Resorts Of Augsburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 6811 Campfield Road, Baltimore, Maryland 21207
- CMS Provider Number
- 215193
- Inspections on file
- 19
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Resorts Of Augsburg during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple neurologic and psychiatric diagnoses had a documented allergy to acetaminophen in the clinical record. Despite this, a physician later ordered scheduled Tylenol for pain in the same note that listed acetaminophen as an allergy, and the medication was administered. The resident’s MPOA reported that the MD prescribed a drug to which the resident was allergic, and in interviews the MD acknowledged missing the allergy, noting that nursing staff and the pharmacy also did not detect the error. Facility leadership stated that the medication error was not identified or documented at the time and was only recognized after the resident’s daughter reported it months later.
A resident sustained a serious injury after an altercation with another resident, resulting in a hospital visit and diagnosis of a foot fracture. While the initial incident was reported to OHCQ as required, the facility failed to submit the follow-up investigation report within the mandated 5 working days. Documentation inconsistencies and lack of submission confirmation were noted during the survey.
The facility's QAPI program was found ineffective during a survey, revealing deficiencies such as failure to provide pain medication to a resident with a suspected fracture, inadequate supervision of residents with wandering histories, and issues with a malfunctioning call bell system. Additionally, a staff member was terminated for not following ADL protocols, and the DON failed to document QA meetings and improvement plans for identified concerns.
The facility failed to ensure the QAA committee met quarterly to address concerns and evaluate action plans. A review of QAPI meeting attendance sheets revealed missing records for several months. The DON acknowledged the failure to meet monthly and quarterly standards from July to November 2023. This issue was discussed with the Administration team.
The facility failed to report abuse and neglect incidents within the required timeframe. A resident with dementia was found with a fracture, but local law enforcement was not notified promptly. Another resident's incident was reported late to the state agency. Additionally, a resident with severe cognitive impairment eloped, and an abuse allegation was reported late to OHCQ. These issues were discussed with the facility's administrative team.
The facility failed to adhere to professional standards for food safety and sanitation, as observed during a recertification survey. Expired food items were found, and staff were not wearing required hairnets or beard restraints. Additionally, the test strips used for evaluating dishwasher sanitation were expired. These issues were confirmed by the Dietary Manager and discussed with the administration team.
The facility failed to maintain accurate medical records, complete an abuse investigation, and provide access to closed records. A resident's care plan inaccurately listed them as at risk for wandering, and an abuse allegation lacked proper documentation. Additionally, staff improperly signed off on care, leading to record inaccuracies.
The facility failed to post staffing information in accessible locations on the Watersedge and Sudbrook units. Surveyors noted the absence of posted information on multiple occasions, and staff interviews revealed that the information was kept in a binder rather than being publicly displayed. Despite staff familiarity with their schedules, the requirement to post staffing information was not met, and the administration was informed of these deficiencies.
A resident reported not receiving menus or food choices, leading to dissatisfaction with meals. Staff interviews confirmed that the facility failed to provide accurate menus and alternative options, with discrepancies in the menu cycle being followed. The issue was acknowledged by the Dietary Manager and Regional Director of Nursing.
A resident did not receive the correct amount of apple juice as specified on their meal ticket, receiving only 4 oz instead of the required 8 oz. This issue was identified during an interview and observation, and the Dietary Manager was informed.
A Geriatric Nursing Assistant (GNA) was found to be working with an expired certification, as verified by the Maryland Board of Nursing (MBON) website. The Director of Nursing (DON) was unable to explain the oversight, and the administration team was notified during the survey exit.
The facility failed to maintain a working call bell system, affecting a resident and two rooms. During a survey, call lights were observed going off, and the call light monitor showed a system failure for two rooms. A resident's call bell was also found non-functional. The Regional Administrator was informed of these issues.
The facility failed to ensure that all staff participated in mandatory abuse training, as evidenced by a GNA who did not complete the required training. Despite the facility's policy requiring annual training, a review of employee files and training records showed no documentation of the GNA's participation. Interviews with staff confirmed the requirement for abuse training, yet the GNA's file lacked evidence of completion.
The facility failed to document that a GNA received required abuse training within the past year, as discovered during a recertification survey. This was highlighted by an incident of alleged verbal abuse involving a resident, with the last recorded training for the GNA being over a year prior. The facility, under new ownership, could not provide the necessary documentation due to lack of access to previous records.
A resident with severe cognitive impairment and a suspected fracture did not receive pain medication despite exhibiting signs of pain and having a PRN order for Tylenol. An LPN delayed the x-ray order, and the resident was later found to have leg fractures. EMS was called, and the resident was transferred to the hospital. The DON confirmed that pain medication should have been given.
A facility failed to thoroughly investigate an abuse allegation involving a resident with a fracture of the right tibia and fibula. The DON described the investigation process, which includes notifying law enforcement if the injury is considered abuse. However, law enforcement was not notified, and the facility could not provide documentation of interviews due to a change in ownership, leaving the current administration without necessary records.
A facility failed to provide a resident and their representative with a complete summary of the initial baseline care plan, which should have included goals, medications, dietary instructions, and services. The absence of documentation was confirmed by the DON during an interview.
A facility failed to develop a care plan for a resident at risk for wandering, diagnosed with vascular dementia. The resident was found outside the building, and although a wandering assessment indicated a risk, no care plan was in place until after the incident. The DON acknowledged the oversight during the survey.
A resident with a swollen wrist and confirmed fracture did not receive documented pain medication for nearly a day, despite having a standing order. The facility staff failed to document medication administration immediately, leading to an incomplete medical record. The DON was informed, but no additional documentation was provided.
A resident with pressure ulcers did not receive updated wound care as prescribed by the wound consultant. Despite changes in treatment orders, nursing staff continued outdated practices, applying Santyl and medihoney to the sacrum and skin prep to the heels, contrary to the consultant's instructions. The wound consultant was unaware of these discrepancies until informed by a surveyor.
Two residents at risk for wandering eloped from the facility due to inadequate supervision. One resident, with aphasia and hemiplegia, was found outside in the parking lot, while another, with Alzheimer's, was found at the ambulance entrance. Both incidents occurred due to a lack of proper care plans and supervision, highlighting deficiencies in the facility's safety measures.
A deficiency occurred when a pharmacist's recommendation for a TSH and T4 lab test for a resident was not addressed by the physician or medical director. The DON confirmed the lack of follow-up, and it was later found that the recommendation was made in error, with only a CBC being correctly ordered and drawn.
Surveyors identified infection control deficiencies in a facility, including uncovered linen carts and items on the floor in linen closets, as well as empty hand sanitizer and soap dispensers in a utility room. Staff acknowledged these issues, indicating lapses in routine checks and maintenance.
The facility staff on the Sudbrook unit failed to report maintenance issues, including non-working lights and a faulty food cart door, which were not documented in the maintenance log. Despite being aware of these problems, staff did not follow the established process for notifying maintenance personnel, leading to deficiencies in the environment of care.
The facility failed to maintain resident dignity and respect, as observed during a survey. A resident with blindness and dementia had urinals left on the floor, and staff were seen using cell phones while assisting two residents with meals. These actions indicate a lack of respect and dignity in resident care.
A resident was neglected when a GNA failed to assist with ADLs, leaving the resident's dinner tray out of reach. This action resulted in the resident being unable to access their meal and receive necessary assistance, as required.
Allergy to Acetaminophen Overlooked When Prescribing Pain Medication
Penalty
Summary
The deficiency involves a resident with multiple diagnoses, including cerebral infarction with resulting hemiplegia and hemiparesis, conversion disorder with seizures or convulsions, anxiety disorder, borderline personality disorder, and vascular dementia, who was severely cognitively impaired and dependent on staff for all ADLs. Clinical record review showed that this resident’s allergy to acetaminophen was documented in progress notes on several occasions shortly after admission. Despite this, a physician progress note later documented the same allergy list, including acetaminophen and eggs, and in the same entry ordered scheduled Tylenol (acetaminophen) for pain management, along with continuation of tramadol and an increased dose frequency of gabapentin. The resident’s daughter, who was the MPOA, reported that the facility’s medical director prescribed acetaminophen despite the known allergy. During interviews, the medical director stated that it was his practice to complete a chart review and obtain and review a resident’s history before assessment, but on the date in question he was covering for another physician, the resident was experiencing discomfort, and he prescribed acetaminophen. He acknowledged that he missed the documented allergy and stated that nursing staff and the pharmacy also did not identify the error. Facility leadership confirmed that the medication error was not identified and documented at the time it occurred and that the issue only came to their attention months later when the resident’s daughter formally reported the incident.
Late Submission of Abuse Investigation Results to OHCQ
Penalty
Summary
The facility failed to report the results of an investigation into an alleged resident-to-resident altercation that resulted in serious bodily injury to the Office of Health Care Quality (OHCQ) within the required 5 working days. Specifically, a resident reported being punched in the face and having their wheelchair overturned by another resident. Following the incident, the affected resident requested hospital evaluation and was found to have an acute fracture of the 5th metatarsal in the left foot. The initial incident report was submitted to OHCQ as required, but the follow-up investigation report was not submitted until more than 5 working days after the incident was identified. During the survey, discrepancies were found in the facility's documentation regarding the submission date of the follow-up report. Two versions of the follow-up investigation report were provided, each with different submission dates and times, and the facility was unable to provide an email confirmation of the submission as requested by the surveyor. Verification with OHCQ confirmed that the follow-up report was received late, beyond the regulatory timeframe. The Nursing Home Administrator and previous DON could not explain the inconsistencies in the documentation.
Deficiencies in QAPI Program and Resident Care
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program, as evidenced by several deficiencies identified during a survey conducted from April 4, 2024, to April 18, 2024. These deficiencies included a failure to provide pain medication to a resident with a suspected fracture, inadequate supervision of residents with a history of wandering, a malfunctioning call bell system, and issues related to neglect and abuse allegations. Specifically, an employee was terminated in December 2023 for not following protocols for providing Activities of Daily Living (ADL) assistance to a resident. During an interview with the Director of Nursing (DON) on April 18, 2024, it was revealed that the facility's Quality Assurance (QA) committee meetings were not consistently documented, with missing records from July 2023 through November 2023. The DON admitted that the neglect and abuse incident involving a resident in December 2023 was not presented to the QA team in January 2024 as it should have been. Furthermore, the DON was unable to provide documentation of staff education or the facility's improvement plan following the incident, indicating a lack of effective processes to address and prevent recurrence of identified concerns.
QAA Committee Meeting Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly to address identified concerns and evaluate the effectiveness of their action plan. This deficiency was identified during a review of the facility's Quality Assurance Performance and Improvement (QAPI) meeting attendance sheets. The survey team requested copies of the QAPI monthly attendance sheets for January 2023 through February 2024, and the facility provided attendance sheets for only a few months, specifically December 2022, January 2023, February 2023, April 2023, June 2023, January 2024, and February 2024. During an interview, the Director of Nursing (DON) stated that the internal team members are expected to meet monthly, while vendors or outside resources are invited quarterly. However, the DON acknowledged that the facility did not meet the standard requirements for meeting monthly and quarterly for the months of July 2023 through November 2023. This issue was discussed with the Administration team at the time of the survey exit.
Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report allegations of possible abuse and neglect to the appropriate authorities within the required timeframe. Specifically, the facility did not notify local law enforcement within two hours when a resident was identified with an injury of unknown source, a fracture, and failed to notify the state agency of potential abuse/neglect incidents within the same timeframe. This deficiency was evident in four out of nine residents reviewed during the recertification survey. Resident #255, who suffered from dementia and was unable to communicate, was found with swelling and bruising on the left lower leg. Despite the discovery of a fracture in the resident's tibia and fibula, the facility did not report the injury to local law enforcement. Additionally, the facility delayed reporting an incident involving Resident #69 to the state agency, submitting the report outside the required two-hour window. Further deficiencies were noted in the facility's handling of incidents involving Resident #54 and Resident #10. Resident #54, diagnosed with severe cognitive impairment, eloped from a locked unit, and the incident was reported to the state agency more than two hours after it occurred. Similarly, an allegation of sexual abuse involving Resident #10 was reported to the Office of Health Care Quality (OHCQ) after the required timeframe. These reporting delays were discussed with the facility's administrative team during the survey process.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies related to food storage, preparation, and sanitation during a recertification survey. Observations revealed that multiple food items, including canned goods and spice containers, lacked expiration dates, and several items were expired, such as thickened orange juice, hashbrown potatoes, and breakfast syrup. The Dietary Manager confirmed these findings and acknowledged that the items should have been labeled and expired items discarded. Additionally, staff were observed not adhering to sanitary conditions, as some were not wearing hairnets or beard restraints, and there was a lack of available hairnets at the kitchen entry. Further deficiencies were noted in the facility's testing supplies for kitchen sanitation. The Hydrion pH and sanitizer test strips used to evaluate the dishwasher's water sanitation concentration were found to be expired. These issues were discussed with the administration team, highlighting the facility's failure to maintain professional standards for food safety and sanitation.
Deficiencies in Medical Record Maintenance and Abuse Investigation
Penalty
Summary
The facility failed to accurately maintain medical records for a resident diagnosed with Alzheimer's Dementia. The resident's care plan indicated a risk for wandering and elopement, but the resident was not included on the facility's list of residents at risk for these behaviors. The Director of Nursing was unaware of this discrepancy until it was pointed out by the survey team, and it was later determined that the resident was not at risk, necessitating a correction to the care plan. The facility also failed to maintain a complete investigation file for an allegation of staff-to-resident abuse. A family member reported the abuse, but the facility's records only contained a police report case number, with no evidence of an internal investigation or reporting to the State Survey Agency or local Ombudsman. The Director of Nursing confirmed the lack of documentation and attributed it to a change in facility ownership, which resulted in missing records from the previous administration. Additionally, the facility was unable to provide surveyors with full access to closed electronic medical records for several residents discharged before the change in ownership. This lack of access prevented validation of care provided during specific shifts. Furthermore, there was an issue with staff members improperly signing off on care provided by others, as evidenced by a staff member charting care under another's login, leading to inaccuracies in the electronic medical records.
Failure to Post Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted in a prominent place readily accessible to residents and visitors on two of its units, Watersedge and Sudbrook. On multiple occasions, surveyors observed that staffing information was not posted on these units. On April 4, 2024, staffing information was missing from both units, and staff interviews revealed a lack of awareness or adherence to the posting requirement. A Geriatric Nursing Assistant mentioned that despite the absence of posted information, staff were familiar with their schedules. However, this does not comply with the requirement to have staffing information visibly posted. Further observations on April 15 and April 16, 2024, confirmed the continued absence of posted staffing information on the Sudbrook and Watersedge units, respectively. Interviews with staff, including an LPN, indicated that the staffing information was kept in a binder inside the nurse's station rather than being posted publicly. On April 17, 2024, the surveyor again noted the absence of posted staffing information on the Watersedge unit. An LPN acknowledged the expectation to post staffing information at the beginning of each shift and identified the nurse responsible for the task, who admitted to not posting the information. The administration was informed of these concerns at the survey exit meeting on April 18, 2024.
Failure to Provide Accurate Menus and Food Choices
Penalty
Summary
The facility failed to provide a resident with an accurate menu of meals being served and did not offer food preference choices or alternative food options. During an interview, the resident expressed dissatisfaction, stating that they were not given menus and had no choices regarding their meals. The resident reported that if they did not like the food served, no alternatives were offered. This issue was confirmed during interviews with staff, who acknowledged that menus were supposed to be reviewed with residents and that alternative options should be available. Further investigation revealed discrepancies in the menu cycle being followed. The Dietary Manager and a Registered Nurse confirmed that the incorrect menu cycle was posted in the kitchen, and no menus were available in the resident's room for reference. The staff admitted that the menu cycle was not being updated as required, leading to confusion and lack of choice for the residents. These findings were brought to the attention of the Dietary Manager and the Regional Director of Nursing, who acknowledged the issues.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to provide a resident with drinks consistent with their needs as specified on their meal ticket. During an interview and observation, it was noted that the resident expressed dissatisfaction with not receiving the correct drinks as indicated on their meal ticket. Specifically, the resident was supposed to receive 8 oz of apple juice but only received a 4 oz container. This discrepancy was observed during a dining observation, and the issue was brought to the attention of the Dietary Manager.
Expired Certification for GNA Identified
Penalty
Summary
The facility failed to ensure that a Geriatric Nursing Assistant (GNA) had an active, current certification as required by state laws. This deficiency was identified during a review of employee files and online sources, as well as through interviews with facility staff. Specifically, the Maryland Board of Nursing (MBON) website indicated that the certification status for GNA #11 was non-renewed, with an expired certification date. During an interview, the Director of Nursing (DON) acknowledged the expired certification and was unable to explain why GNA #11 was working without a valid certification. The administration team was informed of this issue at the time of the survey exit.
Failure to Maintain Working Call Bell System
Penalty
Summary
The facility failed to maintain a working call bell system, as observed during a survey. This deficiency was evident for one resident and two rooms out of the total surveyed. During observation rounds, call lights were noted to be going off at the Meadowood nursing station, and the call light monitor indicated a system failure for two specific rooms. Additionally, when a surveyor pressed the call bell for a resident, it did not function. The Regional Administrator was informed of these observations and acknowledged the issue.
Failure to Ensure Staff Participation in Mandatory Abuse Training
Penalty
Summary
The facility failed to ensure that all staff participated in mandatory abuse training, as evidenced by the case of a Geriatric Nursing Assistant (GNA) who did not complete the required training. The facility's policy mandates that all employees, including management and volunteers, receive training on abuse, neglect, mistreatment, or misappropriation of resident property upon orientation and annually. However, a review of employee files revealed that GNA #43, hired on June 23, 2023, had no documentation of participation in any abuse training. This was further confirmed by the absence of GNA #43's name on the Reporting Abuse Training Attendance Sheet from February 2024 and the lack of relevant training records in her Relias transcript. Interviews with facility staff, including Staff #9 and the Director of Nursing (DON), confirmed that all clinical staff are required to complete twelve mandatory competencies, including abuse training, before providing care to residents. Despite this requirement, GNA #43's employee file did not contain any evidence of completed abuse training. The administration team was informed of these concerns during the survey exit meeting.
Failure to Document Abuse Training for GNA
Penalty
Summary
The facility failed to provide documentation that a Geriatric Nursing Assistant (GNA) received mandatory abuse training at least once every 12 months, as required. This deficiency was identified during a recertification survey when reviewing the records of four GNA employees, specifically noting that Staff #25 had not received abuse training in the year prior to an alleged incident of verbal abuse involving a resident on 09/30/23. The last recorded training for Staff #25 was on 08/30/2022. Additionally, the facility was unable to locate the investigation documents related to the reported incident of verbal abuse, which was reported on 04/09/24. The Director of Nursing (DON) indicated that the current facility ownership, which took over on 01/01/24, did not have access to previous employee educational records, thus failing to provide evidence of compliance with training requirements.
Failure to Administer Pain Medication for Resident with Fracture
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who complained of pain and had a suspected fracture. The resident, who was admitted with a diagnosis of Dementia and had severe cognitive impairment, exhibited non-verbal signs of pain, including labored breathing, moaning, and facial grimacing. Despite having a PRN order for Tylenol, the resident did not receive any pain medication. An LPN documented the resident's condition and informed the physician, who ordered a stat x-ray. However, the x-ray order was delayed, and the resident was found to have fractures in the left leg. The resident's Medication Administration Record showed no administration of pain medication, even though the resident had a PRN order for Tylenol. EMS was called, and upon their assessment, the resident was found to have a chief complaint of left lower leg pain. The resident was then transferred to the hospital for further evaluation and treatment. Interviews with the Director of Nursing and Regional Director of Nursing confirmed that pain medication should have been administered. The LPN involved stated that it was her practice not to give oral medications when a patient is being transferred to the hospital.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an abuse allegation involving a resident with an injury of unknown origin. The incident involved a resident who was admitted with osteoarthritis and was found by a GNA with a swollen and outwardly rotated right lower leg. The resident was subsequently diagnosed with a fracture of the right tibia and fibula after being sent to the emergency room. The facility's investigation process, as described by the DON, includes reporting injuries of unknown origin, conducting staff and resident interviews, reviewing medical records, and notifying law enforcement if the injury is considered abuse. However, in this case, law enforcement was not notified, and the facility could not provide documentation of interviews with staff or the resident. The deficiency was further compounded by the transition in facility ownership, which occurred in January 2024. The current administration, including the Interim Administrator and the DON, reported that the previous owner did not leave a copy of the necessary documentation, such as staff and resident statements. This lack of documentation hindered the facility's ability to demonstrate a comprehensive investigation into the incident, as required by their procedures. The survey team discussed these concerns with the administration team at the time of exit.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a resident and their representative with a complete summary or written summary of the resident's initial baseline care plan. This deficiency was identified for one resident out of 53 reviewed during the survey. The baseline care plan should have included the resident's initial goals, a summary of medications and dietary instructions, services and treatments to be administered, and any updated information based on the comprehensive care plan. A review of the resident's medical record revealed no evidence or documentation that such a summary was provided. During an interview, the Director of Nursing confirmed the absence of documentation showing that the summary was given to the resident or their representative.
Failure to Develop Wandering Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to develop a care plan for a resident at risk for wandering, which was identified during a survey. The deficiency was evident for one resident who was reviewed for accidents. The resident, diagnosed with vascular dementia, was observed outside the building in the adjacent parking lot. Upon admission, a wandering assessment was conducted, indicating the resident was at risk to wander with a score of nine. However, no care plan was developed at that time to address the wandering risk. During an interview, the Director of Nursing (DON) was unable to provide documentation of a wandering care plan for the resident. Instead, an elopement care plan was initiated only after the resident was found outside the building. The DON acknowledged that a care plan should have been developed at the time of the initial wandering assessment upon the resident's admission. This oversight was discussed with the administration team at the time of the survey exit.
Failure to Document Medication Administration
Penalty
Summary
The facility nursing staff failed to adhere to professional standards of nursing practice by not documenting the administration of medications immediately after they were given. This deficiency was identified during a review of records and interviews with facility staff, specifically concerning a resident who was reviewed for abuse. The standard practice is to document medications immediately to ensure accurate records and prevent potential medication errors. However, for one resident, there was no documentation of pain medication administration for nearly an entire day, despite the resident experiencing significant pain and having a swollen wrist. The incident involved a resident who was noted to have a swollen right wrist and complained of pain. The resident was unable to explain the cause of the injury, and an x-ray confirmed a wrist fracture. Despite the resident's condition and the presence of a standing order for pain medication, there was no record of the medication being administered from the time the swelling was noted until the following day. The Director of Nursing was informed of the lack of documentation, but no additional records were provided to the survey team before the survey exit.
Failure to Update Wound Care Orders
Penalty
Summary
The facility nursing staff failed to update a resident's physician-prescribed wound care treatment orders after the facility wound consultant updated the treatment orders following weekly assessments. This deficiency was identified during a recertification survey for a resident who was admitted with a left heel deep tissue injury and bilateral sacrum wounds. The wound consultant provided specific instructions for wound care, including the application of betadine, medihoney, calcium alginate, and foam dressings, which were adjusted during subsequent assessments. Despite these updates, the nursing staff did not reflect these changes in the resident's medication and treatment orders. Instead, they continued to document the application of Santyl ointment and medihoney to the sacrum area and skin prep to the heels, which were not in line with the updated orders. The wound consultant was unaware of this discrepancy until informed by the nurse surveyor, indicating a communication breakdown and failure to adhere to updated treatment protocols.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for residents at risk for wandering, as evidenced by incidents involving two residents. Resident #73, who has aphasia and hemiplegia, was found outside the building in the parking lot. The resident's medical records indicated a risk for wandering, but there was no care plan in place at the time of the incident. The facility's investigation revealed that the resident attempted to follow family members when they were leaving, and staff had to assist the resident back inside. The facility had a new administration team, and the interim administrator was unable to provide additional information about the incident. Resident #54, diagnosed with Alzheimer's and severe cognitive impairment, eloped from the facility and was found outside at the ambulance entrance. The incident report was submitted late, and the police were not notified. The resident's care plan included interventions for wandering and elopement, but the facility failed to adequately supervise the resident, allowing them to follow a visitor off the unit. The facility's documentation was incomplete, lacking proof of staff training and related documents. Both incidents highlight the facility's failure to ensure the safety of residents at risk for wandering. The lack of proper care plans and supervision allowed these residents to elope, posing a significant risk to their safety. The facility's administrative team was informed of these deficiencies during the survey and exit interview.
Deficiency in Medication Regimen Review Process
Penalty
Summary
A deficiency was identified in the medication regimen review process for a resident in the facility. The pharmacist recommended drawing a Thyroid Stimulating Hormone (TSH) lab and a Thyroxine (T4) lab for the resident, which were ordered but not completed. The medical records lacked any action or note from the physician or medical director addressing the pharmacist's recommendation. During an interview, the Director of Nursing (DON) confirmed the absence of a physician's response or follow-up on the pharmacist's recommendation. Later, it was revealed that the pharmacist had made an error in the recommendation, noting that only a Complete Blood Count (CBC) was ordered and drawn, and the lab order for TSH and T4 was made in error.
Infection Control Deficiencies in Linen and Utility Rooms
Penalty
Summary
The facility staff failed to maintain proper infection control practices, as observed by surveyors. Uncovered linen carts were found in the linen closet on the Waters Edge Unit, along with a pillow and a box of gloves on the floor. Infection Preventionist/Educator #6 confirmed that the linen cart is not removed from the closet but is refilled upstairs. Additionally, two blue side rail pads were observed on the floor in the linen closet on the Sudbrook unit, which Infection Preventionist/Educator #6 acknowledged should not have been there. Geriatric Nursing Assistant #53 suggested that the pads might have come from a resident's room. Furthermore, the Soiled Utility Room on the South side of the Sudbrook unit had empty hand sanitizer and soap dispensers. Facilities Maintenance Manager/Environmental Services Director #77 stated that staff are supposed to notify him when dispensers are empty and that environmental services staff are responsible for checking and refilling them every other day.
Failure to Report Maintenance Issues on Sudbrook Unit
Penalty
Summary
The facility staff failed to notify maintenance personnel of maintenance problems on the Sudbrook unit, leading to deficiencies in the environment of care. During a survey, it was observed that the light in the linen closet did not work, and the right side of the food cart could not be closed, leaving trays exposed. Despite these issues being evident, they were not reported in the maintenance log as required. Interviews with staff, including a Licensed Practical Nurse and a Geriatric Nursing Assistant, confirmed that the problems were known but not documented or communicated to the maintenance team. Further investigation revealed that the light in the Soiled Utility Room also did not function. The process for reporting maintenance issues involved writing them in a red folder, which maintenance staff were supposed to check daily. However, the issues with the food cart and non-working lights were not recorded. The Facilities Maintenance Manager/Environmental Services Director explained the maintenance schedule and communication methods, which included cell phones and emails, but acknowledged that the issues were not logged as they should have been.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by several observations during the recertification survey. In one instance, a surveyor observed two urinals on the floor in a resident's room, one of which contained amber-colored fluid. The resident, who has diagnoses of blindness and dementia, was yelling for a nurse to assist with shaving. The resident stated that a nurse had placed the urinal on the floor, but the LPN interviewed was unaware of who was responsible. The urinals remained on the floor during a follow-up observation. In another instance, during a lunch meal observation, a staff member was seen standing over a resident while assisting with eating and simultaneously using a cell phone. The same staff member then assisted another resident with their meal, placing the cell phone on the table and interacting with it during the process. The charge nurse confirmed that the staff member was supposed to accompany another resident to an appointment but was instead asked to assist with the lunch meal. These actions demonstrate a lack of respect and dignity in the care provided to the residents.
Neglect of Resident Due to Inadequate ADL Assistance
Penalty
Summary
The facility failed to protect a resident from neglect when a Geriatric Nurse Assistant (GNA) did not assist the resident with Activities of Daily Living (ADL) as required. The incident involved a resident whose dinner tray was placed on a bedside table across the room, out of the resident's reach, by the GNA. This action prevented the resident from accessing their meal and receiving necessary assistance with ADLs, as requested by the resident. The deficiency was identified during a review of allegations of resident neglect.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Surveyors found that the facility failed to develop and implement comprehensive care plans for two residents. One resident used a motorized wheelchair and had a documented safety assessment and an ED note describing a leg injury that occurred while using the device, yet the care plan contained no documentation or interventions related to motorized wheelchair use. Another resident had a documented diagnosis of PTSD and a history of childhood sexual abuse, and while the care plan noted trauma as a focus, it listed no specific interventions to address PTSD or the trauma history.
Surveyors identified that the facility failed to revise person-centered care plans after significant changes in two residents’ conditions. For one resident, the MOLST and paper chart were updated from Full Code to DNR-B with No CPR and palliative/supportive care orders, but the care plan continued to list the resident as Full Code. For another resident who sustained a fall with injuries and was sent to the ER, the existing fall-prevention care plan was not updated to reflect the incident or any new interventions, and no timely review was documented. During interviews, the rehab director reported that therapy provides recommendations after falls but does not revise care plans, and the DON and regional administrator confirmed that no care plan revisions or fall investigation documentation were available.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Develop Comprehensive Care Plans for Motorized Wheelchair Use and PTSD
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive care plans for two residents. For one resident who used a motorized wheelchair, interviews with the DON, Administrator, and Occupational Therapist confirmed that the resident had a power mobility device and that a safety assessment for its use had been completed by therapy. The resident’s medical record included an Emergency Department physician note documenting the resident’s report that they were in their motorized wheelchair when they sustained a leg skin tear or laceration after running into their bed. The facility’s matrix and records showed the resident had been admitted and later discharged, and a power mobility indoor driving assessment dated several months prior was provided. Despite this information and the confirmed use of a motorized wheelchair, review of the resident’s care plan showed no documentation addressing the resident’s use of a motorized wheelchair. For another resident, record review showed documentation in the facility matrix and in a Quarterly MDS that the resident had a medical diagnosis of post-traumatic stress disorder (PTSD) and a history of trauma related to childhood sexual abuse. The resident’s care plan focus reflected this trauma history; however, the only listed intervention for that focus was the word “trauma,” with no specific interventions identified to address the PTSD diagnosis or trauma history. During an interview, the Nursing Home Administrator was informed that the resident had a PTSD diagnosis, but the surveyor could not locate any detailed interventions in the care plan beyond the generic trauma notation.
Failure to Revise Care Plans After Code Status Change and Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure person-centered care plans were timely updated and revised by the interdisciplinary team following significant changes in residents’ status and events. For one resident, a social services note documented that the Maryland MOLST was reviewed and changed from Full Code to DNR-B on a specified date, and the paper chart contained a MOLST form with orders for No CPR, Option B, Palliative and Supportive Care. However, the resident’s care plan still contained a focus stating that the resident’s Full Code MOLST would remain in place through the review date, and this care plan was not revised to reflect the updated code status. During record review with the Nursing Home Administrator, it was confirmed that the MOLST had been updated but the care plan had not been revised accordingly. The deficiency also includes the facility’s failure to revise a resident’s care plan after a fall event. A progress note by an LPN documented that another resident experienced a fall, sustained several injuries, and was transferred to the emergency room. Review of this resident’s care plan showed that no revisions were made to the existing fall interventions in response to the fall, and the care plan was not documented as reviewed and revised until a later date. During interviews, the Director of Rehabilitation stated that therapy makes recommendations and sees residents after falls but does not revise the care plan and was unsure if nursing was responsible for care plan revisions. The DON and Regional Administrator confirmed that no care plan revisions had been made in response to the fall and that there was no recollection or documentation of a fall investigation.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
