Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Orchard Hill Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to Follow Transfer Orders Resulted in Resident Fall and Ankle Fracture: A resident with an order for a Hoyer lift and 2-person assist, along with a care plan requiring total mechanical and 2-person transfers, was transferred alone by a GNA who did not check the Kardex. The resident’s leg became tangled with the wheelchair, the resident was dropped to the floor, and the resident sustained a broken ankle and was seen with a lower leg cast.
The facility failed to review and revise care plans at least quarterly for multiple residents, with several care plans last updated well beyond the required timeframe. For one resident, family reported inconsistent assistance with drinking, staff were observed helping with water, and an IV was ordered for hydration, but the care plan did not identify hydration as a focus or include interventions to maintain or restore hydration.
The facility failed to complete annual performance reviews for GNAs. Review of 5 of 5 GNA employee files showed no 2025 performance evaluations for the GNAs reviewed, despite the DON stating reviews were supposed to be yearly and stored with HR. The DON later said she had not conducted any GNA performance evaluations and could not find any performance reviews in the files.
Loose pills and capsules were found in all 4 med carts during a medication storage observation, with about 2 to 3 dozen loose meds per cart that had come out of pharmacy-issued bubble packs. The DON stated the facility did not have a specific policy for meds that came out of the bubble packs and noted that crowding in the carts appeared to be causing the meds to be accidentally pushed out.
PPE Not Stocked Near EBP Rooms: Surveyors observed EBP posters on multiple resident room doorways on two units, but hallway PPE dispensers on both stations had no gowns stocked and no PPE was observed inside the rooms. An LPN stated the overnight supervisor stocks empty dispensers during the night shift, and an RN stated gowns are expected to be stocked in the hallway dispensers. The DON was made aware of the concern.
The facility failed to ensure a resident or representative was informed of the risks and benefits before Lorazepam IM was started for breakthrough seizures. The provider ordered the medication as a precaution based on prior EEG findings, but there was no documented seizure diagnosis or seizure activity in the record. Although the provider said the resident had been informed, the consent documentation was dated after the order was written.
A resident had a PRN Lorazepam IM order for breakthrough seizures written for 6 months without a documented seizure diagnosis, evidence of seizure activity, or clinical justification for the extended duration. The ordering provider said it was a precaution based on prior EEG findings and part of a seizure protocol, but could not identify a supporting diagnosis, and the chart showed only monitoring for seizure activity rather than seizure precautions.
A resident with interstitial lung disease, COPD, pulmonary fibrosis, chronic respiratory failure, and dysphagia was admitted to hospice, later discharged from hospice, and then re-enrolled in hospice. The facility completed only one SCSA, and it did not complete a SCSA within 14 days of the hospice enrollment, hospice discontinuation, or later hospice re-enrollment; the MDS coordinator confirmed the missed assessments.
Late Transmission of MDS Discharge Assessments: The facility failed to transmit discharge MDS assessments for two residents within the required timeframe. Survey review found the assessments had been completed but not sent to the State, and the MDS validation report later confirmed they were transmitted only after surveyor inquiry, well beyond the 14-day limit.
MDS assessments were inaccurately coded for two residents. One resident had hospice services ordered and a documented Stage 3 sacral pressure ulcer, but the SCSA MDS did not code hospice care or an unhealed pressure injury. Another resident had a recent right AKA, yet the quarterly MDS incorrectly indicated no surgery within the past 100 days. The MDS coordinator and regional director acknowledged the errors.
The facility failed to keep care plans current for two residents. One resident returned after an AKA, but the care plan was not updated for the re-admission and still referenced a wound on the amputated leg instead of the amputation site. Another resident had a newly documented Stage 3 sacral PU, but the care plan was not started until about 10 weeks later. The DON stated that care plans should be updated when a wound is found.
A resident had a new sacral pressure injury identified as a Stage 3 ulcer, and the Wound NP documented treatment recommendations, but the first wound care order was not found until much later. The DON stated interventions should be put in place immediately for a resident with a pressure ulcer, and the facility policy states the physician authorizes wound treatment orders and helps identify wound management interventions.
Failure to provide ordered nutritional supplements: A resident with a physician order for Magic Cup and Health shakes TID for risk of malnutrition reported not receiving them as expected. Survey observations found the supplements missing from breakfast and lunch trays and meal tickets, while the MAR documented them as administered. An LPN stated the items were obtained from the kitchen at breakfast and acknowledged they were documented as given before the resident actually received them.
A resident developed a Stage 3 sacral pressure ulcer that was documented by nursing and the wound NP, but the resident’s primary MD and facility NP repeatedly failed to identify or assess the wound during multiple visits. The facility policy required the attending physician to evaluate and document wound healing, and the DON confirmed the concern. The NP stated she did not include the wound in her notes because the wound team was following it.
The facility failed to ensure the pharmacist completed an accurate monthly med regimen review for a resident. The EMR showed an order for lorazepam injection PRN for breakthrough seizures, but the resident had no documented seizure diagnosis or evidence of seizure activity. Monthly pharmacist reviews noted no irregularities, and Staff stated the order was part of a seizure protocol because the resident was on Keppra, but could not identify a supporting seizure diagnosis.
A resident had Lorazepam IM ordered PRN for breakthrough seizures and Keppra ordered for seizure, but the chart contained no documented seizure diagnosis or evidence of seizure activity to support either medication. The ordering provider said the Lorazepam was added as a precaution based on prior EEG findings and as part of a seizure protocol, yet no seizure precautions were in place and the Lorazepam order lacked a reassessment parameter.
Inaccurate dialysis orders and TAR documentation: A resident receiving HD had records that did not match the actual schedule. The nephrology note and dialysis communication binder showed T/Th/Sat HD, but the active order and TAR documented M/W/F, with no matching entries for the actual dialysis days. A later nurse note also showed the resident leaving for HD at 6:00 AM while the order still listed the wrong schedule.
The facility failed to ensure GNA education included dementia management training and that annual performance reviews were completed to identify needed in-service education. Review of employee files, education binders, and Relias transcripts for two GNAs found no 2025 performance reviews and no documented dementia training, and the DON confirmed the missing documentation.
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was transferred to the hospital. Although the DON reported interviewing nursing staff who had cared for the resident in the 72 hours before the transfer, the only documented interview and written statement was from the GNA who provided care on the morning of the transfer. No additional interview notes or statements from other staff who had cared for the resident during the prior shifts were found. The NHA confirmed that interviews from those previous shifts were missing and acknowledged that those staff should have been interviewed.
A resident who was unable to manage toileting independently repeatedly called out for help to be changed while two nurses, including the assigned nurse, were present outside the room. The assigned nurse told the resident they had just used the call bell and to wait, but the resident continued to call out, and a strong urine odor was noted from the room. The resident reported they had last been changed during the night and had not been changed by late morning, later stating they were finally changed about an hour after the initial observation. The DON was notified of these observations.
A resident on oxygen via nasal cannula was observed receiving 4 L/min despite a physician order for 2 L/min, and the humidification bottle and oxygen tubing lacked dates indicating when they were opened or applied. The prior day, the resident experienced respiratory distress and was found on a non-rebreather mask, diaphoretic and tachypneic, but the only record was a brief RT note with no further documentation of the event. An NP reported being called for low O2 saturation, placing the resident on a non-rebreather, and administering an Ipratropium breathing treatment for abnormal lung sounds, then admitted she had not documented this assessment, the respiratory episode, or the treatment in the medical record.
A resident did not receive a needed gynecology appointment after the attending MD requested an evaluation for symptoms and possible infection. The request was routed to a staff member responsible for arranging outside appointments and transportation, who was unable to schedule with the usual gynecologists because they would not accept the resident due to the large stretcher required. The staff member stated the resident’s daughter makes all appointments, but the daughter reported she was unaware of the need for a gynecology visit and said she could have obtained an appointment. The DON acknowledged she would look into the situation, but the MD was never informed that the appointment had not been made, and no alternative outside professional resource was secured.
The facility did not maintain adequate nursing staff, resulting in delayed or missed essential care such as cleaning, turning, showers, and therapy for multiple residents. Staff interviews described high resident-to-staff ratios, inability to complete required care tasks, and lack of management support. Documentation confirmed missed showers, delayed therapy, and medication errors due to staffing shortages.
Facility staff did not inform a resident's physician when BiPap therapy, ordered for a resident with a history of respiratory failure and hypercapnia, was not administered on multiple occasions. Despite the critical need for BiPap as noted in the hospital discharge summary and physician orders, there was no documentation or notification to the physician regarding the missed treatments, as confirmed by both the physician and the DON.
A resident with dementia and multiple contractures, fully dependent on staff for mobility, was found to have a displaced right hip fracture after complaining of foot pain and swelling. Although the injury was confirmed by x-ray, the facility did not report the incident to OHCQ within the required two-hour window, instead submitting the report two days later. The DON confirmed the delay in notification.
A resident who sustained a displaced right hip fracture and received opioid pain management was not accurately represented in the MDS assessment, as the fracture and opioid use were omitted from the relevant sections. This deficiency was confirmed through medical record review and staff interview during a complaint survey.
A resident admitted for rehabilitation did not have a baseline care plan reviewed or provided to their representative within 48 hours of admission. The required care plan, which should include initial goals, physician orders, therapy, dietary, and social services, as well as admission medications, was not documented as given or discussed with the representative. Both the DON and the resident confirmed the representative was not included in the care planning process as required.
A nurse failed to administer and accurately document multiple prescribed medications for a resident with end stage renal disease and intact cognition. The nurse, untrained on the medication cart and covering a shift alone, signed off on medications that were not given, which was later confirmed by another staff member and the resident.
Facility staff did not provide scheduled bathing assistance to two residents who were dependent or required partial help with ADLs. One resident did not receive any showers for over a month despite care plans and physician orders, while another missed multiple scheduled showers, with staff citing short staffing and questioning the need for assistance. The DON confirmed these deficiencies through documentation review.
Two residents did not receive care in accordance with physician orders and professional standards. One resident with end stage renal disease did not receive Midodrine at the prescribed time before dialysis, and another resident with dementia and multiple contractures had inadequate documentation and assessment following complaints of pain and swelling, despite physician orders for intervention. The DON confirmed these deficiencies.
A resident with multiple chronic conditions and pressure ulcers did not receive consistent wound care and monitoring, as evidenced by missing documentation of wound assessments and gaps in the Treatment Administration Record. The DON confirmed ongoing issues with documentation and continuity of care due to frequent turnover among wound care staff.
A medication cart was left unlocked and unattended by a nurse, allowing a surveyor to access medications including an opened sterile water vial without a date and multiple insulin pens that were either undated, had broken seals, or lacked resident identification. These actions failed to meet professional standards for medication labeling and storage.
The facility did not ensure complete and accurate medical records for two residents with complex wound care needs. For one resident, wound treatments were not signed off in the TAR on multiple occasions, despite being performed. For another, wound assessments and treatment documentation were missing or incomplete over several weeks, leaving gaps in the medical record.
Facility staff did not maintain accurate nurse staffing records, as schedules provided by the DON did not match actual staff attendance and assignments. Time punch reviews revealed daily discrepancies, with some staff incorrectly listed as working and others omitted. The HR Director confirmed the schedules were outdated and not properly updated due to changes in schedulers, resulting in inaccurate documentation of daily nurse staffing.
The facility was found to have several deficiencies in food storage, labeling, and dishwashing practices. Food items were not properly labeled or discarded, with some found expired and crusty. A juice line was on the floor, and the walk-in freezer had excessive ice accumulation. Cleaning chemicals were improperly stored near food items. The dishwashing machine failed to maintain required temperatures for sanitization, leading to the use of chemical sanitization as a backup. These issues were acknowledged by the Certified Dietary Manager.
The facility failed to maintain accurate records for the administration of Oxycodone for four residents, with discrepancies found between the controlled medication utilization records and the MAR. Staff interviews confirmed the requirement for documentation in both records, which was not adhered to.
The facility's kitchen steam table was found to be in disrepair, with two indicator lights inoperable and four knobs missing, compromising its safe operation. This issue was acknowledged by staff and discussed during the exit conference with the DON and Administrator.
A facility failed to provide a resident with information to formulate an advance directive and ensure its documentation in the medical record. Despite the resident having the capacity to make decisions, there was no record of an advance directive or any discussion about it. The facility's policy requires inquiry and documentation of advance directives, but the Social Services Director confirmed the absence of such documentation, leading to the deficiency.
A resident experienced a significant weight loss over 30 days, dropping from 164.0 lbs to 134.4 lbs, as flagged in the electronic medical record. However, the facility staff failed to notify the physician or resident representative of this change. Interviews with the ADON and Regional Dietician confirmed the lack of documentation and notification, despite acknowledging the necessity of informing the physician and resident representative.
A resident reported that the shower room in one unit lacked hot water, leading to infrequent showers. The Maintenance Director confirmed the water temperature was only 88.8°F, despite other units having adequate hot water. Previous maintenance logs showed similar issues, and although a vendor had repaired the water tank, the problem persisted. The Maintenance Director acknowledged the issue and contacted a plumber, but the deficiency remained unresolved.
A resident's funds were misappropriated by a GNA, who used the resident's bank account for personal transactions. The facility confirmed the misappropriation and terminated the GNA. However, the facility failed to report the incident to the Maryland Board of Nursing, as confirmed by the DON and other staff. This deficiency was noted during the facility's recertification and complaint survey.
A facility failed to implement its policies on abuse and misappropriation, as a GNA misappropriated funds from a resident's bank account. The facility verified the allegations and terminated the GNA, but did not investigate or report additional allegations from other residents. The facility also failed to report the incident to the Maryland Board of Nursing, leading to a deficiency.
A facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who enrolled and discontinued hospice care. Despite having two physician orders for hospice, no SCSAs were completed. The MDS Coordinator and DON confirmed the oversight, acknowledging an error in the resident's MDS documentation.
The facility failed to conduct timely care plan meetings for residents, resulting in care plans being based on outdated MDS assessments. This deficiency was identified for three residents, with care plan meetings either delayed or held before the MDS assessments. Facility staff acknowledged the discrepancies but did not provide evidence to dispute the findings.
A resident with a medical order for nectar thick liquids due to aspiration precautions was found with thin water in their room on multiple occasions. Despite clear directives in the resident's care plan and speech therapy recommendations, the facility failed to adhere to the prescribed diet, as confirmed by an LPN and acknowledged by the facility's nursing leadership.
The facility failed to monitor residents' smoking activities, leading to unsupervised smoking incidents. Residents accessed smoking materials outside scheduled times, and one resident handed a lit cigarette to another, violating the facility's smoking policy. The facility did not conduct immediate follow-up evaluations or update care plans after these incidents.
A resident experienced an 18% weight loss over a month, dropping from 164.0 lbs to 134.4 lbs, without adequate monitoring or intervention by the facility. Despite orders for weekly weight checks, weights were not obtained on two occasions, and the dietician was not notified of the significant weight change. The Regional Dietician confirmed no interventions were in place prior to surveyor intervention, and neither the physician nor the responsible party were informed.
A facility failed to monitor and document pre- and post-dialysis body weights for a resident with end-stage kidney disease, leading to discrepancies between facility and dialysis center records. The resident was hospitalized for respiratory failure due to volume overload, highlighting the importance of accurate weight monitoring. Staff interviews confirmed reliance on a communication record, but inconsistencies were found, which were acknowledged by the ADON.
The facility staff did not post nurse staffing information in an easily accessible location for most of the survey period. The survey team observed that the information was not displayed as required, and later found it placed on a table in the reception area next to holiday decorations. This issue was noted during the exit conference.
During a survey, an unlocked medication cart was observed on a nursing unit, with staff members passing by without securing it. The DON later locked the cart after being informed by the surveyor that it had been unsecured for nearly 15 minutes.
Failure to Follow Transfer Orders Resulted in Resident Fall and Ankle Fracture
Penalty
Summary
The facility failed to follow a physician’s order and the resident’s care plan for Resident #25 during a transfer, resulting in a fall and a broken ankle. The resident had an order for a Hoyer lift with a 2-person assist beginning 11/29/2023, and the most recent care plan dated 11/30/2025 stated the resident required total mechanical and 2-person assistance for transfers. During interview, Resident #25 stated that GNA #41 had dropped them on the floor and broke their ankle, and the resident showed a pink lower leg cast. The DON stated that on 3/1/2026, GNA #41 did not check the Kardex for the resident’s transfer status and was unaware of the Hoyer lift and 2-person assist requirement. Instead, the GNA attempted to transfer the resident alone from the bed to a wheelchair, during which the resident’s leg became tangled with the wheelchair and the resident was dropped to the floor, causing the ankle fracture. The facility investigation included a statement from Employee #41 confirming they did not use the Hoyer lift while transferring the resident.
Missed Quarterly Care Plan Reviews and Incomplete Hydration Care Plan
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised at least quarterly and updated to reflect residents’ current needs for 6 of 9 residents reviewed. During record review on 04/17/2026, Resident #113’s last documented care plan review was 12/18/2025, Resident #107’s was 01/02/2026, Resident #2’s was 12/11/2025, Resident #6’s was 01/09/2026, and Resident #4’s was 01/02/2026. These review dates exceeded the required quarterly timeframe for care plan review and revision. For Resident #3, the family member reported concerns during the initial interview that nursing staff did not consistently assist the resident with drinking throughout the day. Survey observations showed GNAs assisting the resident with drinking water, and the medical staff had ordered an IV for hydration. The resident’s care plan dated 01/09/2026 did not identify hydration as a focus; it only referenced hydration in relation to the potential for infection due to the midline catheter and did not include interventions to maintain or restore hydration, despite a provider order for hydration.
Missing Annual Performance Reviews for GNAs
Penalty
Summary
The facility failed to conduct required annual performance reviews for Geriatric Nursing Assistants (GNAs). Based on interviews with staff and review of employee files, 5 of 5 GNA files reviewed did not contain a 2025 performance review for GNA #42, GNA #43, GNA #44, GNA #45, and GNA #46. The facility policy stated that the job performance of every employee is reviewed and evaluated at least annually, and that the completed evaluation is sent to Human Resources for placement in the personnel record and a copy is provided to the employee. During the survey, the DON stated performance reviews were supposed to be yearly and said they were stored with HR, while Regional HR confirmed they were in employee files. However, review of the files showed no 2025 performance reviews for any of the 5 GNAs. The DON later stated she had not conducted any GNA performance evaluations and, after checking, said she did not find any performance reviews. In an interview, GNA #35 stated he/she could not remember ever having a performance review.
Loose Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure that medications were secured in the pharmacy-issued bubble packs. During a medication storage observation, surveyors found loose pills and capsules in all 4 medication carts, with approximately 2 to 3 dozen loose medications per cart that had come out of the bubble packs provided for residents' medications. The loose medications were collected and given to the DON for disposal, and the DON stated the facility did not have a specific policy for medications that came out of the bubble packs. The DON also stated the facility had ordered 2 additional medication carts because the crowding of the bubble packs appeared to be causing the medications to be accidentally pushed out.
PPE Not Stocked Near EBP Rooms
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when PPE was not stocked appropriately near resident rooms placed on enhanced barrier precautions (EBP). On Station 2, surveyors observed EBP posters on the doorways of Rooms 202, 203, 204, 206, 207, 208, 209, 210, 211, 212, and 213. Two PPE dispensers in the hallway were observed, but neither had gowns stocked, and additional observations inside the rooms did not reveal PPE stocked inside the rooms. On Station 1, surveyors observed EBP posters on the doorways of Rooms 101, 103, 104, 105, 110, 112, 113, and 115. Two hallway PPE dispensers were observed, and neither had gowns stocked, with no PPE observed inside the rooms. An LPN stated the overnight supervisor is responsible for stocking empty PPE dispensers during the night shift, and an RN stated gowns are kept in hallway PPE dispensers and are expected to be stocked. The DON was made aware of the surveyor concerns.
Failure to Inform Resident of Medication Risks and Benefits Before Initiation
Penalty
Summary
The facility failed to ensure that the resident or representative was informed of the risks and benefits of a medication prior to initiation for Resident #2. On 02/13/2026, Resident #2 was ordered Lorazepam Injection 1 mg IM every 24 hours as needed for breakthrough seizures for 6 months, but the record contained no documented diagnosis of seizures and no evidence of seizure activity supporting the medication use. The provider who wrote the order stated the medication was ordered as a precaution due to EEG findings during a prior hospitalization, but could not identify a supporting seizure diagnosis. When asked whether the resident had been informed of the risks and benefits of Lorazepam, the provider stated yes; however, the documentation provided showed that the discussion of diagnosis, prognosis, treatment plan, risks, benefits, alternatives, side effects, and adverse reactions occurred on 04/20/2026, which was after the medication order date.
Unnecessary PRN Lorazepam Order Without Supporting Diagnosis
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary medications by ordering Lorazepam Injection 1 mg IM every 24 hours as needed for breakthrough seizures for a 6-month duration without an adequate indication, supporting diagnosis, or documented clinical justification for the extended PRN use. The order was entered on 02/13/2026, and record review showed no documented diagnosis of seizures and no evidence of seizure activity to support the medication use. During interview, the ordering provider stated the medication had been ordered as a precaution because of EEG findings during a prior hospitalization and described it as part of a seizure protocol, but could not identify a supporting diagnosis for seizures. Review of physician orders showed no seizure precautions in place, only an order to monitor for seizure activity. The DON was informed of the concern regarding the 6-month PRN lorazepam order and the lack of adequate indication, documented justification, or supporting diagnosis, and stated that PRN psychotropic medications may be ordered longer when used for other clinical conditions such as seizure management, but no supporting documentation or policy was provided at the time of exit.
Failure to Complete SCSA for Hospice Enrollment and Discontinuation
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days of a resident’s enrollment in hospice services and discontinuation from hospice services. Resident #1 had an order to admit to hospice on 11/13/25 with diagnoses including interstitial lung disease, COPD, pulmonary fibrosis, chronic respiratory failure, and dysphagia. The resident’s primary physician discontinued that hospice order on 11/18/25, and a second hospice order was later entered on 3/30/26 for interstitial lung disease. Review of the record showed that only one SCSA was completed, on 11/20/25, and the assessment documented Section O0110 K1 Hospice care as “No” on 11/25/25. No SCSA was completed within 14 days of the resident’s initial hospice enrollment, the hospice discontinuation, or the later hospice enrollment. In interview, the Regional MDS Coordinator stated that a SCSA must be completed within 14 days when a resident is placed on hospice or discharged from hospice, and confirmed that none were completed for these events.
Late Transmission of MDS Discharge Assessments
Penalty
Summary
The facility failed to transmit MDS assessments to the State within the required timeframe for 2 residents reviewed for resident assessment. Review of MDS records and validation reports showed that Resident #84 was discharged on 11/30/2025 and Resident #106 was discharged on 12/09/2025, but the discharge assessments for both residents were not transmitted within 14 days of completion. During the survey, Staff #8 stated that both discharge assessments had been completed but had not been transmitted, and copies were requested for review. A later review of the MDS 3.0 Final Validation Report confirmed that both discharge assessments were transmitted on 04/22/2026 after surveyor inquiry identified concerns, showing the transmissions occurred well beyond the required timeframe.
Inaccurate MDS Coding for Hospice, Pressure Injury, and Recent Surgery
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect residents’ clinical status for 2 residents reviewed. For one resident, the record showed an order for hospice services with diagnoses including interstitial lung disease, COPD, pulmonary fibrosis, chronic respiratory failure, and dysphagia. The same resident also had documentation of a new sacral pressure injury, including an interim skin check noting a pressure injury and a wound nurse practitioner note identifying a Stage 3 pressure ulcer. However, the subsequent SCSA MDS did not code hospice care and did not identify any unhealed pressure ulcers or injuries. For another resident, the record showed a readmission after hospitalization that included surgery for a right above-the-knee amputation. The resident’s quarterly assessment later indicated that the resident had not had surgery within the last 100 days, even though the amputation surgery had occurred 39 days before the assessment. During interview, the regional MDS coordinator and regional director acknowledged the coding errors on the assessments.
Delayed and Incomplete Care Plan Updates
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and updated in a timely manner to reflect residents’ current conditions for 2 of 2 residents reviewed for care planning. For one resident, the medical record showed the last care update was dated 1/9/2026, but the resident was later discharged to the hospital on 2/19/2026 for an above-the-knee amputation and returned to the facility on 3/10/2026. Although the MDS was updated for the discharge and re-admission, the care plan was not updated to reflect the re-admission, and the existing care plan still included care for a wound on the great toe of the amputated leg. There was nothing in the care plan regarding care for the amputation site. For another resident, an Interim Skin Check and a wound nurse practitioner progress note both documented a new sacral Stage 3 pressure ulcer on 11/20/2025. However, the care plan for the bilateral coccyx Stage 3 pressure ulcer was not initiated until 2/2/2026, about 10 weeks later. During interview, the DON stated that a resident with a Stage 3 pressure ulcer should be care planned and that the care plan should be updated when a wound is found. The DON acknowledged and confirmed understanding of the concern when the surveyor reviewed the documentation.
Delayed Wound Treatment Order for Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to order and implement treatment for a Stage 3 pressure ulcer in a timely manner for one resident. On 4/20/26, review of the resident’s medical record showed an Interim Skin Check dated 11/20/25 documenting a new skin impairment identified as a pressure injury at the sacrum. The same date, a progress note from the Wound NP documented a Stage 3 pressure ulcer with four treatment recommendations. Review of the resident’s orders on 4/20/26 showed a wound care order for the coccyx dated 1/30/26 for cleansing with NSS and application of calcium alginate border foam gauze daily and as needed. No wound treatment order was found prior to 1/30/26. During interview, the DON stated she would expect interventions to be put in place immediately for a resident found to have a pressure ulcer and acknowledged the concern when the surveyor compared the 11/20/25 skin check and Wound NP note with the later wound treatment order. The facility policy stated the physician will authorize pertinent orders related to wound treatments and help identify medical interventions related to wound management.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide additional nourishment ordered by a physician for Resident #55. The resident was admitted with a diet order dated 4/2/2026 for Magic Cup with meals for risk of malnutrition, 4 oz. three times daily, and Health shakes with meals for risk of malnutrition, 4 oz. three times daily. During an interview, the resident stated that meals were often missing items expected to be received and reported not receiving Magic Cups or health shakes despite being admitted for several weeks. Survey observations showed that on 4/21/2026 the resident’s breakfast tray did not include a Magic Cup or health shake, and the meal ticket also did not list either item. Later that day, the lunch tray was observed and again did not include either item, with the lunch ticket also missing both items. The resident stated they had not received the Magic Cup or health shake for breakfast or afterward. Although the MAR documented that staff administered the supplements at meals since the order was placed, the resident’s care plan meeting notes also reflected the resident’s concern that the Health Shakes and Magic Cup were not being received at every meal as ordered. An LPN stated that the supplements were obtained from the kitchen at breakfast and acknowledged that documenting them as administered before the resident received them was not really standard practice.
Failure to Assess and Document a Resident’s Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident’s primary care provider(s) assessed and monitored a Stage 3 sacral pressure ulcer after it was identified by nursing staff and the wound NP. The resident’s medical record showed a new sacral pressure ulcer documented by nursing assessment and a Stage 3 pressure ulcer documented by the wound NP. The resident was then seen multiple times by the primary care MD and the facility NP over the following months, but their progress notes did not identify or assess the pressure ulcer in the physical examination, assessment and plan, or diagnoses sections. The facility policy stated that the attending physician and nursing staff would assess and document significant risk factors for pressure sores and that the physician would evaluate and document wound healing during resident visits, especially for complicated, extensive, or non-healing wounds. During interview, the DON acknowledged that the resident’s primary care provider was responsible for overall care and confirmed the concern that both the MD and NP failed to identify or assess the pressure ulcer during their visits. The NP stated she saw everyone, was one of the resident’s primary care providers, and admitted she had not included the wound in her notes because the wound team was following it.
Pharmacist Failed to Identify Medication Without Supporting Diagnosis
Penalty
Summary
The facility failed to ensure that the licensed pharmacist completed an accurate monthly medication regimen review for Resident #2 and identified a medication order that did not have a matching documented diagnosis. The electronic medical record showed an order for Lorazepam Injection 1 mg intramuscularly every 24 hours as needed for breakthrough seizures for 6 months, written by Staff #17 on 02/13/26, but the resident’s documented diagnoses contained no diagnosis of seizures and no evidence of seizure activity to support the medication. Monthly medication regimen reviews completed on 02/27/26 and 03/29/26 both documented that no medication irregularities were noted, and the pharmacist did not identify or report the lack of a documented supporting diagnosis. During interview, Staff #17 stated the lorazepam order was part of a seizure protocol because the resident was on Keppra, but she was unable to identify a supporting diagnosis for seizures.
Unnecessary psychotropic and anticonvulsant orders without supporting diagnosis
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when medications were ordered without an adequate indication and supporting diagnosis, and when appropriate parameters were not established for a psychotropic medication ordered as needed. For one resident reviewed, Lorazepam injection 1 mg IM every 24 hours as needed for breakthrough seizures was ordered for a 6-month duration, but the record contained no documented diagnosis of seizures and no evidence of seizure activity to support the order. The resident was also ordered levetiracetam 250 mg for seizure, and this medication likewise lacked a matching medical diagnosis. During interview, the ordering provider stated the Lorazepam had been ordered as a precaution because of EEG findings during a prior hospitalization and as part of a seizure protocol, but could not identify a supporting seizure diagnosis. The provider also stated that because the resident was on Keppra, Lorazepam should be added. Review of physician orders showed no seizure precautions in place, only an order to monitor for seizure activity. The Lorazepam order also had an empty checkbox for reassessment required, and the provider agreed Lorazepam is a medication requiring reassessment but did not respond when asked whether the box should be checked. The DON was informed of the concern and stated she did not think there was a written policy for the seizure medication protocol mentioned by the provider.
Inaccurate Dialysis Orders and TAR Documentation
Penalty
Summary
The facility failed to maintain and document accurate medical records for a resident receiving hemodialysis. Resident #44 stated that hemodialysis was received three times a week on Tuesdays, Thursdays, and Saturdays at 6:00 AM, and the nephrology consult documented ESRD on hemodialysis with a T/Th/Sat schedule via tunneled catheter. However, the resident’s active medical order still listed dialysis on Monday, Wednesday, and Friday, and the Treatment Administration Record documented HD on every Monday, Wednesday, and Friday since admission, with no documentation for Tuesday, Thursday, or Saturday dialysis on any of the months reviewed. The dialysis communication binder showed that the resident had actually been receiving hemodialysis on Tuesdays, Thursdays, and Saturdays since admission to the facility. On review of the record, a nurse progress note later documented the resident leaving for HD at 6:00 AM in stable condition, while the active order still remained Monday, Wednesday, Friday. The discrepancy between the resident’s actual dialysis schedule, the nephrology documentation, the facility order, and the TAR entries was identified during the survey review.
GNA Training Records Lacked Dementia Education and Performance Reviews
Penalty
Summary
The facility failed to ensure nurse aides had continuing education that included dementia management training and education addressing weaknesses identified in performance reviews. During the recertification survey, review of 5 GNA employee files found that 2 files, for GNA #44 and GNA #45, did not contain 2025 performance reviews. The DON stated that performance reviews should be completed at least every 12 months to identify specific in-service education based on the results of those reviews, but she later acknowledged that she could not find any performance reviews for the files reviewed. Surveyors also reviewed the facility’s education binders and Relias transcripts and did not find dementia training documented for the GNAs reviewed. The DON stated the facility had onboarding, a 3-day floor orientation for clinical staff, ongoing in-services, and Relias training, but confirmed that the education binders did not show dementia training and that neither GNA #44 nor GNA #45 had dementia training on their Relias transcripts. She further stated that dementia training was supposed to be covered in orientation, but the surveyor did not observe that documentation in the employee files reviewed. The DON also confirmed there was no dementia training associated with the facility’s self-reported incidents and that the 2025 Skills Fair did not include dementia training.
Failure to Thoroughly Investigate Allegation of Neglect
Penalty
Summary
The facility failed to provide documentation that an allegation of neglect was thoroughly investigated for one resident involved in a facility-reported incident. On 1/20/26, the Regional Director received a call regarding potential neglect of Resident #3 after the resident had been transferred to the hospital. Review of the facility’s investigation showed a summary indicating that the DON had interviewed nursing staff who provided care to the resident during the 72 hours prior to the hospital transfer. However, the only documented interview and written statement in the investigation packet was from the GNA who cared for the resident on the morning of the transfer. There were no additional written statements or interview documentation from other staff who had provided care to the resident during the preceding 72 hours. During an interview on 1/21/26 at 1:30 PM, the NHA reviewed the investigation and confirmed the absence of interviews with other staff who had cared for the resident leading up to the hospital transfer. The NHA also stated that she had searched the previous DON’s files and was unable to locate any such interviews, and confirmed that staff from previous shifts should have been interviewed.
Failure to Provide Timely Incontinence Care and Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living, specifically toileting and incontinence care, for a resident who was unable to perform these tasks independently. On 1/20/26 at 11:00 a.m., Resident #6 was heard calling out from outside their room, requesting to be changed, while two nurses, including the resident’s assigned nurse (Staff #4), were observed standing outside the room. Staff #4 responded to the resident by stating that the resident had just put on the call bell and to give staff a chance to get there, but the resident continued to call out for help. A strong odor of urine was noted coming from the resident’s room at that time. During an interview conducted at the time of the observation, Resident #6 reported not being changed in a timely manner and stated that the last time they had been changed was in the middle of the night, and that as of 11:00 a.m. they had not yet been changed. In a follow-up interview at 1:00 p.m., the resident reported that they were changed about one hour after the initial observation, around 12:00 noon. The Director of Nursing was informed of the observation and responded, “ok.” This deficiency was identified for 1 of 1 residents reviewed for assistance with activities of daily living and toileting/incontinence care.
Failure to Follow Oxygen Orders and Document Respiratory Distress and Treatment
Penalty
Summary
The facility failed to provide respiratory services in accordance with professional standards of practice for one resident receiving oxygen therapy. During observation, the resident was found in bed on oxygen via nasal cannula with the concentrator set at 4 L/min, while the physician’s order in the medical record specified oxygen at 2 L/min. The humidification water bottle and oxygen tubing in use had no dates indicating when the bottle was opened or when the tubing was applied. The DON confirmed at the bedside that the oxygen was set at 4 L/min and stated she would review the nurse’s actions and the physician’s orders. Further record review showed a respiratory therapy note from the previous day documenting that the resident had been found on a non-rebreather mask, diaphoretic, and breathing fast, but there was no additional documentation in the medical record regarding this episode of respiratory distress or the use of the non-rebreather mask. In interviews, the RT reported being called by an NP to assist with the resident, who was on a non-rebreather, and described using breathing techniques and touch therapy with the NP and ADON to help calm the resident and reduce the respiratory rate. The NP stated she had been called because the resident was having trouble breathing with low oxygen saturation, placed the resident on a non-rebreather mask, and administered an Ipratropium breathing treatment due to “junky” lung sounds. When asked, the NP acknowledged she had not documented this assessment, the respiratory distress event, or the treatment in the medical record and stated she would document it after the interview.
Failure to Arrange Required Gynecology Appointment for Dependent Resident
Penalty
Summary
The facility failed to obtain an outside professional gynecological service for Resident #6 after the attending physician requested a gynecology appointment on 11/23/25 for symptoms and possible infection. The physician’s request was sent to Staff #5, who is responsible for arranging outside appointments and transportation. Staff #5 was unable to schedule the appointment because the gynecologists typically used by the facility would not accept the resident due to the large stretcher required, which they stated would not fit through their office doors. Staff #5 reported that the resident’s daughter makes all appointments, but the daughter stated she was unaware that an appointment with a gynecologist was needed and indicated she would have been able to obtain one. The DON stated she would look into the matter, but the physician was never notified that the resident had not yet received the gynecology appointment. This resulted in Resident #6 not receiving the requested evaluation by a gynecologist, and the facility did not employ or obtain an outside qualified professional resource to provide the required service when its usual providers could not accommodate the resident’s needs.
Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple complaints, staff and resident interviews, and review of staffing documentation. Six out of nine complaints submitted to the Office of Health Care Quality alleged inadequate staffing, resulting in delayed or missed essential care such as timely cleaning after bowel movements, turning and repositioning, showers, and basic hygiene. Residents and their representatives reported waiting hours to be changed, being left soiled or wet, missing scheduled showers, and experiencing delays in being assisted after dialysis or for therapy appointments. Documentation confirmed that some residents did not receive scheduled showers, and one resident's physical therapy was delayed due to lack of available therapists. Front-line staff interviews consistently described high resident-to-staff ratios, with some staff responsible for 15 to 20 residents per shift. Staff reported being unable to complete all required care tasks, such as turning and repositioning every two hours, providing showers, and performing nail care. Staff also noted that management did not assist during short staffing, and that excessive charting requirements further limited the time available for direct resident care. Some staff described situations where only one aide was present for an entire unit, and new staff left after orientation due to overwhelming workloads. Review of staffing sheets from multiple days confirmed that units often operated with only two GNAs for 27 to 37 residents, resulting in ratios as high as 1:18 or 1:19. Additional documentation revealed medication administration issues when a nurse was required to cover a cart without proper training, leading to missed medication passes. Observations of staffing boards and further interviews with the DON confirmed ongoing concerns about inadequate staffing levels throughout the facility.
Failure to Notify Physician of Missed BiPap Administration
Penalty
Summary
Facility staff failed to notify a resident's physician when the resident's BiPap therapy was not administered on three separate occasions, as documented in the October 2025 Treatment Administration Record. The resident, who had a history of acute and chronic respiratory failure with hypercapnia, was admitted with physician orders for BiPap use at bedtime and as needed for naps. The hospital discharge summary emphasized the critical importance of BiPap use for this resident due to their history of respiratory failure and CO2 retention. Despite missed BiPap administrations on 10/3, 10/11, and 10/12/25, there was no documentation in the nursing notes indicating that the physician was notified of these omissions. Interviews with the resident's physician and the Director of Nursing confirmed that the expected notification did not occur.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required two-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). Specifically, a resident with a history of dementia, failure to thrive, and multiple contractures was found to have a displaced fracture of the right hip. The resident, who was dependent on staff for all mobility, complained of right foot pain and was observed with swelling. The physician was notified, and orders were given for leg elevation, followed by an x-ray and doppler study. The x-ray, performed the following day, revealed a displaced fracture. Despite the discovery of the injury, the facility did not submit the initial report to OHCQ until two days after the x-ray confirmed the fracture. Review of the facility's investigation confirmed the delay in reporting, and the Director of Nursing acknowledged that staff failed to notify administration in a timely manner. This deficiency was identified during a complaint survey and was evident for one of four residents reviewed for facility-reported incidents.
Inaccurate MDS Assessment Coding for Resident with Hip Fracture
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident who experienced a displaced fracture of the right hip. Medical record review showed that the resident had a physician's order for an x-ray and doppler study, and the x-ray confirmed a displaced fracture. The resident was subsequently sent to the emergency room for further evaluation. Additionally, the resident's Medication Administration Record (MAR) documented administration of Tramadol, an opioid medication, for pain management on two occasions prior to the assessment reference date. Despite these documented events, the MDS assessment with a reference date corresponding to the incident did not capture the fracture in Section I (diagnoses) or the use of Tramadol in Section N (medications). During staff interviews, it was confirmed that these omissions occurred, and it was noted that the facility was without an MDS coordinator at the time, though new staff had recently been hired. The deficiency was identified during a complaint survey and confirmed through both record review and staff interview.
Failure to Provide Baseline Care Plan to Resident's Representative Within 48 Hours of Admission
Penalty
Summary
The facility failed to provide a baseline care plan to a resident's representative within 48 hours of admission, as required. Upon review of the medical record and interviews, it was found that the resident was admitted from the hospital for rehabilitation services, but there was no documentation that a baseline care plan was reviewed or given to the resident's representative. The baseline care plan should have included initial goals, physician orders, therapy services, dietary services, and social services, as well as a list of admission medications. Interviews with the resident's representative confirmed that they were not given a baseline care plan or included in a meeting to discuss the resident's admission within the first 48 hours. The DON stated that the process is to assess the resident and generate a baseline care plan, which is then reviewed with the resident or their representative, but confirmed that this did not occur for this admission. The resident also expressed a desire for their representative to have been involved in the care planning meeting.
Failure to Administer and Document Medications per Professional Standards
Penalty
Summary
Facility staff failed to follow professional standards of practice in medication administration for one resident. The resident, who was admitted with end stage renal disease and was dependent on renal dialysis, had an intact cognitive status as assessed by a BIMS score of 15 out of 15. On the date in question, a nurse (Staff #22) was working their first shift as night supervisor without a preceptor and had to cover a medication cart due to another nurse calling out. Staff #22 reported not being trained on the cart and did not consider passing medications until it was too late, as the next doses were soon due. Documentation review revealed that Staff #22 signed off on the administration of multiple medications for the resident, including Dasatinib, Duloxetine, Fenofibrate, Ferrous Sulfate, Folic Acid, Pantoprazole, a multivitamin, Apixaban, and Midodrine, despite not actually administering them. This was confirmed by another staff member who observed the discrepancy and by the resident, who stated they had not received their medications during the overnight shift. The Director of Nursing confirmed that Staff #22 had documented the administration of medications that were not given.
Failure to Provide Required Bathing Assistance to Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing, to residents who were dependent or required partial assistance. One resident was admitted for rehabilitation and assessed as dependent for bathing, with a care plan and physician orders specifying scheduled showers twice weekly. Despite these orders and the resident's representative requesting showers, documentation and staff interviews confirmed that the resident did not receive any showers from admission until discharge, a period of approximately one and a half months. Another resident, who required partial to moderate assistance with bathing, reported missing multiple scheduled showers. The resident stated that GNAs told them it was unnecessary for staff to remain in the shower room and cited short staffing as a reason for not providing assistance. Review of shower logs and GNA documentation confirmed that several scheduled showers were not provided, with entries marked as not applicable. The DON reviewed and confirmed these findings during the survey.
Failure to Provide Care and Documentation per Physician Orders and Standards
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for two residents. For one resident with end stage renal disease and dependent on renal dialysis, the hospital discharge summary and physician notes specified that Midodrine should be administered one hour prior to hemodialysis, typically at 5:00 AM. However, review of the Medication Administration Record showed that the medication was given at 5:30 AM and 5:25 AM on two occasions, rather than at the prescribed time. The DON confirmed that the medication was not administered at the correct time as ordered. For another resident with a history of dementia, failure to thrive, and multiple contractures, there was a lack of documentation and assessment following a complaint of right foot pain and observed swelling. Although the physician was notified and ordered the leg to be elevated, and later ordered an x-ray and doppler study, the medical record did not contain documentation of an assessment of the swelling, a specific pain assessment of the leg/ankle, or details of the conversation with the physician when the x-ray was ordered. The DON confirmed the absence of this documentation.
Failure to Provide Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate treatment and services to prevent and heal pressure ulcers for a resident with multiple complex medical conditions, including lymphedema, chronic kidney disease, and a history of infected wounds. Upon admission, the resident was noted to be bed bound with chronic wounds and pressure ulcers at the sacrum and right thigh. Medical documentation indicated the presence of a stage 3 pressure ulcer on the right thigh and a stage 2 ulcer on the sacrum, with wound therapy assessments and specific wound care orders in place. However, there were significant gaps in the documentation of wound assessments, including missing weekly skin assessments with measurements and wound characteristics, making it unclear whether the prescribed treatments were consistently performed or effective. Further review of the Treatment Administration Record (TAR) revealed blank entries on several dates, indicating that wound care may not have been administered as ordered. The Director of Nursing confirmed challenges with documentation and continuity of care due to turnover among wound care nurses and the use of multiple outside wound care teams. No wound assessments or measurements were found for an entire month, and the facility was unable to provide documentation to demonstrate ongoing evaluation or progress of the resident's wounds during that period.
Unsecured Medication Cart and Improper Medication Labeling
Penalty
Summary
Facility staff failed to keep a medication cart locked when it was left unattended outside a resident's room. The nurse responsible for the cart was inside the room and not visible from the hallway, leaving the cart accessible. During this time, a surveyor was able to open the top drawer of the cart and found an opened 20 ml vial of sterile water without a date indicating when it was opened. Additionally, several insulin pens were found in the cart, some of which were opened without being dated, and one insulin pen had a broken seal and no resident name. Another insulin pen was opened and dated, but still present beyond the recommended usage period. According to the National Institute of Health, sterile water vials should be discarded no later than 4 hours after being punctured, and insulin pens should be dated when opened and discarded 28 days after opening, per manufacturer instructions. The observed failure to properly label and store medications and biologicals, as well as to secure the medication cart, constituted a deficiency in compliance with accepted professional principles for medication management.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by professional standards. For one resident with multiple sclerosis and a stage IV sacral pressure ulcer receiving hospice care, review of the Treatment Administration Records (TARs) for August, September, and October revealed that staff did not sign off on wound treatments on several specific dates. The wound nurse confirmed in an interview that the dressings were completed on those days but she forgot to document them in the TARs. The Director of Nursing also confirmed the lack of accurate documentation for the wound treatments on the identified dates. For another resident admitted with multiple chronic conditions, including bilateral lower extremity wounds, lymphedema, and severe chronic kidney disease, the medical record review showed incomplete wound documentation. There were missing wound assessment notes for over a month, and the TAR for wound care was left blank on several days, making it unclear if treatments were performed. Additionally, weekly skin sheets lacked measurements for multiple weeks, resulting in an incomplete medical record related to the resident's wounds.
Failure to Maintain Accurate Nurse Staffing Data
Penalty
Summary
Facility staff failed to maintain accurate nursing staffing data over an 18-day period, as evidenced by discrepancies between the actual worked nursing schedules and staff statements during a complaint survey. The surveyor found that the schedules provided by the DON did not match the investigation findings regarding which staff worked on specific days. Upon further review, time punches were requested to verify the accuracy of the schedules, revealing inconsistencies such as staff being listed as worked when they had not, and others who had worked not being included on the schedule. The Human Resources Director confirmed that the schedules given to the surveyor were not correct, attributing the issue to a lack of updates in the On-Shift scheduling system due to changes in schedulers. The schedules provided were outdated and did not reflect the actual staff assignments, and even the posted schedules were inaccurate. This failure to accurately document and post daily nurse staffing information was communicated to the DON, highlighting the facility's inability to keep an accurate account of staff presence and assignments for each day and shift during the reviewed period.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility was found to have several deficiencies related to food storage, labeling, and sanitation practices. During an inspection, it was observed that food items in the kitchen were not properly labeled or discarded according to their use-by dates. Specifically, a metal container of gravy and several side item containers were found with expired labels and crusty appearances, indicating they were not discarded in a timely manner. Additionally, a juice line was found lying on the kitchen floor, which was stained and had debris, posing a contamination risk. Further observations revealed issues with the facility's walk-in freezer, which had extensive ice accumulation covering a significant portion of the ceiling. This could potentially affect the storage conditions of food items. In the kitchen's storage room, cleaning chemicals were improperly stored near disposable food pans and utensils, increasing the risk of contamination. The storage practices were not in line with professional standards, as chemicals were placed next to food-related items, and cleaning tools were resting on food storage racks. The facility's dishwashing machine was also found to be deficient, as it was unable to maintain the required temperatures for hot water sanitization. The temperature gauges on the machine were not functioning properly, and the machine was observed to be using chemical sanitization as a backup method. The facility was awaiting the installation of a larger booster to address the temperature issues, as the current setup was inadequate to meet the necessary sanitization standards. These deficiencies were acknowledged by the Certified Dietary Manager and discussed during the facility's exit conference with the Director of Nursing and Administrator.
Discrepancies in Narcotic Medication Documentation
Penalty
Summary
The facility failed to maintain accurate drug records for the administration of narcotic medications, specifically Oxycodone, for four residents. The surveyor found discrepancies between the controlled medication utilization records (count sheets) and the Medication Administration Records (MAR) for these residents. For Resident #100, the count sheet showed three administrations of Oxycodone that were not recorded in the MAR. Resident #31's MAR indicated an administration of Oxycodone that was not documented on the count sheet. Resident #52's MAR showed multiple administrations of Oxycodone that were missing from the count sheet, and the count sheet also recorded administrations not found in the MAR. Similarly, Resident #14 had several administrations documented on the count sheet that were absent from the MAR. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the facility's protocol required documentation of controlled medications in both the MAR and the count sheet. The staff acknowledged the discrepancies and verified that the nurses were expected to document the date, time, quantity used, remaining, and signature for each administration. The Director of Nursing confirmed the requirement for accurate documentation and validated the surveyor's findings.
Deficiency in Kitchen Steam Table Maintenance
Penalty
Summary
The facility failed to maintain the kitchen steam table in safe operating condition, as observed during the surveyor's initial tour. The steam table, which was used to hold food, had two out of six indicator lights inoperable and four out of six knobs missing, which are essential for controlling the temperature levels of the steam wells. This deficiency was confirmed through interviews with a staff member and the Certified Dietary Manager, who acknowledged the longstanding issue with the steam table. The concern was also discussed during the facility's exit conference with the Director of Nursing and Administrator present.
Failure to Document and Provide Information on Advance Directives
Penalty
Summary
The facility failed to provide a resident with information to formulate an advance directive and ensure that a current copy of the resident's advance directive was in the medical record. This deficiency was identified during a recertification/complaint survey for one resident. The review of the resident's medical record revealed that there was no documentation of an advance directive or any discussion about it, despite the resident having the capacity to make such decisions as noted in a hospital discharge summary. The facility's policy requires that the social services director or designee inquire about the existence of any written advance directives and provide information on the right to refuse or accept medical treatment and to formulate an advance directive. However, the Social Services Director confirmed that there was no documentation in the medical record indicating that the resident was offered assistance in establishing an advance directive. The lack of documentation and adherence to the facility's policy led to the deficiency.
Failure to Notify of Significant Weight Loss
Penalty
Summary
The facility staff failed to notify a provider and/or resident representative of a significant weight loss for a resident. This deficiency was identified during a review of the medical records for a resident who experienced a significant weight loss over a 30-day period, as documented in the electronic medical record. The resident's weight decreased from 164.0 pounds to 134.4 pounds, which was flagged in the medical record. However, there was no documentation indicating that the physician or resident representative was informed of this significant change. Interviews with the Assistant Director of Nursing (ADON) and the Regional Dietician confirmed the absence of notification to the physician and resident representative regarding the weight loss, despite acknowledging that such notification is necessary.
Failure to Maintain Proper Shower Water Temperature
Penalty
Summary
The facility staff failed to ensure that the showers in one of the nursing units maintained proper temperatures, as observed during a recertification/complaint survey. A resident from Unit 2 reported that the shower room did not have hot water, resulting in fewer showers being taken. During a facility tour, the Maintenance Director confirmed that the water temperature in the Unit 2 shower room was only 88.8 degrees Fahrenheit, which is below the acceptable range for hot water. Despite checking other units and finding adequate hot water, the issue persisted in Unit 2. The maintenance logs revealed that the water temperature in the Unit 2 shower room had previously dropped to 55 degrees Fahrenheit on two occasions, prompting a vendor to repair the water tank. Although the vendor confirmed that hot water had returned, the problem reoccurred, with the water temperature remaining below 100 degrees Fahrenheit. The Maintenance Director acknowledged the ongoing issue and indicated that a plumber had been contacted to address the problem. However, the deficiency remained unresolved at the time of the survey.
Misappropriation of Resident Funds by GNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal funds, as evidenced by a verified incident involving a Geriatric Nursing Assistant (GNA) who misused the resident's bank account. The incident was reported by the resident's family, who noticed unusual financial transactions on the resident's account. The facility's investigation confirmed that the GNA used the resident's bank account to pay a water bill and received a personal payment into the resident's account. This misappropriation was substantiated by the facility, leading to the termination of the GNA involved. Further investigation revealed that the same GNA was implicated in another incident involving a different resident, where they were observed accessing the resident's purse. Despite these findings, the facility did not report the misappropriation incidents to the Maryland Board of Nursing, as confirmed by interviews with the Director of Nursing (DON) and other staff members. The lack of reporting was acknowledged by the facility's administration during the survey process. The surveyor's review of the facility's documentation and interviews with staff highlighted the failure to report the GNA's actions to the appropriate regulatory body. This oversight was discussed with the facility's leadership, who confirmed their understanding of the surveyor's concerns. The deficiency was noted during the facility's recertification and complaint survey, with no documentation provided to indicate that the misappropriation had been reported to the Maryland Board of Nursing.
Failure to Implement Policies on Misappropriation of Resident Funds
Penalty
Summary
The facility failed to implement its policies and procedures regarding abuse, neglect, exploitation, and misappropriation, as evidenced by the misappropriation of funds from a resident's personal bank account. The incident involved a Geriatric Nursing Assistant (GNA) who was found to have used the resident's bank account information to pay a personal water bill and received a payment intended for another employee into the resident's account. The facility verified these allegations and terminated the GNA's employment. During the investigation, it was revealed that there were additional allegations of misappropriation involving other residents, which were not adequately addressed by the facility. Two residents reported missing personal belongings and credit cards, but the facility did not conduct investigations or report these incidents to the appropriate authorities. The Business Office Director and the Administrator were unaware of any actions taken in response to these additional allegations. Furthermore, the facility did not report the misappropriation by the GNA to the Maryland Board of Nursing, as required by their policies. Despite the facility's policies mandating thorough investigations and reporting of such incidents, the facility failed to comply with these requirements, leading to a deficiency in their handling of the situation.
Failure to Complete Significant Change Assessment for Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for a resident who was enrolled and then discontinued from hospice care. This deficiency was identified during a recertification/complaint survey. The Minimum Data Set (MDS) is a federally mandated assessment tool used to gather information on each resident's strengths and needs, which drives care planning decisions. A SCSA is required when a resident enrolls in or discontinues hospice services to ensure a comprehensive review of the resident's condition and care planning. However, for one resident, there were no SCSAs completed for the periods when hospice services were initiated and discontinued. The resident in question was admitted to the facility and had two separate physician orders for hospice care. The first order was from September 23, 2022, to October 3, 2022, and the second order was from April 22, 2023, to the present. Despite these orders, the facility did not complete the required SCSAs. Interviews with the MDS Coordinator and the Director of Nursing confirmed the absence of these assessments. The MDS Coordinator acknowledged an error in not marking the resident's annual MDS as a significant change MDS, and the Director of Nursing verified the lack of SCSAs for the hospice orders.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of the Minimum Data Set (MDS). This deficiency was identified for three residents during a recertification/complaint survey. The MDS is a core set of data elements that form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. Care plans are required to be developed within seven days of the completion of a resident's admission comprehensive MDS assessment and revised at least every quarter. However, the facility did not adhere to this timeline, resulting in care plans being developed based on outdated assessments. For Resident #55, care plan meetings were held significantly after the MDS assessments, with delays ranging from one to two months. Resident #104 had care plans developed before the completion of the MDS, leading to potential inaccuracies. Resident #37's care plan meetings were either held before the MDS assessment or not held at all after certain assessments. Interviews with facility staff, including the Director of Nursing and social workers, confirmed the discrepancies between the MDS assessments and care plan meetings. The staff acknowledged the issue but did not provide evidence to dispute the findings.
Failure to Follow Medical Orders for Thickened Liquids
Penalty
Summary
The facility failed to ensure that medical orders for thickened liquids were followed for a resident. During the survey, it was observed that the resident, who was supposed to receive nectar thick liquids due to aspiration precautions, had thin water available in their room on multiple occasions. The resident's medical record indicated a diet order for pureed texture and nectar thick liquids, which was not adhered to as evidenced by the presence of thin water. The surveyor noted that the resident's care plan, initiated months prior, specified the need for nectar thick liquids, and this was confirmed by a speech therapy discharge summary. Despite these clear directives, the resident was found with thin water in their room, which was acknowledged by an LPN who removed the inappropriate liquids. The facility's Assistant Director of Nursing and Director of Nursing were informed of the issue, and they acknowledged the deficiency.
Failure to Monitor Resident Smoking Leads to Potential Hazards
Penalty
Summary
The facility failed to adequately monitor and assess residents in relation to smoking, leading to potential smoking accidents. This deficiency was identified during a recertification/complaint survey involving five residents. On one occasion, four residents were found smoking in the courtyard outside of scheduled smoking times. The facility's policy required cigarettes to be kept in a lockbox and residents to smoke only at designated times under supervision. However, these residents managed to access smoking materials and smoke unsupervised, possibly by following a family member of another resident. The facility did not conduct immediate follow-up evaluations or update smoking assessments after this incident. Additionally, another incident involved a resident handing a lit cigarette to another resident during a scheduled smoking time, which was against the facility's smoking policy. Despite the facility's policy prohibiting the sharing of smoking materials, this behavior was observed on video footage. The facility's response included discussions with the involved residents and their family members, but there was no updated care plan or smoking evaluation for the residents involved in this incident.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address a significant weight loss in a resident, identified as Resident #113, during a recertification/complaint survey. The resident experienced an 18% weight loss over a one-month period, dropping from 164.0 lbs to 134.4 lbs. Despite having an order for weekly weight checks, the facility did not obtain weights on two occasions, specifically on 1/29/25 and 3/12/25. This lack of monitoring was confirmed by the Assistant Director of Nursing. Furthermore, the facility's policy required that any weight change of 5% or more be retaken the next day for confirmation and that the dietician be notified immediately in writing, which did not occur in this case. The Regional Dietician confirmed that prior to surveyor intervention, no interventions were put in place to address the resident's significant weight loss, and neither the physician nor the responsible party were notified. The dietician could not explain why no further action was taken. The resident's medical record did not show any evidence of the dietician being notified or addressing the weight loss, highlighting a failure in communication and intervention regarding the resident's nutritional needs.
Failure to Monitor Dialysis Weights
Penalty
Summary
The facility staff failed to properly monitor and document pre- and post-dialysis body weights for a resident requiring hemodialysis, leading to discrepancies in records. The resident, who has end-stage kidney disease, was admitted to the hospital due to respiratory failure with hypoxia secondary to volume overload, and was recommended for follow-up with outpatient paracentesis. Despite the use of a 'Hemodialysis Communication Record' form to communicate with the dialysis center, the facility's records showed inconsistencies with the dialysis center's treatment reports, indicating a lack of accurate monitoring. Interviews with staff revealed that the facility relied on the communication record to monitor residents' conditions, including vital signs and body weights. However, the surveyor identified discrepancies in the recorded weights, which were crucial for monitoring the resident's condition, especially given the recommendation for repeat paracentesis. The Assistant Director of Nursing acknowledged the importance of monitoring body weight for dialysis residents and validated the concerns raised by the surveyor.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility staff failed to post nurse staffing information in an easily accessible location for 4 out of the 7 days during the recertification/complaint survey. Upon entrance and during subsequent tours, the survey team observed that the staffing information was not displayed as required. On March 14, 2025, the survey team noted that the staffing information was placed on a table in the reception area, adjacent to St Patrick's Day decorations. This deficiency was communicated to the facility during the exit conference.
Medication Cart Security Lapse
Penalty
Summary
The facility staff failed to ensure medications were kept in a secure location, as observed during a recertification/complaint survey. On Unit Two, an unlocked medication cart was found between rooms, with no residents present in the hallway at the time. Three facility staff members passed by the cart without locking it. At 8:22 AM, the Director of Nursing (DON) approached the cart, opened the controlled substance logbook, and then pushed in the lock. The surveyor informed the DON that the cart had been unlocked for almost 15 minutes, which the DON confirmed.
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 1,523 citations issued within 25 miles in the last 12 months — including the 5 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 Towson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chestnut Grn Hlth Ctr Blakehur | 0.5 mi | ★★★★★ | 13 | 0 |
| Pickersgill Retirement Community | 0.6 mi | ★★★★★ | 6 | 0 |
| Edenwald | 0.9 mi | ★★★★★ | 3 | 0 |
| Autumn Lake Healthcare At Ruxton | 1.1 mi | ★★★★★ | 43 | 0 |
| Towson Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.