Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Western Md Hospital Center during CMS and state inspections, most recent first.
A facility failed to employ a qualified FSD. The FSD confirmed he was not a CDM and had only completed the class, with the exam not yet scheduled. The facility’s dietitian worked part-time on clinical duties and was not involved in the day-to-day kitchen operations, and no documentation was provided by survey exit showing the FSD had the required credentials.
The facility failed to identify that the automatic dishwasher was operating outside the manufacturer’s stated rinse and final rinse temperatures, with logs showing the final rinse at or above 200 degrees on most recorded occasions and direct observation confirming temperatures as high as 218 degrees. The facility also failed to store food prep and service containers in a sanitary manner, as surveyors observed wet nesting in metal pans and a large plastic nested container near the 3-comp sink.
Facility staff failed to ensure that a resident’s facility-held personal funds account was interest-bearing. Surveyors reviewed in-house account statements and found one resident with a balance over $100 whose account showed deposits but no earned interest. Staff were unsure whether the accounts earned interest, and the NHA stated he was unaware that interest needed to be paid on the account.
A resident with schizoaffective disorder was receiving an antipsychotic routinely and PRN, but the PRN order did not include a stop date or 14-day limit. The DON stated the facility’s process for PRN psychotropic medications was to limit use to 14 days, and the facility policy also required PRN psychotropic medications to be limited to 14 days.
Pressure injury care and prevention were not appropriately provided for a resident with existing buttock pressure ulcers. The resident's air mattress was observed set to the maximum 400-lb weight setting despite the resident weighing 115.8 lbs, and the assigned RN did not verify that the setting matched the resident's weight. The wound RN confirmed the setting was incorrect and stated that checking bed settings was part of her wound management process, but it had been missed.
Roof Leak Not Repaired: Surveyors observed a ceiling tile askew on 2 East with a plastic tube running from the ceiling into a metal can labeled not for trash, while a resident was assigned nearby. The MDS reported the roof had been leaking for years, causing water to drip and the floor to get wet, and said the tube-and-can setup was used to funnel water away from the floor while the facility waited for funding approval for roof replacement.
Failure to Post Daily Nurse Staffing Information: The facility did not ensure nurse staffing information was posted daily in a prominent, readily accessible location. A lobby whiteboard showed the facility name, date, and unit census, but no staffing information during an observation, and the ADON and NHA confirmed the lobby posting had been stopped after a family member used staff names on social media. Staffing information was reportedly posted in front of nursing stations on each unit, and a later lobby observation showed a printed staffing-hours sheet.
A resident dependent on mechanical ventilation was disconnected during a transfer by two GNAs, leading to a deficiency in respiratory care. The GNAs, who were agency staff, were unaware of the need for a respiratory therapist's presence during such procedures. The incident highlighted a lack of proper training and orientation for agency staff in handling ventilator-dependent residents.
A facility failed to honor a resident's DNR order, resulting in CPR being administered despite the resident's MOLST form indicating otherwise. The resident was resuscitated and hospitalized, returning with chest tubes. Additionally, the facility did not document discussions about advanced directives for another resident, who was cognitively intact, leaving no evidence of the resident being informed of their rights. These deficiencies were identified during a survey, highlighting issues with communication and documentation of residents' wishes.
The facility failed to store food according to professional standards, with expired items found in the kitchen and improper date markings on thawing liquid eggs. Additionally, temperature logs for residents' personal food refrigerators were incomplete or showed temperatures outside the recommended range. A temporary halt in dietary staff duties during a COVID outbreak led to a lapse in monitoring, as per the facility's policy.
The facility did not include behavioral health training in their staff competencies, despite identifying that 23 to 34% of residents had such needs. A review of employee files confirmed the absence of this training, and the Director of Quality acknowledged the oversight.
The facility did not have a current written transfer agreement with a local hospital, which is essential for the timely transfer of residents needing medical care. The Director of Quality confirmed the absence of such an agreement, despite routine transfers occurring without incident.
A facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to a deficiency identified during a survey. A resident who relied on bed rails for mobility was found to have loose rails. The Maintenance Director admitted that regular inspections were not conducted, and the Director of Quality confirmed that inspections were not performed prior to the survey. Documentation of inspections was only completed after the survey began.
The facility failed to include an Infection Preventionist in six consecutive QAPI meetings from November 2023 to April 2024, despite a requirement for their attendance starting in January 2024. This was confirmed by the Director of Quality during an interview.
The facility failed to develop comprehensive care plans with measurable objectives for residents with seizure disorders, PTSD, dental issues, and pressure ulcers. A resident with a seizure disorder lacked a care plan addressing anticonvulsant use, while another with PTSD had no specific triggers identified. A resident experiencing tooth pain had no dental care plan, and a resident with a pressure ulcer lacked measurable wound care goals. Staff acknowledged these deficiencies during the survey.
The facility failed to provide written notice to two residents or their responsible parties before room changes, as required by policy. One resident with severe cognitive impairment experienced two room changes without prior written notification, despite disagreement from their responsible party. Another resident, who is alert and oriented, was moved without receiving written notice, although they verbally agreed to the change. Staff interviews revealed a lack of adherence to the requirement for written notification.
The facility failed to maintain a safe and homelike environment, with unresolved water stains and infrastructure damage observed in two nursing units. Despite having a system for reporting maintenance issues, no work orders were submitted for these deficiencies, as confirmed by the Maintenance Director.
The facility failed to include comprehensive care plan goals in the transfer documentation for two residents sent to the hospital, compromising the safe and effective transition of care. Staff confirmed that the transfer packets typically included progress notes, labs, and EKG results, but not the care plan goals.
The facility failed to provide written notifications of transfers to residents, their representatives, and the Ombudsman. Two residents were transferred to the hospital without receiving the required written notifications. Staff interviews revealed that notifications were typically done verbally, and the social work department did not include the Ombudsman in the notification process. The Nursing Home Administrator acknowledged the oversight.
A resident with severe cognitive impairment and dependence on staff for self-care did not receive consistent oral hygiene services as required. Observations revealed white secretions in the resident's mouth, and a review of care records showed multiple instances of undocumented oral care. The Unit Nurse Manager confirmed the lack of documentation, acknowledging the concern that oral care was not provided.
A facility failed to ensure GNAs were competent in caring for a resident on mechanical ventilation. The incident involved GNAs disconnecting the ventilator tubing during a transfer without respiratory staff supervision, revealing a gap in training and competency. Documentation showed signed competency forms but lacked detailed training content, and a blank orientation form indicated incomplete training implementation.
A resident with hypertension received an antihypertensive medication without adherence to the prescribed parameters, as the facility failed to document the required apical pulse before administration. The medication was given daily despite the absence of documentation for the necessary parameters, leading to a deficiency in medication administration.
The facility failed to store safety lancets in their original packaging with visible expiration dates and did not maintain proper refrigerator temperatures for medications, as observed in two nursing units. Medications such as Trulicity, Pneumococcal vaccine, and ASPART insulin were stored at temperatures below the manufacturer's recommended range.
A resident experienced frequent tooth pain, but the facility failed to update the care plan or secure a dental consult. Despite multiple staff documenting the resident's pain and need for dental care, no order for a dental appointment was found. The resident's pain was managed with temporary measures, but the underlying dental issues were not addressed in the care plan. Challenges in finding a dental provider for non-ambulatory residents contributed to the delay.
The facility failed to conduct a root cause analysis on deficiencies, leading to repeated issues such as not sending transfer notices to residents' representatives and not following physicians' orders. The facility's plan of correction was incomplete, and they failed to secure a transfer agreement with a local hospital. Additionally, the facility did not meet compliance dates for several deficiencies due to delayed staff education.
A resident with severe cognitive impairment was involved in an abuse allegation that was not reported to the state agency within the required timeframe. The NHA was informed of the allegation but delayed reporting it due to her absence from the facility, violating the policy that mandates timely reporting of such incidents.
The facility failed to document thorough investigations into abuse allegations for three residents. One resident reported maltreatment, but the facility could not provide investigation details. Another resident's abuse allegation during medication administration lacked supporting documentation, and a third resident's injury investigation did not include staff interviews. The facility's reports to OHCQ concluded no abuse, but documentation was insufficient.
A facility failed to implement physician orders for 15-minute safety checks for a resident with a history of depression and suicide attempts. The resident was found with a cord around their neck and was transferred for psychiatric evaluation. Despite an active order, the facility did not document the checks, indicating a lapse in care and monitoring procedures.
A facility failed to provide adequate care for a resident with a Stage 3 pressure ulcer. The resident's medical records lacked proper documentation and assessment of the ulcer, including its stage and measurements. The wound nurse admitted that wound measurements were not being conducted due to other responsibilities. Additionally, the care plan was not comprehensive, failing to specify the ulcer's location and stage, and inaccurately documented the schedule for skin assessments.
The facility failed to ensure that physicians reviewed and documented responses to pharmacy recommendations for two residents. One resident had multiple pain medications and a positive Cologuard test, while another had potential drug interactions affecting INR levels. The facility's policy lacked clear procedures for physician response, leading to the deficiency.
A resident with bipolar disorder was prescribed Mirtazapine, but the facility staff failed to monitor the resident for specific behaviors and side effects related to the medication. The unit nurse manager was unsure how the physician's orders for behavior monitoring were integrated into the EHR, leading to a lack of documentation and oversight.
The facility failed to maintain accurate medical records for residents, including missing documentation for prescribed treatments and improperly voided MOLST forms. A resident with contractures lacked documentation of palm protector use, while another's contracture management was not recorded. Additionally, a resident's MOLST was not voided correctly, leading to multiple active orders.
Unqualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified food service director, as the one food service director identified was not a Certified Dietary Manager. On 11/20/25, the food service director confirmed he had taken the class and was eligible to take the exam but had not yet been scheduled for testing. On 11/21/25, he stated the facility consults a dietitian for guidance, and the dietitian reported she worked 20 hours per week primarily doing clinical work such as nutritional assessments and was not involved in the day-to-day running of the kitchen. The surveyor reviewed the concern with the Nursing Home Administrator on 11/21/25, and by survey exit on 12/2/25 no documentation had been provided showing the current food service director had the required credentials.
Dishwasher Temperature and Wet Nesting Issues
Penalty
Summary
The facility failed to ensure staff identified when the automatic dishwasher was in need of maintenance and repair. During the kitchen tour, the dishwasher was observed running with the final rinse temperature ranging between 192 and 200 degrees F, and then reaching 205 degrees F while the Food Service Supervisor stated staff had no control over the machine temperature. The dishwasher operation manual showed the rinse cycle minimum temperature was 160 degrees and the final rinse was 180 degrees. A Dishwasher Temperature Log later reviewed by the surveyor showed the final rinse temperature was recorded at or above 200 degrees on 45 of 61 occasions, and when the dishwasher was observed again the rinse temperature maxed at 155 while the final rinse rose as high as 218 degrees before dropping to 199-202. The Maintenance Director later reported the manufacturer confirmed the rinse should be 160 and the final rinse 180, and that the machine was too high. The facility also failed to ensure containers used for food preparation and service were stored in a sanitary manner. During the initial kitchen tour, the surveyor observed shelving near the three-compartment sink with metal pans used for tray line service, and a small amount of water was present in 2 of the 3 nested metal pans. On a later observation, 3 of 3 metal pans were dry, but water was present in 1 of 1 large nested plastic container observed. The practice of storing dishes before they are completely air dried was identified as wet nesting.
Facility-Held Resident Funds Not Kept in Interest-Bearing Account
Penalty
Summary
The facility failed to ensure that resident personal funds accounts were held in an interest-bearing account. During the investigation, surveyors identified that one resident had a facility-held personal funds account with a balance over $100. The resident’s statement showed the account was opened with an opening balance of $500, with two later deposits of $60 and $40, and an ending balance of $600. The statement did not show any withdrawals or earned interest. Facility staff provided two lists of residents with personal funds accounts, including a list of four residents whose funds were kept by the facility. The Fiscal Accounts Technician stated that the “HOUSE” designation meant the funds were held by the facility. When asked whether the in-house accounts earned interest, staff said she was not sure and later thought no interest was paid if the facility held the account. The Nursing Home Administrator stated he was unaware that interest needed to be paid on that account, and the Fiscal Services Chief was interviewed regarding the failure to pay interest on facility-held personal funds accounts for one of four residents.
PRN Antipsychotic Order Lacked Required 14-Day Limit
Penalty
Summary
The facility failed to ensure that a PRN antipsychotic medication order for Resident #5 was limited to 14 days. Resident #5 was admitted in mid-2025 and had a diagnosis of schizoaffective disorder. A review of the medical record showed that the resident was receiving an antipsychotic medication both routinely and on a PRN basis, and the PRN antipsychotic order had a start date of 11/14/25 but did not include a stop date. During an interview, the DON stated that the facility's process for psychotropic medications, including antipsychotics, was to place a 14-day limit on PRN use. The facility policy for psychotropic medication monitoring and assessment also stated that PRN psychotropic medications are limited to 14 days. When the order was reviewed with the DON, it was confirmed that the PRN antipsychotic medication order did not indicate a limit or end date.
Pressure Injury Care and Mattress Setting Not Matched to Resident Weight
Penalty
Summary
The facility failed to ensure that a resident with existing pressure injuries received appropriate services for treatment and prevention. Resident #7 was admitted with diagnoses including unstageable pressure ulcers of the left and right buttocks, Alzheimer's disease, and type 2 diabetes mellitus, and the medical record showed the resident still had pressure ulcers. During observation, the resident was transferred from a wheelchair to bed using a mechanical lift, and the bed was equipped with an air mattress whose controls were located at the foot of the bed. The mattress was observed set to alternating mode on the maximum weight setting of 400 lbs, while the resident's recorded weight was 115.8 lbs. The air mattress remained set at 400 lbs on a later observation. The RN assigned to the resident stated she ensured the mattress was on and inflated during her shift but did not check whether the weight setting matched the resident's weight. She confirmed the setting was 400 lbs and said she did not know the resident's weight. The wound RN stated she was responsible for setting up air mattresses and ensuring the resident's weight matched the mattress setting, and during observation she confirmed the setting was 400 lbs and said it obviously needed to be adjusted. She also stated that checking bed settings was part of her wound management visits and that it had been missed.
Roof Leak Not Repaired
Penalty
Summary
The facility ownership failed to ensure identified issues with the roof were repaired, and this was observed on the 2 East hallway across from room H E232. Surveyors observed one ceiling tile askew with a gap running the length of the tile, and a clear plastic tube about 1.5 inches in diameter extending from the ceiling into a large metal can with a green liner and a sign stating, "THIS CAN IS NOT FOR TRASH !!!" The can was sitting on a white bath towel, and a resident was assigned to room H E232 at the time of the observation. The Maintenance Director reported that there was a roof leak on 2 East and that when it leaks, water drips and the floor in that section gets wet. He stated that about a year earlier the facility set up the tubing and can so water would funnel into the can instead of the floor, and that the can was checked about once a week. He also reported the roof problem had been ongoing for seven years and that funding for a new roof had not been approved. The Nursing Home Administrator confirmed seeing the tube coming down from the ceiling and stated the facility was waiting on approval of funding. Documentation later provided showed the facility had been attempting to obtain approval for roof repairs for several years, including a project justification form, a roof replacement manual from DGS, and emails to DGS since December 2023, but no documentation showed that a request for bids had been initiated.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure nurse staffing information was posted on a daily basis. During an observation of the facility lobby on 11/19/25 at approximately 8:30 AM, a whiteboard displayed the facility name, current date, and census of each unit, but there was no staffing information posted. This deficient practice was identified for 7 of the 8 days of the recertification survey. During interviews, the ADON stated the facility had previously posted the complete staffing schedule, including staff names, on the lobby whiteboard but stopped doing so in November 2025 because of a safety concern after a resident's family member began looking up staff names on social media platforms. The ADON also stated staffing information was posted in each unit in front of the nursing stations. The NHA confirmed the lobby whiteboard staffing posting had been stopped and acknowledged that federal regulation requires daily staffing information to be posted in a prominent place readily accessible to residents, staff, and visitors. On 12/2/25 at 10:25 AM, the lobby whiteboard was observed with a printed paper showing the facility name, current date, census, and staffing hours for licensed and unlicensed staff.
Failure to Ensure Safe Respiratory Care During Resident Transfer
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who was dependent on mechanical ventilation due to respiratory failure. The resident, who had a history of stroke and severe cognitive impairment, was observed to be disconnected from the ventilator during a transfer from bed to a recliner chair. This disconnection occurred when two geriatric nursing assistants (GNAs) were transferring the resident using a Hoyer lift, and the ventilator alarm sounded, alerting a respiratory therapist who reconnected the ventilator. The incident was documented by both the respiratory therapist and a nurse, who noted that the disconnection lasted approximately two minutes. The GNAs involved in the transfer were not aware that a respiratory therapist needed to be present during such procedures. One of the GNAs admitted to disconnecting the ventilator tubing, while the other GNA expressed reservations about the action but did not prevent it. The GNAs were agency staff, and one of them had been working at the facility for about three months without prior experience with ventilator-dependent residents. The facility's documentation revealed that the GNAs had not been adequately educated on the proper procedures for handling ventilator-dependent residents. The respiratory therapist and unit nurse manager confirmed that the GNAs were informed post-incident about the critical nature of keeping residents connected to ventilators, as these devices are essential for their breathing. The lack of proper orientation and training for agency staff contributed to the deficiency, as evidenced by the blank Nursing Service Orientation Topic Validation form in the employee file of one of the GNAs.
Failure to Honor Resident's DNR Order and Document Advanced Directive Discussions
Penalty
Summary
The facility failed to ensure that the resident's wishes for resuscitation were communicated effectively to staff, resulting in harm to a resident with a do not resuscitate (DNR) order. The resident, who was on a ventilator, became apneic and unresponsive, leading staff to initiate cardiopulmonary resuscitation (CPR) without verifying the resident's Medical Order for Life-Sustaining Treatment (MOLST) form. Despite the MOLST form indicating a DNR status, CPR was performed, and the resident was resuscitated and transferred to the hospital, where they remained for eight days and returned with chest tubes inserted in each lung. The facility also failed to document discussions regarding advanced directives for another resident, who was cognitively intact and had been residing in the facility for long-term care. The medical record review revealed no evidence that the resident had an advanced directive or that the facility periodically informed the resident of their right to formulate one. The social worker confirmed that discussions about the resident's right to formulate an advanced directive had occurred but were not documented in the medical record. These deficiencies were identified during a survey, highlighting the facility's failure to follow procedures for verifying code status and documenting discussions about advanced directives. The lack of proper communication and documentation led to the inappropriate administration of CPR to a resident with a DNR order and the absence of evidence that another resident was informed of their rights regarding advanced directives.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to store food in accordance with professional standards, as observed during a survey of the kitchen. Surveyors noted expired food items in the walk-in freezer and refrigerator, including pureed turkey, semi-mac and cheese, semi-turkey, tropical fruit, mandarin oranges, and meatballs. The food service administrator, Staff #53, confirmed these items were expired and discarded them. Additionally, liquid eggs were found thawing without proper date markings, and an opened container of Ken's Italian dressing lacked an opening date. A dented can of diced pears was also found on the floor, which Staff #53 acknowledged should be discarded. The facility also failed to maintain proper temperature logs for refrigerators containing residents' personal food. The temperature logs for the 1 East resident refrigerator showed temperatures outside the recommended range on 26 out of 31 days. Furthermore, Resident #12's personal room refrigerator had incomplete temperature logs, with only 5 out of 31 days documented. The dietary staff was responsible for recording these temperatures, but there was a temporary halt in their duties during a COVID outbreak, leading to a break in monitoring. The facility's policy titled 'Resident Outside Food Storage on Unit' was reviewed, indicating that the Hostess service, referring to dietary staff, should maintain daily temperature logs and cleaning for resident personal food items. However, due to the COVID outbreak, dietary staff did not visit the units, resulting in a lapse in monitoring. An observation of Resident #9's room revealed a personal refrigerator with a lock but no temperature log, further highlighting the deficiency in maintaining proper food storage and monitoring practices.
Deficiency in Staff Competency for Behavioral Health Needs
Penalty
Summary
The facility failed to include necessary staff competencies in their facility-wide assessment, specifically omitting behavioral health training despite identifying that 23 to 34% of the resident population had behavioral health needs. On June 4, 2024, a review of the facility assessment revealed this oversight, and further examination of employee files showed no evidence of behavioral health training being provided. During an interview, the Director of Quality acknowledged the concern, admitting that the competencies listed did not cover the level and type of care needed for all identified resident populations.
Lack of Written Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a current written transfer agreement with a local hospital, which is necessary to ensure residents can be moved quickly for medical care when needed. During a review conducted on June 4, 2024, it was found that the facility's assessment did not include a written agreement with a local hospital willing to accept residents from the facility. In an interview, the Director of Quality acknowledged the absence of such an agreement, although she noted that residents had been routinely transferred to the local hospital without incident. No additional documentation was provided to support the existence of a transfer agreement before the survey concluded.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which led to a deficiency identified during a survey. This was particularly evident in the case of a resident who had been in the facility since 2016 and relied on bed rails for mobility due to weakness in the left arm. During an interview, the resident demonstrated the use of the bed rails, which were found to be loose. The Unit Nurse Manager acknowledged that assessments related to bed rails were documented in both electronic and hard copy records, but there was no documentation of regular inspections for bed safety. The Maintenance Director admitted that regular inspections of bed rails were not conducted, as he was only called upon by the Nursing department for installation or removal of bed rails. Despite the Nursing Home Administrator's claim of having conducted inspections with the Maintenance Director, documentation to support this was not initially provided. The Director of Quality later confirmed that inspections were not performed prior to the survey, and the documentation presented was completed only after the survey began. The deficiency was discussed with facility staff during the survey exit conference, but no further comments or documentation were provided.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to establish a Quality Assurance and Performance Improvement (QAPI) committee that included an Infection Preventionist at every meeting, as required. The deficiency was identified through a review of attendance sign-in sheets for QAPI meetings held from May 2023 through May 2024. It was found that the Infection Preventionist did not attend six consecutive meetings on specific dates from November 2023 to April 2024. During an interview, the Director of Quality confirmed the absence of the Infection Preventionist at these meetings and noted that the requirement for their attendance at every meeting began in January 2024.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans with measurable objectives and timeframes for several residents, leading to deficiencies in addressing their medical needs. For Resident #6, who had a seizure disorder and was on anticonvulsant medications, the care plan lacked measurable goals to manage the condition effectively. Despite having physician orders for seizure precautions, the care plan did not reflect these needs, which was acknowledged by the unit nurse manager. Resident #34, diagnosed with dementia, depression, and PTSD, had a care plan that was not person-centered. The plan failed to identify specific triggers that could re-traumatize the resident, despite the severe cognitive impairment documented in the MDS assessment. The care plan's goal was vague, stating that the resident would not experience PTSD triggers, but it lacked detailed interventions to prevent such occurrences, as noted by the unit nurse manager and assistant director of nursing. Resident #9 experienced frequent tooth pain, which was documented in the MDS assessment and medical records. However, the care plan did not address the dental issues or the need to find a dentist, despite multiple notes indicating the resident's discomfort. Similarly, Resident #24, who had a pressure ulcer, had a care plan that lacked measurable objectives and timeframes for wound care. The wound nurse admitted to not measuring wounds due to time constraints, which contributed to the inadequate care planning for the resident's pressure ulcer.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice to residents or their responsible parties before making room changes, as required by policy. This deficiency was identified for two residents during the survey. Resident #31, who has severe cognitive impairment due to dementia, experienced two room changes without prior written notification to their responsible party. The responsible party did not agree with the second room change, yet the move proceeded without documented discussion or resolution of their concerns. The facility's policy mandates a 30-day written notice and an interdisciplinary team meeting if there is disagreement about a room change, but these steps were not documented in Resident #31's case. Similarly, Resident #9, who is alert and oriented but dependent on staff for mobility, was moved to a new room without receiving written notice. Although the resident verbally agreed to the move after a discussion with the social worker, there was no documentation of written notice being provided, including the reason for the change. Interviews with staff, including the Nursing Home Administrator and the social worker, revealed a lack of awareness and adherence to the requirement for written notification, indicating a systemic issue in the facility's process for handling room changes.
Facility Fails to Address Maintenance Issues
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment as evidenced by the presence of water stains and damaged infrastructure in two nursing units. On May 20, 2024, a surveyor observed water stains on the ceiling above a resident's bed in room K on unit 1 East, and a cracked wall protector below the handrail across from room E on unit 1. Despite the facility's protocol for reporting and addressing maintenance issues through an electronic work order system, these deficiencies were not addressed. During a follow-up tour on May 31, 2024, with the Maintenance Director, the previously identified issues remained unresolved, and an additional water stain was noted on a ceiling tile in the 1 East hallway. The Maintenance Director acknowledged the presence of a chiller pipe with bad insulation above the ceiling in room K but indicated there was no feasible permanent solution. Furthermore, the Maintenance Director confirmed that no work orders had been submitted for the identified areas, highlighting a lapse in the facility's maintenance and repair processes.
Failure to Communicate Care Plan Goals During Resident Transfers
Penalty
Summary
The facility failed to communicate the comprehensive care plan goals of residents to the receiving healthcare institution during transfers, which is a requirement for ensuring safe and effective transitions of care. This deficiency was identified for two residents who were reviewed for hospitalizations. Resident #24, who had been residing in the facility since 2020, was sent to the hospital twice in 2024. During an interview, a Registered Nurse (RN) described the process for preparing documentation for a resident's transfer, which did not include care plan goals. The unit nurse manager confirmed that the transfer packet did not contain care plan goals, highlighting a gap in the communication process. Similarly, for Resident #19, who experienced a change in condition and was transferred to the hospital, the medical record review revealed that the transfer documentation did not include the resident's comprehensive care plan goals. The unit nurse manager acknowledged that the transfer packet typically included progress notes, labs, and EKG results, but not the care plan. This oversight in documentation and communication was discussed with the unit nurse manager, emphasizing the facility's failure to ensure the safe and effective transition of care for residents being transferred to other healthcare institutions.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification of transfers to residents, their representatives, and the Office of the State Long-Term Care Ombudsman, as required. This deficiency was identified during a review of medical records and staff interviews, specifically affecting two residents who were hospitalized. Resident #19 experienced a change in condition and was transferred to the hospital without receiving written notification of the transfer. The Licensed Social Worker (SW) acknowledged that written notifications were only sent to the resident's representative if the resident remained out of the facility for more than 24 hours, and that the Ombudsman was not notified. Similarly, Resident #24 was transferred to the hospital twice in 2024 without written notifications being sent to the resident, their representative, or the Ombudsman. Interviews with nursing staff and the Unit Nurse Manager revealed that notifications were typically done verbally, and written notifications were handled by the social work department. However, the social worker confirmed that the Ombudsman was not included in the notification process. The Nursing Home Administrator was informed of this oversight and acknowledged the concern.
Failure to Provide Oral Hygiene to Dependent Resident
Penalty
Summary
The facility failed to provide necessary oral hygiene services to a resident who was unable to perform activities of daily living independently. The resident, who had been residing in the facility since 2016, was observed with white secretions in the mouth, indicating poor oral care. The resident's Minimum Data Set (MDS) assessment revealed severe cognitive impairment and dependence on staff for self-care, including oral hygiene. Despite the resident's needs, the facility did not consistently document the provision of oral care as required. A review of the resident's orders indicated that oral care was to be administered four times daily. However, the administration history from late April to late May showed numerous instances where oral care was not documented, including several days where no care was recorded at all. The Unit Nurse Manager confirmed the lack of documentation and acknowledged the concern that oral care was not provided to the dependent resident, emphasizing the nursing principle that if care is not documented, it is considered not done.
Inadequate Competency in Ventilator Care
Penalty
Summary
The facility failed to ensure that geriatric nursing assistants (GNAs) were competent in providing care to a resident dependent on mechanical ventilation. This deficiency was identified during a review of an incident involving a resident who was admitted with a history of stroke and respiratory failure, requiring mechanical ventilation. The resident, who had severe cognitive impairment and was non-verbal, was involved in an incident where GNAs disconnected the ventilator tubing during a transfer without the presence of a respiratory therapist. The incident occurred when two agency GNAs attempted to transfer the resident using a hoyer lift, during which the ventilator tubing was disconnected. A respiratory therapist discovered the disconnection upon responding to a ventilator alarm. The GNAs involved were not aware that they should not disconnect the ventilator or transfer the resident without respiratory staff supervision. One of the GNAs admitted to not understanding the difference between ventilator and tracheostomy care, highlighting a gap in their training and competency. Documentation revealed that the GNAs had signed competency forms indicating they were trained in respiratory care, but the forms lacked detailed descriptions of the training content. Additionally, a blank Nursing Service Orientation Topic Validation form was found in the employee file of one of the GNAs, indicating that the necessary orientation and training had not been fully implemented prior to the incident. This lack of proper training and competency assessment led to the deficiency in care provided to the resident.
Failure to Follow Medication Administration Protocol for Antihypertensive Medication
Penalty
Summary
The facility failed to ensure that a resident received medication according to the attending physician's orders, leading to a deficiency in medication administration. Resident #32, who was admitted in December 2022 with a diagnosis of hypertension, had an order for an antihypertensive medication to be administered twice daily. The order included specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 100 mmHg or the apical pulse was less than 55 beats per minute. However, the medication administration records (MARs) for April and May 2024 showed that the resident received the medication daily without documentation of these parameters. Further investigation revealed that the vital signs history for the resident during this period only contained records of the radial pulse and not the apical pulse, which was required by the physician's order. Interviews with staff members, including licensed practical nurses and the assistant director of nursing (ADON), confirmed that the apical pulse was not documented as required. The ADON acknowledged the oversight and noted that the nurses were supposed to check the apical pulse instead of the radial pulse, indicating a failure in following the prescribed medication administration protocol.
Improper Storage of Medical Devices and Medications
Penalty
Summary
The facility failed to properly store medical devices and medications according to the manufacturer's guidelines, as observed during a survey. On two separate nursing units, safety lancets were found outside of their original packaging, with no visible expiration dates. Nurse Supervisor Staff #13 confirmed that the lancets were not stored in their original boxes and was unable to provide expiration dates. Additionally, a large quantity of safety lancets was discovered in a wall cabinet, also without original packaging or known expiration dates. Furthermore, the facility did not maintain appropriate refrigerator temperatures for medication storage. Observations revealed that the medication refrigerator in the [NAME] Wing had a temperature reading between 30 and 32 degrees Fahrenheit, which is below the manufacturer's recommended storage temperature for several medications, including Trulicity, Pneumococcal 20-valent Conjugate vaccine, and ASPART insulin. Despite adjustments made by the Maintenance Director, the temperature remained below the required range. The facility's policy mandates that medications be stored according to the manufacturer's instructions, which was not adhered to in this case.
Failure to Address Resident's Dental Needs
Penalty
Summary
The facility failed to ensure that a dental care plan and appropriate orders were in place for a resident experiencing frequent tooth pain. The resident, who had been living at the facility for several years, was alert, oriented, and dependent on staff for mobility. Despite the resident's repeated complaints of tooth pain, documented by various staff members, there was no order for a dental consult or a care plan addressing the dental issues. The resident's medical record showed multiple instances where staff documented the resident's tooth pain and the need for a dental consult. However, the care plan was not updated to reflect these dental concerns, and no order for a dental appointment was found. The resident's pain was managed temporarily with Anbesol gel and acetaminophen, but the underlying dental issues were not addressed in the care plan. Interviews with staff revealed challenges in finding a dental provider for non-ambulatory residents. Although a provider was eventually identified, and an appointment was scheduled, the delay in addressing the resident's dental needs and updating the care plan constituted a deficiency in the facility's care planning process.
Recurrent Deficiencies and Compliance Failures
Penalty
Summary
The facility failed to conduct a root cause analysis on deficiencies cited during a recertification survey, leading to the recurrence of the same issues. During a revisit survey, it was found that the facility did not send transfer notices to residents' representatives as required, and staff failed to follow physicians' orders for medication administration. The facility's plan of correction focused only on specific orders, neglecting to address all physician orders. Additionally, the facility did not effectively implement a plan of correction for care plan evaluations, as social workers, who were not qualified to evaluate care plans, were tasked with this responsibility. The facility also failed to secure a transfer agreement with a local hospital, despite stating they would make a good faith attempt by a specified date. Furthermore, the facility did not meet its alleged compliance date for several deficiencies, including unnecessary medications and medication storage, as staff education was not completed on time. Interviews with facility staff revealed a lack of timely intervention and education for certain staff members, contributing to the failure to meet compliance deadlines.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility staff failed to report an allegation of abuse involving a resident with severe cognitive impairment in a timely manner. The resident, admitted in August 2022 with a diagnosis of dementia, was the subject of an abuse allegation reported to the Nursing Home Administrator (NHA) on February 7, 2024, at approximately 4:20 PM. However, the NHA did not report the allegation to the state agency until February 9, 2024, which was beyond the required timeframe for reporting such incidents. The facility's policy mandates that allegations of abuse must be reported to the appropriate agencies within 24 hours, or within 2 hours if serious bodily injury or abuse is alleged. Despite this policy, the NHA confirmed during an interview that the report was delayed because she was not present in the building when the allegation was initially reported to the social worker. This delay in reporting constitutes a failure to adhere to the facility's own procedures and regulatory requirements for timely reporting of abuse allegations.
Failure to Document Thorough Abuse Investigations
Penalty
Summary
The facility failed to provide documentation of thorough investigations into allegations of abuse for three residents. Resident #98 reported maltreatment by a staff member, but the facility could not provide any employee statements or resident interviews that comprised the investigation. The current administrator, who was not in position at the time of the investigation, was unable to locate the investigation file. Similarly, for Resident #9, who reported an abuse allegation during medication administration, the facility's documentation lacked evidence of interviews with staff or residents, and the full name of a witness was not identified. The final report submitted to the Office of Health Care Quality (OHCQ) concluded no evidence to substantiate the allegation, but supporting documentation was insufficient. For Resident #15, who had a blister of unknown origin, the facility's investigation concluded that abuse was not substantiated, and a police report indicated no criminal investigation was required. However, the facility failed to provide documentation of staff interviews conducted during the investigation. The resident was unable to report how the blister occurred, and the facility's documentation did not include evidence of a thorough investigation. The surveyor reviewed these concerns with the Director of Nursing and the Nursing Home Administrator, highlighting the facility's failure to document comprehensive investigations into the allegations.
Failure to Implement 15-Minute Safety Checks for Resident
Penalty
Summary
The facility failed to implement physician orders for 15-minute safety checks for a resident with a history of depression and previous suicide attempts. The resident was discovered with a cord wrapped around their neck and was subsequently transferred to a local hospital for psychiatric evaluation. Despite having an active physician order for 15-minute safety checks, the facility did not document these checks in the nursing binder or the electronic health record during the time the order was in place. The administrator acknowledged the lack of documentation and stated that the facility had transitioned to recording 15-minute safety checks in the electronic health record. However, no documentation was provided for the required checks during the specified period, indicating a failure to adhere to the physician's orders and ensure the resident's safety. This deficiency was identified during a survey, highlighting a significant lapse in the facility's care and monitoring procedures for residents with behavioral or emotional care needs.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice to prevent the development of pressure ulcers and promote healing of existing pressure ulcers for a resident. The resident had a Stage 3 pressure ulcer on the left lower buttock, which was not properly documented or assessed. The facility's electronic medication administration record (eMAR) showed inconsistencies in the administration of prescribed treatments, with a missed application of a moisture barrier cream and incorrect scheduling of skin assessments. The medical record review revealed that the facility did not document the stage of the pressure ulcer or conduct regular wound measurements, which are essential for monitoring the healing process. The wound nurse, responsible for initial wound assessments and guiding staff on wound treatments, admitted that wound measurements were not being done due to her other responsibilities. This lack of consistent wound measurement and documentation was a significant oversight in the resident's care. Additionally, the resident's care plan was not comprehensive or resident-centered, failing to specify the location and stage of the pressure injury. The care plan inaccurately documented the schedule for skin assessments, which did not align with the actual practice. The facility's failure to conduct ongoing assessments and revise the care plan based on the resident's changing needs put the resident at risk for impaired wound healing.
Failure to Document Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the pharmacist during monthly drug regimen reviews were reviewed by the attending physician, and that the physician documented the review and any actions taken in the medical record. This deficiency was observed in two residents. For Resident #6, the pharmacist identified several irregularities, including the use of multiple pain medications and the need for a PPI due to a positive Cologuard test and the use of Eliquis. Despite these recommendations, there was no documentation in the resident's medical record indicating that the attending physician reviewed or addressed these issues. Similarly, for Resident #9, the pharmacist noted potential drug interactions between ibuprofen and warfarin, which could affect the resident's INR levels. The pharmacist recommended discontinuing ibuprofen and considering alternative pain therapies. However, the medical record lacked documentation that the primary care provider reviewed or addressed these recommendations. Interviews with staff revealed that the facility had inconsistent procedures for notifying physicians of pharmacy recommendations, contributing to the lack of documented responses. The facility's Drug Regimen Review policy did not specify a timeframe for physicians to respond to pharmacist recommendations or require documentation of the response in the medical record. This lack of clear procedures and documentation led to the deficiency, as the facility failed to ensure that physicians reviewed and addressed monthly pharmacy recommendations, as evidenced by the cases of Residents #6 and #9.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by not adequately monitoring a resident for behavior, side effects, or adverse consequences related to the use of psychotropic medication. This deficiency was identified for a resident who had been in the facility for long-term care since February 2020 and had a diagnosis of bipolar disorder. The resident was prescribed Mirtazapine, an antidepressant, to be taken daily. However, there was no documentation in the resident's medical record indicating that the facility staff conducted ongoing monitoring for the specific behaviors for which the psychotropic medication was prescribed or for any side effects of the medication. During an interview, the unit nurse manager acknowledged that the physician wrote the order for the psychotropic medication and behavior monitoring, but she was unsure how this was integrated into the electronic health record. The nurse manager indicated that the order should automatically populate into the resident's administration record for nurses to document accordingly. Despite being made aware of the concerns regarding the lack of monitoring for behavior and potential side effects, the nurse manager did not provide further explanation.
Deficiencies in Medical Record Documentation and Order Management
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by the survey findings. Resident #6, who had been residing in the facility since February 2020, was observed with hand contractures but without the prescribed palm protectors. The electronic medication administration record (eMAR) lacked documentation of the application of these protectors from May 1 to May 22, 2024, despite an order from September 2022. Additionally, there was an incomplete order for Silver Nitrate, lacking specific application instructions, which was acknowledged by the unit nurse manager. Resident #21, diagnosed with spastic quadriplegic cerebral palsy and contractures, was observed without the necessary splints or devices. The eMAR for May 2024 did not document the application of pillow rolls/bolsters as ordered for contracture management. The Therapy Services Manager and Restorative Nurse/MDS Coordinator noted limitations in the EHR software that hindered accurate documentation. Furthermore, an order for a mineral oil rectal enema lacked a clear indication for administration, which was recognized as a concern by the staff. Resident #96's chart contained multiple Maryland Orders for Life-Sustaining Treatment (MOLST), with a prior MOLST not properly voided according to protocol. The Medical Director confirmed the presence of more than one MOLST and acknowledged the incorrect voiding of the old MOLST. These deficiencies highlight issues in documentation and adherence to medical orders within the facility.
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 351 citations issued within 25 miles in the last 12 months — including the 6 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 Hagerstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coffman Nursing Home | 0.3 mi | ★★★★★ | 16 | 0 |
| Hagerstown Healthcare Center | 2.2 mi | ★★★★★ | 28 | 0 |
| Julia Manor Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 47 | 0 |
| Complete Care At Hagerstown | 2.9 mi | ★★★★★ | 23 | 1 |
| Creekside Center For Rehabilitation And Nursing | 3.5 mi | ★★★★★ | 34 | 1 |
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 July 2026) and official state health department websites.