaccine alongside the flu vaccine in the fall. The administrator confirmed this plan and did not provide further documentation prior to the end of the survey.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a vulnerable resident from verbal and physical abuse, as evidenced by an incident involving a resident and a GNA. The incident occurred when the resident reported feeling that the GNA was rough during care and not attentive to their needs. The day shift nurse reported the allegation to the administrator, prompting an investigation. However, the night shift LPN did not report the incident as abuse, as the resident only described the GNA as 'rude.' Interviews conducted with other residents revealed similar concerns about the GNA's behavior, including rough handling and lack of attentiveness. Multiple residents reported negative experiences with the same GNA, including one who felt the GNA was not listening and insisted on actions despite the resident's pain. Another resident mentioned the GNA's inattentiveness while on the phone, and others described the GNA as rough and argumentative. These accounts indicate a pattern of behavior that compromised the residents' dignity and safety, leading to the deficiency noted in the survey.
Inaccurate MDS Assessment Coding for Resident Fall
Penalty
Summary
The facility failed to ensure comprehensive assessments were coded accurately for a resident who had been residing in the facility since 2022. The deficiency was identified during a review of the resident's medical records and interviews. The resident experienced an unwitnessed fall resulting in a fracture, which was reported in October 2024. However, during a subsequent review of the Minimum Data Set (MDS) assessment conducted with an Assessment Reference Date (ARD) of March 5, 2024, it was found that the resident was incorrectly coded as having no falls since the last assessment. This error was confirmed by the Registered Nurse Assessment Coordinator, who acknowledged missing the fall that occurred on February 15, 2024. The Registered Nurse Assessment Coordinator admitted to the oversight during an interview and indicated that the period reviewed for the MDS assessment was between March 5, 2024, and the day after the ARD of the previous assessment, December 8, 2023. The Director of Nursing was informed of the error, acknowledging the concern regarding the inaccurate coding of the MDS assessment. The failure to accurately code the resident's fall history in the MDS assessment highlights a deficiency in the facility's assessment process, impacting the accuracy of resident care planning decisions.
Inadequate Supervision During Resident Care
Penalty
Summary
Facility staff failed to provide adequate supervision for a resident during care, leading to an accident. The resident, identified as having a potential for skin breakdown and a history of pressure ulcers, was care planned for self-care deficit and falls related to dementia. The care plan specified the need for two staff members to assist with bed mobility. However, a review of documentation revealed that on most days, only one geriatric nursing assistant (GNA) was involved in bathing the resident. On a specific occasion, a GNA was bathing the resident alone when the resident slid from the bed, resulting in bruising and an abrasion. The GNA admitted to routinely bathing the resident without assistance, despite having access to the resident's care plan, which indicated the need for two staff members. Another GNA also reported occasionally bathing the resident alone, noting that the resident's ability to assist varied. The Director of Nursing confirmed that staff were expected to follow the care plan and check the resident profile for the required level of assistance before providing care.
Deficiency in Chest Tube Care Documentation and Policy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring chest tube management, as evidenced by the lack of adherence to physician orders and absence of a comprehensive policy for chest tube care. Specifically, the facility did not document the drainage of the resident's chest tube on two occasions, despite having physician orders to do so every other day and as needed. Additionally, there was no documentation of care provided to the chest tube insertion site, and the facility lacked specific orders or a policy to guide such care. Interviews with the Director of Nursing and the Regional Nurse revealed that the facility relied on a nursing manual for procedures, but there was no specific guidance or physician order for the care of the chest tube site. The Regional Nurse acknowledged that the facility nurse should have contacted the physician for specific site care orders. The Nursing Home Administrator and the DON confirmed the deficiency, acknowledging the absence of documentation and specific policies for chest tube site care.
Failure to Maintain Clean and Sanitary Shower/Bathroom Environment
Penalty
Summary
A deficiency was identified when surveyors observed that a ceiling tile in stall #1 of the 3rd floor shower/bathroom was discolored and covered with a black and fuzzy white substance, indicating a lack of cleanliness and sanitation. The observation was made in the presence of a nurse, the NHA, and the DON, all of whom confirmed the condition of the tile. The NHA stated that there had been recent repairs for a leaking pipe in the same stall and suggested the tile may not have been replaced after the repair. However, the Maintenance Director later reported that the tile had been replaced following the repair and that the current issue with the black and fuzzy white substance had not been reported to him by staff. No additional information was provided by the facility prior to the end of the survey. The deficiency was limited to one of two combination shower/bathrooms observed during the survey, and no specific residents or their medical conditions were mentioned in relation to the incident.
Failure to Maintain Walk-In Refrigerator Door in Kitchen
Penalty
Summary
The facility failed to maintain essential kitchen equipment by not ensuring that the walk-in refrigerator door would routinely close. During a kitchen tour, the surveyor observed that the refrigerator door was not fully closed and noted a sign reminding staff to ensure the door closed completely. The Certified Dietary Manager (CDM) confirmed that the door had ongoing issues with closing, despite previous attempts to fix it. Staff were required to monitor the door closely and check refrigerator temperatures more frequently due to this problem. The surveyor, accompanied by the CDM, observed the door failing to close on its own in multiple attempts. Further observations showed that the door did not close behind staff members entering or exiting the refrigerator. The CDM acknowledged the persistent issue and stated that staff needed to push the door forcefully to ensure it closed. The problem had been ongoing for some time, and the CDM confirmed the deficiency during interviews and direct observation with the surveyor. The issue was also discussed with the Nursing Home Administrator and the Director of Nursing.
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 288 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 Westernport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Keyser Healthcare Center | 5.7 mi | ★★★★★ | 19 | 1 |
| Egle Nursing Home | 5.8 mi | ★★★★★ | 31 | 0 |
| Frostburg Rehab Center | 12.5 mi | ★★★★★ | 0 | 0 |
| Mountain City Rehab Center | 12.8 mi | ★★★★★ | 33 | 0 |
| Complete Care At Dawnview Llc | 14.6 mi | ★★★★★ | 11 | 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 August 2026) and official state health department websites.