Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stella Maris, Inc. during CMS and state inspections, most recent first.
Failure to maintain resident dignity and privacy: one resident was observed during wound care with the door fully open and no privacy curtain, allowing visibility from the hallway, and another resident was found asleep in bed with a Hoyer sling left wrapped around them while an uncovered breakfast tray sat untouched nearby. Staff confirmed the wound care setup was not expected and acknowledged the second resident needed two staff for transfer assistance and feeding help.
Verbal abuse occurred when a GNA called a resident fat and made insulting comments about the resident’s incontinence. A witness reported the GNA was angry and repeatedly used names related to the resident’s bowel and bladder incontinence while expressing frustration about using a sit-to-stand lift instead of a stand/pivot transfer. The allegation was substantiated during the facility investigation.
Failure to timely report abuse and an injury of unknown origin: A GNA was observed hitting a resident, but the allegation was not reported to OHCQ within the required timeframe. In a separate case, a resident developed left knee pain and was later found on MRI to have a nondisplaced distal femur fracture with no reported fall; the DON and Administrator stated the facility did not know the cause and no report was made to OHCQ.
A resident was sent to the ER via 911 after a change in condition, but the facility had no documentation showing the resident and/or RP was given written notice of the transfer and the reason for it. The NHA stated the reason was included in the transfer packet and that the resident was told verbally, but written verification could not be provided.
Improper Transfer of Resident Requiring Mechanical Lift: Staff failed to use the required 2-person Hoyer lift for a resident with an AKA and muscle weakness, instead performing a stand/pivot transfer to a wheelchair before dialysis. The resident said “ouch” during the transfer and later reported leg/foot pain; the DON confirmed the staff knew the resident required a mechanical lift.
Inaccurate resident medical records were identified for two residents during survey review. One resident’s care plan used the wrong resident name, and another resident’s transfer care plan listed 1-2 staff assistance even though the resident required a mechanical lift/Hoyer transfer by 2 staff per the facility’s policy and staff training materials. Interviews with the UM and DON confirmed the transfer documentation error and the incorrect name entry.
Failure to Maintain Infection Prevention and Control Program: A resident receiving wound care was observed with the room door open, no privacy curtain in use, and the wound nurse performing dressing care while seated on the bare floor with supplies placed directly on the floor and no barrier underneath. Two other residents with EBP orders for dialysis catheter and multiple wounds had no EBP signs posted on their room doors during observation.
Unsafe and Uncomfortable Bathroom Conditions: Surveyors found gray fuzzy buildup on bathroom vents in multiple rooms, a gouged-out bathroom wall near a toilet, and an over-the-toilet commode with chipped paint exposing a brown area on the lateral bar. The Unit Mgr was notified of the findings and agreed the conditions were not like a comfortable environment; facility records also showed the vents had been noted for cleaning in prior Ops mtg minutes.
The facility did not report multiple allegations of abuse, neglect, and injuries of unknown origin to the Office of Health Care Quality within the required 2-hour timeframe. Staff and administration delayed notifying the regulatory agency after learning of incidents involving rough handling, intimidation, and unexplained bruises among residents, including those with dementia. Documentation and interviews confirmed repeated late reporting and a lack of adherence to mandatory reporting protocols.
The facility did not conduct comprehensive investigations into multiple allegations of abuse, neglect, and unexplained injuries, often failing to interview other residents or staff who may have had relevant information. In several cases, residents with cognitive impairments or those who expressed fear were not adequately assessed, and investigations were limited to statements from the accused or the reporting individual, resulting in incomplete reviews of the incidents.
Surveyors observed that staff failed to maintain proper food temperatures during meal service, with hot foods served below 135°F and cold foods above 41°F. Food items in kitchen storage were found without required dates or labels, and unsanitary practices were noted in dining areas, including undated food, personal items on serving counters, and food left at room temperature. Staff interviews confirmed inconsistent adherence to food safety and infection control standards.
The facility did not maintain an effective pest control program, as evidenced by repeated findings of mice and droppings in several nursing units and the kitchen. Multiple residents and families reported mouse sightings, and staff interviews confirmed ongoing rodent issues, especially since construction began. Vendor logs documented frequent rodent activity, and identified structural issues were not addressed promptly due to communication lapses between facility staff.
Facility staff administered a new medication to a resident with severe cognitive impairment without first obtaining consent from the resident's representative. The psychiatric practitioner ordered Depakote for behavioral disturbances, but documentation showed no evidence that the representative was notified or involved in the decision prior to administration. This was confirmed by both the representative and the Assistant Director of Nursing.
A resident with dementia sustained a significant facial bruise and a gash, prompting a provider to order an ophthalmology consult. Despite the inability to secure the consult, staff did not notify the provider as expected, and there was no documentation of the consult or communication about the failure to obtain it. The DON confirmed the lack of documentation regarding physician notification.
A resident with significant medical and cognitive conditions was physically abused by an LPN, who slapped the resident in the face and used expletives during morning care after the resident became agitated. The incident was witnessed by a GNA, who delayed reporting due to fear of retaliation. The resident was medically evaluated and found to have no significant injuries. The LPN had a documented history of behavioral and disciplinary issues.
Facility staff did not accurately code MDS assessments for several residents, failing to document falls with injury, use of antifungal treatments, and the presence of hallucinations, despite these events being recorded in medical records and progress notes. The MDS Coordinator confirmed these errors during surveyor interviews.
Two residents with dementia and their representatives were not provided with baseline care plans or written summaries of initial goals, physician orders, and services within 48 hours of admission. Interviews confirmed that neither verbal meetings nor written documentation were given, and facility leadership acknowledged the absence of required documentation in the medical records.
Staff did not update the care plan for a resident who developed skin integrity issues, including a pressure ulcer and IAD. Although treatments were ordered and administered, the care plan only addressed immobility and a head laceration, lacking specific interventions for the new skin conditions. The care plan was not revised to reflect the resident's changing needs, as confirmed by staff and nursing leadership.
Facility staff did not administer prescribed eye medications to a resident with multiple eye conditions, failed to complete required neuro checks after falls for another resident, and did not timely obtain or follow physician orders for nephrostomy tube care for a third resident. These actions did not meet professional standards of practice.
Facility staff did not complete required weekly wound assessments with measurements for a resident who had a Stage IV sacral pressure ulcer. This lapse in documentation and monitoring was confirmed by the ADON and resulted in missed opportunities to track the wound's progress and ensure effective treatment.
Facility staff did not obtain required weekly weights for a newly admitted resident with dementia, missing several scheduled weigh-ins. Despite a 10-pound weight loss over three weeks, there was no documented reassessment by the dietitian or evidence of further nutritional intervention, as confirmed by the DON.
A resident did not consistently receive prescribed topical medications, including A&D ointment and a topical analgesic, due to delays in reordering and supply issues. Documentation and staff interviews confirmed that medications were often unavailable, and there was a lack of timely notification to providers about these delays, resulting in missed doses and unmet pharmaceutical needs.
Surveyors observed multiple instances where medication carts were left unlocked and unattended, allowing unauthorized access to resident medications. In several cases, opened insulin pens were found in the carts without dates indicating when they were first used, contrary to policy and best practice. LPNs and other staff were not consistently ensuring medication security or proper labeling of opened medications.
A resident with dementia had a C. diff stool sample ordered by a Nurse Practitioner, but facility staff did not collect or send the specimen to the lab before the resident was discharged. The resident experienced ongoing diarrhea, prompting a request for hospital evaluation, and the Assistant DON confirmed the test was never completed.
Facility staff failed to secure timely outside professional consults for two residents: one with chronic kidney disease who did not receive a nephrology consult as ordered, and another with dementia and significant eye bruising who did not receive an ophthalmology evaluation after a provider's request.
A resident's medical record lacked required hospice documentation, including progress notes, assessments, and care plans, despite the resident being on hospice services. The DON confirmed the absence of these records during the survey.
Surveyors observed improper storage of clean and soiled linens, as well as patient care items, on two units. Clean linens and supplies were left uncovered on tray tables and soiled linen carts, and personal items were mixed with soiled materials. Staff confirmed these practices did not meet infection control standards.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain dignity and privacy for Resident #55 during wound care. On 07/15/2025 at 3:30 PM, the resident was observed seated in a wheelchair next to the bedside while Wound Nurse #21 performed wound care to the resident’s left lower extremity with the door completely open and no privacy curtain in use, allowing the resident to be seen from the hallway. Unit Manager #22 later confirmed the observation and stated this was not the expectation for wound care and would be reported to the DON. The facility also failed to maintain dignity for Resident #84. On 07/15/2025 at 9:54 AM, the resident was observed lying in bed asleep with a Hoyer lift sling wrapped under and surrounding them, with no staff present, while an uncovered breakfast tray sat on the bedside table and appeared uneaten. Unit Manager #17 confirmed the sling should not have been left on the resident in bed and that the resident required staff feeding assistance. GNA #18 stated they were going to look for someone to help because the resident required two staff for transfer assistance, but the surveyor observed the GNA collecting dirty dishes and not returning to the room with additional staff.
Verbal Abuse of a Resident by GNA Staff
Penalty
Summary
The facility failed to ensure Resident #199 was free from verbal abuse by staff. During the investigation, the resident reported that GNA Staff #25 called the resident fat and questioned the resident about not being able to hold urine and stool. Medical record review showed that the resident was incontinent at the time of the incident. Witness GNA #27 stated that GNA Staff #25 was angry and repeatedly called Resident #199 names related to the resident’s incontinence, while expressing frustration about needing to use a sit-to-stand lift instead of performing a stand/pivot transfer. The facility’s investigation substantiated the allegation of verbal abuse, and the incident was reviewed as part of the survey findings.
Failure to Timely Report Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an allegation of abuse and an injury of unknown origin to the Office of Health Care Quality (OHCQ) within the required timeframe. For Resident #177, the record showed that a GNA stated they observed another GNA hit the resident at approximately 9:00 AM, but the facility did not report the allegation to OHCQ until 4:55 PM on 07/02/25. During interview, the DON acknowledged there was a delay in reporting the alleged physical abuse to OHCQ. The facility also failed to report Resident #161’s fracture as an injury of unknown origin. The resident had persistent left knee pain with difficulty bending the joint, a negative X-ray, and an MRI ordered for further evaluation. The MRI of the left knee showed a nondisplaced vertical/oblique fracture through the anterolateral distal femur. A physician note stated the resident did not have any fall and that the mechanism of injury suggested a pathological fracture, with a DEXA scan to evaluate for osteoporosis. The DON stated the facility did not know how or why the resident sustained the fracture, and the Administrator and DON stated there was no report made to OHCQ regarding the fracture/injury of unknown origin.
Failure to Provide Written Transfer Notification
Penalty
Summary
Facility staff failed to notify the resident and/or resident representative in writing of a transfer/discharge and the reason for the transfer for one resident who was sent to the ER via 911 after a change in condition. Medical record review showed the resident was transferred to the hospital, but there was no documentation or evidence that written notification of the reason for the transfer had been provided to the resident and/or representative. During interviews, the Nursing Home Administrator stated the reason for transfer was documented in the change in condition form included in the transfer packet and that the resident was notified verbally, but the facility was unable to provide documentation verifying written notification was given.
Improper Transfer of Resident Requiring Mechanical Lift
Penalty
Summary
The facility failed to ensure that a resident who required a Hoyer lift for transfers was transferred correctly. Resident #161 had a care plan initiated on 12/31/2024 identifying an ADL self-care performance deficit related to a right above-the-knee amputation and muscle weakness, with an approach requiring a mechanical lift (Hoyer) and 2 staff assistance for transfers. During an interview on 07/16/2025, the resident alleged that staff assisted him/her into a wheelchair and that the transfer resulted in a left lower extremity fracture. Review of the medical record showed that on 05/09/2025, prior to dialysis, Staff #7 and #8 transferred the resident to a wheelchair using a stand/pivot transfer instead of the required Hoyer lift. During the transfer, the resident stated “ouch” and said that staff #8 had stepped on his/her foot, though the resident said he/she was okay. Facility documentation later noted the resident returned from dialysis in stable condition and denied pain, but the next day the resident complained of left leg/foot pain and a stat x-ray was ordered. The radiology report dated 05/10/2025 showed no evidence of fracture. The DON confirmed that Staff #7 and #8 failed to transfer the resident with a Hoyer lift, and facility investigation statements indicated both staff were aware the resident required a 2-person Hoyer lift but performed a stand, turn, pivot transfer instead.
Inaccurate Resident Care Plans
Penalty
Summary
Resident medical records were found to be inaccurate for 2 of 6 residents reviewed during the recertification survey. For one resident, the care plan referred to the resident by an incorrect resident name. During interview, the DON was made aware of the error and stated the facility would correct the care plan. The record review showed that the resident’s care plan contained the wrong name, which did not match the resident identified in the survey findings. For another resident, the care plan listed transfer assistance as mechanical lift/Hoyer transfer by 1-2 staff, even though the resident required a mechanical lift transfer and the facility’s safe transfers policy stated that all mechanical lift and Hoyer lift transfers require two-person trained staff. The facility’s GNA orientation materials also stated that two-person use is always required. During interviews, the Unit Manager stated that the GNA went to find help from another staff member because the resident required transfer assistance of two staff, and the DON acknowledged that the care plan should have stated 2-person assist. The revised care plan later reviewed by surveyors listed mechanical lift/Hoyer transfer by 2 staff assistance.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment for residents #161, #3, and #55. Resident #55 had an Enhanced Barrier Precautions sign on the door, but during observation the room door was completely ajar, the privacy curtain was not in use, and Wound Nurse #21 was performing wound care to the resident’s left lower extremity while seated cross-legged on the bare floor with dressing gauze supplies placed directly on the bare floor and no protective barrier observed under the staff or supplies. The Unit Manager confirmed the observation during the surveyor interview. For Resident #161 and Resident #3, both had orders for Enhanced Barrier Precautions related to dialysis catheter and multiple wounds, respectively, with precautions to be used during high-risk activities and no room restriction required every shift. During observation rounds, no Enhanced Barrier Precautions signs were observed on the doors of either resident. The Director of Nursing stated that the wound care dressings for Resident #55 were redone and specimens were taken, and the record later showed the wound nurse received disciplinary action and in-service training.
Unsafe and Uncomfortable Bathroom Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents in 1 unit out of 9 units investigated during the survey. During observation rounds on the 1st Floor unit, surveyors found bathroom vents in rooms 164, 166, 168, and 170 covered with approximately 1 inch of gray fuzzy matter. A Unit Manager was notified and stated that a request for cleaning had been mentioned at the last Ops Meeting in June. Facility records reviewed later showed that the Ops meeting minutes from 06/20/25 included a nursing update that the vents in 1K needed to be cleaned. Surveyors also observed additional environmental concerns on the same unit. In one resident bathroom, there was a gouged-out area in the wall approximately 1 1/2 feet by 1/2 foot with visible plaster disruption adjacent to the toilet just above the cove base. In another resident bathroom, an over-the-toilet commode had chipped paint revealing a brown area on the lateral bar that could potentially contact a resident's lower extremity while the commode was in use. The Unit Manager was informed of both findings and agreed that the conditions were not like a comfortable environment. The concern about maintaining a safe, functional, sanitary, and comfortable environment was shared with the Administrator, DON, and Executive Director during the exit conference.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe. Multiple incidents were identified where staff either delayed notifying administration or failed to report to OHCQ promptly after becoming aware of alleged abuse or suspicious injuries. In several cases, staff members, including GNAs, LPNs, and other personnel, did not immediately escalate allegations or observations of potential abuse, resulting in late reporting to both facility administration and the regulatory agency. Specific events included residents and their families alleging rough handling, intimidation, and physical abuse by staff, as well as the discovery of unexplained bruises. In some cases, staff were aware of the incidents but delayed reporting due to fear or uncertainty, while in others, administration was not notified until days later. Documentation reviews revealed that initial reports to OHCQ were consistently submitted well beyond the 2-hour requirement, with some reports sent several hours or even a day after the incident was known to staff. Interviews with facility leadership confirmed these delays and lapses in timely reporting. Additionally, the facility failed to report multiple instances of bruises of unknown origin for a resident with dementia, despite documentation in the medical record. The lack of timely reporting was confirmed through interviews with the DON, ADON, and other staff, who acknowledged the delays and, in some cases, a misunderstanding of the regulatory requirements. The findings were evident for twelve residents reviewed during a complaint survey, highlighting a pattern of noncompliance with mandatory reporting protocols.
Failure to Thoroughly Investigate Alleged Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents of alleged abuse, neglect, and injuries of unknown origin involving several residents. In numerous cases, when allegations were made by residents or their families regarding rough handling, verbal abuse, or unexplained bruising, the facility's investigations were incomplete. Specifically, the investigations often lacked interviews with other residents who may have been under the care of the accused staff members, and in many instances, there were no additional staff interviews conducted to corroborate or refute the allegations. This pattern was observed across a range of incidents, including those involving residents with cognitive impairments such as dementia, who may have been unable to clearly communicate their experiences. For example, in one case, a resident expressed fear and alleged being hit by a GNA, but the facility did not interview other residents or staff to determine if there was a pattern of similar behavior. In another instance, a resident with a history of anxiety and fear of falling was found with bruising, but the facility attributed the injuries to the resident's own actions without conducting further interviews or assessments. There were also cases where residents reported being treated roughly or verbally abused by staff, yet the investigations were limited to statements from the accused staff or the reporting resident, with no broader inquiry into the experiences of other residents or staff on the unit. Additionally, the facility did not consistently assess or interview residents who were non-verbal or cognitively impaired to determine if they felt safe or had experienced similar issues. In several cases, the documentation of the investigation was limited to a few statements or medical notes, and there was a lack of comprehensive review or follow-up. The failure to conduct thorough investigations, including interviews with potentially affected residents and relevant staff, resulted in incomplete assessments of the alleged incidents and did not ensure that all possible concerns were identified and addressed.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
Facility staff failed to store, prepare, and serve food in accordance with professional standards, as evidenced by multiple observations during meal service and kitchen inspections. During a lunch meal service, hot foods such as minestrone soup, fried chicken, and broccoli were served below the required temperature of 135 degrees, while cold foods like pudding and milk were above the safe temperature of 41 degrees. These temperature discrepancies were confirmed by both the surveyor and facility staff. Additionally, food items in the kitchen freezer were found without expiration dates, and several items in the refrigerator, such as eggs, ground meat, and mashed potatoes, were not dated or labeled. Staff interviews revealed a lack of consistent understanding and application of food labeling and dating requirements. Further observations in nourishment and dining rooms on various units revealed unsanitary storage practices, including undated and unlabeled food and drink items, personal belongings such as cell phones and pocketbooks on food service counters, and food left out at room temperature. Staff interviews, including those with infection control nurses, confirmed that these practices posed sanitary and infection control concerns. The findings were reviewed with facility leadership, including the Administrator and Director of Nursing.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing and repeated sightings and findings of mice and mouse droppings in multiple nursing units (1P, 3P, 3S) and the kitchen. Facility pest control logs documented several incidents, including staff disposing of dead mice, finding significant mouse droppings, and receiving resident complaints about mice in their rooms. Vendor pest control logs further confirmed persistent rodent activity, with multiple dead mice found in the kitchen on numerous occasions, rodent droppings, and evidence of mice in other facility areas such as the chapel. Residents and their families also reported frequent mouse sightings, with one family providing video evidence of mice in a resident's room. Staff interviews revealed that mice had been a recurring issue, with increased activity noted since construction began. The Director of Environmental Services stated that the pest control vendor visits weekly, but vendor reports indicated that identified issues, such as gaps in floors and holes in walls, were not addressed in a timely manner. Communication lapses between the Director of Environmental Services and the Director of Facilities contributed to delays in addressing vendor-identified concerns, as the Director of Facilities was not consistently receiving vendor reports. These actions and inactions led to the facility's failure to prevent and control pest infestations as required.
Failure to Obtain Consent Before Administering New Medication
Penalty
Summary
Facility staff failed to obtain consent from a resident's representative prior to administering a new medication. The resident, who had a diagnosis including dementia and was assessed to have severe cognitive impairment with a BIMS score of 4 out of 15, was seen by a psychiatric practitioner who ordered Depakote for behavioral disturbances. Documentation indicated that the practitioner was unable to reach the resident's representative to discuss the treatment plan, and there was no evidence in the medical record that the representative was notified before the medication was given. The resident's representative later confirmed that medications were administered without a meeting to discuss the behavior or care plan. The Assistant Director of Nursing also confirmed that there was no evidence of notification prior to administration.
Failure to Notify Physician of Inability to Obtain Ophthalmology Consult After Resident Injury
Penalty
Summary
Facility staff failed to notify the physician when they were unable to obtain an ophthalmology consult for a resident who had sustained a significant bruise and a small gash to the left peri-orbital region. The resident, who had dementia and was unable to follow instructions, was found with facial bruising and initially gave conflicting accounts of how the injury occurred. Medical documentation indicated that an ophthalmology consultation was ordered to further evaluate the injury, but there was no evidence in the medical record that the consult was ever completed. Despite the provider's expectation that they would be notified if an ophthalmology appointment could not be secured promptly, there was no documentation that the nurse practitioner was informed of the failure to obtain the consult. The Director of Nursing confirmed the absence of such documentation. This lack of communication and follow-through on the consult order constituted the deficiency identified during the complaint survey.
Resident Physically Abused by LPN During Morning Care
Penalty
Summary
A deficiency occurred when a resident with paraplegia, epilepsy, intellectual disability, aphasia, and multiple co-morbidities was subjected to physical abuse by an LPN during morning care. The incident took place while a GNA was assisting the resident, who became agitated and attempted to swing at the GNA. The LPN entered the room, closed the door, and then slapped the resident hard on the right side of the face, accompanied by yelling and the use of expletives. The resident was left holding their face, which appeared red, and became quiet following the incident. The GNA who witnessed the event did not immediately report the abuse due to fear of retaliation, as the LPN was described as confrontational and intimidating. The GNA reported the incident the following day to another nurse and then to administration, expressing emotional distress over the event. Another GNA corroborated the hostile behavior of the LPN, noting previous instances of yelling at residents. Documentation and staff interviews confirmed the sequence of events and the delay in reporting. Medical evaluation of the resident following the incident included a physician's assessment for headache and a referral to the emergency room to rule out head injury. The resident underwent a CT scan of the head and C-spine, which were unremarkable, and no significant injuries were found. The LPN involved had a documented history of behavioral issues, including previous write-ups for insubordination, inappropriate language, and harsh interactions with residents.
Inaccurate MDS Coding for Falls, Treatments, and Symptoms
Penalty
Summary
Facility staff failed to ensure the accuracy of Minimum Data Set (MDS) assessments for multiple residents, as evidenced by medical record reviews and staff interviews. In several cases, significant clinical events and treatments were not properly coded in the MDS. For example, one resident experienced an unwitnessed fall resulting in a head laceration requiring staples, but the MDS did not capture the fall with injury. Additionally, the same resident received antifungal powder for a rash, but this treatment was not documented in the relevant MDS section. Another resident with a history of visual hallucinations, including seeing snakes, had these symptoms documented in both progress notes and a physician's history and physical, but the admission MDS failed to capture the presence of hallucinations. In a separate case, a resident who was found on the floor after attempting to walk was not recorded as having had a fall in the MDS, despite clear documentation in the progress notes. A further incident involved a resident with chronic inflammatory demyelinating polyneuritis who was assisted by staff after sliding from a wheelchair. The resident was placed on the floor and then transferred using a Hoyer lift, with the event witnessed by a family member. However, the MDS assessment did not reflect that a fall had occurred. In each instance, the MDS Coordinator confirmed the errors in coding during interviews with surveyors.
Failure to Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to implement a process to ensure that baseline care plans were provided to residents and their representatives within 48 hours of admission. Specifically, for two residents with dementia, there was no evidence in the medical records that a baseline care plan, including initial goals, physician orders, therapy, dietary, and social services, was reviewed or given to the residents or their representatives. Interviews with the residents' representatives confirmed that they were not given a baseline care plan or had a meeting with facility staff to discuss the plan. Further interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that the facility's current process involved discussing goals with the resident and family within 72 hours of admission, but nothing was provided in writing to the resident or their representative. The DON confirmed that there was no documentation in the medical record showing that the baseline care plans were reviewed and provided to the residents or their representatives.
Failure to Update Care Plan for Altered Skin Integrity
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, resident-centered care plan addressing altered skin integrity for one resident. The resident was noted to have erythema and a rash on the buttocks and thighs, for which antifungal powder was ordered and administered. Subsequent documentation revealed the development of incontinence-associated dermatitis (IAD) and a pressure injury, with additional topical treatments ordered for wound care. Despite these changes in the resident's skin condition and the initiation of new treatments, the care plan was not updated to reflect these developments. The existing care plan only addressed the potential for skin impairment related to immobility and a head laceration, with interventions limited to encouraging range of motion exercises and weight-bearing mobility. No specific interventions were included to address the resident's evolving skin integrity issues, such as the documented pressure ulcer and IAD. Staff interviews confirmed that the care plan was initiated by the admitting nurse and relied on the electronic medical record system to autotrigger updates, but the care plan remained incomplete and was not revised to address the resident's changing needs.
Failure to Provide Care and Treatment According to Orders and Standards
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for three residents. For one resident with legal blindness and diagnoses of glaucoma, entropion, and dry eye, the eye doctor ordered specific eye ointment and drops to be administered regularly. However, a review of the medication administration records over several months showed that these medications were neither ordered nor administered as prescribed. Another resident with a history of falls experienced unwitnessed falls on two occasions. Post-fall neurological assessments were incomplete, with missing documentation of the COMA scale, vital signs, and hand grip assessments at various required intervals. Additionally, some scheduled neuro checks were not documented at all, as confirmed by facility leadership. A third resident, who had a nephrostomy tube placed following hospitalization for septic shock and pyelonephritis, requested tube flushes upon return to the facility. There was no documentation that this request was communicated to a physician in a timely manner, resulting in a delay before an order was obtained. Furthermore, the nephrostomy tube was flushed by nursing staff prior to obtaining a physician's order, contrary to facility policy requiring such an order for nephrostomy care.
Failure to Complete Weekly Wound Assessments for Pressure Ulcer
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident with a history of a Stage IV sacral pressure ulcer. The resident was admitted with this condition and later readmitted following a hospitalization. Medical record review revealed that staff did not complete required weekly wound assessments with measurements on multiple occasions, specifically on 12/23/22, 12/30/22, 1/13/23, 2/17/23, and 3/3/23. The absence of these weekly wound assessments impeded the ability to monitor the wound's progress, identify any issues that could affect healing, and ensure the effectiveness of the treatment plan. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the lack of documented weekly wound assessments for the resident's sacral pressure ulcer.
Failure to Obtain Weekly Weights and Address Significant Weight Loss
Penalty
Summary
Facility staff failed to obtain weekly weights for a resident with dementia who was newly admitted. According to the facility's weight policy, newly admitted LTC residents are to be weighed on admission, weekly for four weeks, and then monthly. The resident's medical record showed weights were only documented on admission, and then at two subsequent points, with missing weekly weights on three occasions. The initial nutritional assessment by the dietitian indicated that weekly weights were to be initiated to evaluate the need for further intervention. Additionally, the resident experienced a 10-pound weight loss over a three-week period, but there was no documentation that the resident was reassessed by the dietitian or that further interventions were considered. The DON confirmed that the required weekly weights were not obtained and that no further assessment was documented after the significant weight loss.
Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of a resident, as evidenced by inconsistent administration and delayed reordering of prescribed topical medications. Specifically, an order for A&D ointment to be applied every shift for skin protection was not consistently fulfilled. Documentation in the Medication Administration Record (MAR) showed multiple instances where the ointment was not administered, with progress notes indicating it was on order, awaiting delivery, or being reordered. Staff interviews confirmed that the ointment was sometimes unavailable due to delays in reordering and supply, and that the process of obtaining the medication could take time, especially when only small tubes were available and frequent use was required. Additionally, a prescribed topical analgesic (Biofreeze) for knee pain was not available for several days after being ordered, and there was a lack of timely physician notification regarding its unavailability. The order for the analgesic was eventually changed after six days, but during that period, nursing notes repeatedly documented that the medication was on order or awaiting delivery. Interviews with nursing leadership acknowledged that staff did not act quickly enough to reorder medications or notify providers about the delays, resulting in the resident not receiving prescribed treatments as ordered.
Unattended and Unlocked Medication Carts; Undated Opened Medications
Penalty
Summary
Facility staff failed to ensure that medication carts were kept locked when unattended and that medications were properly dated when opened. During random observations on three of seven nursing units, surveyors found multiple instances of unattended and unlocked medication carts containing resident medications. On one unit, a medication cart was left unlocked outside a resident's room while the LPN was inside the room. On another unit, a medication cart was left unlocked at the nurse's station while the LPN and unit secretary were occupied with other tasks, allowing the surveyor to access medications, including a Heparin vial. On a third unit, a medication cart was left unlocked in the hallway with the keys on top, and the surveyor was able to access insulin pens in the top drawer after the nurse walked away. Additionally, several insulin pens belonging to different residents were found in the unlocked cart without dates indicating when they were opened, despite the requirement that insulin pens are only good for 28 days after opening. The LPN present was unable to accurately date the insulin pens, as she was not the one who had administered them. The facility's medication storage policy requires that medication carts be locked or attended by authorized personnel at all times, but this was not followed during the observations.
Failure to Obtain Ordered Laboratory Test for C. diff
Penalty
Summary
Facility staff failed to obtain laboratory services as ordered for a resident admitted with dementia. The medical record showed that a Nurse Practitioner ordered a C. difficile (C. diff) stool sample for the resident, but no specimen was collected or sent to the laboratory from the time of the order until the resident's discharge. During this period, a change of condition was documented, noting that the resident's representative requested hospital evaluation due to ongoing diarrhea lasting over two weeks. The Assistant Director of Nursing confirmed in an interview that the ordered C. diff specimen was never sent.
Failure to Obtain Timely Outside Professional Consults
Penalty
Summary
Facility staff failed to obtain timely outside professional services for two residents as required. For one resident with chronic kidney disease stage IV, a physician ordered a nephrology consult upon admission in December 2024. However, as of early April 2025, the resident had not been seen by a nephrologist nor had an appointment scheduled. This was confirmed by both the Director of Nursing and Assistant Director of Nursing, who acknowledged that staff did not schedule the necessary consult. In a separate incident, another resident with dementia developed significant bruising and swelling around the left eye, with a small gash to the eyebrow. The nurse practitioner requested an ophthalmology consult to evaluate the injury, but review of the medical record showed that no such consult was obtained following the incident. Although the resident had a preplanned retinal specialist appointment a month after the injury, this was unrelated to the acute event. The DON agreed that the resident could have been sent to an eye clinic or emergency room for timely evaluation, but this did not occur.
Failure to Maintain Complete Hospice Documentation in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Medical record review showed that the resident was admitted to the facility in August 2023 and began receiving hospice services in June 2024. However, the resident's medical record did not contain any documentation from hospice, such as progress notes, assessments, or care plans. This lack of hospice documentation was confirmed during an interview with the Director of Nursing, who acknowledged that the records were missing at the time of review.
Failure to Follow Infection Control Guidelines for Linen and Patient Care Item Storage
Penalty
Summary
Surveyors identified that the facility failed to implement effective infection control practices during the handling and storage of linens and patient care items. On two separate units, soiled linen carts were observed with clean patient care items, such as gloves, cleanser, ointment, and a beverage bottle, improperly stored on top. Additionally, a list containing resident names and weights, along with a pen, was found on a soiled linen cart. Clean linens, including sheets, towels, and diapers, were observed uncovered on over-bed tray tables and on carts in hallways. These items were not protected from potential contamination, and clean and soiled items were not kept separate as required by infection control guidelines. Staff interviews confirmed that these practices were not acceptable and did not align with infection control standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,559 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Timonium
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchard Hill Rehabilitation And Healthcare Center | 3 mi | ★★★★★ | 42 | 0 |
| Edenwald | 3.1 mi | ★★★★★ | 3 | 0 |
| Chestnut Grn Hlth Ctr Blakehur | 3.4 mi | ★★★★★ | 13 | 0 |
| Towson Rehabilitation And Healthcare Center | 3.5 mi | ★★★★★ | 18 | 0 |
| Pickersgill Retirement Community | 3.6 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Stella Maris, Inc..
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.