Ridgeway Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Catonsville, Maryland.
- Location
- 5743 Edmondson Avenue, Catonsville, Maryland 21228
- CMS Provider Number
- 215227
- Inspections on file
- 16
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Ridgeway Rehab Center during CMS and state inspections, most recent first.
A resident reported possible abuse during an investigation, but the facility did not follow up or document any further inquiry into the allegation. The acting DON was unaware of the claim, and the resident later denied current abuse, but the initial lack of investigation led to a deficiency.
Two residents had care plans that were not reviewed or updated as required, with the most recent updates occurring several months prior to the survey. The DON confirmed that the quarterly care plan reviews were overdue for both individuals.
The facility was found to have deficiencies in maintaining a safe and clean environment for residents. Observations during a survey revealed marring on walls in several rooms, dirty floors, and a bathroom with unsanitary conditions, including a strong ammonia odor. The DON and Maintenance Director were informed, with the latter attributing the issues to high staff turnover.
The facility failed to provide written notification to residents or their representatives regarding hospital transfers. In four reviewed cases, the facility did not issue the required written transfer forms, and residents or their representatives were not informed in writing about the reasons for the transfers. Staff interviews confirmed that the facility's practice was to provide verbal notifications only, indicating a systemic issue in handling hospital transfers.
The facility's kitchen failed to maintain food integrity by not labeling and dating opened food items. Observations revealed undated and expired items in the refrigerator, dry storage, and cooking areas. The CDM confirmed the expectation for proper labeling, and the surveyor discussed these concerns with facility leadership.
A facility failed to maintain a resident's Advanced Directives in their medical record. Despite procedures to review and request these documents upon admission, the facility did not have a copy of the resident's Power of Attorney. This deficiency was identified during a review of the resident's electronic medical record, which lacked documentation of Advanced Directives.
The facility failed to include care plan goals in the documentation during resident transfers, affecting two residents hospitalized. The DON confirmed that care plans were not sent, and LPNs followed a checklist that did not include care plans. A review of the checklist confirmed this omission.
The facility failed to notify residents and their representatives in writing of the bed hold policy during hospital transfers. This was evident for three residents whose records lacked documentation of written notification. Interviews confirmed that the policy was communicated verbally and not automatically provided in writing.
A facility failed to accurately code a resident's MDS assessment, reflecting their functional status inaccurately. The resident, with a history of hemiplegia and hemiparesis, was initially assessed as requiring partial assistance for toileting, but later assessments showed total dependence. The MDS Coordinator admitted the coding error, citing fluctuating assistance needs and a recent change in facility ownership as contributing factors.
A facility failed to implement a care plan for a resident identified as high risk for wandering and elopement. The resident's medical record showed wandering behavior and a high elopement risk score, yet no care plan was in place to address these issues. The facility's policy mandates care plans for such risks, but this was not followed, as confirmed by the DON and a Corporate Designee.
A facility failed to ensure accurate documentation of a resident's code status, resulting in conflicting orders between the EHR and a paper MOLST form. The EHR indicated 'Attempt CPR,' while the paper form stated 'No CPR, Option B, Palliative and Supportive Care / DNR.' The discrepancy arose because the outdated MOLST form was not voided when a new one was created, leading to confusion about the resident's code status.
A facility failed to provide activities based on a resident's preferences and care plan, as the resident with dementia was observed without activity stimulation. Despite the care plan's focus on cognitive stimulation, the activity log showed only two activities for the month, with no refusals documented. Interviews revealed a lack of proper documentation and communication between the Activities Director and Assistant.
The facility failed to properly assess and treat a resident with an unknown injury, did not implement physician orders for another resident's fall precautions, and neglected to assess a third resident upon readmission. An LPN did not perform a thorough assessment or report an incident, leading to a hospital transfer for a resident with a laceration and sprained knee. Another resident's order for bilateral floor mats was not followed, and a third resident was not assessed upon readmission, as required by policy.
The facility failed to conduct competency evaluations for three GNAs, as required by their protocol. Despite being hired at different times, none of the GNAs had evaluations on file, which should occur annually and at the 90-day mark for new hires. The DON confirmed the requirement, and the COO acknowledged the absence of these evaluations.
The facility did not post the required nursing staffing data on the Daily Staffing Schedule for six days. The posted staffing sheet lacked the facility's census and the actual and total hours worked by GNAs, LPNs, and RNs. This issue was confirmed with the Chief Operations Officer, highlighting non-compliance with staffing data posting regulations.
The facility failed to ensure that the attending physician or DON documented and signed in the medical record to show they had reviewed irregularities or recommendations identified by the pharmacist during the MRR. This deficiency was evident in three residents investigated for unnecessary medications, psychotropic medications, and medication regimen review. The clinical pharmacist identified irregularities and made recommendations, but there was no documentation of review or action taken by the attending provider or DON within the required timeframe.
A facility failed to limit a PRN order for hydroxyzine, a psychotropic medication, to 14 days as required by policy. This was discovered during a review of a resident's medical record, which showed an active order without the necessary limitation. The deficiency was confirmed through staff interviews and policy review.
The facility failed to ensure the safe storage of medications and medical supplies. Expired items, including Banatrol Plus and Curad Xeroform dressings, were found in the medication room, along with leftover medications for two residents. In the medical supply room, expired Jevity Complete Balanced Nutrition bottles were noted. The DON confirmed these findings and removed the expired items.
The facility failed to serve meals according to predetermined menus that incorporated resident preferences. During a meal service, three residents did not receive the meals as indicated on their meal tickets. A resident requested a peanut butter and jelly sandwich, which was not provided, another received rice not listed on their ticket, and a third was served rice instead of the indicated roasted red skin potatoes. Staff confirmed these discrepancies, and the issue was reviewed with the facility.
A facility failed to maintain accurate physician orders for a resident receiving 2 liters of oxygen by nasal cannula. Staff confirmed the resident had been on continuous oxygen for a long time but could not find a physician's order authorizing this treatment. A review of the medical record revealed no such order, and staff acknowledged the oversight, indicating the physician would be notified for clarification.
The facility did not have an onsite Infection Preventionist Designee to oversee its Infection Prevention and Control Program. The DON, new to the facility, was set to attend training, while a certified Corporate Infection Control Designee was assisting remotely. The requirement for an onsite Infection Preventionist was acknowledged, and hiring efforts were underway.
The facility failed to maintain essential patient care equipment, with three hand sanitizer dispensers found empty or unsecured and a DS Smart vital sign machine non-functional due to improper connections. Staff confirmed the machine was broken and acknowledged a shortage of working vital sign equipment, impacting the ability to obtain resident vital signs.
A resident was found with a bleeding lip in another resident's room, and the LPN failed to report the injury as required by the facility's policy. The resident was later hospitalized for a laceration and a sprained knee. The deficiency was identified during a survey, highlighting the failure to follow protocol for reporting injuries of unknown sources.
The facility did not submit the required direct care staffing information based on payroll data to CMS for the quarter. This deficiency was identified during a review of the CASPER PBJ Staffing Data Report, and an interview with the COO revealed that the incident occurred under the previous ownership. The issue was discussed during the exit meeting with the surveyor.
Failure to Investigate Resident's Allegation of Abuse
Penalty
Summary
The facility failed to appropriately respond to an alleged violation of abuse reported by a resident during an ongoing investigation into another incident. During a review of records related to a facility-reported incident, it was discovered that a resident had answered affirmatively to all questions on the Resident Interview form for abuse, but no further comments or additional information were documented regarding the claim. There was no evidence that the facility followed up on the resident's statements or initiated an investigation into the possible abuse as required. When questioned, the acting DON was unaware of the resident's prior claim and indicated that the previous DON had conducted the interviews at the time. The resident was later interviewed by the surveyor and recalled the situation, stating that the staff member involved was no longer employed at the facility and denied any current concerns or abuse. Despite the resident's current denial of abuse, the initial failure to investigate the reported allegation constituted a deficiency in the facility's response to potential abuse.
Failure to Review and Revise Resident Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that care plans for residents were reviewed and revised at least quarterly and as necessary to address changes in residents' conditions. Record review showed that for two residents, the most recent care plans were significantly outdated, with one last updated in March and the other in April, despite the current review taking place in October. During an interview, the Director of Nursing confirmed that the quarterly care plans for both residents were overdue. This deficiency was identified during a complaint survey and was based on both documentation and staff interview.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as observed during a survey conducted on multiple dates. During an entrance tour, several rooms were found with marring on the walls, including Rooms #200, #201, #203, #204, #205, and #206. Additionally, Rooms #204 and #208 had dirty floors with dark substances noted throughout. A specific bathroom was observed with a yellow water substance around the base of the toilet, wet dark brown stains on the floor extending up the wall, flaking paint, and a strong ammonia odor. The Director of Nursing was informed of these observations, and later, the Maintenance Director acknowledged the issues, citing a high turnover of environmental staff as a contributing factor. The Maintenance Director committed to addressing the concerns by touring the affected hallway and beginning work on the identified areas. The administrative team was also made aware of these deficiencies at the time of the survey exit.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the reasons for their transfer to the hospital. This deficiency was identified during a survey, which reviewed the cases of four residents who were hospitalized. In each case, the facility did not provide the required written transfer forms, and the residents or their representatives were not informed in writing about the reasons for the transfers. Interviews with staff, including the President of a sister company and the Business Office Manager, confirmed that the facility's practice was to provide verbal notifications only, and written notifications were not automatically provided. The surveyor's review of the medical records for the residents revealed a lack of documentation indicating that the residents or their representatives were notified in writing about the transfers. The Director of Nursing and the Business Office Manager confirmed during interviews that the facility did not send written notifications for transfers or discharges. This failure to provide written notification was consistent across all reviewed cases, indicating a systemic issue within the facility's procedures for handling hospital transfers.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The kitchen at the facility failed to maintain the integrity of food items by not properly labeling and dating opened food products. During an initial observation of one of the kitchen refrigerators, several items were found to be improperly stored. These included orange slices, dijon mustard, a block of yellow American cheese, and containers of mayo, relish, and chopped garlic, all of which were either past their use-by dates or undated. Additionally, an unidentified food item was found, which the cook was unable to recognize and subsequently discarded. Further inspection of the dry storage area revealed multiple opened and undated food items, including pasta bags, a box of rice, a bag of croutons, cereal bags, and a container of oats. The Certified Dietary Manager (CDM) confirmed that the expectation was for all opened items to be labeled with the date they were opened and their use-by date. In the cooking area, opened and undated items such as peanut butter, soy sauce, and oil were also found and discarded by the CDM. The surveyor discussed these concerns with the CDM, Director of Nursing, and the Nursing Home Administrator, highlighting the failure to ensure proper food storage practices.
Failure to Maintain Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure that a copy of a resident's Advanced Directives was obtained and maintained in the resident's medical record. This deficiency was identified during a review of the electronic medical record of a resident, where no documentation of Advanced Directives was found. The resident's record included a Social Services note indicating that the Resident Representative was also the Power of Attorney (POA), and an Admission Contract signed by the Resident Representative in the designated space for the POA. The contract stated that if the resident had an Advance Directive, a copy should be provided to the facility. During an interview with the Business Office Manager, it was revealed that the facility's procedure involves reviewing Advanced Directives with the resident or their representative upon admission and requesting a copy if one exists. This document is then supposed to be uploaded into the resident's electronic medical record, and the resident's profile updated to reflect the authoritative title. However, the facility was unable to provide a copy of the resident's Power of Attorney, indicating a lapse in their system for managing and maintaining these critical documents.
Failure to Include Care Plans in Resident Transfers
Penalty
Summary
The facility failed to include resident care plan goals with the required documentation during transfers, as evidenced by the cases of two residents reviewed for hospitalization. Resident #55 was hospitalized on two occasions, and Resident #37 was hospitalized on another occasion. In both instances, the Director of Nursing confirmed that care plans were not sent with the residents upon transfer from the facility. Interviews with two Licensed Practical Nurses (LPNs) revealed that they follow a transfer checklist to determine what documents to send with a resident, but the checklist did not include care plans. A review of the blank transfer checklist confirmed the absence of care plans as a required document for transfer. At the time of the survey exit, the surveyor discussed the concern regarding the failure to ensure care plans are sent with residents upon transfer.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to have a system in place to ensure that residents and/or their representatives were notified in writing of the bed hold policy at the time of discharge or transfer to a hospital. This deficiency was identified during a survey, where it was found that three out of four residents reviewed for hospitalizations did not receive written notification of the bed hold policy. Specifically, Resident #41's electronic medical record did not contain documentation indicating that the resident or their representative was notified in writing of the bed hold policy upon transfer to the hospital. Interviews with the Director of Nursing and the Business Office Manager confirmed the absence of such documentation. Similarly, Resident #55 was hospitalized on two occasions, and the facility was unable to provide a copy of the written bed hold policy form for one of the hospitalizations. The form from the other hospitalization lacked the resident's signature or any indication that the resident was informed. Interviews revealed that the policy was communicated verbally and not automatically provided in writing. Resident #37 also experienced hospitalizations, and the facility could not provide copies of the written bed hold policy forms for these events. The Business Office Manager confirmed that the policy was not sent to the family and was only available upon request.
Inaccurate MDS Coding for Resident's Functional Status
Penalty
Summary
The facility failed to ensure accurate coding of a resident's assessment by the MDS Coordinator, which did not reflect the resident's actual status at the time of the assessment. This deficiency was identified during a survey investigation for a resident with a history of hemiplegia, hemiparesis, and malignant neoplasm of the larynx. The MDS assessment completed on 06/14/24 indicated that the resident required partial assistance for toileting. However, a subsequent quarterly assessment showed a decline in the resident's functional status, indicating total dependence on staff for toileting assistance. The MDS Coordinator acknowledged that the coding on the quarterly assessment did not accurately reflect the resident's functional status. She explained that the resident's needs fluctuated between requiring minimal and maximum assistance, and she had coded the resident's needs somewhere in the middle. The discrepancy was attributed to a recent change in facility ownership, which required reviewing information from the old system to determine the resident's decline. The administration team was informed of these concerns at the time of the survey exit.
Failure to Implement Care Plan for Wandering and Elopement Risk
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident identified as high risk for wandering and elopement. This deficiency was discovered during a survey when reviewing the electronic medical record of a resident who exhibited wandering behavior and expressed a desire to go home. The resident's medical record included a skilled progress note indicating the resident was walking aimlessly and refusing redirection. An Elopement Evaluation note further identified the resident as high risk for elopement with a score of 3. Despite these findings, the resident's care plans did not include any strategies or interventions to address the wandering and elopement risk. The facility's policy requires that residents identified as at risk for wandering or elopement have a care plan in place to ensure their safety. During an interview with the Director of Nursing and a Corporate Designee, it was confirmed that no care plan had been initiated for the resident's wandering and elopement risk.
Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to maintain an effective system for ensuring accurate documentation of resident code status regarding Cardiopulmonary Resuscitation (CPR). This deficiency was identified for one resident, who had conflicting code status orders in their medical records. The resident's Electronic Health Record (EHR) indicated a code status of 'Attempt CPR,' while a paper MOLST form in the nursing station binder indicated 'No CPR, Option B, Palliative and Supportive Care / Do Not Resuscitate (DNR).' The inconsistency arose because the MOLST form dated earlier was not voided when a new form was created, leading to conflicting information about the resident's code status. Interviews with the Director of Nursing (DON) revealed that the facility did not have hard paper charts and relied on the EHR for resident MOLST forms and code status. However, MOLST forms were also kept in binders at the nursing station and with the Social Worker. The DON acknowledged that the MOLST forms should reflect one another and that outdated forms should be voided when new ones are created. The failure to void the outdated MOLST form resulted in a discrepancy between the EHR and the paper MOLST form, leading to confusion about the resident's code status orders.
Failure to Provide Resident-Specific Activities
Penalty
Summary
The facility failed to provide activities to a resident based on their preferences and care plan, as evidenced by the case of one resident reviewed for activities. The resident, who has cognitive deficits related to dementia, was observed on multiple occasions without any activity stimulation, despite their care plan indicating the need for cognitive stimulation. The resident's preferences included reading materials, music, news, pets, and coloring, but the activity log showed only two documented activities for the entire month, with no records of refusals. Interviews with the Activities Director and Assistant revealed that while they claimed to visit residents daily and document activities or refusals, the documentation for this resident was lacking. The Activities Director acknowledged the deficiency in the activity log and had communicated expectations to the assistant. The surveyor noted the concern regarding the failure to provide activities based on the resident's interests and care plan during the exit review.
Failure to Assess and Implement Orders for Residents
Penalty
Summary
The facility failed to ensure proper assessment and immediate treatment for a resident who sustained an injury of unknown origin. A resident was found in another resident's room with a bleeding lip, but the LPN on duty did not perform a thorough assessment, notify the family or physician, or report the incident to administration. The resident was later transferred to the hospital, where a laceration requiring sutures and a sprained knee were diagnosed. This incident highlights a lack of adherence to protocol in assessing and reporting injuries. Additionally, the facility did not implement physician orders for another resident who required bilateral floor mats as a fall precaution. Observations revealed that only one floor mat was in place, contrary to the active order. The DON acknowledged the discrepancy, noting that the other side posed a fall risk to the resident's ambulatory roommate. Furthermore, a third resident was not assessed upon readmission to the facility, as required by the facility's policy. The lack of documentation for the admission assessment was confirmed by the Corporate Infection Control Designee, indicating a failure to follow established procedures for new or readmitted residents.
Failure to Conduct Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that all nursing staff had competency evaluations, as evidenced by the lack of such evaluations for three Geriatric Nursing Assistants (GNAs) out of five randomly selected staff members. Specifically, GNA #10, hired in March 2024, GNA #30, hired in August 2016, and GNA #31, hired in June 2018, did not have any competency evaluations on file. According to the Director of Nursing, competencies should be conducted annually and at the 90-day mark for new hires. However, the Chief Operations Officer confirmed that no performance evaluations could be found for these staff members, indicating a lapse in the facility's adherence to its competency evaluation protocol.
Failure to Post Required Nursing Staffing Data
Penalty
Summary
The facility failed to post the required nursing staffing data on the Daily Staffing Schedule for six consecutive days during the survey. Observations made by the surveyor on multiple days revealed that while a staffing sheet was posted, it did not include the facility's census or the actual and total number of hours worked by Geriatric Nursing Assistants (GNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). This deficiency was confirmed during a review with the Chief Operations Officer, indicating non-compliance with the required nursing staff data posting regulations.
Failure to Document Review of Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician or Director of Nursing (DON) documented and signed in the medical record to show they had reviewed irregularities or recommendations identified by the pharmacist during the Medication Regimen Review (MRR). This deficiency was evident in three out of five residents investigated for unnecessary medications, psychotropic medications, and medication regimen review. The clinical pharmacist identified irregularities and made recommendations for these residents, but there was no documentation of review or action taken by the attending provider or DON within the required timeframe. For Resident #19, the pharmacist made recommendations on multiple occasions from February to September 2024, but the attending physician only reviewed the recommendations from August and September in October 2024. Similarly, for Resident #41, recommendations made in July and September 2024 were not reviewed within 30 days. Resident #50 also had recommendations made in May, June, July, and September 2024, with no documentation of review or action taken. The DON confirmed that the MRR policy had not been followed for some time, and there was a lack of timely review and documentation of the pharmacist's recommendations.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility staff failed to comply with the policy regarding the limitation of PRN orders for psychotropic medications to 14 days. This deficiency was identified during a review of a resident's medical record, which revealed an active order for hydroxyzine, a medication used to control anxiety and tension, prescribed as needed every 8 hours. The order, dated 9/19/24, did not include a 14-day limitation as required by the facility's policy. This oversight was confirmed during a staff interview and a review of the facility's policy on psychotropic medication use.
Failure to Safely Store Medications and Medical Supplies
Penalty
Summary
The facility failed to ensure the safe storage of medications and medical treatment supplies, as observed by the surveyor. In the medication room, expired items were found, including a box of Banatrol Plus and packs of Curad Xeroform Petroleum dressing. Additionally, medications such as Sodium Polystyrene Sulfonate and Ceftriaxone Sodium injection solution were left over after their prescribed courses for two residents, and an opened, undated vial of Lidocaine was also present. These medications were confirmed by the Director of Nursing (DON) and Corporate Designee to be unused and should have been returned to the pharmacy or destroyed. In the medical supply room, labeled as the linen room, the surveyor noted expired bottles of Jevity Complete Balanced Nutrition with Fiber. The DON confirmed the presence of these expired bottles during an interview and subsequently removed them from the supply room. These observations indicate a failure in the facility's protocol for monitoring and managing the expiration and storage of medications and medical supplies.
Failure to Serve Meals According to Resident Preferences
Penalty
Summary
The facility failed to ensure that residents were served meals according to predetermined menus that incorporated their preferences. This deficiency was observed during a meal service where three residents did not receive the meals as indicated on their meal tickets. Resident #32 requested a peanut butter and jelly sandwich, which was noted on their meal ticket, but it was not included on their tray. Similarly, Resident #8's meal ticket did not list rice, yet rice was included on their tray. Resident #17's meal ticket indicated roasted red skin potatoes as the starch, but they were served rice instead. The surveyor confirmed these discrepancies through observations and interviews with staff members, including a GNA and the Certified Dietary Manager (CDM). The CDM acknowledged that the expectation was for residents to receive meals as specified on their meal tickets. The surveyor reviewed these findings with the facility at the time of exit, highlighting the failure to ensure residents received meals according to their documented preferences and dietary needs.
Failure to Maintain Accurate Physician Orders for Oxygen Use
Penalty
Summary
The facility failed to maintain accurate physician orders for the use of oxygen for a resident. During observation rounds, the resident was observed to be on 2 liters of oxygen by nasal cannula. Staff confirmed that the resident had been receiving oxygen continuously for a long time but could not find a physician's order authorizing this treatment. A review of the resident's medical record revealed no physician orders for the administration of oxygen. Staff acknowledged the absence of a physician order and indicated that the physician would be notified for clarification.
Lack of Onsite Infection Preventionist
Penalty
Summary
The facility failed to have an Infection Preventionist Designee onsite to oversee the Infection Prevention and Control Program. During the entrance conference, the Administrator and the Director of Nursing (DON) revealed that the DON, who had been at the facility for about a month, was scheduled to attend an Infection Control training class. In the meantime, the facility was relying on a Corporate Infection Control Designee who is certified but does not work onsite. The Administrator was informed that the Infection Control Designee must be present at the facility and not operate in an off-site corporate capacity. An interview with the Corporate Infection Control Designee confirmed her awareness of the requirement for the Infection Preventionist to work onsite, and she mentioned that the facility was in the process of hiring for this position.
Deficiency in Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential patient care equipment in safe and working conditions, as observed during a survey. Three hand sanitizer dispensers located outside rooms #108 to #115 were found to be either empty or not properly secured to the wall. Additionally, a DS Smart vital sign machine was observed to be non-functional, as it would not turn on and had connection wires that did not fit properly. Staff confirmed the machine was broken and acknowledged a shortage of working vital sign equipment on the floor, which hindered the ability to obtain resident vital signs effectively.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of an unknown source for a resident, which was discovered during a survey. The incident involved a resident who was found in another resident's room with a bleeding lip. A Geriatric Nursing Assistant (GNA) found the resident and informed a Licensed Practical Nurse (LPN), who cleaned the resident's face but did not conduct a further assessment or notify the family, physician, or administration. The LPN also failed to write an incident report. The facility's policy requires that injuries of an unknown source be immediately reported to the administration, which was not done in this case. The resident was later transferred to the hospital, where it was determined that they had a laceration on the upper lip requiring sutures and a sprained right knee. The facility's failure to report the injury promptly and follow the established protocol for such incidents was identified as a deficiency during the survey. The surveyor confirmed with the facility's Administrator that the LPN should have reported the injury immediately, as per the facility's abuse policy.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to submit the required direct care staffing information based on payroll data to the Centers for Medicare/Medicaid Services (CMS) for the quarter. This deficiency was identified during a review of the CASPER Payroll-Based Journal (PBJ) Staffing Data Report document from CMS, which revealed the absence of the necessary submission. An interview with the Chief Operations Officer indicated that this incident occurred under the previous ownership of the facility. The issue was further discussed during the exit meeting with the surveyor, highlighting the facility's failure to comply with the staffing data submission requirements.
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.
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.
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.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
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 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.
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.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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