Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Solomons Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident with dementia, wandering, and a documented history of agitation and aggression was not sufficiently supervised to prevent a resident-to-resident altercation. Records showed repeated behaviors including pacing, running, entering other residents’ rooms, and becoming combative with staff and residents, with care plan interventions for redirection, meal supervision, and separation from others when indicated. During the incident, the resident pushed another resident near the nurses’ station, causing a fall and head injury that required transfer to the ED. Staff interviews confirmed the resident had been aggressive for months and that close monitoring began only after the altercation.
A resident with dementia, agitation, psychosis, and anxiety had a Quarterly MDS that was coded with no wandering, no rejection of care, and no behavioral symptoms even though the record and staff interviews showed daily wandering, agitation, resistive care, and combative behaviors. Staff documented repeated wandering, grabbing, spitting, scratching, yelling, and refusal of care or meds during the look-back period, and the MDS nurse stated the behaviors were not coded because they were already addressed in the care plan.
Meals were observed being served at unsafe temperatures during tray line and meal cart checks. A pork entree, sides, fruit, and milk were found below the stated hot and cold holding temperatures, and the FSD confirmed the concerns after the observations.
Food Stored Improperly in Kitchen and Storage Areas: The surveyor observed multiple expired dry goods, dented cans, and opened pudding mixes without dates in the kitchen storage area. Sliced bologna in the walk-in was not dated, and multiple boxes of food deliveries and nutritional supplements were stored directly on the floor. The FSD acknowledged that food should not be stored on the floor and that the bologna needed to be dated.
Two residents with urinary catheters were observed with drainage bags exposed without privacy bags in place. One resident’s catheter bag was hooked to a wheelchair without a cover, and another resident was seen at the nursing station with the drainage bag uncovered until staff later placed it inside a privacy bag. The facility policy required catheter drainage bags to be covered at all times, and the ADON confirmed the resident should have had a privacy bag in place.
Unclean and Damaged Resident Rooms and Laundry Area: Surveyors observed holes in a resident bathroom wall, peeling paint and holes behind two residents' beds, and stained ceiling tiles in the soiled laundry room. The MD toured the areas with the surveyor and acknowledged the damaged walls and stained tiles.
Incomplete bed hold notification after hospital transfer: A resident with a BIMS of 2 was transferred to the hospital, but the bed hold form in the record was left mostly blank and there was no documentation that the completed written bed hold notice was provided to the resident or representative. Staff said the transfer packet was sent with the resident, but the form was not fully completed and there was no record of the required follow-up call about the bed hold policy.
Failure to invite residents to quarterly care plan meetings: two residents did not receive the required interdisciplinary care plan meetings, and one resident reported never being invited. Record review showed missed quarterly meetings, while staff gave conflicting accounts about who was responsible for invitations and how the meetings were scheduled.
Failure to assess a resident complaint and maintain Foley catheter documentation. A resident with stomach cramps was not assessed by the RN before the physician was notified, and the resident later reported the nurse still had not seen him/her. In a separate finding, another resident with an indwelling Foley catheter was unsure why it was present, and the record lacked an order, catheter care documentation, and a care plan; staff could not determine when or why the catheter had been placed.
A resident was found heavily soiled in bed with brown stains on the night gown, chuck pad, and fitted sheet, with some stains appearing dried. The DON observed the resident and said it looked like diarrhea. An LPN stated her morning walkthrough did not include checking for soiling, and the resident’s care plan called for regular checks, toileting assistance, and pericare after each incontinent episode.
A resident with an active order for a two-person transfer assist using a wheelchair, safety belt, and proper footwear fell during a transfer after a GNA attempted to use a sit-to-stand device that did not work and then tried to transfer the resident alone. The resident slid from the toilet and struck the back of the head on the toilet. Staff interviews confirmed the aide was alone, did not request help until after the fall, and that sit-to-stand devices typically require two staff members.
A resident with a left heel pressure ulcer had an active order for moon boots at all times while in bed, but was observed lying in bed without the boots or heel offloading with a pillow. Staff acknowledged the resident often refused the boots, yet the resident stated staff did not ask, and a GNA assisted the resident into bed without providing the ordered protection until the issue was identified.
Respiratory Care Deficiencies: Two residents receiving oxygen therapy were observed without Oxygen in Use signs on their doors, and the oxygen concentrator humidification bottles and tubing were not dated. For one resident with COPD on continuous O2, the humidifier bottle was empty, the resident reported a dry nose, the tubing and bottle remained undated, and the resident stated the bottle had not been changed and that no staff had come to assess the issue.
Inaccurate narcotic reconciliation was identified for a resident’s liquid morphine on a med cart. The narcotic book showed 6.5 ml, while the bottle contained about 12 ml, and an LPN confirmed she relied on the book count without checking the bottle. The DON later showed an unopened morphine bottle with a volume that did not match the pharmacy label, and the surveyor noted nurses were signing off on an inaccurate volume without properly reconciling the narcotic.
Surveyors found improper medication storage in a medication room and on a med cart. The room contained non-medication items in resident bags, expired meds mixed with current stock, and a bag of discontinued meds left there for months. The cart had an unopened insulin vial and insulin pen that required refrigeration, an expired vial of Lantus, and medication for discharged residents. An RN confirmed the items were stored improperly and said there was no set process for checking carts for expired meds.
A resident with an order for a mechanical soft ground diet with double portions did not receive the ordered breakfast items, and staff had to return the tray to the kitchen after the resident complained that the extra milk and cold cereal were missing. The resident reported this happens almost every day and that the correct tray often takes about 30 minutes to arrive. Later, the resident was observed trying to eat a whole sausage patty on the replacement tray, and an RN told the resident it was okay to eat even though it was not mechanically soft ground.
Inaccurate MAR documentation for Lorazepam administration: A resident had orders for both Lorazepam tablets and oral concentrate, with a prior order to discontinue the tablets when the liquid arrived and not give both forms. An RN documented both forms as given at the same times even though he stated he administered only the liquid doses; the controlled drug record confirmed only the oral concentrate was administered, and the discontinue order did not appear on the MAR for staff to view and sign off.
Lack of designated IDT member for hospice services: A resident receiving hospice for heart failure had no hospice election form or recertification available in the facility record during survey review. The DON said hospice usually does not provide the election form to the facility and noted the SW worked some with hospice, while the NHA stated the facility did not have a designated IDT member working directly with hospice on behalf of the facility.
Staff failed to maintain infection control for two residents with urinary catheters. One resident’s catheter bag was observed dragging on the floor while an aide pushed the resident in a wheelchair, and another resident’s drainage bag was seen hooked to the wheelchair and partially on the floor. Staff acknowledged the bags should not touch the floor, and records showed both residents had catheter care plans.
The facility failed to ensure staff received education on the current COVID-19 vaccine. During record review, the surveyor could not locate documentation of staff education, and the ICP reported that only 2 staff had received the current COVID-19 vaccine. The ICP stated staff were offered a flu clinic and could go to Walgreens for the COVID-19 vaccine, but no education had been provided.
A resident with multiple comorbidities, moderate cognitive impairment, and high fall risk experienced a fall from bed. Despite facility policy requiring assessment, post-fall documentation, incident reporting, and notification of the physician, family, and oncoming staff, the assigned RN did not complete the required paperwork, did not document the fall, and was unsure if it was reported to the next shift. A GNA reported the resident’s leg as "wobbly" and, with a CMA, assisted the resident back to bed after being told the nurse had assessed the resident. The following day, another RN noted swelling, discoloration, and abrasions of the resident’s leg and ankle, and an LPN later requested physician evaluation, leading to hospital transfer where imaging revealed a comminuted fracture of the distal tibia and fibula.
A survey revealed that the facility failed to maintain a homelike environment in resident rooms, with issues such as missing towel hangers, damaged footboards, and bathroom fixture problems. These deficiencies were confirmed by the Administrator and Director of Maintenance.
The facility failed to ensure effective mechanical ventilation in resident bathrooms, affecting 5 out of 7 rooms reviewed. During a tour with the Administrator and the Director of Maintenance, it was observed that bathrooms in certain rooms did not have effective ventilation, as confirmed by a test using a thin piece of paper. The Director of Maintenance attributed the issue to likely nonfunctional motors in the rooftop ventilation units.
The facility failed to protect residents from abuse, as evidenced by grievances and interviews. A resident reported verbal abuse by a GNA/CMA, corroborated by a social worker's grievance. Another resident reported rough treatment and public embarrassment by the same GNA/CMA. A third resident alleged physical abuse by a GNA, which was documented but not investigated. The facility's grievance process was inadequate, leading to a failure to address and prevent abuse.
A resident with diabetes and neuropathy experienced harm due to inadequate foot care. Despite a podiatrist's recommendation for antibiotic ointment and monitoring, no orders were documented, and confusion about which toe was affected persisted. The resident's condition worsened, leading to a hospital transfer and partial amputation. The facility's failure to document and follow through with care recommendations contributed to the harm.
The facility failed to resolve grievances filed by residents, including verbal abuse, rough handling, and unresolved complaints about care and personal belongings. Despite grievances being logged and assigned to department supervisors, there was no documentation of resolution or follow-up. Interviews revealed a lack of communication and follow-up in the grievance process, leading to unresolved grievances and a failure to protect residents' rights.
The facility failed to report residents' allegations of theft and abuse in a timely manner. A resident reported missing money, but the facility delayed reporting to OHCQ. Another resident's abuse allegation was not investigated promptly. Multiple grievances about verbal abuse and rough treatment were documented but not resolved, indicating systemic issues in handling such complaints.
The facility failed to conduct thorough investigations and maintain documentation for multiple abuse allegations involving residents. Incidents included physical and verbal abuse by GNAs, with missing documentation of interviews and follow-ups. The NHA acknowledged the deficiencies, and the DON noted systemic issues in handling such allegations.
A resident with a history of diabetes and other conditions experienced a delay in receiving scheduled medication due to altered mental status. The medication, Glimepiride, was scheduled for administration at 8:30 AM but was not attempted until 10:40 AM, two hours late. The facility's policy requires medications to be given within one hour of the scheduled time, which was not followed in this instance.
A facility failed to deliver meals at appropriate temperatures, as observed during a survey. A resident and families reported that food was lukewarm and not palatable. A test tray showed food temperatures below expected levels, with chicken at 119°F, rice at 126°F, potato at 117°F, and peas at 120°F.
The facility failed to store food according to professional standards, with unlabeled and expired items found in the kitchen and personal items in the freezer. Significant ice buildup was also observed, creating a slippery area. The Certified Dietary Manager confirmed these issues, indicating a lapse in following the facility's food labeling and dating procedures.
The facility failed to maintain accurate medical records and incident documentation for three residents. Two residents had conflicting MOLST forms in their charts, leading to potential confusion about their code statuses. Additionally, the facility did not properly document falls and related injuries for two residents, with one resident's fall protocol not completed immediately and another's pain management assessments failing to note a significant fracture and surgery.
A facility failed to notify a resident's medical Responsible Party (RP) about changes to the care plan, specifically the end of Medicare-covered services, contacting only the financial RP instead. Interviews revealed a misunderstanding of notification protocols, leading to the medical RP being uninformed on multiple occasions.
A resident's diet was changed from mechanical soft to pureed texture and chopped meats without prior notification to the Responsible Party (RP) or documented rationale. The LPN involved believed the change was due to dental needs, but there was no evidence of RP notification or documentation supporting the change, leading to a deficiency noted by the surveyor.
The facility failed to promptly address concerns from the family council group for several months. Despite the NHA's claim of timely responses, evidence showed delays in addressing issues raised in meeting minutes from April, May, July, August, and September. The deficiency was identified through a complaint and confirmed by reviewing meeting minutes and interviews.
The facility did not have the required Residents' Rights information, including contact details for the Maryland Long-Term Care Ombudsman and the state survey agency, posted in accessible locations. This was noted across all resident care areas, and staff confirmed the postings were removed during renovations. The NHA later provided the necessary poster for display.
The facility staff did not display the annual recertification survey results in an accessible location for residents, family members, and legal representatives. The survey results were initially kept in the NHA's office and were not available in the lobby or any open area. The NHA explained that the binder might have been removed due to renovations. Eventually, the survey results were placed in the reception area, but the most recent results were from 2019.
The facility failed to maintain copies of Advance Directives for three residents and did not address a resident's request to discontinue thickened liquid treatment. Despite acknowledging the presence of Advance Directives, the facility did not ensure they were included in medical records. Additionally, a resident's desire to stop a specific treatment was not discussed with relevant parties, leaving the request unaddressed.
The facility failed to provide written notification of hospital transfers to two residents and their representatives, as required by regulations. One resident was transferred twice without written notice, and another was transferred after becoming unresponsive, with no documentation of notification. The Director of Nursing was unaware if notifications were being done.
A resident with flaccid hemiplegia was observed without the prescribed arm support, despite a physician's order and care plan intervention for a Comfy Grip Splint to be worn during the daytime. A staff member confirmed the need for the splint and applied it after the surveyor's inquiry, highlighting a lapse in care.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. On four specific days, there was no RN coverage for 24 hours. The DON confirmed the absence of staffing waivers and acknowledged the issue, particularly on weekends. The Staff Scheduler noted challenges in securing weekend RN coverage, although a weekend supervisor who is an RN was expected to start soon.
The facility failed to prevent infection spread and maintain equipment standards. A resident with Covid-19 was found without droplet precaution signage, and another resident's oxygen equipment was improperly labeled and maintained. Staff acknowledged and addressed these deficiencies.
The facility failed to maintain the walk-in freezer in safe operating condition, resulting in ice buildup on the ceiling and floor, creating a slippery hazard. Despite a previous assessment attributing the issue to condensation, the problem persisted, and recent documentation of service calls was not provided. The deficiency highlights a failure to ensure essential equipment is working safely.
A facility failed to ensure a resident had a call bell within reach, as observed by a surveyor on two occasions, despite being informed by an LPN. Additionally, another resident with a history of surgical amputation and mobility issues was not provided with necessary bedrails in a timely manner, as the facility delayed ordering additional bedrails despite the identified need.
The facility failed to conduct timely care plan meetings and include necessary interventions for residents. A resident had no care plan meetings documented for quarterly assessments, while another resident's care plan lacked interventions for therapeutic activities. The scheduling process for care plan meetings was flawed, leading to missed meetings.
The facility failed to maintain good personal hygiene for two residents. One resident, requiring extensive ADL assistance, had inconsistent shower documentation, and the DON could not confirm showers were given. Another resident experienced a 52-minute delay in toileting assistance despite activating the call light. The DON acknowledged the need for timely response.
The facility failed to document wound care responses for a resident with a sacral wound, leading to unclear treatment effectiveness. Additionally, another resident requiring two-person assistance for transfers was moved by a single aide, resulting in shoulder pain. These deficiencies highlight lapses in documentation and adherence to care protocols.
Inadequate supervision of a cognitively impaired resident with aggressive behaviors
Penalty
Summary
The facility failed to ensure that supervision and behavioral interventions for a cognitively impaired resident were sufficient to prevent a resident-to-resident altercation. The resident involved had diagnoses including dementia with agitation, dementia with behavioral disturbance, dementia with psychotic disturbance, generalized anxiety disorder, psychosis, and chronic pain. The resident’s care plan identified multiple behavioral concerns, including wandering, resistive care, physical aggression, agitation, pacing, disrobing, inappropriate verbal responses, violence toward staff and others, and use of utensils aggressively. The care plan also included interventions such as monitoring for behavioral triggers, administering medications as ordered, psychiatric follow-up, redirecting during agitation, supervising meals, separating the resident from others during meals when indicated, and using diversion and de-escalation techniques. Progress notes documented repeated episodes of agitation, wandering, physical aggression, and attempts to redirect the resident. Notes described the resident swinging at staff, going after another resident with a fork during lunch, pushing and hitting staff, wandering into other rooms, refusing treatment and medication, and running down the hallway. On 3/23/26, after the resident-to-resident altercation, the resident was placed on close supervision with 15-minute safety checks and staff were instructed to keep the resident within line of sight in the day room or in front of the nurses’ station. A later note documented concern that the resident’s behaviors were worsening and that there was concern for harm to self or others. The incident involved another resident who was ambulating near the nursing station when the aggressive resident pushed that resident, causing the resident to hit the wall, fall to the floor, and strike the head. The injured resident had diagnoses including dementia with behavioral disturbance, difficulty walking, history of falls, and cognitive communication deficit. Nursing and provider notes documented that the resident had head injury and neuro changes after the fall and was transferred to the emergency department. Staff interviews confirmed that the aggressive resident wandered daily, had a wander guard, became combative with staff and residents, and had a history of aggression before the incident. Interviews also confirmed that close monitoring did not begin until after the resident pushed the other resident.
MDS assessment did not reflect wandering and behavioral symptoms
Penalty
Summary
The facility failed to ensure the Quarterly MDS assessment accurately reflected Resident #11’s wandering and behavioral symptoms. Resident #11 was admitted with diagnoses including dementia with agitation, dementia with behavioral disturbance, dementia with psychotic disturbance, generalized anxiety disorder, and psychosis. The Quarterly MDS assessment was coded as showing no behavioral symptoms, no rejection of care, and no wandering, despite the resident being cognitively impaired and having multiple care plans identifying elopement risk, resistive behavior, aggression, pacing, wandering, disrobing, inappropriate verbal responses, crying, violence toward staff and others, and refusal of staff assistance with dressing. The record review showed that during the MDS look-back period, staff documented wandering, repeated movement, rejection of care, pinching, scratching, spitting, and grabbing. A progress note also documented that the resident was agitated and continued to ambulate independently, with times of increased agitation. Additional documentation showed the resident refused vital sign checks. Staff interviews described the resident as confused, wandering daily throughout the facility with a wander guard in place, carrying blankets and personal belongings, becoming agitated when belongings were removed, grabbing staff during care, refusing medications at times, and exhibiting yelling, striking, swatting, screaming, spitting, and combative behavior toward staff and other residents. The MDS nurse stated the resident’s wandering, rejection of care, and other behaviors were not coded on the Quarterly MDS assessment because they believed behaviors already addressed in the care plan did not need to be coded, even if they occurred during the 7-day look-back period. The Regional MDS Consultant stated that behavioral symptoms occurring during the look-back period should be coded accurately and that the resident should have had wandering and behavioral symptoms reflected on the Quarterly MDS assessment.
Meals Served at Unsafe Temperatures
Penalty
Summary
The facility failed to ensure that meals were delivered to residents at safe and palatable temperatures. During a kitchen tray service line observation, the surveyor observed pork loin at 100 F, apple juice at 43 F, and a milkshake at 42 F. When interviewed about the tray line temperatures, facility staff stated that the tray line temperature should be maintained between 150-160 F and said the pork loin would be placed back into the hot steamer for 10 minutes. When the Food Service Director rechecked the pork loin, its temperature was 50 F. During later meal cart observations, Resident #6's lunch tray on the Chesapeake Unit contained Sweet and Sour Pork at 82 F, steamed broccoli at 90 F, fried rice at 80 F, diced pineapple at 50 F, and fat-free milk at 51 F. On the Patuxent Unit, a lunch test tray on cart #3 contained sweet and sour pork at 100 F, fried rice at 90 F, steamed corn at 100 F, and whole milk at 45 F. The Food Service Director was interviewed afterward and confirmed the concerns identified above.
Food Stored Improperly in Kitchen and Storage Areas
Penalty
Summary
The facility failed to store food in a manner consistent with professional standards for food service safety. During the initial kitchen tour, the surveyor and Food Service Director observed multiple expired dry storage items, including several spices, pudding mixes, crackers, cookies, cream of rice, nutritional drinks, and tomato juice. The surveyor also observed two dented cans of whole kernel golden corn, and a box of vanilla instant pudding and a box of chocolate instant pudding that had been opened but were not dated. In the walk-in refrigerator, sliced bologna was stored in a white plastic container with a green lid and was not dated. The surveyor also observed fifteen boxes of food deliveries stored directly on the floor in front of the dry storage room door, and later observed additional boxes of nutritional supplements sitting on the floor in the dry storage area. The Food Service Director stated that delivery items had just arrived and staff were waiting to put them away, and acknowledged that food items are not supposed to be stored directly on the floor and that the sliced bologna was required to be dated.
Failure to Maintain Dignity With Exposed Catheter Drainage Bags
Penalty
Summary
The facility failed to maintain resident dignity for two residents with urinary catheters by leaving catheter drainage bags exposed without privacy bags in place. Resident #9 was observed in his/her room with the urinary catheter bag hooked to the side of the wheelchair and no privacy bag covering it. The facility’s Catheter Care Policy stated that privacy bags would be available and catheter drainage bags would be covered at all times while in use, and the Administrator acknowledged the concern during interview. Resident #69 was observed sitting in front of the nursing station in a wheelchair with the urinary catheter drainage bag hooked to the bottom of the wheelchair and not inside a privacy bag. A GNA stated that a privacy bag should have been over the drainage bag and said the resident’s privacy bag had ripped and needed replacement. A later observation showed the drainage bag inside a privacy bag. The resident’s care plan included use of a privacy bag for the urinary catheter, and the ADON confirmed the resident should have had the privacy bag covering the urine collection bag while at the nursing station.
Unclean and Damaged Resident Rooms and Laundry Area
Penalty
Summary
The facility failed to ensure resident rooms and the soiled laundry room were maintained in a clean, homelike environment. During survey observations, holes were seen across the wall at the baseboard in Resident #7's bathroom, peeling paint was observed on the wall behind Resident #17's bed, and peeling paint and holes were observed on the wall behind Resident #91's bed. In the soiled laundry area, multiple brown stains were observed on the ceiling tiles above the washer and dryers. During a later tour with the Maintenance Director, the damaged walls in Resident #7's bathroom and the resident rooms of Residents #17 and #91 were again observed, and the stained ceiling tiles in the soiled laundry room were also noted.
Incomplete Bed Hold Notification After Hospital Transfer
Penalty
Summary
The facility failed to ensure that Resident #101 or the resident representative received a completed bed hold notification form in writing after the resident was transferred to the hospital. The medical record contained a signed transfer notice dated 11/11/2025, but the bed hold form in the record had only the resident’s name written on it and the remainder of the form was left blank. When the Nursing Home Administrator was asked for the bed hold form, a copy was later provided, and the administrator explained that Resident #101 had a BIMS score of 2 and was not able to sign the form. Staff interviews showed that the facility’s transfer process included sending paperwork with the resident, but the bed hold form was not completed in full for Resident #101. RN #2 stated that the Unit Clerk #8 usually completed the transfer summary and bed hold form, or the RN would do it if the unit clerk was unavailable, but she only filled in the resident’s name and did not know the bed hold charge. The Business Office Manager stated the facility’s process was to send the transfer summary and bed hold form with the resident and then follow up by phone within 24 hours, but there was no note in Resident #101’s medical record documenting a call to discuss the bed hold policy and form.
Failure to Invite Residents to Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents were invited to and provided quarterly care plan meetings. For Resident #7, the resident stated during interview that he/she had never received an invitation to attend care plan meetings. Record review showed care plan meetings were held only on 02/20/25 and 09/23/25, and the resident had not received quarterly meetings. The Social Worker stated she believed a family member attended the meetings and confirmed the resident had not been invited. The Unit Manager reported that the Social Worker and Receptionist invite residents, while the Social Worker later stated she did not have a process to invite the resident and believed nursing staff did it. The NHA acknowledged residents had not received invitations and stated he planned to implement a process by posting invitation cards in resident rooms. For Resident #61, the resident denied having any recent care plan meetings. Medical record review showed the resident had not had a care plan meeting since 8/12/2025 and remained in the facility. The Social Worker confirmed the resident had not had a care plan meeting since that date and stated the resident should have had one in November, but she was unsure how it was missed.
Failure to assess resident complaints and maintain Foley catheter orders
Penalty
Summary
The facility failed to provide services that met professional standards of practice for a resident who complained of stomach cramps. During an interview, the resident was observed grimacing and reported having stomach cramps but had not told the nurse. When the concern was relayed to RN #2, the RN said she would check whether the resident had any medications and would check on the resident. Later, the resident reported that the nurse had still not seen him/her and the stomach cramps continued. RN #2 then stated that she had notified the physician based on what the surveyor reported, but she had not assessed the resident before contacting the physician. The RN acknowledged that this was not her normal practice, and the NHA stated that the expectation was for the nurse to assess a resident who complained of a medical concern before notifying the physician. The facility also failed to maintain appropriate orders and documentation for a resident with a Foley catheter. The resident stated he/she was unsure why the Foley catheter was in place, and the surveyor observed clear yellow urine without sediment or hematuria. Review of the medical record found a diagnosis of bladder incontinence but no order for a Foley catheter, no Foley catheter care order, and no care plan for the catheter. The record did include a voiding trial order with clamp and unclamp instructions and a planned discontinuation date, and the MDS assessment identified the resident as having an indwelling catheter. During follow-up review, the surveyor and DON could not determine when or why the resident received the Foley catheter, and the DON acknowledged the concern.
Delayed Incontinent Care and Soiled Bedding
Penalty
Summary
The facility failed to ensure ADL care was provided in a timely manner for one resident who was found in bed heavily soiled with large brown stains on the back of the night gown, chuck pad, and fitted sheet. During the surveyor’s observation, some of the stains had dried circles around them, indicating they were not new. The surveyor photographed the stains and showed them to the DON, who observed the resident and stated it looked like diarrhea and said she would get the assigned GNA to clean the resident and investigate. During interviews and record review, an LPN reported that her morning walkthrough around 7:00 a.m. was limited to checking whether the resident was breathing and not in distress, and that it was the GNA’s responsibility to check each resident for soiling at the start of the shift. The resident’s care plan included interventions for bowel incontinence, including checking the resident every two hours, assisting with toileting as needed, and providing pericare after each incontinent episode. The care plan was later revised to include checking the resident after breakfast and assisting with incontinent care as needed. The DON later reported that the GNA stated she checked the resident at the beginning of the shift and the resident was dry.
Failure to Follow Ordered Two-Person Transfer Assistance
Penalty
Summary
The facility failed to ensure that Resident #13 received transfers in accordance with the resident’s active order for a two-person assist using a wheelchair, with a safety belt in place and proper footwear donned. On 01/12/2026, the resident reported that a GNA attempted to use a sit-to-stand machine, but the equipment did not work, and the GNA then attempted to transfer the resident, during which the resident fell and struck the back of his/her head. A nursing note documented that the resident slid from the toilet and hit the back of his/her head on the toilet, with no redness, bruising, pain, or other injuries noted at that time. Record review and staff interviews confirmed that the aide attempted the transfer without assistance after the sit-to-stand device malfunctioned. LPN #7 stated that the aide was alone in the room and did not request help until after the resident had already fallen, and also confirmed that sit-to-stand devices typically require two staff members. Unit Manager #11 identified the aide as GNA #27 and stated that the aide and other staff were educated after the incident. The DON also confirmed that the resident had an active transfer order requiring two-person assistance and that staff education was provided as a result of the incident.
Failure to Provide Ordered Heel Offloading for Resident With Pressure Ulcer
Penalty
Summary
Failure to provide appropriate pressure ulcer care was identified for a resident with an active left heel pressure ulcer and an order for moon boots at all times while in bed for skin protection. On observation, the resident was found lying in bed without moon boots and without a pillow under the heels to offload pressure, while the moon boots were sitting in a chair. The resident also had a pressure ulcer of the left heel with an onset date of 09/25/2025. During the investigation, staff acknowledged that the resident frequently refused the moon boots and that a pillow could be used if the boots were refused. However, when the resident was observed in bed without heel protection, the resident stated that staff did not ask about wearing the moon boots. A GNA assisted the resident into bed without placing the moon boots or a pillow under the feet, and the LPN confirmed the feet were not elevated until after the concern was identified.
Respiratory Care Deficiencies
Penalty
Summary
Provide safe and appropriate respiratory care for residents when needed was not met for two residents receiving oxygen therapy. During unit rounds, Resident #16 and Resident #26 were observed using oxygen in their rooms without an Oxygen in Use sign posted on their doors. An oxygen concentrator was also observed at the bedside of both residents, and the humidification bottle and oxygen tubing were not labeled with the date placed in use or the required replacement date. For Resident #16, the surveyor later observed that the humidifier bottle was empty and the resident stated that his/her nose felt dry. The surveyor confirmed the bottle was empty and that the oxygen tubing and humidifier bottle were not dated. At a later follow-up, Resident #16's oxygen tubing remained undated, the humidifier bottle was still empty and was not connected to the oxygen concentrator, and the resident stated that the humidifier bottle had not been changed. The resident also stated that nobody had come in to assess or address the issue. Record review showed orders for continuous oxygen at 3 LPM via nasal cannula or mask for COPD, weekly changes of the humidifier bottle and tubing, oxygen saturation monitoring each shift, padding of tubing around the ears each shift, and PRN oxygen at 2 LPM for shortness of breath.
Inaccurate Narcotic Reconciliation for Morphine
Penalty
Summary
Pharmaceutical services failed to ensure medications were accurately reconciled for one resident whose liquid morphine was stored on medication cart #1. During observation, the narcotic book documented Resident #56’s morphine count as 6.5 ml, while the morphine bottle contained approximately 12 ml when observed by the surveyor. This discrepancy was identified during the annual recertification survey as part of the facility’s narcotic count process. An interview with an LPN confirmed the morphine count was approximately 5.5 ml off and that she relied on the narcotic book count by subtracting administered doses from the documented amount without checking the bottle to verify accuracy. Later, the DON brought two morphine bottles to the conference room and showed one unopened bottle with an approximate volume of 18 ml even though the pharmacy label indicated 15 ml. The DON stated she had contacted the pharmacy about the inaccurate calibration and that the pharmacy would not correct the volume, and she explained this may have accounted for the discrepancy in the opened bottle. The surveyor expressed concern that the resident may not have received the medication as ordered and that nurses were signing off on an inaccurate volume without reconciling the narcotic correctly.
Improper Medication Storage and Expired Drugs Found in Medication Room and Cart
Penalty
Summary
Medications and biologicals were not properly labeled, secured, or stored in locked compartments, and controlled drugs were not separately locked. During observation of the locked medication storage room with the RN Unit Manager, surveyors found multiple non-medication items stored in the room, including unlabeled resident bags containing unopened beer bottles, unopened alcohol, soda cans, magazines, tin foil, headphones, laundry detergent, hip pads for a discharged resident, candy, cases of soda, and an open bottle of wine. The room also contained several expired medications in non-secured cabinets and drawers, including house stock osteo Bi-Flex, loperamide, famotidine, dextrose and sodium chloride, discharged resident albuterol sulfate neb solution, and resident ceftazidime. A bag of discontinued medications for a resident had also remained in the room since August 2025, and the Unit Manager confirmed the items were improperly stored and that expired medications were mixed with unexpired medications. Medication cart #2 also contained improperly stored medications. Surveyors observed a discharged resident’s unopened vial of Lantus that was not refrigerated, along with another vial of Lantus that had expired, an unopened insulin pen that required refrigeration, and biofreeze cream for a discharged resident. During interview, RN #2 confirmed that unopened insulin vials and pens were marked to refrigerate until opened and were improperly stored on the cart. RN #2 also stated there was no set process for checking medication carts for expired medications and that it was up to staff to check when they were on the cart. A review of the medication administration policy stated that if a medication is identified as expired, the licensed nurse will notify the nurse manager.
Therapeutic Diet Tray Not Provided as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for one resident who had an order for a mechanical soft ground diet with double portions. During a random observation, a GNA delivered the resident’s breakfast tray, and the resident complained that the tray did not include the requested double portions, extra milk, or cold cereal. The GNA checked the tray, agreed the items were missing, removed the tray, and said she would get a new tray from the kitchen. The resident reported that this happens almost every day and that it usually takes about 30 minutes before the correct tray is brought back. Later that morning, the resident was observed attempting to eat a whole sausage patty from the replacement breakfast tray. The tray contained one portion of sausage that was mechanical soft ground and one whole round sausage that was not mechanical soft ground. The surveyor informed the resident that the sausage was not mechanically soft ground, and the resident stated that the kitchen tried and that he or she would be okay. When the surveyor reported this to an RN, the RN went to the resident and advised that the resident could eat the sausage because it was not mechanically soft ground. During interview, a GNA stated she returned the original tray to the meal cart, notified the kitchen of the missing items, and then delivered a new tray after the kitchen sent a small plate with sausage, milk, and cold cereal; she also stated she was not aware of the resident’s diet.
Inaccurate MAR Documentation for Lorazepam Administration
Penalty
Summary
The facility failed to ensure medical records were accurate for one resident when the Medication Administration Record (MAR) showed Lorazepam oral tablets and Lorazepam oral concentrate as both being administered at the same 2:00 AM and 5:00 AM time frames. The resident had orders for Lorazepam oral tablet 0.5 mg, 2 tablets by mouth every 3 hours for anxiety/shortness of breath, and Lorazepam oral concentrate 2 mg/mL, 0.5 mL by mouth every 3 hours for agitation and air hunger. A separate order placed the day before directed that the Lorazepam pills be discontinued when the liquid arrived and that both forms not be given together. During interview and MAR review, the RN stated the liquid Lorazepam had arrived just before his shift and that he administered only the liquid doses at 2:00 AM and 5:00 AM, confirming he did not give the tablet form at those times. He also confirmed he had documented both the liquid and tablet forms as administered and stated the tablet should have been documented as not given; he then corrected one tablet entry to not given. Review of the controlled drug administration record confirmed that only the oral concentrate was administered, and additional record review showed the discontinue order for the tablets did not appear on the MAR for nursing staff to view and sign off when completed.
Lack of designated IDT member for hospice services
Penalty
Summary
The facility failed to have a designated Interdisciplinary Team (IDT) member for hospice services for one resident receiving hospice care. Resident #7 reported receiving hospice services, and the medical record showed the resident was placed on hospice for heart failure with Chesapeake Hospice and remained on hospice beyond the initial 6-month period. During record review, the surveyor could not locate the resident’s hospice election form or recertification documentation to continue hospice services after the initial admission date. During interviews, the DON stated that hospice normally does not provide the election form to the facility because the agreement is between the resident or resident representative and the hospice company, and said the Social Worker works some with hospice. The NHA later reported that the facility did not currently have a designated IDT member who worked directly with hospice on behalf of the facility. After the surveyor requested documentation, the facility received hospice records, and the surveyor later confirmed the presence of a recertification form, an election form signed by the resident representative, and summaries of the plan of care.
Infection Control Failure With Urinary Catheter Drainage Bags
Penalty
Summary
The facility failed to ensure staff practiced infection control for residents with urinary catheters. During an observation on 01/22/26, an Activities Aide pushed a resident in a wheelchair down the hallway while the resident’s foley catheter bag was dragging across the floor. The aide stated he had not noticed the bag on the floor and said it is usually hung higher so it does not touch the floor. An LPN was informed of the observation and reported she would change the foley catheter bag due to an infection control concern. The resident had a care plan for a suprapubic catheter with interventions initiated on 07/06/24. A second resident was observed on 1/23/2026 sitting in a wheelchair in front of the nursing station with a urinary catheter drainage bag hooked to the bottom of the wheelchair and lying partially on the floor. A GNA confirmed that the drainage bag should not be touching or on the floor. During a later observation, the drainage bag was connected to the wheelchair and held off the floor. Record review showed the resident had orders for care of an indwelling urinary catheter since 9/05/2025 and a care plan for a urinary catheter with interventions initiated on 9/10/2025. The Assistant DON later confirmed that the drainage bag should have been kept off the floor.
Failure to Educate Staff on Current COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure education was provided to staff regarding the current COVID-19 vaccination status. During review of staff COVID-19 vaccination records with the Infection Control Preventionist, the surveyor was unable to locate documentation of education for the current COVID-19 vaccination status. The Infection Control Preventionist reported that only 2 staff members had received the current COVID-19 vaccination and stated that she conducts a flu clinic for staff with an option to go to Walgreens for the current COVID-19 vaccination. When asked whether staff were provided education about the current COVID-19 vaccination, she stated no education had been provided and that she would make sure education was offered going forward.
Failure to Assess, Document, and Report Resident Fall and Resulting Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and post-fall procedures for a resident at high risk for falls. The facility’s Fall Prevention Program policy required that when any resident experiences a fall, staff must assess the resident, complete a post-fall assessment and incident report, notify the physician and family, review and update the care plan as indicated, document all assessments and actions, and obtain witness statements in the case of injury. Resident #2, admitted with heart failure, polyneuropathy, bone density disorders, protein-calorie malnutrition, and anemia, had moderate cognitive impairment and required substantial to maximal assistance with mobility and toileting. The resident’s care plan identified them as high risk for falls due to impaired mobility and poor safety awareness. Staff interviews and the facility’s own incident investigation revealed that the resident fell from bed at approximately 6:00 AM on 12/10/2025. Following this fall, RN #21 (also referenced as RN #2 in interview) stated she looked at the resident and did not observe any injuries but did not complete any of the required fall-related documentation, including the incident report, post-fall assessment, or documentation of the fall itself. She also stated she was not sure she reported the fall to anyone on the oncoming shift, and there was no evidence that the physician or responsible party were notified at that time. GNA #22 reported to RN #21 that the resident’s leg was “wobbly” on the morning of the fall and later asked a CMA to help place the resident back in bed, telling the CMA that the nurse had already assessed the resident. No pain was reported at that time. The next day at 6:00 AM, another RN noted swelling, pain with movement, purplish discoloration, and abrasions on the resident’s left lower leg and ankle. Later that morning, an LPN observed that the ankle appeared abnormal and discolored, requested a physician evaluation, and the resident was sent to the ER, where imaging showed a comminuted fracture of the distal tibia and fibula. The DON and Administrator both confirmed that the expected process—assessment, documentation, and notification of the provider, responsible party, and oncoming staff—was not followed for the 12/10/2025 fall.
Failure to Maintain Homelike Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a homelike environment in resident rooms, as observed during an environmental survey. The survey, conducted with the Administrator and the Director of Maintenance, revealed several deficiencies across seven resident rooms. These included the absence of towel hangers in bathrooms, damaged footboards with protective layers peeling away, and issues with bathroom fixtures such as a damaged gasket and exposed bolts on toilets. Additionally, some rooms had short pull cords for overhead lights, non-functional night lights, and loose toilet seats, which posed safety risks. The survey also identified a loose wall plate of the overhead sprinkler in one of the rooms. These deficiencies were confirmed by the Administrator and the Director of Maintenance during the tour. The report highlights the facility's failure to provide a safe, clean, comfortable, and homelike environment for its residents, as required by regulations.
Ineffective Mechanical Ventilation in Resident Bathrooms
Penalty
Summary
The facility failed to ensure effective mechanical ventilation in resident bathrooms, as observed during an environmental survey. This deficiency was identified in 5 out of 7 resident rooms reviewed for increased occupancy. During a tour conducted with the Administrator and the Director of Maintenance, it was noted that the bathrooms in rooms 18, 17, 32, 33, and 16 did not have effective ventilation. The effectiveness of the ventilation was tested by observing if a thin piece of paper was drawn towards and held against the ventilation intake on the ceiling, a test performed by the Director of Maintenance. The Director confirmed the ineffectiveness of the ventilation in these rooms and attributed the issue to likely nonfunctional motors in the rooftop ventilation units.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as evidenced by multiple grievances and interviews with residents and staff. Resident #58 reported being verbally abused by GNA/CMA #19, who allegedly screamed at the resident and invaded their personal space during a confrontation. This incident was corroborated by a grievance filed by the Director of Social Work, who witnessed the GNA/CMA yelling at the resident. Additionally, Resident #58 had previously filed a grievance about staff rushing and hollering during care, which was not adequately addressed by the facility. Resident #18 also reported rough treatment and verbal abuse by the same GNA/CMA, expressing a desire to move to a different unit to avoid further mistreatment. The resident felt embarrassed by the GNA/CMA's public reprimand regarding candy consumption. Despite these grievances being documented, there was no evidence of follow-up or resolution by the facility's administration, indicating a systemic failure to address and prevent abuse. Furthermore, Resident #291 alleged physical abuse by a GNA who roughly handled them, causing injury. This grievance was documented but not reported to the appropriate authorities, nor was an investigation conducted. The facility's grievance process was flawed, with grievances being logged but not followed up on, leading to a failure to protect residents from abuse and neglect.
Failure to Provide Adequate Foot Care Leads to Harm
Penalty
Summary
The facility failed to provide adequate treatment for a resident with a foot concern, resulting in harm. The resident, who had a medical history including type 2 diabetes mellitus with diabetic neuropathy, was seen by a podiatrist in February 2021. The podiatrist noted erythema on the right great toe and recommended the application of topical antibiotic ointment and continued monitoring. However, no order for the ointment or monitoring was documented in the Treatment Administration Record (TAR) for February, March, or April 2021. Additionally, there was confusion regarding which toe was affected, as the podiatrist's note included a diagram indicating the left toe, but no clarification was made in the medical record. In March 2021, a Psychiatric Nurse Practitioner assessed the resident as restless and irritable, recommending Depakote, but no order was documented. The resident was noted to have an abrasion on the toe after kicking a door, yet no treatment was ordered. By early April, a Licensed Practical Nurse observed redness, swelling, and an open area on the left great toe, and a fax was sent to the primary care physician. However, the fax was initially unsuccessful, delaying the response. A wound consult was eventually ordered, and the wound physician recommended antibiotics and an x-ray, but no antibiotics were ordered. By mid-April, the resident's condition worsened, with the left great toe showing erosion and bone exposure. The resident was transferred to the emergency room, where a bone scan confirmed osteomyelitis, leading to a partial amputation. The facility's failure to document and follow through with the podiatrist's recommendations, as well as the lack of timely treatment and communication, contributed to the resident's harm.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to adequately address and resolve grievances filed by residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident #58 filed grievances regarding verbal abuse and staff rushing care, which were documented by the Director of Social Work (SW) #17. Despite these grievances being logged and assigned to the appropriate department supervisors, there was no documentation of resolution or follow-up. Additionally, Resident #18 filed a grievance about rough treatment and embarrassment caused by a staff member, which was also not resolved or documented. Resident #291's grievances were similarly mishandled. The resident's family member complained about issues such as a non-working phone, therapy questions, and food concerns, but follow-up was only partially documented. Another grievance involved rough handling by a Geriatric Nursing Assistant (GNA), resulting in an injury, and being left in soiled diapers for an extended period. These grievances were not followed up on, and there was no documentation of resolution. Furthermore, a request to switch beds for accessibility reasons and missing clothes were not addressed, and there was no record of these grievances being resolved. Interviews with the Nursing Home Administrator (NHA) and SW #17 revealed a lack of communication and follow-up in the grievance process. The NHA acknowledged the grievances as potential abuse cases but confirmed that there was no documentation of resolution or follow-up. The facility's grievance procedure was not effectively implemented, leading to unresolved grievances and a failure to protect residents' rights.
Failure to Report and Address Allegations of Theft and Abuse
Penalty
Summary
The facility failed to ensure timely reporting of residents' allegations of theft and abuse to the appropriate authorities. In one instance, a resident reported $100 missing from their wallet, but the facility delayed reporting the incident to the Office of Health Care Quality (OHCQ) beyond the required 24-hour timeframe. Similarly, another resident's report of theft was not submitted to OHCQ within the mandated period. These delays in reporting indicate a failure in the facility's protocol for handling allegations of theft. Additionally, the facility did not adequately respond to and report allegations of abuse. A resident reported being roughly handled by a Geriatric Nursing Assistant (GNA), but the Nursing Home Administrator (NHA) was unaware of the allegation, and no investigation was conducted until much later. The social worker who documented the incident did not follow up or ensure the allegation was reported to the necessary authorities, highlighting a breakdown in communication and procedure within the facility. The facility also failed to address grievances related to verbal abuse and rough treatment by staff. Multiple grievances were filed by residents, including one where a staff member was witnessed yelling at a resident. Despite these grievances being documented and assigned to department supervisors, there was no evidence of follow-up or resolution. The NHA acknowledged the grievances as potential abuse but confirmed that no documentation of resolution or follow-up existed, indicating a systemic issue in handling and addressing resident grievances and allegations of abuse.
Inadequate Investigation and Documentation of Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations and maintain proper documentation for several allegations of abuse involving multiple residents. In one instance, an investigation into an allegation that a Geriatric Nursing Assistant (GNA) hit a resident on the head was incomplete, lacking documentation of interviews and statements from involved parties. Additionally, there was no evidence that the GNA was placed on leave during the investigation, although a time card indicated otherwise. The Nursing Home Administrator (NHA) acknowledged the missing documentation and confirmed that the abuse allegation was not reported to the police or the Office of Health Care Quality (OHCQ). Further deficiencies were noted in the handling of grievances related to verbal and physical abuse. A social worker documented incidents of a GNA yelling at a resident and another resident's complaint of rough treatment and embarrassment. Despite these grievances being logged and forwarded to the appropriate supervisors, there was no documentation of follow-up or resolution. The NHA admitted that these grievances met the definition of abuse and recognized a pattern of complaints involving the same GNA, yet no actions were documented to address these issues. The facility also failed to properly investigate and document incidents reported in the Facility Reported Incident (FRI) files. One resident reported rough treatment and neglect by a GNA, but the investigation lacked essential components such as staff interviews and resident assessments. Another incident involving a resident being hit by a GNA was reported, but the facility could not provide the investigation file. The Director of Nursing (DON) acknowledged that many FRI investigations were incomplete prior to her tenure, indicating systemic issues in the facility's handling of abuse allegations.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide timely administration of medications for Resident #298, as evidenced by a review of medical records and interviews. Resident #298, who was admitted in early April 2021, has a medical history that includes type 2 diabetes, disorientation, epilepsy, and acute cystitis. On April 17, 2021, a progress note by LPN #29 indicated that the resident was nearly unresponsive and had not been responsive enough to eat breakfast. The Medication Administration Record (MAR) showed that a scheduled 6 AM medication was administered at 6:18 AM, but the next medication, Glimepiride, scheduled for 8:30 AM, was not administered due to the resident's altered mental status and subsequent transfer via Emergency Medical Service. The Director of Nursing confirmed that the facility's policy is to administer medications within one hour before or after the scheduled time. However, the surveyor noted that LPN #29 did not attempt to administer the scheduled medication until 10:40 AM, which was two hours after the scheduled time. This delay in medication administration was acknowledged by the Director of Nursing, indicating a failure to adhere to the facility's medication administration policy.
Failure to Deliver Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This deficiency was identified during an observation and interview process conducted by the Surveyor. A resident reported that the food was lukewarm and not palatable, and similar complaints were received from resident families about the food being cold by the time it reached their loved ones. The issue was further substantiated during a test tray observation where the Surveyor noted that the food temperatures were below the expected levels for palatability. During the observation of the lunch tray line, it was noted that the first tray was prepared at noon, and the final tray was placed on the meal cart at 1:00 PM. The meal cart was then taken to the nursing unit, and the test tray was the last to be distributed. The temperature of the food items on the test tray was recorded as follows: chicken breast at 119 degrees Fahrenheit, rice at 126 degrees Fahrenheit, potato at 117 degrees Fahrenheit, and peas at 120 degrees Fahrenheit. These temperatures were below the expected levels for maintaining hot food palatability, indicating a failure in the facility's process to deliver meals at appropriate temperatures.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety, as observed during a surveyor's inspection of the kitchen. In the main walk-in refrigerator, there was an opened and unlabeled 1-gallon tub of Sysco mayo, a 1-gallon tub of Sysco mustard with a received date, and a 1-gallon tub of Kens Homestyle Ranch with a received date. In the dry goods storage pantry, there were several opened and unlabeled food items, including a 28 oz box of Quaker Cream Of Wheat, Ralson Foods Quick oats, and a tub of Goldmetal Chocolate Fudge icing, among others. Additionally, the main walk-in freezer contained personal items such as a grocery bag with personal food items and a bouquet, alongside other frozen foods. There was also significant ice buildup in the freezer, with mounds of ice on the ceiling and floor, creating a slippery area. The Certified Dietary Manager (CDM) confirmed the surveyor's findings and acknowledged the presence of unlabeled and expired food items, as well as personal items in the freezer. The CDM also confirmed the issue of ice buildup in the walk-in freezer, stating that it required removal a couple of times a week. The facility's procedure for labeling and dating foods was reviewed, which mandates that opened packages be re-dated with the date of opening and used by the safe food storage guidelines or the manufacturer's expiration date. However, this procedure was not followed, leading to the deficiency in food storage practices.
Deficiencies in Medical Record Accuracy and Incident Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as identified during an annual survey. For two residents, there were discrepancies in the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) forms. One resident's chart contained two MOLST forms with conflicting code statuses: one indicating Do Not Resuscitate (DNR) and the other indicating Cardiopulmonary Resuscitation (CPR). Another resident's chart also had two MOLST forms, one with a DNR status and the other with a Do Not Intubate (DNI) status. The nursing staff was expected to void the old MOLST form and retain only the most recent one to prevent errors, but this procedure was not followed, leading to potential confusion regarding the residents' code statuses. Additionally, the facility failed to accurately document incidents and assessments related to falls for two residents. One resident's electronic medical record contained conflicting nursing notes about the timing of a fall, and the fall protocol was not completed immediately after the incident. Another resident's pain management assessments failed to document a significant injury—a left femoral fracture—sustained from a fall, despite the resident having undergone surgery for the fracture. The pain management notes inaccurately reported no recent acute incidents or trauma, indicating a lack of proper documentation and assessment of the resident's condition following the fall.
Failure to Notify Medical RP of Care Plan Changes
Penalty
Summary
The facility failed to notify the designated medical Responsible Party (RP) of a change to a resident's plan of care, specifically regarding the end date for Medicare-covered services. The resident, admitted in mid-2013, had a spouse/friend listed as the medical RP and a separate financial RP. Despite this clear distinction, the facility contacted only the financial RP about the cessation of Medicare services, neglecting to inform the medical RP. Interviews with the Director of Nursing (DON) and Social Worker #17 revealed a misunderstanding or misapplication of the facility's protocol for notifying RPs. The DON stated that both the medical and financial RPs should be contacted when Medicare services are stopped, while the social worker indicated that only the medical RP should be notified for medical decisions. This discrepancy led to the medical RP not being informed on three occasions, as the facility mistakenly involved only the financial RP.
Failure to Notify Responsible Party of Diet Change
Penalty
Summary
The facility failed to inform a resident's Responsible Party (RP) in advance of a change in the resident's plan of care, specifically regarding a diet change. This deficiency was identified during a review of the medical records and interviews conducted by the surveyor. The resident in question had a medical history that included muscle weakness, malnutrition, dementia, and dysphagia. On a specific date, a Licensed Practical Nurse (LPN) documented an incident where the resident was found on the floor, and the RP was notified. However, a subsequent order was placed to change the resident's diet from mechanical soft to pureed texture and chopped meats without any documented reason or prior notification to the RP. During interviews, the Director of Nursing (DON) confirmed that any change in the plan of care should involve notifying the RP. The LPN involved believed the diet change was due to a dental need, as the resident refused to use denture cream and did not want new dentures. Despite this belief, there was no documentation to support the rationale for the diet change or evidence that the RP was informed prior to the change. The lack of documentation and communication with the RP led to the deficiency noted by the surveyor.
Delayed Response to Family Council Concerns
Penalty
Summary
The facility failed to promptly respond to concerns raised by the family council group (FCG) for several months. The Nursing Home Administrator (NHA) was responsible for addressing these concerns, which were communicated through monthly meeting minute notes sent via email. Despite the NHA's assertion that he responded to the FCG's concerns before the next meeting, evidence showed that responses for April, May, July, August, and September 2023 were delayed. Specifically, the responses for April and May were only documented in June, while the responses for July, August, and September were not addressed until October. The deficiency was identified through a complaint received by the Office of Health Care Quality (OHCQ) and was corroborated by interviews and a review of the meeting minutes. The complainant provided documented evidence of timely email communication of the meeting minutes to the NHA. The surveyor's review confirmed the lack of prompt responses, highlighting a failure in the facility's process for addressing family council concerns. The NHA and the Director of Nursing (DON) were informed of these findings during the survey and at the exit conference.
Failure to Post Residents' Rights Information
Penalty
Summary
The facility failed to ensure that information related to the Residents' Rights, including contact information for Maryland's Long-Term Care Ombudsman program and a statement informing residents of their right to file a complaint with Maryland's Survey Agency, was posted in easily viewed and accessible locations. This deficiency was observed on all units and halls with resident care areas. During a tour, the surveyor noted the absence of these postings in the Chesapeake, Patuxent, The Lodge, and Rehab areas. Staff #10 acknowledged that the postings were removed during renovations that began a year ago. The Nursing Home Administrator later provided the notice of Resident Rights poster to the survey team, indicating it would be posted in the hallway between two units, opposite the main dining area.
Failure to Display Survey Results in Accessible Location
Penalty
Summary
The facility staff failed to display the results of the annual recertification survey and plan of correction in a location that was easily accessible to residents, family members, and legal representatives. During observations on two separate days, surveyors noted the absence of the survey inspection results in the lobby or any other open area within the facility. An interview with the Director of Nursing (DON) revealed that the Survey Results binder was kept in the Nursing Home Administrator's (NHA) office, and the DON confirmed that the staff did not place the survey results in an accessible location. The NHA later provided the survey team with the binder, explaining that it might have been removed from the reception area due to renovations. Eventually, the survey results were observed in a binder on a table in the reception area, but the most recent survey results available were from a recertification survey conducted in 2019.
Failure to Maintain Advance Directives and Address Resident Treatment Preferences
Penalty
Summary
The facility failed to ensure that copies of residents' Advance Directives were obtained and maintained in their medical records. This deficiency was identified for three residents. For one resident, the facility's Social Worker acknowledged that the resident had an Advance Directive and a Durable Power of Attorney (DPOA) but did not follow up to obtain a copy for the medical record. The Director of Nursing later retrieved the DPOA from the resident's representative and placed it in the medical record. Another resident's medical record review revealed the presence of a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) but lacked a copy of the Advance Directive. The Social Worker documented that the resident had an Advance Directive during the initial assessment, but no attempt was made to obtain the document for the medical record. The Director of Nursing was unable to provide a copy of the Advance Directive when notified of its absence. For the third resident, the facility did not address the resident's expressed desire to discontinue thickened liquid treatment, despite the resident's capability to make informed decisions. The resident's medical record lacked documentation of any discussion or meeting with the primary care physician or interdisciplinary team to address this request. The Nursing Home Administrator was aware of the resident's wishes but did not take steps to discuss the matter with Risk Management or the facility's Medical Director.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of hospital transfers to residents and their representatives, as required by regulations. This deficiency was identified during a review of medical records and interviews with facility staff. Resident #8 was transferred to the hospital on two occasions, once in January and again in June, without any documentation or evidence that the resident or their representative was notified in writing of the reasons for these transfers. Although the Ombudsman was notified, there was no written notice provided to the resident or their representative. The Director of Nursing was unaware if the written notifications were being done. Similarly, Resident #20 was transferred to the hospital in June after becoming unresponsive during breakfast, but there was no documentation indicating that the resident or their representative received written notification of the transfer. The facility was unable to provide any evidence of written notice for this hospitalization. These findings highlight a failure in the facility's process for notifying residents and their representatives of hospital transfers, as required by regulations.
Failure to Provide Prescribed Arm Support for Resident
Penalty
Summary
The facility failed to provide appropriate treatment to maintain a resident's limited range of motion. A surveyor observed a resident with a flaccid right arm sitting in a wheelchair using their left hand to stabilize the right arm. The resident was not provided with the necessary arm support as prescribed. A staff member confirmed that the resident should have an arm support and subsequently retrieved and applied a splint to the resident's right arm. The resident's medical record indicated a physician's order for the resident to wear a Comfy Grip Splint during the daytime due to flaccid hemiplegia affecting the right dominant side. Additionally, a care plan intervention was in place to apply a splint for contracture management, with instructions to assess the skin prior to application and upon removal for skin breakdown. Despite these orders, the resident was observed without the splint, indicating a lapse in care.
Deficiency in RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during the annual survey, where it was found that on four specific days, there was no RN coverage for 24 hours. The Director of Nursing (DON) confirmed the absence of any Federal or State nursing staffing waivers and acknowledged the issue of insufficient RN coverage, particularly on weekends. The daily staffing sheets reviewed by the Surveyor revealed that on 7/28/2024, 8/10/2024, 8/11/2024, and 8/17/2024, there was no RN coverage for the entire day. Interviews with the Staff Scheduler and the DON highlighted the challenges in securing RN coverage for weekend shifts, although a weekend supervisor who is an RN was expected to start soon.
Infection Control and Equipment Labeling Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the spread of infections, as evidenced by two specific incidents involving residents. Resident #72, who was diagnosed with Alzheimer's Disease and other conditions, tested positive for Covid-19 and was placed on droplet precautions. However, during an observation, Resident #72 was found lying on a mat in the dayroom with the door open and no signage indicating droplet precautions. Another resident without a Covid-19 diagnosis was present in the same room, and neither resident was wearing a mask. This oversight was acknowledged by staff, who then took immediate action to rectify the situation. In another incident, Resident #22, who had multiple diagnoses including Dementia and Chronic Diastolic Heart Failure, was observed with a nasal cannula lying on the floor while the oxygen concentrator was in use. The nasal cannula and humidifier bottle were not dated or labeled with the resident's name, contrary to the facility's policy. Staff confirmed these findings and removed the equipment for replacement. The facility's policy requires that such equipment be changed weekly and properly labeled, which was not adhered to in this case.
Ice Buildup in Walk-In Freezer
Penalty
Summary
The facility failed to maintain the walk-in freezer in a safe operating condition, leading to ice buildup, including ice frozen to the floor. During a follow-up tour of the kitchen, a surveyor observed ice mounds on the ceiling and floor of the freezer, particularly around the condenser fan unit and a pipe. This ice accumulation created a slippery surface, posing a safety hazard. The Certified Dietary Manager confirmed the surveyor's findings and mentioned that ice buildup had to be removed multiple times a week. A repairman had assessed the freezer a year prior, attributing the issue to condensation, but the problem persisted. The facility's administrator informed the surveyor that Southern Maryland Refrigeration was responsible for repairs, and the last assessment was conducted about a year ago. Despite requests, the administrator did not provide recent documentation of service calls or repairs before the surveyor's visit. The Director of Maintenance indicated that a work order for the freezer had been submitted and was in the process of being serviced. However, the lack of timely documentation and persistent ice buildup indicated a deficiency in maintaining essential equipment in safe working condition.
Failure to Provide Call Bell and Mobility Accommodations
Penalty
Summary
The facility failed to ensure that a resident had a call bell within reach and was able to use it if desired. During a tour of the facility, a surveyor observed a resident lying in bed with the call bell on the floor at the foot of the bed. Despite the surveyor expressing this concern to an LPN, the issue persisted the following day when the call bell was again found on the floor. The LPN confirmed that the resident should have had the call bell within reach, indicating a failure to accommodate the resident's needs for communication and assistance. Additionally, the facility did not provide reasonable accommodations for another resident to assist with mobility. The resident, who had a history of surgical amputation and required assistance with personal care, was identified as needing bedrails to aid in bed mobility and activities of daily living. Although an order for bedrails was placed, the facility did not have any available at the time, and the order for additional bedrails was not placed until several weeks later. This delay in providing necessary equipment further demonstrates the facility's failure to accommodate the resident's needs for mobility assistance.
Failure to Conduct Timely Care Plan Meetings and Include Interventions
Penalty
Summary
The facility failed to conduct care plan meetings after each Resident Assessment and hold quarterly care plan meetings for residents, as required. This deficiency was evident in three out of four residents reviewed for care planning. For Resident #290, there were no care plan meeting notes for the quarterly MDS assessments conducted on two occasions. The Director of Nursing (DON) and Social Worker #17, who were not in their positions at the time of the assessments, could not provide documentation that the meetings were held. The process for scheduling care plan meetings was flawed, as it relied on the Responsible Party to initiate the meeting, which was not happening. For Resident #8, there was no evidence of care plan meetings held around the time of the quarterly or annual MDS assessments. The last documented care plan meeting was in December of the previous year, and the resident's name did not appear on the care plan meeting log for the following months. Additionally, Resident #72's care plan for therapeutic activities lacked interventions to achieve the stated goal. The DON was unaware of the missing interventions until notified by the surveyor, and the care plan was later updated.
Deficiencies in Personal Hygiene and Timely Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for two residents, as evidenced by the surveyor's findings. Resident #291, who requires extensive assistance with activities of daily living (ADLs) due to conditions such as dysphagia, dysphonia, muscle weakness, and unsteadiness, did not have consistent documentation of showers being provided. The facility's policy requires at least two full baths or showers per week, but records showed gaps in documentation, and the Director of Nursing (DON) could not confirm that showers were given without the necessary records. Additionally, Resident #45, who has ADL limitations and is at risk for bladder/bowel incontinence, experienced a delay in assistance for toileting needs. The resident's call light was activated, and a staff member entered the room but did not assist with the request to use the bathroom. It took 52 minutes and a second call light activation for the resident's needs to be addressed. The DON acknowledged that the resident's needs should have been addressed promptly after the first request.
Documentation and Transfer Assistance Deficiencies
Penalty
Summary
The facility failed to adequately document responses to treatment of skin conditions for Resident #291. The resident, admitted in January 2023, had a medical history including dysphagia, dysphonia, muscle weakness, and unsteadiness of feet, requiring assistance with personal care. On February 20, 2023, an LPN documented an open area on the resident's coccyx, while an RN noted only blanchable redness. Despite treatment orders for daily dressing changes, documentation was inconsistent, with missing entries on several dates in March and April 2023. The facility's policy required weekly assessments and documentation of wound characteristics, which were not consistently followed, leading to a lack of clarity on the wound's status and treatment effectiveness. The facility also failed to provide the required two-person assistance for Resident #29 during transfers, compromising the resident's safety. The resident, with a history of hemiplegia, hemiparesis, and an above-knee amputation, reported pain in the left shoulder after a rough transfer by a single aide. The resident's care plan and physician's orders specified the need for two-person assistance due to limited mobility and arthritis. However, the incident on June 15, 2024, where the resident was transferred by one person, resulted in shoulder pain, although an X-ray showed no fracture. The Director of Nursing was informed of both deficiencies, highlighting the lack of proper documentation for Resident #291's wound care and the failure to adhere to the two-person transfer requirement for Resident #29. These deficiencies indicate lapses in following established care protocols and documentation practices, which are essential for ensuring resident safety and effective treatment.
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What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Solomons
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Asbury Solomons | 0.6 mi | ★★★★★ | 1 | 0 |
| Chesapeake Shores Nursing Center | 6.5 mi | ★★★★★ | 13 | 0 |
| St. Mary's Nursing Center Inc | 10.4 mi | ★★★★★ | 11 | 0 |
| Calvert County Nursing Ctr. | 16.6 mi | ★★★★★ | 29 | 0 |
| Charlotte Hall Veterans Home | 19.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.