Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Patapsco Healthcare during CMS and state inspections, most recent first.
QAPI Program Documentation and Performance Improvement Deficiencies: The facility failed to maintain adequate QAPI documentation showing how it obtained feedback, collected and trended data, monitored adverse events, identified areas for improvement, and tracked corrective actions or PIPs. Review of the QAPI plan and committee meeting records showed no clear process for identifying and correcting deficiencies, no goals for the next review period, and no PIPs despite ongoing review of common concern areas such as falls, pressure ulcers, pain management, employee retention, and housekeeping. The NHA stated he served as the QAPI Coordinator, but the records reviewed did not show effective tracking, trending, or evaluation of the facility’s quality efforts.
Surveyors found that the facility failed to maintain complete and accurate medical records in several areas. Multiple residents identified as independent smokers lacked required admission and quarterly Safe Smoker Assessments, and a resident with a fall history had repeated Fall Risk Evaluations that were missing medication and gait documentation. One resident’s MOLST and code status were inconsistently documented across paper and electronic records and dialysis communication forms, while capacity certifications for two residents were completed with only one physician signature instead of two. A resident who reported missing clothing had no personal belongings inventory in the record. For residents with urinary catheters and other complex needs, urology consult notes and other outside provider documentation were not present in the charts until after surveyor intervention. Additionally, a hospital transfer form for a resident contained conflicting dates and times for the transfer and clinical information, and the DON could not explain the discrepancies, confirming that the form should have been reviewed for accuracy.
Failure to Maintain Resident Dignity, Clothing, Laundry, and Privacy: Staff entered resident rooms without knocking, several dependent residents were left in bed in gowns instead of being dressed and out of bed, multiple residents had dirty laundry piled in their rooms with some reporting they lacked clean clothes, and residents were exposed during care and a Hoyer lift transfer with room doors open and briefs visible from the hallway. One resident was observed uncovered in bed with the door open, and another cried out during transfer while staff performed the lift with the room open to passersby.
A facility failed to honor resident choice by canceling scheduled smoke breaks when outdoor temperatures were 32 degrees or below. Two residents reported being unable to smoke for extended periods, and surveyors observed no residents smoking during the scheduled smoke times. The NHA said the facility would continue the restriction, while the MD stated alert, oriented residents with appropriate attire may go outside to smoke and that it is the resident's right.
Kitchen sanitation, food storage, and temperature control failures: Surveyors observed pooling water, heavy debris on walls, floors, sinks, equipment, and food-contact surfaces, improper storage of dishes and food items, and a non-commercial microwave being used to reheat resident food. Staff were also observed plating and assembling trays without hair nets, and meal temperatures were below acceptable levels, including a fish patty at 123F, vegetables at 119F, and milk at 53F on the tray line.
QAPI committee meetings were not documented for several quarters, and the quarterly meeting attendance sheet showed the Medical Director or designee did not attend one quarterly meeting. Surveyors also found no documentation of QAPI meetings for multiple months, despite the facility stating its goal was to hold monthly meetings and quarterly meetings with representatives from all disciplines, including the Medical Director, IP, DON, and NHA.
Unsafe and unclean resident rooms and hallway vents were observed during survey. One resident’s room had clothes and belongings piled along the wall and walk space, another had an oversized TV leaning on a dresser without visible stabilizing legs, a third had bathroom ceiling tile damage, and another had clothes placed on top of a bed. Two ceiling vents in the hallway also had dark and grey matter visible inside and on the covers, and the CDM acknowledged the concern.
Failure to protect residents from abuse: staff observed a resident repeatedly touching another resident and staff inappropriately, including buttocks contact and sexually inappropriate touching. The facility’s investigation confirmed the behavior, and records showed the resident had ongoing wandering, unsafe behaviors, physical aggression when redirected, and a recent hx of agitation, assaultive behavior, and prior EP requiring a structured, closely supervised environment.
Failure to Timely Report Abuse Allegation and Notify Required Agencies: The facility received an allegation that a resident was inappropriately touching another resident and male staff, but the incident was only self-reported to OHCQ and was not reported to law enforcement or the Ombudsman. The Administrator confirmed no documentation of agency notification, and the Ombudsman later stated the incident was never reported to their office. The file also included a staff statement that the same resident slapped another resident on the buttocks, but that resident was not investigated or identified as an alleged victim.
Incomplete Investigation of Inappropriate Touching Incident: The facility did not complete a thorough investigation after a resident was observed inappropriately touching another resident and staff. The file showed the resident was placed on 1:1 supervision and the Psychiatric NP was notified, but there was no evidence law enforcement or the Ombudsman were properly notified, and the investigative file did not include a full review of all affected residents. Staff statements also described additional inappropriate touching involving another resident, but that resident was not included as an alleged victim and no further assessment was documented.
The facility failed to provide written transfer notices and bed hold policy information to resident representatives for two residents with hospital transfers. Survey review found one resident had a hospital transfer without a completed transfer form, and another resident had multiple hospitalizations with no documentation that the resident representative received written notice; the DON stated the facility relied on verbal communication and only provided forms if the representative was present.
MDS assessments were inaccurately coded for tobacco use for three residents. Record review showed each resident was identified elsewhere in the chart as a smoker or independent smoker, yet Section J1300 on the admission or annual MDS was coded No for tobacco use. During interviews, the residents stated they were current smokers, and the MDSC said resident interviews were not conducted when completing the MDS.
Incomplete person-centered care plans were identified for a resident who wanted access to the courtyard for fresh air, two smokers whose care plans did not address smoking, and a resident who spoke Spanish. Record review and staff interviews showed missing activity assessment and activity care planning, absent smoking interventions in the care plans despite smoking assessments and smoker status, and a communication care plan that did not identify the resident’s specific language barrier or resident-specific interventions.
Failure to use interpreter for a Spanish-speaking resident: Staff spoke to a resident in English without using the facility’s Language Line App or other interpretation device, despite the resident’s MDS showing Spanish as the preferred language and a need for an interpreter. The resident’s care plan identified a communication problem related to a language barrier, and a prior nursing note showed staff waited for the spouse to translate after an unwitnessed fall before the resident’s pain could be assessed.
A resident with an order for 1:1 supervision 24/7 due to inappropriate sexual behavior was observed on the unit without the required continuous supervision in place. At the time, the unit had only one GNA and one RN/LPN-type nurse present, and staff stated a scheduled GNA had called out with no replacement available. The DON confirmed staffing shortages prevented adherence to the supervision order.
Fall Mat Positioned Away From Bed: A resident with a history of falls and ongoing fall risk was observed sleeping in bed while a fall mat was placed several feet away from the bed, leaving hard tile flooring between the bed and the mat. An LPN stated the mat was used because the resident sometimes rolls out of bed, but acknowledged the placement was not helpful when asked during the observation. The resident’s care plan called for a low bed with bilateral floor mats when in bed.
Oxygen Therapy Not Provided as Ordered: A resident with acute and chronic respiratory failure with hypoxia, kidney failure on dialysis, liver failure, and heart failure had an order for O2 at 2 L/min via NC every shift for SOB. Surveyors observed the resident receiving O2 at 3 L/min without a humidifier bottle and later at 3.5 L/min with a humidifier bottle, rather than the ordered rate.
Failure to Assess, Obtain Consent, and Secure Orders for Bedrail Use: Surveyors observed multiple residents with quarter-size bed rails raised at the head of the bed, including residents who were awake, nonverbal, oriented to varying degrees, or had contractures and aphasia. Record review found no quarterly bed rail assessments, signed consent, physician orders, or care plans for the residents, despite the facility policy requiring a physician order, Bed Safety Evaluation, education on risks and benefits, informed consent, and a care plan for bed rail use.
Insufficient staffing prevented ordered 1:1 supervision for a resident with behavioral problems. Observation showed the resident was not being continuously supervised as ordered, with only one GNA and one nurse assigned to the unit and no replacement staff available after the GNA called out. The DON confirmed the resident had a 24/7 1:1 supervision order and that staffing shortages prevented compliance.
Unattended Unlocked Treatment Cart: An unlocked treatment cart labeled LIBERTY TX CART was observed unattended across from an unattended nurses' station on the 2nd floor. An LPN confirmed the cart was left unlocked and stated it should have been locked when authorized staff finished using it.
Failure to obtain routine dental services for a resident with poor dentition, missing teeth, poor oral care, and a tooth with internal black/grey discoloration. The resident stated he/she had not been seen by a dentist since admission and wanted to see the dentist. Record review found no documentation of routine or emergent dental visits, and an LPN and the DON were unable to provide documentation of any dental service for the resident.
Food was not ensured to be palatable or served at a safe, appetizing temperature. A resident reported that meals were disgusting and sometimes cold. During tray testing, mixed vegetables were difficult to chew with hard pieces, breaded fish was too cool, and the bread roll was served cold and not appetizing. The ADM was informed of the concerns.
Oxygen equipment for a resident was observed without proper dating and labeling, including an unlabeled humidifier bottle and tubing, and staff could not identify who was responsible for the labeling. In a separate observation, clean linen carts in the laundry area were uncovered with folded linen exposed while the door to the washing machine room was left open, despite posted instructions that it remain closed.
Dishwasher plumbing was observed in severely eroded condition with pooling water on the kitchen floor and debris on the dishwasher surface beneath the plumbing. The CDM confirmed the dishwasher was used in hot water mode and acknowledged the surveyor’s concerns, and the Administrator stated that parts had been ordered but would not arrive soon.
Housekeeping and maintenance services were not provided to keep resident areas and the laundry room clean and in good repair. Surveyors observed dried food and debris on floors, overflowing trash, sticky surfaces, urine odors, wet used washcloths on a shower room floor, dark stains in a shower room, a liquid substance on a fall mat, piles of unclean laundry, missing paint and wood on resident doors, and a buildup of lint above dryers. Staff said they would notify housekeeping, and the DON and Administrator were informed.
Facility staff did not notify a resident's representative about significant changes in the treatment plan, including the scheduling and completion of a vascular intervention for a resident with severe cognitive impairment and peripheral artery disease. The representative only became aware of the procedure after receiving an insurance statement, as there was no documentation of notification by staff.
A resident sustained facial bruising, and the facility failed to conduct a thorough investigation into the cause of the injury. Initial reports conflicted, with one GNA stating the resident poked themselves in the eye and later accounts suggesting a fall during a transfer. The facility did not complete comprehensive assessments, failed to interview all relevant staff or residents, and did not update the care plan to reflect the resident's changing needs.
A resident with complex medical needs was transferred to the hospital for a worsening pressure wound, but the facility failed to document a comprehensive assessment, notify the physician, or provide necessary written notifications and summaries to the resident, their representative, or the receiving hospital.
The facility did not have a qualified activities director on staff for an extended period, as confirmed by staff interviews and review of the staff roster. The position was vacant for over a month, with the previous director leaving and a new one not hired until later.
A facility with 160 beds did not employ a qualified full-time social worker during two separate periods, relying instead on the Activities Director and a Regional Social Worker to handle social services tasks. The absence of a full-time qualified social worker was confirmed by staff interviews and review of the staff roster.
The facility failed to secure narcotic medications, leading to missing medications and discrepancies in inventory sheets. An LPN left a medication cart unlocked, allowing a resident to take medications. Another nurse was unable to account for missing medications, and discrepancies were found in narcotic counts. A blister pack was tampered with, and narcotics for a discharged resident were not removed as per policy.
The facility failed to maintain a dignified environment for residents, with multiple instances of residents being left in undignified and unsanitary conditions. A resident was repeatedly observed in a hospital gown despite wanting to get dressed, and another had to provide their own linens due to the facility's failure. Unsanitary conditions were prevalent, with soiled items left unattended and clogged toilets not addressed, reflecting systemic neglect in care.
The facility failed to maintain a safe and homelike environment due to insufficient linens and a water leakage incident. Observations revealed a shortage of necessary linens, confirmed by staff and a resident, impacting care delivery. Additionally, a water leak on the Promenade unit was not promptly addressed by staff, leaving a resident in a potentially unsafe situation without available towels or blankets to manage the water.
The facility failed to develop and implement baseline care plans within 48 hours of admission for several residents, as required. This deficiency was identified during an annual survey, where it was found that 7 out of 12 residents reviewed did not have timely baseline care plans. Additionally, there was no documentation to confirm that baseline care plans were provided to some residents or their representatives, and one resident with an indwelling catheter lacked a care plan for its management.
The facility failed to report and investigate incidents involving residents within the required timeframes. Incidents included injuries of unknown origin, elopement, misappropriation of property, and potential abuse. Reports were often submitted late, and follow-up investigations were delayed or incomplete, highlighting deficiencies in compliance with regulatory requirements.
A nurse practitioner failed to ensure proper documentation and management of resident care, leading to several deficiencies. Pharmacy recommendations for a resident were not properly signed or addressed, and oxygen therapy orders for another resident were incomplete. Additionally, a resident with heart failure was not properly monitored, and a critical incident involving a change in mental status and hypoxia was not documented, despite the nurse practitioner's assessment.
A facility failed to provide appropriate care and documentation for three residents. One resident with severe cognitive impairment refused a swallow evaluation, but the refusal was not documented, nor was the POA notified. Another resident lacked dentures and hearing aids for extended periods despite grievances filed by their representative. A third resident with respiratory issues did not receive supplemental oxygen as needed, leading to hospitalization. These deficiencies highlight lapses in care and communication within the facility.
The facility failed to prevent resident-to-resident altercations and ensure a safe environment. Two residents with a history of wandering were involved in altercations, resulting in injuries. Additionally, a resident was found with a microwave in their room, posing a safety hazard. These incidents highlight inadequate supervision and monitoring of residents.
Two residents experienced deficiencies in care: one due to the misappropriation of oxycodone by an agency nurse, and another due to prolonged mismanagement of dentures and hearing aids. The facility failed to maintain accurate medication records and safeguard resident property, resulting in unresolved issues despite multiple communications with staff.
A resident was discharged from a facility without an adequate discharge process, leading to a deficiency in ensuring continuity of care at the receiving facility. The resident, who was cognitively intact and required assistance with certain ADLs, was discharged due to a violation of a smoking and behavioral contract. However, the facility failed to document a discharge plan or confirm that the receiving facility was informed of the resident's care needs.
A facility failed to transmit an MDS assessment within the required 14 days for a resident. The MDS, a crucial tool for care planning, was transmitted 37 days after completion. This deficiency was confirmed by the MDS Coordinator during an interview.
A resident complained of heartburn and abdominal pain, and despite being assessed and medicated by a nurse, the physician was not notified until hours later. The delay in contacting the physician led to a late hospital transfer order, violating facility protocols.
The facility failed to complete care plans for two residents, one receiving hospice care and another prescribed oxygen therapy. A resident's care plan did not reflect their hospice status, conflicting with their MOLST form, while another resident lacked a care plan for oxygen therapy. These issues were acknowledged by the DON.
A facility failed to conduct quarterly care plan meetings for a resident, as required. The absence of these meetings was confirmed through a review of the resident's electronic medical record and interviews with facility staff. The Social Work Assistant responsible for scheduling the meetings had not been working at the facility for the past three quarters, leading to the oversight. The Social Work Director acknowledged the issue, confirming that the meetings were not held as required.
The facility failed to adhere to professional standards in oxygen administration and narcotic handling. A resident received oxygen without a specified order, and multiple issues were found with narcotic counts, including missing signatures and unreported discrepancies. An investigation into missing narcotics was ongoing.
Facility staff failed to arrange medical transportation for a resident's follow-up appointment, leading to a missed appointment for urinary catheter removal. The resident's treatment records lacked documentation of catheter care, and the DON admitted no baseline care plan was created due to the absence of a qualifying urinary diagnosis. The appointment was noted in the resident's chart, but the unit manager did not arrange transportation.
A facility failed to maintain an accurate staffing schedule and ensure agency staff wore name badges. During a survey, the assignment board was outdated, and the staff present did not match the listed assignments. Agency staff were also not wearing name badges, as required. Interviews revealed that the nurse on duty was unaware of the responsibility to update the board, and the GNAs confirmed they were not provided with badges.
A pharmacist failed to timely communicate the need to discontinue duplicate Flonase orders for a resident, resulting in both orders being signed off as administered. Despite pharmacy reviews in August and September, no recommendations were made, and the pharmacist admitted to delays in updating records.
A resident with cracked teeth and tooth pain did not receive necessary dental care due to the facility's failure to follow physician orders and schedule appointments. The in-house dental provider did not accept the resident's insurance, and no alternative provider was sought.
The facility failed to properly store and label food items, with expired and undated products found in the kitchen and freezer. Additionally, the Dietary Manager inaccurately maintained dishwasher temperature logs, recording specific temperatures on a day she was not present.
QAPI Program Documentation and Performance Improvement Deficiencies
Penalty
Summary
The facility failed to ensure the care and services it delivered met acceptable standards of quality and failed to maintain documentation showing how it obtained feedback, collected data, monitored adverse events, identified areas for improvement, implemented corrective and preventive actions, tracked performance, and conducted performance improvement projects. The deficiency was identified during record review and staff interview and was noted to be evident by repeated citations from the previous annual survey and during the current annual survey QAPI review. The most recent QAPI plan reviewed was dated 10/12/2022, and QAPI committee meeting documentation from 10/30/2025, 11/21/2025, 12/26/2025, and 1/29/2026 did not show how data was obtained to identify facility system concerns, how deficiencies were identified and corrected, or how data was used to track and trend concerns for improvement, implement corrective actions, and evaluate effectiveness. The facility also failed to establish goals for the next review period, prioritize quality deficiencies for a performance improvement project, and maintain meeting agendas, minutes, attendance records, and QAPI program progress reports for January 2025 through [DATE]. During interview, the NHA stated that he was the QAPI Coordinator and that the facility had been conducting continuous audits for deficiencies from the last recertification survey, but the documentation reviewed did not show how the facility tracked and trended concerns or evaluated effectiveness. The NHA also stated that the QAPI committee reviewed falls, pressure ulcers, pain management, employee retention, and housekeeping, but had no performance improvement projects since beginning in May 2025.
Incomplete and Inaccurate Medical Records, Missing Assessments, and Absent Consult Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and readily available medical records in accordance with accepted professional standards. Surveyors found that multiple residents who were identified as independent smokers did not have required Safe Smoker Assessments completed at admission or at required quarterly intervals, despite being listed on the facility’s smoker list. For one resident with a history of falls, several Fall Risk Evaluations were incomplete, lacking required documentation of medications used and gait analysis, even though the resident had a known fall history. Another resident’s personal belongings were not documented anywhere in the medical record or paper chart, despite the resident reporting missing clothing and the facility’s expectation that belongings be recorded on a personal belongings form at admission and updated as needed. The surveyors also identified serious inconsistencies and omissions in documentation related to advance directives, capacity determinations, and hospital transfers. One resident had two conflicting Maryland MOLST forms in the paper chart—one indicating Do Not Resuscitate/Do Not Intubate and another indicating attempt CPR—while the electronic medical record contained an active physician order and uploaded MOLST reflecting full code. This conflicting documentation extended into other records, including a care conference note and dialysis communication forms, where the resident’s code status was alternately documented as full code and DNI. For two other residents, Physician Certifications of incapacity were completed with only one physician signature, despite the requirement for two qualified professionals to certify lack of decision-making capacity. Surveyors further found that the facility failed to maintain and retain outside consult documentation from urology and other providers in residents’ medical records. For one resident with a urinary catheter, no urology specialist documentation could be found in either the electronic or hard-copy chart, even though facility documentation referenced urology visits and refusals. For another resident reviewed in connection with a neglect complaint, the DON initially could not provide nurse practitioner notes or urology consult records and could not confirm whether urology records were present in the chart; subsequent review confirmed that urology consults were not in the resident’s medical record until they were later obtained from the outside provider. In addition, for a resident who had two separate hospital transfers, the hospital transfer form contained inconsistent dates, with the transfer date and hospital notification date not matching the dates of the clinical information and vital signs documented on the same form, and the DON was unable to explain these discrepancies. Collectively, these findings show that the facility did not ensure that medical records, including assessments, code status documentation, capacity certifications, personal property records, outside consult notes, and transfer forms, were complete, accurate, and maintained in accordance with professional standards. Finally, the surveyors noted that for one resident who called 911 and was transported to the hospital, the DON initially stated there was no transfer form because the resident dialed 911, but then produced a transfer form that contained conflicting dates and times for the transfer and clinical data. The DON acknowledged that the information on the transfer form should have been reviewed to ensure accuracy and that it should reflect the resident’s status at the time of transfer. Across these various findings, the surveyors determined that the facility failed to maintain medical records that accurately and completely reflected residents’ conditions, services provided, and external consultations, as required by accepted professional standards and practices.
Failure to Maintain Resident Dignity, Clothing, Laundry, and Privacy
Penalty
Summary
The facility failed to provide residents with respect and dignity by allowing staff to enter resident rooms without knocking or asking permission first. During breakfast tray delivery on the Liberty Hall Unit, a GNA entered five resident rooms without knocking or announcing entry. When questioned, the GNA apologized, and the UM acknowledged the concern and stated staff would be educated on knocking and announcing themselves before entering resident rooms. The facility also failed to ensure dependent residents were dressed and out of bed to a chair. Resident #23, Resident #124, and Resident #74 were observed on multiple occasions lying in bed in gowns. Resident #23 stated that staff had not gotten him/her out of bed in over a week and that the chair had been removed from the room and not replaced. Resident #23, Resident #124, and Resident #74 all had observations of clothing in their closets or cabinet spaces that was scattered, unfolded, and of unclear cleanliness. Record review showed Resident #23 and Resident #74 were dependent on staff for ADLs and transfers, and Resident #124 was totally dependent on staff for dressing and for transfers using a mechanical lift. The facility failed to ensure resident clothing was timely laundered. Several residents had baskets, totes, or piles of dirty laundry in their rooms, and some residents reported not knowing when their clothes had last been washed or not having clean clothes available. The laundry manager stated a washing machine had been down on 1/27/2026 and that the department was catching up on laundry, with each resident assigned a specific collection schedule. The facility also failed to maintain privacy and appropriate covering during care and transfers. One resident was observed lying in bed with the gown positioned so the adult brief was exposed and no top sheet or blanket covering the resident, with the room door open and the resident visible from the hallway. Another resident was transferred from a Hoyer lift to bed with the room door open, the brief exposed and visible to passersby, and the resident repeatedly yelling that he/she did not want to fall during the transfer.
Failure to Honor Resident Choice for Smoking Breaks
Penalty
Summary
The facility failed to accommodate residents by allowing them to smoke at the designated facility times, affecting all residents who smoked, including two residents reviewed during the survey. One resident stated that he or she had not been allowed to go outside to smoke for approximately two weeks and reported that the facility was canceling smoke breaks when the temperature was below 32 degrees. The resident also described a prior period around Christmas Eve when the elevator to the ground level was not working and residents on that level were not allowed to go outside to smoke for about one week, leaving the resident feeling trapped inside the building. Another resident stated that he or she had not been allowed to go outside to smoke for a long time and reported that the facility posted a sign stating smoke breaks would be cancelled if the temperature reached a certain degree, despite the resident stating a willingness to smoke in cold weather while wearing a heavy coat and hat. Surveyors observed that on two days of the survey, no residents were seen smoking outside in the designated area during the facility's scheduled smoke times of 9:00 AM, 12:00 PM, and 3:00 PM. During interviews, the Nursing Home Administrator stated the facility would continue to follow its policy and not allow residents to smoke at the designated times when the temperature was 32 degrees or less, and said the Medical Director had provided input into the restriction policy. However, the Medical Director later stated he had no recollection of providing input into the smoking restrictions and said that if a resident is alert and oriented and has appropriate attire, the resident can go outside and smoke, describing it as the resident's right.
Kitchen sanitation, food storage, and temperature control failures
Penalty
Summary
The facility failed to ensure food service safety during surveyor observation of the kitchen, dish room, tray line, and food storage areas. During the initial kitchen tour, the surveyor observed pooling water on the dishwashing floor, thick black and brown debris on walls behind and around the dishwasher, black speckled debris at the ceiling corners, dirty dish racks stored directly on the floor, worn and chipped dish equipment, and black dish buckets with a white film. The surveyor also observed a glove on top of debris on the dishwasher, gray fuzzy debris on lines above the dishwasher, a severely worn cooking pot with a dark area inside, and a handwashing sink area containing cleaning items, a dirty mop bucket, dark debris on the floor, and dark liquid with brown, black, and white debris in the sink. Additional observations showed extensive debris and poor storage practices throughout the kitchen. The surveyor observed an electric fan with an extensive layer of gray matter, a cloth rag wrapped around a wall fixture with wiring present, debris around and behind the floor drain and three-compartment sink, and cookware, serving ware, food storage containers, and lids with crumbs and debris on their surfaces. A cart near the food serving and cook line held food plates, pellets, a broken plastic clipboard, and debris on the cart and plate surfaces. Uncovered condiment containers had speckled debris, a damaged and missing area of plastic wall in the refrigerator curtain was observed, and a prep table shelf had food crumbs. In the walk-in freezer, packaged bread items were stored above a floor surface with beverage ice, dark matter, a bottle of water, and frozen dessert containers on the floor. The kitchen trash can had no lid and was nearly full beside the bread rack, with splattering and food debris on the adjacent wall and peeling paint. The surveyor also observed food service practices that did not meet professional standards. The microwave used to reheat resident food was confirmed by the CDM to not be commercial grade. On the tray line, staff were observed plating and assembling food without hair nets. A stack of dishes used to plate food was out of the heat warmer and sitting on the tray line food area for resident meal trays. During meal service, the surveyor observed loose-fitting lid covers sliding off resident meal carts. Temperature checks found a breaded fish patty at 123F, an assorted vegetable medley at 119F, a carton of milk on the tray line at 53F, and a carton of milk in the walk-in refrigerator at 42F. The CDM stated milk should be 40F or below and food should be 135-140F leaving the food line.
QAPI Committee Lacked Required Attendance and Quarterly Documentation
Penalty
Summary
The facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee had the required members in attendance and met at least quarterly. During record review, surveyors found documented QAPI meetings on 10/30/2025, 11/21/2025, 12/26/2025, and 1/29/2026, but the quarterly attendance sheet for 1/29/2026 showed that the Medical Director or designee did not attend. Further review did not reveal documentation of QAPI meetings held from January 2025 through September 2025. In interview, the Nursing Home Administrator stated that the facility’s goal was to meet monthly and hold quarterly meetings with representatives from all disciplines and departments, including the Medical Director, Infection Preventionist, DON, and NHA.
Unsafe and Unkempt Resident Rooms and Dirty Ceiling Vents
Penalty
Summary
The facility failed to ensure the environment was kept safe, clean, comfortable, and homelike for multiple residents. Resident #4’s room was observed with a pile of clothes and personal belongings piled in the corner and extending along the wall and walk space near the resident bed. Resident #41’s room was observed with an oversized TV placed on top of the dresser and leaning back against the wall, with no legs observed underneath the TV to stabilize it. Resident #31’s bathroom had an open area and bubbling noted on the ceiling tile that needed repair. Resident #121’s room was observed with clothes on top of another bed in the room. During the survey, a resident stated a desire to have a place to put all personal belongings. In addition, two ceiling vents in the ground floor hallway were observed with oscillating components open and containing copious amounts of dark matter, with grey matter present on the outer vent cover and within and beyond the vent cover. The Certified Dietary Manager observed and acknowledged the vent concerns and stated that the grey matter was probably a filter that needed changed. The concerns were later shared with the Administrator, Regional Director of Clinical Operations, DON, and maintenance staff.
Failure to Protect Residents from Inappropriate Touching and Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse when Resident #69 was observed touching other residents and staff inappropriately, including touching Resident #86 and male staff members. The initial self-report identified the allegation as sexual abuse and also noted suspected physical abuse. The facility documented that Resident #69 was placed on direct 1:1 staff supervision and that the psychiatric nurse practitioner was notified, but law enforcement and other agencies were not contacted. The investigative file included statements from staff who witnessed the behavior. One GNA reported seeing Resident #69 touch another male resident's buttocks outside of his pants during dinner tray delivery, and identified that resident as Resident #86. An activities assistant reported that Resident #69 tried to touch her buttocks earlier in the day, and another GNA reported witnessing Resident #69 slap Resident #39 on the buttocks during dinner time. The facility's final self-report concluded that the investigation confirmed Resident #69 inappropriately touched Resident #86 and male staff. Resident #69's record showed ongoing wandering, repeated attempts to enter other residents' rooms, continued sexually inappropriate touching, and the need for 1:1 supervision. A nursing progress note documented inappropriate sexual behaviors and physical aggression when redirection was attempted, along with a high elopement risk and use of a wander guard. The record also showed Resident #69 had previously been emergency petitioned for agitation, aggressive behavior, and assaulting individuals, with discharge recommendations for a structured and supervised environment and continuous monitoring. The DON later confirmed she had no knowledge of this recent prior history of assault and prior emergency petition.
Failure to Timely Report Abuse Allegation and Notify Required Agencies
Penalty
Summary
The facility failed to ensure an allegation of abuse was timely reported and failed to ensure all applicable agencies were notified for a facility-reported incident involving Resident #69 and Resident #86. The investigative file showed that on 1/27/26 the evening shift supervisor informed the DON that Resident #69 was observed touching male employees and Resident #86 inappropriately. The facility’s initial self-report to the Office of Health Care Quality identified the allegation as sexual abuse and physical abuse, documented Resident #86 as the alleged victim and Resident #69 as the alleged perpetrator, and noted that the Psychiatric Nurse Practitioner was notified and Resident #69 was placed on direct 1:1 supervision. The surveyor found no evidence that law enforcement or other agencies were notified at the time of the incident, and the Administrator confirmed during interview that the facility did not report the incident to law enforcement and had called the Ombudsman without leaving a message or having documentation that contact was made. The Ombudsman later stated that the incident was never reported to their office. The facility’s follow-up self-report listed the status of any report to law enforcement or another state agency as N/A, and the final investigative file contained no evidence that any agency besides the Office of Health Care Quality was notified. The file also included a staff statement that Resident #69 slapped Resident #39 on the buttocks during dinner, but there was no further investigation into Resident #39 and that resident was not identified as an alleged victim on the self-report forms.
Incomplete Investigation of Inappropriate Touching Incident
Penalty
Summary
The facility failed to ensure a thorough investigation of Facility Reported Incident #2728128 involving inappropriate touching by one resident toward another resident and staff. The initial self-report identified Resident #86 as the alleged victim and Resident #69 as the alleged perpetrator, and documented that the resident was observed touching male employees and Resident #86 inappropriately. The facility placed Resident #69 on 1:1 staff supervision and notified the Psychiatric Nurse Practitioner, but the investigative file showed no evidence that law enforcement or other agencies were notified at that time. The complete investigative file contained staff statements describing additional incidents involving Resident #69. One GNA stated the resident touched Resident #86 on the buttocks, an Activities Assistant stated the resident tried to touch her buttocks and was redirected, and another GNA stated the resident slapped Resident #39 on the buttocks during dinner. Despite this information, the file did not contain further investigation or assessment related to Resident #39, and Resident #39 was not identified as an alleged victim on the facility’s self-report forms. Several staff statements were documented by the DON as verbal statements, and there was no documented evidence of interview questions asked. The file also lacked evidence of a complete unit-wide investigation. The surveyor noted there were no documented assessments or interviews of other residents on the memory care unit in the complete investigative file. Although the DON later documented an attempt to interview other residents, the file still did not include assessments of residents deemed incapable of interview. The Ombudsman later confirmed that the facility had not reported the incident to that office, and the facility Administrator acknowledged there was no documentation showing contact with the Ombudsman or law enforcement.
Failure to Provide Written Transfer and Bed Hold Notifications
Penalty
Summary
The facility failed to provide written notification to the resident representative of hospital transfers and failed to provide written notification of the bed hold policy upon transfer for 2 residents reviewed during the annual survey. For one resident, the record showed a 911 call on 12/18/25 requesting transfer to the hospital, and later an assessment on 1/31/26 for difficulty breathing that resulted in another hospital transfer. When surveyors asked for transfer documentation, the facility produced a transfer form for the 12/18/25 event but could not provide a transfer form for the 1/31/26 hospital transfer. The DON and NHA confirmed that a hospital transfer form is to be provided to the resident and/or responsible party upon transfer. For the second resident, the record showed multiple hospital transfers and survey review found no documentation that the resident representative was provided written notification of the transfers or the facility's bed hold policy for the hospitalizations. The DON stated that the facility provides verbal communication to the resident representative regarding transfers and bed hold policy, and that a copy of the eInteract Transfer Form and Bed Hold Policy form can be given if the representative is present when the resident is sent to the hospital. The DON was unable to provide documentation showing written notification was given, and confirmed the nursing department does not send such written notice; later review confirmed the Business Office and Admissions Office also do not send written notification of hospital transfers to resident representatives.
MDS Tobacco Use Coding Was Inaccurate for Three Residents
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for tobacco use for 3 residents reviewed during the annual survey. Record review showed that Resident #99 was admitted as a smoker and had a Smoking Contract completed on admission, Resident #2 had an Engage Safe Smoker Assessment identifying the resident as an independent smoker with a smoking apron, and Resident #125 also had an Engage Safe Smoker Assessment identifying the resident as an independent smoker with a smoking apron. Despite this documentation, each resident’s MDS assessment coded Section J1300 as No for tobacco use on the admission or annual assessment reviewed. During interviews, Resident #125, Resident #2, and Resident #99 each stated they were current smokers. The MDS Coordinator stated that Section J1300 tobacco use is assessed during admission, annual, and significant change MDS assessments, but said there was no UDA for tobacco use and that was why J1300 was coded No. The MDS Coordinator also stated that resident interviews were not conducted to determine whether residents smoked at the time of the MDS assessment.
Incomplete Person-Centered Care Plans for Activities, Smoking, and Language Needs
Penalty
Summary
The facility failed to ensure comprehensive person-centered care plans were developed and implemented for residents with identified needs, including activities, smoking, and communication-sensory needs. For Resident #84, the resident stated they wanted to go out to the courtyard for fresh air and reported they were only allowed outside when smokers went out. The resident also stated that if the outside temperature was 32 degrees or less, smokers could not go outside. Record review showed there was no activities assessment documented to capture the resident’s interests, and activities was not included in the care plan. For Resident #55, record review showed the resident was a smoker and had smoking assessments completed, but smoking was not included in the care plan. The DON stated that smokers are to have a care plan with smoking as a focus and interventions listed. After the concern was raised, the DON reviewed the care plan and was unable to find smoking addressed on it. Resident #53 was also identified as an independent smoker on the facility smoker’s list, but review of the electronic medical record did not reveal a smoking care plan. The facility’s smoking policy stated that safe smoking measures are to be documented on each resident’s care plan and communicated to staff, visitors, and volunteers responsible for supervising residents while smoking. For Resident #5, interview and record review showed the resident spoke Spanish and did not speak English. The quarterly MDS identified Spanish as the preferred language and indicated the resident wanted or needed an interpreter to communicate with staff. Although the care plan included a general communication problem related to language barrier and listed broad communication interventions, it did not identify the resident’s specific language barrier or resident-specific interventions. The DON and RDCO acknowledged that the care plan should identify the preferred language, translation services, communication aids, staff education, and evaluation of effectiveness to provide resident-centered care.
Failure to Use Interpreter for Spanish-Speaking Resident
Penalty
Summary
The facility failed to ensure the use of a functional communication system for a resident who did not speak English and spoke Spanish. During observation, a GNA entered the resident’s room with breakfast and spoke to the resident in English, but no language interpretation device was used and the resident remained asleep. The resident was later interviewed and confirmed not speaking English. The resident’s quarterly MDS identified Spanish as the preferred language and indicated a need or desire for an interpreter to communicate with health care staff, and the care plan listed a communication problem related to a language barrier. Record review also showed a nursing note from a prior unwitnessed fall in which the resident was unable to express pain because of the language barrier, and staff waited until the spouse arrived to translate before the resident’s pain location was identified and the physician was notified. During interview, the DON and RDCO stated the facility uses a Language Line App for Spanish interpretation, but survey observations did not show nursing staff using a language interpretation device while interacting with the resident.
Failure to Provide Ordered One-to-One Supervision
Penalty
Summary
The facility failed to ensure adequate one-to-one supervision for Resident #69 as ordered by the physician. During observation rounds, the resident was seen on the unit without the required continuous supervision in place, even though the unit had only one GNA and one licensed nurse present at the time. Review of the medical record showed an order for one-to-one supervision every shift, 24 hours per day, 7 days per week due to inappropriate sexual behavior toward staff and other residents. Staff stated that a scheduled GNA had called out and no replacement staff were available, and the DON confirmed that staffing shortages prevented adherence to the supervision order. Staff also stated that the resident needed close supervision and constant redirection because of the behaviors.
Fall Mat Positioned Away From Bed
Penalty
Summary
A deficiency was identified for failure to ensure a resident’s environment was free from accident hazards. During the initial tour, Resident #105 was observed sleeping in bed while a fall mat was positioned flat on the floor against the wall next to the doorway, several feet away from the bed, with hard tile flooring between the mat and the bed. The mat was not placed adjacent to the bed at the time of the observation. When interviewed, an LPN stated the resident had the fall mat in place because the resident sometimes rolls out of bed. During a dual observation, the surveyor asked whether the mat placed that far away from the resident was helpful for the stated problem, and the LPN said it was not. The surveyor then observed the LPN move the mat closer to the bed so it covered the hard tile area between the mat and the bed. The resident’s record showed a care plan for a history of falls and ongoing fall risk, with interventions including a low bed and bilateral floor mats when the resident is in bed.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
Failure to provide oxygen therapy as ordered by the physician was identified for one resident. Resident #5 had diagnoses including acute and chronic respiratory failure with hypoxia, kidney failure on dialysis, liver failure, and heart failure, and had recently developed increased shortness of breath. The physician ordered oxygen at 2 L/min via nasal cannula every shift for shortness of breath on 1/28/2026. During observation, the resident was seen on 2/2/2026 wearing a nasal cannula connected directly to the oxygen concentrator without a humidifier bottle while receiving oxygen at 3 L/min, and on 2/3/2026 the resident was observed with a nasal cannula connected to the concentrator with a humidifier bottle labeled 2/3/2026 while receiving oxygen at 3.5 L/min. During interview, the Unit Manager was informed that the resident’s oxygen was being delivered at rates higher than the ordered 2 L/min and was not provided as ordered by the physician.
Failure to Assess, Obtain Consent, and Secure Orders for Bedrail Use
Penalty
Summary
The facility failed to ensure residents were properly assessed for the safe use of bedrails, obtain consent from the resident or resident representative before bedrail use, and obtain a physician's order for bedrails for 4 of 7 residents reviewed for accidents. During the annual survey, the surveyor observed Resident #23, Resident #74, Resident #87, and Resident #124 in bed with quarter-size bed rails raised on both sides at the head of the bed. Resident #23 was awake and oriented x3 with a contracted left arm and stated the bed rails were used to help reposition in bed. Resident #74 was awake, nonverbal, and had involuntary body movements. Resident #87 was awake and oriented to person and place but was unable to verbalize whether the bed rails were used for bed mobility. Resident #124 was awake and alert to person with aphasia and bilateral upper extremity contractures and was unable to communicate whether the bed rails were used for mobility. The surveyor observed Resident #74 and Resident #124 sleeping with both bed rails raised on 2/3/2026, and later observed Resident #23, Resident #74, and Resident #124 with both bed rails raised on 2/5/2026. Review of the facility's Safe Use of Bed Rails Policy showed that bed rails may only be used to assist in mobility and transfer and require a physician's order, a Bed Safety Evaluation, education to the resident or representative on risks and benefits, signed informed consent, and a care plan. Record review for Resident #23 found a Peak Side Rail Evaluation completed on 7/28/2025, but no quarterly bed rail assessments, signed consent, physician's order, or care plan. Similar record review for Resident #74, Resident #87, and Resident #124 found no quarterly bed rail assessments, signed consent, physician's order, or care plan. During interview, the Unit Manager was informed of these findings and stated they would review the residents' electronic medical records.
Insufficient Staffing Prevented Ordered 1:1 Supervision
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet resident needs and provide ordered one-to-one supervision for Resident #69. On 2/6/26 at approximately 6:30 AM, observation showed Resident #69, who had a physician's order for 1:1 supervision due to behavioral problems, was not being continuously supervised as ordered. At that time, only one GNA and one nurse were assigned to the unit, and no staff were providing continuous 1:1 supervision. The nurse and GNA stated that the GNA called out and no replacement staff were assigned. The DON confirmed that Resident #69 had a 24/7 1:1 supervision order and acknowledged that staffing shortages prevented adherence to the order.
Unattended Unlocked Treatment Cart
Penalty
Summary
The facility failed to ensure that medications were secure in a locked medication cart under the direct observation of authorized staff in an area where residents could not access it. During a tour of the 2nd floor Liberty Hall nursing unit, the surveyor observed an unattended, unlocked treatment cart labeled LIBERTY TX CART located across from the unattended nurses' station. An LPN on duty confirmed that the cart was unattended and unlocked and stated that it should have been locked when authorized staff finished using it. The LPN then locked the treatment cart. The concern was later discussed with the UM and the DON, and the UM stated that staff had been educated.
Failure to Obtain Routine Dental Services
Penalty
Summary
The facility failed to obtain routine dental care for Resident #23, who was observed with poor dentition, missing teeth, poor oral care, and a tooth with internal black/grey discoloration. During interview, the resident stated he/she had not been seen by a dentist since admission to the facility and wanted to see the dentist. Record review found no documentation of any routine or emergent dental visits after admission. An LPN stated they did not recall the last time the resident was seen by the dentist and said residents can be added to the list for the dental company when they come into the facility. The DON stated that every resident is seen routinely by dental services and for emergency dental services if needed, but was unable to provide documentation of any dental service provided to Resident #23 after repeated requests.
Food Served at Improper Temperature and Poor Palatability
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and served at a safe and appetizing temperature. During an interview, a resident who requested anonymity stated that the food was disgusting, sometimes cold, and mostly not that good. During palatability testing of a meal tray provided by the facility, mixed vegetables were found to be difficult to chew with hard pieces present and were not swallowed due to the consistency, breaded fish was too cool in temperature, and the bread roll was served cold and was not appetizing because of its temperature. The facility Administrator was informed of these concerns and stated that the surveyor's concerns were taken seriously.
Oxygen Equipment Not Labeled and Clean Linen Improperly Stored
Penalty
Summary
The facility failed to ensure oxygen equipment was properly dated and labeled for Resident #136. On 2/2/2026 at 9:33 AM, the resident was observed receiving oxygen at 2 liters per minute via nasal cannula, and the oxygen humidifier bottle did not have a date showing when it was initiated or last changed. The oxygen tubing was also observed without a label identifying an initiation date or change date. During follow-up observation on 2/3/2026 at 10:00 AM, the humidifier bottle was observed dated 1/28/2026, and the oxygen was not running. During interview at 10:15 AM, nurse staff #13 stated he did not know who labeled the bottle and was not aware of who was responsible for labeling the resident's oxygen humidifier bottle. Later that day at 1:00 PM, the humidifier bottle had been changed and dated 2/3/2026, but the oxygen tubing remained unlabeled. The facility also failed to store clean linen appropriately in the laundry room. During a tour on 2/6/26 at 11:40 AM, three linen carts were observed lined against the wall in front of the washing machine room, and the door to the washing machine room was wide open despite a taped sign stating, "This Door Must Remain Closed at all times." The three linen carts were uncovered with folded linen exposed, and the first cart had folded clothes sitting on top of it. The EVS Director stated that the door to the washing machine room is to be always closed and the linen carts are to be always covered.
Dishwasher Plumbing Left in Severely Eroded Condition
Penalty
Summary
The facility failed to ensure maintenance of the dishwasher plumbing. During the surveyor’s initial tour of the kitchen, the Certified Dietary Manager confirmed that the dishwasher was used in hot water mode. When the surveyor conducted a dual observation of the kitchen, multiple areas of pooling water were seen on the dishwashing area floor. The plumbing connected to the facility’s commercial conveyor dishwasher was observed to be in severely eroded condition, with white and brown flaky and powdery appearing areas, and a layer of white and brown debris was seen on the top surface of the dishwasher beneath the eroded plumbing. The CDM observed and acknowledged the surveyor’s concerns. On a later observation, pooling water was again seen beneath the dishwasher plumbing. During an interview, the Administrator stated that the concerns were taken seriously and that parts had been ordered for the dishwasher plumbing, but they would not arrive soon. The survey team shared all concerns with the Administrator and the DON.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a clean, sanitary, and homelike environment in good repair on the Promenade Unit, Liberty Unit, and in the laundry room. During observation rounds, a room on the Promenade Unit had dried food and debris on the floor, an overflowing trash can with spilled contents on the floor, a full resident clothing bin, and a noticeable urine odor. Another room on the same unit had multiple dried food particles and a sticky floor with dried substance, and large chips of paint and wood were missing from resident doors. In the shower room, several wet used washcloths were observed lying on the floor. On the Liberty Unit, large dark stains were noted inside the shower room, a fall mat beside a bed had a large liquid substance on top of it, and several resident rooms had large piles of unclean laundry emitting a urine odor. In the laundry room, a large buildup of gray-colored lint was observed on the ceiling area above three dryers. Staff members present during the observations stated they would notify housekeeping, and the DON and Administrator were informed during the entrance conference.
Failure to Notify Resident Representative of Significant Change in Treatment Plan
Penalty
Summary
Facility staff failed to notify a resident's representative of significant changes in the resident's treatment plan, specifically regarding a scheduled and completed vascular intervention. The resident, who had severe cognitive impairment and multiple wounds related to peripheral artery disease, was evaluated by a physician and determined to require a right lower extremity angiogram with intervention. Documentation showed that the need for the procedure, its scheduling, and its completion were recorded in the medical record, but there was no evidence that the resident's representative was informed at any of these stages. The medical record indicated that the representative was notified when a new wound was first identified, but subsequent significant developments—including the scheduling of a vascular specialist appointment, the recommendation and scheduling of the angiogram with intervention, and the outcome of the procedure—were not communicated to the representative. The deficiency was identified during a complaint survey after the representative learned of the procedure through an insurance statement, rather than from facility staff.
Failure to Conduct Thorough Investigation of Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury sustained by a resident, as evidenced by incomplete documentation and inconsistent accounts regarding the cause of the injury. The initial self-report indicated that a resident was found with bruising to the left eye, and the GNA who provided care stated the resident had poked themselves in the eye. However, subsequent investigation reports referenced a fall during a transfer as the cause of injury, with two GNAs reportedly corroborating this account, but without clear identification or statements from these staff members. There was also a lack of documentation explaining the discrepancy between the initial and final accounts of the incident. Further review revealed that the facility did not complete a comprehensive assessment of the resident when the injury was first identified, nor was there evidence of an assessment of other residents on the same assignment. The investigation documentation lacked interviews with other staff or residents who may have witnessed or been aware of the incident. Additionally, there was no documentation in the medical record to confirm that a fall had occurred prior to the resident's transfer to the hospital, nor was there evidence that a comprehensive assessment was completed after the facility became aware of the fall. The resident's care plan and medical record showed inconsistencies regarding the level of assistance required for transfers and ambulation, with some documentation indicating a need for two-person assist and others indicating hand-held assistance. The facility also failed to update the care plan to reflect changes in the resident's status or with each MDS assessment. There was no evidence of staff abuse training or education related to RAI documentation in the investigation materials. These deficiencies were acknowledged by the Nursing Home Administrator during the surveyor's review.
Failure to Document and Communicate Required Discharge and Transfer Information
Penalty
Summary
The facility failed to ensure that discharge information was sufficiently documented in the medical record for a resident who was transferred to the hospital. The medical record review revealed that the resident, who had complex medical conditions including pressure wounds, was admitted in February and transferred to the hospital in October after a request for hospital evaluation due to a worsening sacral wound. Documentation in the electronic medical record only noted the resident's request to go to the hospital and that the outgoing nurse sent the resident for wound evaluation, but did not include a comprehensive assessment prior to transfer, the reason for the transfer, or evidence that the physician was notified of the resident's request and status. Further review showed there was no documentation that appropriate and necessary information, such as a summary of the resident's status and the reason for transfer, was communicated to the receiving hospital. Additionally, there was no evidence that the resident or their representative was notified in writing of the transfer and the reasons for the move, nor was a written bed-hold notice specifying the duration of the bed-hold policy provided. The medical record also lacked a discharge summary completed by the resident's physician following the transfer and discharge from the facility.
Failure to Employ Qualified Activities Director
Penalty
Summary
The facility failed to employ a qualified activities director for the period from October 2024 to December 2024. This deficiency was identified during a complaint survey, which included a review of staff rosters and staff interviews. The last activities director left in October 2024, and a new activities director was not hired until December 2024, leaving the position vacant for the entire month of November 2024. Interviews with facility staff, including the current activities director and a unit manager, confirmed the absence of a qualified activities director during this time frame. The administrator, who began employment in May 2025, was not aware of the deficiency until informed by the surveyor.
Failure to Employ Full-Time Qualified Social Worker in Facility Over 120 Beds
Penalty
Summary
The facility, with a capacity of 160 beds, failed to employ a qualified full-time social worker during two separate periods: from April 2025 to May 2025, and again from July 2025 to the present. This deficiency was identified during a complaint survey, where it was confirmed through staff interviews and review of the staff roster that the last full-time qualified social worker left in June 2025. During the periods without a full-time social worker, the Activities Director assisted with social services tasks, and a Regional Social Worker provided supervision and support as needed. The Administrator confirmed the absence of a full-time qualified social worker during the specified periods and acknowledged that the facility relied on other staff to fulfill social services responsibilities.
Narcotic Medication Security Breach
Penalty
Summary
The facility failed to maintain a secure system for storing and counting narcotic medications, as evidenced by incidents involving two medication carts. On one occasion, an agency LPN left a medication cart and narcotics box unlocked, resulting in the disappearance of four narcotic pain medication blister packs belonging to three residents. The incident was reported to the Unit Manager and the Director of Nursing (DON), who initiated an investigation. An Environmental Service (EVS) employee observed a resident taking medication from the open cart and failed to report the incident immediately. In another instance, during a narcotic observation, an agency nurse was unable to account for missing medications and noted discrepancies in the controlled substance shift inventory sheets. The outgoing nurse had not signed the inventory sheet, and the incoming nurse was unaware of the missing medications. The DON confirmed that the missing narcotics were related to the previous incident involving the resident taking medications from the cart. Additionally, a surveyor and an agency nurse discovered discrepancies in the narcotic count on another unit. A blister pack had been tampered with, and a pill was replaced and taped shut. The outgoing nurse claimed the narcotic count was accurate, but the incoming nurse had not signed the inventory form. The surveyor also noted that narcotics for a discharged resident were still being counted, contrary to the facility's policy of removing such medications weekly.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to provide a dignified environment for residents, as evidenced by multiple observations and interviews. Resident #42 was repeatedly observed in bed wearing a hospital gown despite expressing a desire to get dressed and out of bed. The staff's protocol for getting residents up was inconsistent, and the resident's request to have the television turned on was not initially honored. Additionally, Resident #2 was found to have urine and stool in a plastic bag inside the bedside commode, a practice not aligned with facility protocol, indicating a lack of proper care and respect for the resident's dignity. Several residents were found in unsanitary and undignified conditions. Resident #48 was observed wearing only an incontinence brief without proper covering, and the room was in disarray with soiled items. Resident #71 reported having to urinate on the floor due to the unavailability of a urinal, and was found in a soiled incontinence brief. Resident #76's room had a strong odor due to residents urinating inappropriately, and Resident #281's family had to provide clean linens due to the facility's failure to supply them. These conditions reflect a broader issue of neglect and inadequate care. The facility also demonstrated a lack of cleanliness and maintenance, as seen with the clogged toilets in shared bathrooms and the insufficient supply of linens on the units. Resident #34's room had soiled pads left unattended, and Resident #15 was found uncovered with a saturated pad on the floor. These observations highlight systemic issues in maintaining a clean and dignified environment for residents, contributing to the overall deficiency in care and respect for residents' rights.
Deficiency in Providing a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment as evidenced by the lack of sufficient linens and a water leakage incident. During a facility tour, it was observed that the laundry room had insufficient linens to meet the required PAR level, resulting in a shortage of towels, washcloths, gowns, and pillowcases in the second-floor linen closet. Interviews with staff and a resident confirmed the shortage, with staff indicating they often had to wait for laundry to be completed to provide care. The administrator acknowledged the issue, stating that extra linens had been ordered, but they continued to disappear. Additionally, a water leakage incident was observed on the Promenade unit, where water was coming through a sprinkler above a light fixture and trickling down the bathroom wall, creating a puddle on the floor. Staff at the nurse's station were aware of the alarm but did not immediately address the situation. A GNA on the Liberty unit was observed standing by as a resident tried to understand the situation, and there were no towels or blankets available to absorb the water. The administrator later assisted the resident and confirmed that maintenance had been notified to address the issue.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for several residents, as required. This deficiency was identified during an annual survey, where it was found that 7 out of 12 residents reviewed did not have timely baseline care plans. For instance, Resident #27's baseline care plan was completed 15 days after admission, and Resident #104's was completed 16 days post-admission. Additionally, there was no documentation to confirm that baseline care plans were provided to Residents #12 and #48 or their representatives. Furthermore, Residents #49 and #54 had baseline care plans completed, but there were no signatures from the residents or their representatives to confirm receipt and understanding of the care plans. Resident #281's case highlighted a specific issue where the resident was admitted with an indwelling catheter but lacked a care plan for its management. The DON admitted that a baseline care plan was not created due to the absence of a qualifying urinary diagnosis, despite the resident's need for catheter care. This oversight in creating and communicating baseline care plans compromises the continuity of care and safety of the residents, as these plans are crucial for addressing immediate healthcare needs upon admission.
Failure to Timely Report and Investigate Incidents
Penalty
Summary
The facility failed to report and submit facility-related incident reports (FRI) to the Office of Health Care Quality (OHCQ) within the required two-hour timeframe for initial reports and five days for follow-up reports. This deficiency was evident in nine out of 38 facility-reported incidents reviewed during the survey. The incidents involved various issues, including injury of unknown origin, serious bodily injury, elopement, misappropriation of resident property, and potential employee-related abuse towards residents. One significant incident involved a resident who was found with a left breast hematoma of unknown origin. The initial facility incident report was submitted almost a month after the condition was first documented, and the final report was submitted even later. Another case involved a resident who eloped from the facility, and the initial report was submitted beyond the required timeframe. Additionally, there were instances of alleged staff abuse where the facility failed to submit timely reports to the state agency, and in some cases, follow-up investigation reports were either delayed or not completed at all. The facility also failed to report incidents of misappropriation of resident property, such as missing dentures, and did not conduct timely investigations into allegations of abuse. In one case, a resident's daughter reported a fractured rib, but the facility had not documented or reported the incident until after the daughter's notification. These failures to report and investigate incidents in a timely manner highlight significant deficiencies in the facility's compliance with regulatory requirements for reporting and investigating incidents involving residents.
Deficiencies in Documentation and Resident Care Management
Penalty
Summary
The nurse practitioner at the facility failed to ensure proper documentation and management of resident care, leading to several deficiencies. For Resident #56, pharmacy recommendations from May to July 2024 were not properly signed, dated, or addressed, resulting in a lack of changes to the medication administration record. The Director of Nursing acknowledged that the process for handling pharmacy recommendations was not followed before their tenure. Additionally, for Resident #67, an order for oxygen therapy was incomplete, lacking specific details on the amount of oxygen required. Resident #129's records showed incomplete documentation and monitoring of treatment effectiveness for heart failure and pleural effusions. The nurse practitioner did not document the effectiveness of a diuretic treatment or monitor the resident's weight. Furthermore, for Resident #139, there was a failure to document the nurse practitioner's assessment during a critical incident involving a change in mental status and hypoxia, which led to a hospital transfer. The nurse practitioner admitted to not documenting the resident's condition, including observed bruises and swelling, during the assessment.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to ensure that Resident #27 received appropriate treatment and care according to professional standards. The resident, who had severe cognitive impairment and dementia, was referred for a swallow evaluation to potentially change their diet from pureed to mechanical soft. However, the resident refused the evaluation, and there was no documentation of this refusal in the medical record. Additionally, the resident's Power of Attorney (POA) was not notified of the refusal, which was a necessary step given the resident's cognitive impairment. The Director of Rehabilitation confirmed that the proper parties should have been contacted to ensure the resident received appropriate care. Resident #104 experienced a deficiency in care related to missing dentures and hearing aids. The resident, also diagnosed with severe cognitive impairment and dementia, had been without dentures for about a year and hearing aids for approximately eight months. Despite multiple reports and grievances filed by the resident's representative, the facility failed to resolve the issue. The facility's administration had not followed up adequately on the resident's dental insurance status or the missing hearing aids, leaving the resident without essential aids for an extended period. Resident #61's care was compromised due to a failure to administer supplemental oxygen as needed. The resident, with a history of chronic obstructive pulmonary disease and other respiratory issues, experienced a significant drop in oxygen saturation levels, leading to hospitalization. The medical records did not document the administration of oxygen as ordered, nor did they include the resident's oxygen levels on the day of the incident. The Director of Nursing acknowledged that no interventions were implemented during the time the resident's oxygen levels were critically low, indicating a lapse in the standard of care provided.
Inadequate Supervision and Safety Hazards in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations, as evidenced by incidents involving three residents. In the first incident, a resident with a history of wandering entered another resident's room and was struck, resulting in a skin tear. The facility did not have a record of an investigation into this incident. In the second incident, another resident wandered into a room and was hit on the head, causing a laceration. Both incidents highlight a lack of effective monitoring and intervention for residents known to wander. Additionally, the facility failed to ensure that residents were free from accident hazards. During observation rounds, a resident was found with a microwave plugged in and resting on the bed, which posed a potential safety risk. The resident stated that the microwave was used to heat food because staff did not assist with this task. The microwave was subsequently removed by the Maintenance Director, indicating a lapse in ensuring a safe environment for residents.
Misappropriation of Medication and Mismanagement of Resident Property
Penalty
Summary
The facility failed to maintain accurate records and safeguard controlled medications, leading to the misappropriation of oxycodone for Resident #101. On 4/1/24, it was discovered that the medication and its count log were missing from the medication cart. An investigation revealed discrepancies in the narcotic count process, with conflicting reports from staff about who completed the count. Camera footage confirmed that an agency nurse removed the medication and count sheet, leading to the termination of involved staff and a report to the board of nursing. Resident #104 experienced a prolonged period without dentures and hearing aids due to mismanagement and miscommunication regarding insurance and replacement processes. The resident's representative reported the missing dentures and hearing aids, which had been absent for about a year and eight months, respectively. Despite multiple communications with facility staff, including the Unit Manager and Nursing Home Administrator, the issues remained unresolved, and the resident continued to lack these essential items. The medical record for Resident #104 indicated severe cognitive impairment and a care plan addressing potential oral health problems. Despite documented interventions, the facility failed to ensure the resident received necessary dental and hearing aid replacements. Interviews with staff confirmed the resident's previous possession of these items and highlighted the lack of follow-up on insurance and replacement arrangements, leaving the resident without essential aids for an extended period.
Inadequate Discharge Process for Resident
Penalty
Summary
The facility failed to implement a proper discharge process for a resident, leading to a deficiency in ensuring continuity of care at the proposed post-discharge facility. The resident, who was cognitively intact and their own representative, was discharged without adequate planning. The resident was wheelchair-bound, a complete paraplegic, and required assistance with showering. They had diagnoses including depression, neurogenic bladder requiring urinary catheterizations, and schizophrenia, and were on medications such as antipsychotics, antidepressants, opioids, and anticonvulsants. The deficiency was identified during a revisit survey following a complaint. The complaint alleged that the resident was discharged without an adequate process in place. The facility's Nursing Home Administrator and Director of Nursing were unable to provide evidence of a documented discharge plan or confirmation that the receiving facility was aware of the resident's transfer and care needs. The discharge was reportedly due to the resident violating a smoking and behavioral contract, which was grounds for involuntary discharge according to a settlement agreement. However, there was no documentation to support that the resident's care needs were communicated to the receiving facility.
Delayed Transmission of MDS Assessment
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessments within the required 14 days of completion for a resident. The MDS is a federally mandated assessment tool used to gather information on each resident's strengths and needs, which is crucial for care planning decisions. The assessment for a resident was completed, but the transmission of this data to the State was delayed, occurring 37 days after the assessment was completed. This deficiency was confirmed during an interview with the MDS Coordinator, who acknowledged the failure to meet the 14-day transmission requirement.
Failure to Timely Notify Physician of Resident's Condition Change
Penalty
Summary
The facility staff failed to notify the physician in a timely manner regarding a significant change in condition for a resident receiving MD or ID services. On 10/7/23, at approximately 3 AM, the resident complained of heartburn and was assessed by Nurse #59 during the night shift. The nurse administered antacid and pain medication. However, at 5:30 AM, the resident's daughter called, reporting the resident's abdominal pain and suggesting hospital transfer if the facility's intervention was ineffective. Despite this, the physician was not contacted until 7 AM, at which point an order was given to transfer the resident to the hospital via 911. The delay in contacting the physician constituted a failure to follow facility protocols, as verified by the Administrator.
Failure to Complete Care Plans for Hospice and Oxygen Therapy
Penalty
Summary
The facility failed to complete care plans for two residents, leading to deficiencies in their care management. Resident #67, who was receiving hospice care, did not have a care plan reflecting this status. Instead, the care plan indicated the resident was a Full Code, which conflicted with the resident's MOLST form that specified No CPR Option B Palliative & Supportive Care. This discrepancy was acknowledged by the Director of Nursing during an interview. Additionally, Resident #126, who was prescribed oxygen therapy, did not have a care plan for the administration of oxygen, which was also brought to the attention of the Director of Nursing.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility staff failed to conduct quarterly care plan meetings for a resident, as required. During a review of the electronic medical record for a resident, it was found that there were no notes indicating that care plan meetings had been held. Interviews with facility staff revealed that the Social Work Assistant, responsible for scheduling these meetings, had not been working at the facility for the past three quarters, which contributed to the oversight. The Social Work Director confirmed that the meetings were not held quarterly as required and acknowledged the issue was identified in August 2024. The deficiency was evident in the lack of documentation and the absence of quarterly care plan meetings for the resident. The Social Work Director explained that all department heads, along with the resident and family, are supposed to attend these meetings, and if the family cannot attend in person, they are invited to participate via phone. However, the process was not followed, and the resident did not receive the necessary quarterly care plan meetings, as confirmed by the review of care plan notes and sign-in sheets.
Deficiencies in Oxygen Administration and Narcotic Handling
Penalty
Summary
The facility staff failed to adhere to professional nursing standards in several instances. For Resident #67, a Nurse Practitioner ordered oxygen therapy as needed for shortness of breath, but the order did not specify the number of liters to be administered. Despite this, the resident was observed receiving 2 liters of oxygen via nasal cannula. When questioned, LPN #26 indicated that residents are generally started on 2 liters, but the order lacked specific instructions. This oversight in following proper protocol for oxygen administration was noted during the survey. Additionally, there were multiple deficiencies related to the handling of narcotics. Agency RN #63 did not complete the narcotic count at the beginning of their shift, and LPN #26 failed to provide a report or verify the narcotic count. The Controlled Substance Shift Inventory Form was incomplete, lacking the signature of the incoming nurse. Furthermore, there were incidents of narcotics being taped in blister packs without proper reporting or wasting procedures. An investigation into a separate incident revealed that narcotic blister packs were missing, and the narcotic count sheets were not properly signed. The Director of Nursing confirmed these discrepancies and acknowledged that the investigation was ongoing.
Failure to Arrange Medical Transportation for Resident's Follow-Up Appointment
Penalty
Summary
Facility staff failed to arrange medical transportation for a resident's follow-up appointment, resulting in the resident missing a scheduled appointment to have their urinary catheter removed. During the survey, it was discovered that the resident and a family member reported the missed appointment, which was scheduled for 8:30 AM. The review of the resident's treatment administration records did not reveal any urinary catheter treatments or a care plan. The Director of Nursing (DON) admitted that a baseline care plan was not created because the resident was admitted without a qualifying urinary diagnosis. Additionally, the DON explained that the follow-up appointment was noted in the resident's paper chart, but the unit manager failed to arrange the necessary medical transportation.
Inaccurate Staffing Schedule and Lack of Name Badges
Penalty
Summary
The facility failed to ensure that the posted staffing schedule was updated and accurate, as observed during a survey conducted on the Memory Unit. During a tour at 2:15 AM, the assignment board was found to be outdated, displaying staff assignments from the previous day. The nurse on duty was not the one listed on the board, and one of the GNAs present was not listed, while another listed GNA was absent. Additionally, the agency staff present were not wearing name badges, which is a requirement. Interviews with the staff revealed that the nurse on duty was an agency nurse who did not usually work at the facility and was unaware of the responsibility to update the assignment board. The GNAs, also from an agency, confirmed they were not provided with name badges. The Nursing Home Administrator acknowledged the issues when informed and stated that the nurse was responsible for updating the board and that agency staff should have badges or temporary ones from the front desk.
Pharmacist's Delay in Addressing Duplicate Medication Orders
Penalty
Summary
The deficiency involved a failure by the pharmacist to communicate the need to discontinue two unnecessary intranasal medications for a resident. The issue was identified during a review of the resident's medication administration record, which revealed duplicate orders for Flonase, both of which were being signed off as administered by the nursing staff. The initial order for Flonase was made in June, followed by a duplicate order in August. Despite the pharmacy review conducted in August and September, no recommendations were made to address the duplicate medication orders. The surveyor's investigation included interviews with the pharmacist and nursing staff. The pharmacist acknowledged the duplicate orders and indicated that a recommendation to address the issue was pending communication to the physician. However, the pharmacist admitted that recommendations are sometimes staggered and aimed to be updated by the end of the month. The review of the resident's monthly medication reviews for August and September showed no pharmacy recommendations, indicating a lapse in timely communication and action to rectify the unnecessary medication orders.
Failure to Schedule Dental Appointments for Resident
Penalty
Summary
Facility staff failed to follow physician orders and schedule necessary dental appointments for a resident experiencing tooth pain. The resident reported pain in their left upper and lower molars due to cracked teeth, but had not been taken to a dentist. Despite having physician orders for dental consults on two separate occasions, the facility did not ensure these appointments were scheduled or attended. The Director of Nursing was unaware of the resident's dental issues until prompted by the surveyor, and a new dental appointment order was only placed after the surveyor's inquiry. The facility's in-house dental provider did not accept the resident's insurance, and there was no documentation of attempts to find an alternative provider. This lack of action resulted in the resident's dental needs being unmet.
Deficiencies in Food Storage and Record-Keeping
Penalty
Summary
The facility failed to properly store and label food items in accordance with professional standards, as observed during an initial tour of the kitchen. The walk-in refrigerator contained ham loosely covered with saran wrap and undated, and ground beef logs without expiration dates. The dietary staff in charge was unable to confirm the safety of these items for consumption. Additionally, several food products were mislabeled with incorrect expiration dates, and some items, such as pickles and celery, were confirmed to be expired. The walk-in freezer contained undated hamburger and hotdog buns, and an open jar of jelly was improperly stored with spices instead of being refrigerated. Mold was also found on a loaf of bread with an expired date. The facility also failed to accurately maintain dishwasher temperature logs. The Dietary Manager admitted to signing the logs for specific temperatures on a day she was not present, relying instead on verbal confirmation from another staff member that the dishwasher was functioning properly. This discrepancy in record-keeping raises concerns about the accuracy and reliability of the facility's documentation practices.
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 1,617 citations issued within 25 miles in the last 12 months — including the 7 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 Randallstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Future Care Old Court | 1.4 mi | ★★★★★ | 2 | 0 |
| North Oaks Communities | 2 mi | ★★★★★ | 13 | 0 |
| Courtland, Llc | 3 mi | ★★★★★ | 0 | 0 |
| Chapel Hill Nursing Center | 3.5 mi | ★★★★★ | 27 | 0 |
| Autumn Lake Healthcare At Pikesville | 4.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Patapsco Healthcare.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.