Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northwest Healthcare Center during CMS and state inspections, most recent first.
A resident who was ending skilled therapy and nursing services did not receive a signed NOMNC showing that the resident or representative was notified that Medicare-covered services were ending. Surveyors found a notice indicating therapy services were to end, but there were no signatures confirming receipt, and staff confirmed there was no evidence the required 48-hour notice was provided.
A resident bathroom shared by 4 residents was observed with standing water in the sink, a broken faucet knob, a hole in the wall, and a cobweb with a spider on the ceiling. Staff confirmed the sink had not been draining for days and that the condition was known to the facility, while the Maintenance Director later acknowledged no TELS tickets had been entered for the sink, tiles, or wall hole before the surveyor's observation.
A resident with a BIMS of 15 did not have a signed admission agreement in the chart after admission. The Admissions Director could not provide proof that the agreement had ever been signed or offered, and the facility policy required admission paperwork to be completed within 48 hours.
Failure to provide ordered and routine dental services affected three residents. One resident had a physician referral for severe periodontal disease with broken and eroded tooth roots, but the facility could not initially produce dental follow-up records and later provided only routine in-facility exams. Another resident reported never seeing a dentist despite an order for consults as needed and a care plan noting oral/dental problems, and a third resident with broken and missing teeth had no documented dental evaluation or routine dental services since admission; the DON confirmed no annual oral health assessment or routine dental services for that resident.
Opened, unlabeled bags of french fries and chicken tenders were found in the freezer during an initial kitchen observation. The Culinary Director stated the items should have been labeled, and the concern was later reviewed with the DON.
Failure to Schedule Ordered Outside Follow-Up Services: A resident needed a nuclear medicine renal scan and a urology follow-up, but the facility did not show that the ordered imaging or urology appointment were scheduled for months. Staff could not find documentation of the appointments being arranged, and only one refusal for radiology testing was available; there was no documented refusal for the urology visit.
Missing Required Staff Training: Record review showed that two GNA staff members lacked documented dementia management training and resident abuse prevention training, and both had less than the required 12 hours of annual training. The DON stated that these trainings were expected to have been completed.
The facility failed to adhere to professional standards for food safety and storage, affecting 83 residents. Observations revealed staff not wearing hair or beard nets, undated and improperly stored food items, and cleanliness issues in the kitchen, including mildew and dirt buildup. The Healthcare Services Group District Manager confirmed the need for cleaning and adherence to food safety policies.
A resident and an Activities Director were attacked by another resident, but the facility failed to notify the resident's representative. The AD intervened during the assault and informed the former Administrator, who did not consider the incident serious. There was no documentation in the resident's medical record, and it is unclear if the responsible party was informed.
The facility failed to provide written discharge notices to two residents and their representatives. One resident was sent to the hospital after an assault, and another was transferred to a dementia unit without a 30-day notice. Staff confirmed that notifications were typically given verbally.
A facility failed to develop a comprehensive care plan for a resident with a history of substance use disorder. The care plan lacked necessary interventions for over two weeks after the resident's admission, despite documented history. The Executive Director admitted the oversight during an interview.
The facility failed to update care plans for three residents after significant events or assessments. A resident received Narcan for an opioid overdose, but no substance use prevention interventions were added to the care plan. Another resident's care plan was not reviewed within the required timeframe after an MDS assessment. Additionally, a resident's behavior care plan was not revised following an assault on another resident.
A facility failed to implement an effective discharge planning process for a resident, lacking documentation of ongoing planning, resident goals, and intervention evaluations. The Social Services Director initiated contact with a Medicaid waiver program, but follow-up documentation was missing, and no formal discharge care plan was developed.
The facility failed to document provider discharge summaries for two residents after their discharge. Both residents were transferred to a local hospital for psychiatric evaluation and did not return to the facility. The Executive Director admitted that the discharge summaries were not entered into the residents' medical records.
The facility failed to maintain complete medical records by not filing X-Ray reports in a resident's record and not documenting an assault incident involving a resident and the Activity Director. Additionally, the facility lacked a system to secure investigative records, as evidenced by the inability to locate an investigation report for a reported incident.
The facility failed to ensure that two residents had advance directives or were provided with written information about their rights to accept or refuse medical treatment and to formulate an advance directive. The Social Services Director confirmed the absence of documentation and information provision, violating the facility's policy.
The facility failed to protect residents from abuse, involving incidents where a resident was punched during an argument, two residents engaged in a physical altercation, and an employee verbally and physically abused a resident by positioning their wheelchair to face a wall. The residents involved had varying degrees of cognitive impairment and psychiatric diagnoses.
The facility failed to report incidents of injury of unknown origin and resident-to-resident abuse to the state agency in a timely manner. One resident with severe cognitive impairment had rib fractures, and another resident required Naloxone for suspected opioid overdose, but reports were delayed. Additionally, a resident-to-resident abuse incident was not documented or reported, and another resident's injury was reported four days late.
The facility failed to thoroughly investigate multiple allegations of abuse involving residents. Incidents included unexplained injuries, resident altercations, and staff abuse allegations, with insufficient documentation and lack of interviews with involved parties. The facility did not adhere to its policy requiring immediate reporting and investigation of such incidents.
A resident was transferred to the hospital after an assault without documented preparation and orientation for the transfer. The absence of documentation was confirmed by an LPN during an interview.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Medicare beneficiary with a written Notice of Medicare Non-Coverage for Resident #26 when skilled therapy and nursing services were ending. During review of Beneficiary Protection records, surveyors found that the facility had a document stating NOMNC therapy services were to end on 6/23/25, but the document did not contain any signatures from the resident or the resident representative showing that the notice had been received and understood. During an interview, the facility Social Worker stated that NOMNC notifications were part of her responsibilities, but she was not hired at the time the resident notification deadline occurred. She confirmed that residents are supposed to be notified 48 hours before the end of service date and stated that the previous social worker was supposed to provide and review the NOMNC with Resident #26 by 6/21/2025. She later confirmed there was no evidence that the resident or resident representative received the end of Medicare service notification. The Business Office Manager was also interviewed, and the administrator was made aware of the concern.
Failure to Maintain a Home-Like Resident Bathroom Environment
Penalty
Summary
The facility failed to provide a home-like environment in room [ROOM NUMBER] on the Terrace Unit. During observation, the bathroom sink shared by 4 residents was filled with water and was not draining, one faucet knob was broken, there was a hole in the bathroom wall, and a cobweb with a spider was observed on the bathroom ceiling. The condition of the room was documented as part of the annual survey, and the deficiency was identified in 1 of 3 rooms observed. Staff interviews confirmed the bathroom sink was not working and that the issue had been known to the facility for at least 2 days. Staff also acknowledged awareness of the cobweb and spider in the bathroom. A later interview with the Maintenance Director confirmed there had been a communication problem and that no TELS tickets had been placed for the bathroom sink, tiles, or hole in the wall before the surveyor's observations.
Missing Signed Admission Agreement
Penalty
Summary
The facility staff failed to obtain a signed admission agreement from Resident #12 upon admission. The resident was originally admitted with a BIMS score of 15, and a review of the medical record showed no documentation of a signed admission agreement in the chart. During an interview, the Admissions Director stated she was unable to provide proof that the resident had ever signed an admissions agreement. A follow-up interview with the Admissions Director confirmed that the resident should have had the admission paperwork completed within 48 hours of admission. A review of the facility’s admission policy stated that the resident is required to sign the admission agreement and that the Admissions Director, Manager on Duty, or designee meets with the resident or resident representative to complete and sign all admission paperwork within 48 hours of admission. The administrator later confirmed there was no documentation proving the resident had ever been offered an admission agreement.
Failure to Provide Ordered and Routine Dental Services
Penalty
Summary
The facility failed to provide dental services following a physician’s referral and failed to provide routine dental services for 3 residents reviewed for dental care. One resident had been admitted since 8/4/2023 and stated it had been a long time since seeing a dentist. The record showed a physician order on 9/27/2024 to refer the resident to a dentist for severe periodontal disease, with progress notes documenting severe periodontal disease, multiple small broken and eroded tooth roots in the maxilla with large surrounding periapical lucencies on CT scan, and a plan to refer to a dentist and start chlorhexidine rinse BID. When the surveyor requested dental records, the facility could not initially locate them, and the records later provided showed only in-facility dental exams in 2025, without proof of follow-up for the ordered referral. Another resident stated the dentist never showed up 3 or 4 months earlier and that they had never seen a dentist; the record showed admission on 12/4/2023, an order for dental consults as needed, and a care plan noting oral/dental problems and a history of poor oral hygiene. A third resident reported broken teeth and no dental services since admission, and the surveyor observed missing teeth. The record review for that resident failed to reveal any dental evaluation or routine dental services since admission. The facility’s dental policy stated it would assist residents in obtaining routine dental services, defined to include annual oral inspection, diagnosis of dental disease, cleaning, radiographs, and smoothing of broken teeth, but the DON stated that resident had not received an annual oral health assessment or routine dental services.
Unlabeled Opened Food Items Found in Freezer
Penalty
Summary
Food items were not stored in a manner that maintained the integrity of the products. During an initial observation of the kitchen upon facility entry on 01/13/2026 at 7:52 AM, surveyors found a bag of french fries and chicken tenders in the freezer that were opened and unlabeled. At that time, the Culinary Director acknowledged that the items should have been labeled. The concern was later reviewed with the DON on 01/21/2026 at 12:08 PM, and she indicated that she understood.
Failure to Schedule Ordered Outside Follow-Up Services
Penalty
Summary
The facility failed to follow up on physician-ordered outside services for one resident who needed a nuclear medicine renal scan and a urology appointment. Resident #47 reported that the kidney function test ordered in January 2025 was not completed until September 2025 and that the results were needed by the urologist. Record review showed multiple recommendations dated 2/25/25, 5/22/25, and 7/25/25 to schedule a nuclear medicine renal scan for renal function, and the 7/25/25 document also stated the resident must see a urologist. Facility staff were unable to provide evidence that the urology appointment had been scheduled or that the renal scan had been arranged for the earlier recommendations. The appointment scheduler stated nurses were supposed to submit follow-up forms so she could schedule appointments and transportation, but she could not find paperwork showing a urology appointment or imaging appointment had been set up for the months reviewed. The DON stated the resident had refused certain appointments, but the facility could provide only one refusal for radiology testing dated 9/3/2025 and no documentation of refusal for a urology appointment. Staff later confirmed the urology appointment was never scheduled and that there were no documented refusals for it.
Missing Required Staff Training
Penalty
Summary
The facility failed to ensure that all direct care staff received required dementia management training, resident abuse prevention training, and 12 hours of annual training. Record review showed that two Geriatric Nursing Assistants, Staff #7 and Staff #14, did not have documentation of completed dementia management training or resident abuse prevention training. The same record review also showed that Staff #7 had 7.10 hours of training and Staff #14 had 11.15 hours of training, which was less than the required 12 hours. During interview, the DON stated that these trainings were expected to have been completed, and the surveyor reviewed the concerns with her, after which she indicated that she understood the concerns.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage, preparation, distribution, and service in accordance with professional standards, potentially leading to food-borne illness among 83 residents. During observations, the Infection Preventionist was seen in the kitchen without a hair net, and a staff member with a beard was not wearing a beard net. Several food items, including applesauce, thickened apple juice, cream of wheat, and strawberry shakes, were found opened and undated, contrary to the facility's policy requiring dates for opened items. Additionally, the kitchen had cleanliness issues, such as black mildew behind the dishwasher, expired chlorine test strips, dirt buildup on the ice machine, and debris on the kitchen floor. Further observations revealed an opened and undated bag of cereal on the food preparation table and a dirty air conditioning unit blowing air onto kitchen utensils. The Healthcare Services Group District Manager confirmed the need for cleaning and acknowledged the responsibility of dietary staff for maintaining cleanliness. The facility's policy emphasized the importance of discarding unsafe foods and maintaining proper storage conditions, which were not adhered to, as evidenced by the observations of undated and improperly stored food items.
Failure to Notify Resident Representative of Assault
Penalty
Summary
The facility staff failed to notify a resident representative of a resident-to-resident assault involving Resident #20. The incident occurred on 11/3/21 when Resident #20 and a staff member, identified as the Activities Director (AD), were attacked by another resident. The AD recalled the incident, stating that the aggressor was hitting and kicking Resident #20, and when the AD intervened, they were also kicked. Despite informing the former Administrator, the incident was not deemed serious, and there was no documentation in Resident #20's medical record regarding the incident. The AD was unsure if the facility staff followed up with Resident #20's responsible party. This issue was later discussed with the Administrator and Mobile Director of Nursing (MDON).
Failure to Provide Written Discharge Notices
Penalty
Summary
The facility staff failed to provide written discharge or transfer notices to residents and their representatives, as required. In the case of one resident, after being assaulted by another resident, the individual was sent to the hospital for evaluation. Although the resident's guardian was notified of the incident by the Unit Manager, there was no evidence that a written discharge notice was provided to either the resident or their representative. Interviews with the Unit Manager and the Social Services Director confirmed that the facility typically notifies residents and their representatives verbally rather than in writing. In another instance, a resident was transferred to another facility with a dementia unit. The Social Work Director informed the resident's responsible party about the planned transfer, but there was no documentation of a 30-day involuntary notice of transfer being issued to the resident or their representative. The Social Work Director confirmed in an interview that neither the resident nor their responsible party received the required 30-day notice. These deficiencies were discussed with the facility's Administrator and Mobile Director of Nursing.
Failure to Develop Comprehensive Care Plan for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident with a history of substance use disorder. During an annual survey, it was found that the care plan for this resident did not include necessary interventions to prevent or assist with difficulties related to their substance use disorder. This deficiency was identified through a review of records, which showed that the resident had been admitted with a documented history of substance use disorder, yet the care plan lacked appropriate interventions for over two weeks after admission. The Executive Director of the facility acknowledged during an interview that the care plan was not fully developed to include interventions for the resident's substance use disorder. This oversight was noted for one of the fifty residents reviewed during the survey.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to review and revise resident care plans after each assessment or as resident care needs changed over time, affecting three residents. For Resident #911, the facility administered Narcan to reverse an opioid overdose on 5/2/23, but did not update the care plan to include interventions for substance use prevention. The Executive Director acknowledged this oversight during an interview. Resident #51's care plan was not reviewed and revised within 7 days after the Quarterly MDS assessment on 3/8/24, as required. The next care plan meeting was delayed until 6/4/24, just before the subsequent Quarterly MDS assessment. Additionally, Resident #14's care plan, which addressed behavioral issues, was not updated following a resident-to-resident assault on 6/15/23. The Administrator confirmed that the care plan was not evaluated or revised to address the aggressive behavior.
Deficiency in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, which was evident during a survey. The resident was admitted in September 2022, and the Social Services Director (SSD) initiated contact with the Medicaid waiver program in January 2023 to enroll the resident. However, there was no follow-up documentation regarding the callback from the waiver program. In March 2023, a waiver interview was conducted, and the application was sent to the waiver coordinator. By November 2023, the resident was on the waiver program waitlist, but there was no documentation of the updated status in the resident's record. The comprehensive care plan for the resident lacked a discharge planning component, and there was no documentation of an ongoing discharge planning process. This included the absence of the resident's goals, actions taken by staff to facilitate goal achievement, evaluation of intervention effectiveness, and updates on progress. During an interview, the SSD acknowledged that discharge planning was discussed at admission and quarterly care plan meetings but confirmed that a formal discharge care plan was not developed. Instead, progress notes were used to document ongoing discharge care planning needs.
Failure to Document Provider Discharge Summaries
Penalty
Summary
The facility failed to place a provider discharge summary on the medical records of two residents after their discharge. For one resident, the medical record review revealed no evidence of a provider discharge summary following their discharge from the facility after being transferred to a local hospital for psychiatric evaluation. The Executive Director confirmed that the resident did not return to the facility after receiving psychiatric treatment at the hospital and admitted that the facility failed to enter the discharge summary on the resident's medical record. Similarly, for another resident, the medical record review showed no evidence of a provider discharge summary after their discharge from the facility. This resident was also transferred to a local hospital for psychiatric evaluation and did not return to the facility after treatment. The Executive Director acknowledged the omission of the discharge summary in the resident's medical record.
Deficiencies in Medical Record Maintenance and Incident Documentation
Penalty
Summary
The facility staff failed to maintain complete and accurate medical records for a resident by not ensuring that X-Ray reports were filed in the medical record. Physician orders for repeat lumbar X-Rays were dated, but the reports were not found in the resident's record until the surveyor intervened. The Unit Manager LPN later provided copies of the reports, indicating that they should have been uploaded into the Electronic Medical Record (EMR) but were not. This oversight was only corrected after the surveyor requested the reports, highlighting a lapse in the facility's record-keeping procedures. Additionally, the facility failed to document an assault incident involving a resident and the Activity Director, who were both assaulted by another resident. There was no documentation in the assaulted resident's medical record regarding the event, including any assessment or interventions implemented by the facility staff. Furthermore, the facility lacked a system to ensure investigative records were secured, as evidenced by the inability to locate an investigation report for a facility-reported incident. The Administrator admitted that the investigation could not be found, which was a concern during the survey.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents had an advance directive in place or were provided with written information about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for two residents during a review of their electronic medical records (EMR). The facility's policy on advance directives, dated 03/27/24, mandates that upon admission, the facility should determine if a resident has an advance directive and provide information on how to formulate one if not. However, for Resident 61 and Resident 55, there was no documentation in their EMRs indicating that they had an advance directive or that they were given the necessary information to formulate one. During an interview, the Social Services Director confirmed that the residents did not have advance directives and that there was no documentation available to show that they were provided with written information regarding their rights. Additionally, there was no evidence of a signed Admission Package, which would have included information about advance directives. This lack of documentation and failure to provide necessary information to the residents or their representatives constitutes a violation of the facility's policy and the residents' rights.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal, mental, and physical abuse, affecting four of the 61 residents reviewed. In one incident, a resident with severe cognitive impairment attempted to intervene in an argument between two other residents and was punched in the nose by one of them. This resident was visibly upset and required hospital evaluation for a nosebleed. The resident who committed the act had a moderate cognitive impairment and a history of paranoid schizophrenia. In another incident, two residents with psychiatric diagnoses, including schizophrenia and PTSD, were involved in a physical altercation in the hallway. One resident, displaying agitation, shoved the other, who retaliated by shoving back. Both residents were separated, and no injuries were noted. The resident who initiated the altercation was severely impaired and had a history of generalized anxiety. Additionally, an employee was reported for verbally and physically abusing a resident by positioning the resident's wheelchair to face a wall as a form of punishment. This incident was witnessed by two LPNs, who reported that the GNA involved yelled at the resident and refused to explain their actions. The resident involved had a history of altered mental status and a very low cognitive score, indicating severe impairment.
Failure to Timely Report Incidents and Injuries
Penalty
Summary
The facility failed to report incidents of injury of unknown origin and resident-to-resident abuse to the state agency in a timely manner. For one resident, an injury of unknown origin was identified, but the initial incident report was not submitted to the state survey agency within the required two-hour timeframe. Additionally, the five-day report following the investigation was not submitted. This resident had severe cognitive impairment and was found to have rib fractures, which were identified through an x-ray after complaints of pain. Another resident, who was cognitively intact, experienced an altered mental status and required Naloxone for suspected opioid overdose. The initial investigation report was submitted late, and the facility could not provide documentation of the completed investigation being submitted to the state. Furthermore, a complaint involving a resident-to-resident abuse incident was not documented or reported to the state agency as required. The incident involved a resident and a staff member being attacked by another resident, but no documentation was found in the medical records. The facility also failed to report an injury of unknown origin for another resident within the required timeframe. The resident had discoloration to the left lower eye, but the report was submitted four days after the injury was identified. These deficiencies indicate a failure in the facility's reporting processes, as outlined in their policy, which requires timely reporting of incidents to federal, state, and local authorities.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility staff failed to thoroughly investigate allegations of abuse for several residents. In one instance, a resident was found with a large cut above the right eye, but the investigation did not attempt to rule out abuse or determine how the injury occurred. Another complaint involved a resident and a staff member being attacked by another resident, but there was no documentation of an investigation into the incident. Additionally, a resident was found with a black eye, but the investigation did not include interviews with staff or other residents to determine the cause of the injury. In another case, a resident reported being hit by another resident with a walking cane, but the investigation lacked interviews with the involved residents or witnesses. The final report stated the incident was substantiated, but there was no evidence of a thorough investigation. Furthermore, a staff member was alleged to have been verbally and physically abusive to a resident, but the facility could not provide documentation of an investigation into the allegation. The facility also failed to properly investigate an altercation between two residents, where one resident was shoved by another. The investigation did not include interviews with other residents or documentation of a PTSD evaluation for the resident displaying agitation. The facility's policy on abuse, neglect, and misappropriation requires immediate reporting and investigation of such incidents, but the facility did not adhere to these guidelines.
Failure to Prepare Resident for Safe Transfer
Penalty
Summary
The facility staff failed to ensure that a resident was adequately prepared and oriented for a safe and orderly transfer from the facility. This deficiency was identified during a survey review of 50 residents, specifically concerning one resident who was sent to the hospital for evaluation after being assaulted by another resident. The medical record review revealed a Social Services note indicating the transfer, but there was no documentation showing that the resident was prepared and oriented for the transfer. An interview with the Unit Manager, an LPN, confirmed the absence of such documentation, as she was unable to explain or find any record of preparation and orientation for the resident prior to the hospital transfer.
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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.
Illustrative
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Illustrative
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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) |
|---|---|---|---|---|
| Blue Point Healthcare Center | 0.7 mi | ★★★★★ | 27 | 0 |
| Levindale Hebrew Ger Ctr & Hsp | 0.8 mi | ★★★★★ | 11 | 1 |
| Autumn Lake Healthcare At Arlington West | 1 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Alice Manor | 1 mi | ★★★★★ | 1 | 0 |
| Roland Park Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 9 | 1 |
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