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 The Nursing And Rehab Center At Stadium Place during CMS and state inspections, most recent first.
A resident with a colostomy had physician orders for colostomy bag and stoma care and was documented in a progress note as frequently manipulating and removing the colostomy bag, leading to frequent bag changes and irritation at the colostomy site. However, the resident’s care plan did not include the behavior of manipulating or removing the colostomy bag, nor any interventions to address or prevent this behavior. During interview, the DON confirmed the resident’s frequent removal of the colostomy bag and inability to reattach it, and the surveyor noted that these behaviors and related interventions were not incorporated into the care plan.
The facility did not maintain adequate nursing staff coverage, resulting in GNAs covering multiple floors and frequent absence of required RN coverage. Residents experienced prolonged call bell response times, often exceeding 15 minutes, with some waiting over 30 minutes for assistance. Observations and staffing records confirmed these deficiencies, and the DON acknowledged the staffing and response time issues.
The facility did not maintain an accurate and up-to-date facility-wide assessment of staffing requirements, as the documented staffing levels did not match actual staffing practices. Both the DON and Administrator acknowledged discrepancies between the assessment and current staffing, and the most recent assessment available was outdated or incomplete.
A resident's clinical record contained inaccurate documentation regarding the acquisition and dates of pressure injuries to both heels. The wound assessment note by a nurse practitioner incorrectly stated the wounds were not facility-acquired and listed an incorrect date, while the DON confirmed the wounds were acquired in the facility. The documentation error was later acknowledged and corrected.
Surveyors found that several residents were using bedrails without documented assessments or informed consent. In multiple cases, residents either had not been consulted about the use of bedrails or were unaware of their purpose, and their medical records lacked required documentation such as bedrail assessments and consent forms. This deficiency was observed through direct resident interviews, record reviews, and staff confirmation.
Surveyors identified multiple infection control and food safety deficiencies in two facility kitchens, including staff not wearing hairnets during food preparation, personal items in food prep areas, open and unlabeled food storage, unclean cabinets and equipment, expired food items, and poor overall kitchen cleanliness.
A resident experienced a significant delay in receiving assistance due to staff not carrying or using the required pagers for the call bell system. Multiple staff members, including GNAs and nurses, did not have pagers as per facility policy, resulting in the resident having to yell for help instead of relying on the call system. The DON confirmed that all staff should have pagers, but some were lost or not returned, leading to inconsistent response to resident needs.
A resident with osteoarthritis and muscle weakness reported that a nurse failed to provide assistance when requested, instead questioning why the resident did not ask an aide for help. The incident was confirmed through interviews and facility records, which documented that the nurse's conduct did not reflect respectful or patient-centered care.
A resident was not given the required Notice of Medicare Non-Coverage (NOMNC) at least 48 hours before the end of their Medicare services. Instead, the notice was provided after coverage had expired, resulting in the resident being incorrectly billed. The Business Office Manager confirmed the error during interviews and documentation review.
A resident's care plan and active physician's orders listed them as Full Code, despite the presence of a physician's note and a signed MOLST form indicating DNR/DNI status. This inconsistency was identified during a survey and confirmed by the DON, revealing that the care plan was not reviewed and revised to match the resident's current code status.
A resident's tube feeding was administered outside the prescribed hours and the associated flush bag was not labeled, contrary to the physician's order and facility policy. The feeding was observed running in the morning when it should have been scheduled for overnight hours, and required labeling details were missing.
A resident with a recent leg fracture experienced regular pain and reported delays in staff response to call bells and in receiving PRN pain medication. Despite orders for pain assessment and PRN Tylenol, the MAR lacked documentation of administration during two evening shifts, and the assigned LPN did not sign off on these doses. Both the resident and their spouse confirmed the medication was received after significant delays.
Staff failed to consistently use required PPE for two residents on Enhanced Barrier Precautions, including an LPN not wearing a gown during wound care for a resident with an amputation, and the absence of EBP signage and a PPE cart for another resident with a healing sacral wound, despite active physician orders.
The facility did not retain required documentation for two separate abuse allegations, including investigation records and incident reports. In both cases, when surveyors requested records, the DON was unable to provide electronic or hard copy documentation, despite evidence that investigations had occurred and actions were taken, such as staff suspension and psychiatric follow-up for a resident.
Staff failed to maintain accurate and complete medical records for two residents, including missing documentation of PRN pain medication administration and delayed response to pain management requests for a resident with a tibia fracture. Another resident with multiple diagnoses had an inaccurate fall risk assessment that omitted key medical history and fall history after an unwitnessed fall. Additionally, conflicting documentation of code status was found in the records, with both DNR/DNI and Full Code orders present for the same resident.
Failure to Update Care Plan for Resident’s Colostomy-Related Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan after a documented change in condition related to colostomy care. A complaint alleged that nursing staff failed to provide adequate colostomy care to one resident. Medical record review showed the resident had physician orders for care and maintenance of a colostomy bag and stoma. A progress note dated 2/18/26 documented that the resident frequently manipulated and removed the colostomy bag, which required staff to change the bag frequently and resulted in irritation at the colostomy site. Despite this documented behavior and its effects, review of the resident’s care plan showed no evidence that the behavior of manipulating or removing the colostomy bag and stoma was included, and no interventions were listed to address or prevent this behavior. During an interview, the DON confirmed that the resident frequently removed the colostomy bag and did not understand how to reattach it independently, and the surveyor identified that these behaviors and related interventions were not reflected in the resident’s care plan.
Failure to Maintain Adequate Nursing Staff and Timely Call Bell Response
Penalty
Summary
The facility failed to provide adequate nursing staff coverage and did not ensure timely response to resident call bells across all four nursing units. Observations revealed that a Geriatric Nursing Assistant (GNA) was required to cover multiple floors due to short staffing, and staffing sheets confirmed that the number of GNAs on duty was frequently below the facility's stated standard. Additionally, there were multiple days when the facility did not have the required 24-hour Registered Nurse (RN) coverage, with entire shifts lacking an RN. The Director of Nursing (DON) confirmed these staffing levels and acknowledged the shortfalls. Residents reported excessive wait times for staff to respond to call bells, with documented response times frequently exceeding the DON's stated expectation of 15 minutes, and in some cases, residents waited over 30 minutes. Review of call bell response logs and interviews with residents and staff corroborated these delays. On several occasions, surveyors observed units with no nursing staff present for extended periods, further confirming inadequate staffing and delayed response to resident needs.
Facility Assessment Failed to Reflect Actual Staffing Requirements
Penalty
Summary
The facility failed to ensure that its facility-wide assessment accurately reflected the actual staffing requirements and current staffing practices. During a complaint survey, the DON confirmed participation in the assessment process and believed the assessment was up to date, but the document reviewed was dated August 2024. The staffing levels outlined in the assessment did not match the actual staffing practices reported by the DON, who described lower staffing levels than those documented. Staffing sheets from July 2025 also confirmed that the facility was operating below the levels indicated in the assessment. When the Administrator was interviewed, he also believed the assessment was current, but upon review, the staffing information was found to be incorrect or missing. The Administrator provided a second copy of the assessment, also dated August 2024, with the staffing section left blank. Both the DON and Administrator acknowledged that the assessment did not accurately reflect the facility's current staffing requirements or practices, and no updated assessment for 2025 was available.
Inaccurate Documentation of Pressure Injury Acquisition and Dates
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's clinical record regarding the date and acquisition of pressure injuries. Review of the resident's Minimum Data Set (MDS) and electronic medical record revealed inconsistencies in the documentation of pressure injuries to both heels. Initial assessments indicated the resident had intact skin, but a subsequent assessment documented unstageable pressure injuries and deep tissue injuries. The wound assessment note completed by the Wound Nurse Practitioner incorrectly stated that the wounds were not acquired in the facility and listed an inaccurate acquisition date. During interviews, the Director of Nursing (DON) confirmed that the wounds were acquired in the facility and were first noted on the same day the resident was transferred to the hospital. The DON acknowledged the discrepancy between her statement and the wound documentation. The Wound Nurse Practitioner later admitted to the documentation error and confirmed that an addendum was written to correct the information. The inaccurate documentation of wound acquisition and dates led to the deficiency cited during the complaint survey.
Failure to Assess and Obtain Consent for Bedrail Use
Penalty
Summary
Surveyors identified that the facility failed to perform required bed rail assessments and obtain informed consent prior to the use of bedrails for multiple residents. In several cases, residents were observed with bedrails in use, but their electronic medical records did not contain documentation of a bed rail assessment or signed consent forms. For example, one resident was found in bed with bilateral bedrails and reported that staff had not discussed the use of bedrails, despite using them for mobility and bed exit assistance. The resident's record lacked a bed rail assessment at the time of review. Another resident was observed with half bedrails in place and stated that they had not requested or been asked about the need for bedrails, though they found them helpful for mobility. The electronic medical record for this resident did not include a Bed Side Rail Tool assessment, consent for use, or a device assessment for the bedrails. Similarly, a third resident reported that bedrails were already present upon admission and did not express a need for them, yet there was no documentation of assessment or consent in the record. A fourth resident was observed with half bedrails raised on both sides of the bed and appeared anxious and restless, attempting to get out of bed using the bedrail. The review of this resident's record also failed to reveal documentation of a Bed Side Rail Tool assessment. These findings demonstrate that the facility did not consistently assess residents for bedrail safety risks or obtain and document informed consent prior to bedrail use, as required.
Infection Control and Food Safety Deficiencies in Facility Kitchens
Penalty
Summary
Surveyors observed that the facility failed to maintain proper infection control procedures and did not store or prepare food in accordance with professional standards in two of four kitchens. During a tour of the 2nd floor kitchen, staff were seen preparing breakfast without wearing hairnets, and one staff member stated that hairnets had run out and were awaiting delivery. Personal items, including a handbag, a book, and bottles of soda, were found in the food preparation area. The handbag was later moved to a cabinet that contained open, unlabeled bags of sugar and flour. The cabinets and drawers had sticky substances and stains, and contained stained towels, trash bags, and serving utensils. Fans in the kitchen were covered in thick dust, and the floor had visible stains, especially in the corners. In the 3rd floor kitchen, surveyors found a container of watermelon in the refrigerator that was not fully covered, and an opened carton of thickened cranberry cocktail that was past the recommended discard date. Cabinets and drawers in this kitchen also had sticky substances and stains, and contained stained towels, trash bags, serving utensils, and a cup of dried brown meat. The kitchen floor was stained, and a cup with a white granule-like substance was found in the dry goods area. These observations were confirmed during interviews with dietary management staff.
Failure to Ensure Staff Use of Call Bell Pager System
Penalty
Summary
The facility failed to ensure that a functioning call system was available and used by staff to respond to residents' needs in a timely manner. A resident reported having to wait two hours for assistance with personal care over a weekend and stated that staff did not respond to the call bell system, leading the resident to resort to yelling for help. During the survey, the resident demonstrated the use of the call bell, but staff in the hallway were not alerted, and a Geriatric Nursing Assistant (GNA) did not have the required pager to receive such alerts. Further interviews with staff and administration revealed that several staff members, including nurses and GNAs, did not have pagers as required by facility policy. Some pagers were reported as lost or taken home by staff, resulting in inconsistent use of the call bell alert system. The Director of Nursing (DON) confirmed that all nursing staff should have pagers to receive alerts from the call bell system, and that staff without pagers were expected to conduct frequent rounds. However, observations and interviews indicated that this protocol was not consistently followed, as multiple staff members did not have pagers and were not promptly alerted to resident needs. The deficiency was evidenced by the resident's prolonged wait for assistance and the lack of an effective system to ensure timely staff response to call bells in resident rooms and bathrooms.
Failure to Promote Resident Dignity and Respect During Care
Penalty
Summary
Facility staff failed to provide an environment that promotes dignity and respect for a resident who required assistance with daily care. The resident, who had diagnoses including osteoarthritis of the right hip and muscle weakness, reported that a nurse did not provide assistance when requested. Specifically, the resident asked the nurse for help with the TV remote, but the nurse questioned why the resident did not ask the aide instead and did not assist at that time. The resident subsequently contacted their daughter to report the incident, and the daughter documented the staff member's name and the date of the occurrence. Interviews with the resident and their daughter confirmed the details of the incident, and facility records indicated that the nurse's conduct during the interaction was deemed inappropriate and not reflective of respectful, compassionate, and patient-centered care. The Director of Nursing confirmed that the nurse was present in the resident's room and failed to assist as requested, which was considered unacceptable behavior and not in line with the facility's expectations for staff to assist residents when needed.
Failure to Provide Timely Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide timely notification to a resident or their representative regarding the end of Medicare coverage and the associated financial liability. Specifically, the Notice of Medicare Non-Coverage (NOMNC), which is required to be given at least 48 hours prior to the scheduled end of coverage, was not provided to the resident until after the services had already expired. Documentation reviewed by surveyors showed that the resident signed the notice after the expiration date of their Medicare services. During interviews, the Business Office Manager acknowledged that the notice should have been given two days before the end of coverage and confirmed that the resident was incorrectly billed for services after Medicare coverage ended. The facility's records indicated that the resident's account was adjusted to remove the charges, and the error was recognized by staff during the survey process. The deficiency was identified for one resident among those reviewed for liability notices.
Failure to Update Care Plan to Reflect Resident's DNR/DNI Status
Penalty
Summary
The facility failed to ensure that a resident's person-centered care plan was reviewed and revised to accurately reflect the resident's current code status. Specifically, a review of the resident's electronic medical record revealed a physician's note and a signed MOLST form indicating the resident's code status as Do Not Resuscitate/Do Not Intubate (DNR/DNI). However, the active physician's orders and the care plan still listed the resident as Full Code, which is inconsistent with the documented advance directives and medical orders. This discrepancy was identified during a surveyor's review of the resident's records and confirmed in an interview with the Director of Nursing (DON), who acknowledged that the care plan had not been updated to reflect the resident's current wishes and medical orders. The failure to update the care plan occurred despite the presence of clear documentation in the medical record and MOLST form indicating the resident's DNR/DNI status.
Failure to Follow Physician's Orders and Labeling Requirements for Tube Feeding
Penalty
Summary
A deficiency was identified when a resident receiving tube feeding was observed to have their feeding running at 75 mL/hour during the morning, despite an active physician's order specifying that the tube feeding should be administered from 5 PM to 3 AM only. Additionally, the flush bag associated with the tube feeding was not labeled as required. The resident's electronic medical record confirmed the specific timing and rate for the tube feeding, and facility policy required both the tube feeding and flush bag to be properly labeled with the resident's information, formula details, rate, date and time hung, and nurse initials. These requirements were not followed, as observed by the surveyor and confirmed in interviews with facility staff.
Failure to Document and Timely Administer PRN Pain Medication
Penalty
Summary
Facility staff failed to document the administration of as needed (PRN) pain medication for a resident diagnosed with a displaced closed fracture of the left tibia. The resident and their spouse reported regular occurrences of right leg pain and delays in staff response to call bells, resulting in prolonged periods of unmanaged pain. Despite communication with nursing staff and some improvements, delays in response and medication delivery persisted, particularly during evening shifts. The resident's spouse specifically noted having to return to the facility due to the resident's distress over untimely pain and bedtime medication administration. A review of the resident's care plan and medication administration record (MAR) revealed an order for pain assessment and PRN Tylenol, but no documentation that the medication was administered during the evening shifts on two specific dates. The assigned LPN did not sign off on the MAR for these administrations, even though both the resident and spouse stated the medication was eventually received 30 to 60 minutes after being requested. The deficiency was confirmed through interviews, record reviews, and examination of staffing assignments, with the lack of documentation and delayed response being evident.
Failure to Implement and Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff consistently donned appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) and did not maintain or follow EBP orders as required. In one instance, a resident with a left great toe amputation and a wound covered by a dressing was observed receiving wound care from an LPN who wore gloves but did not wear a gown, despite the EBP signage indicating that both gown and gloves were required for wound care and dressing changes. The LPN stated that a gown was not necessary because there was no anticipated contact with body fluids and the dressing change was performed in a way to avoid contact with clothing or the resident's body. In another case, a resident with a healing sacral wound and an active physician's order for EBP did not have the required EBP sign on the door or a PPE cart outside the room. This was confirmed during a tour of the nursing unit, and facility leadership acknowledged that residents with EBP orders should have both the sign and PPE cart in place. These deficiencies were identified through observation, record review, and staff interviews.
Failure to Maintain Documentation of Abuse Allegations
Penalty
Summary
The facility failed to maintain required documentation related to allegations of abuse for two of six facility reports reviewed during the annual recertification survey. In one instance, the surveyor requested information regarding an abuse allegation reported to the State Agency, but the Director of Nursing (DON) stated that no records related to the report were available. Although the State Agency's records indicated that the investigation was completed and reporting occurred within the required timeframe, the facility did not retain documentation of the incident investigation or the reporting process, and exact incident times were not documented. In another case, a resident reported that a geriatric nursing assistant (GNA) tried to fight and refused to assist with personal care. The incident was documented as a change in condition, and the GNA was suspended pending investigation. The resident was followed by psychiatric services, and the facility determined there was insufficient evidence to support the abuse allegation. However, when the surveyor requested the facility report and Facility Reported Incident (FRI) documentation, the DON was unable to provide either electronic or hard copy records related to the incident.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. One resident, admitted with a displaced closed fracture of the left tibia, reported regular right leg pain and delays in staff response to call bells, resulting in prolonged periods of pain. Both the resident and their spouse stated that pain medication was received 30 to 60 minutes after being requested on two occasions, and the medication administration record (MAR) did not document the administration of PRN Tylenol on those dates. Additionally, the MAR included an order for pain assessment every shift, but there were issues with timely medication delivery and documentation. Another resident, admitted with multiple diagnoses including hemiplegia, hemiparesis, seizures, and diabetes, experienced an unwitnessed fall. The initial Fall Risk Scoring Tool assessment completed after the fall did not include the resident's predisposing diagnoses of stroke and seizures, nor did it account for the use of antiseizure medication or the current fall history. This resulted in an inaccurate assessment of the resident's fall risk, which was later corrected after the surveyor raised concerns. A further deficiency was identified regarding the documentation of code status for the same resident. The electronic medical record contained conflicting information, with a physician's note and a MOLST form indicating DNR/DNI status, while an active physician's order listed the resident as Full Code. This inconsistency in the resident's code status documentation was confirmed by the DON during the survey.
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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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Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Future Care Homewood | 1 mi | ★★★★★ | 1 | 0 |
| Future Care Charles Village | 1.2 mi | ★★★★★ | 30 | 0 |
| Keswick Multi-care Center | 1.5 mi | ★★★★★ | 23 | 0 |
| Future Care Cold Spring | 2 mi | ★★★★★ | 29 | 0 |
| Future Care Sandtown-winchester | 2.1 mi | ★★★★★ | 2 | 0 |
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