Inspection Report Summary
The most recent inspection on July 25, 2025, identified deficiencies related to wound care documentation, medication administration, infection control, care planning, and environmental cleanliness. Earlier inspections showed similar issues with care planning, medication errors, notification of condition changes, and maintaining a homelike environment, along with substantiated abuse incidents and an immediate jeopardy finding corrected in 2022. Inspectors cited recurring problems with pressure ulcer care, medication management, infection control, and communication with residents’ representatives. Complaint investigations were mostly substantiated, particularly regarding wound care and failure to notify family members of significant changes. The pattern of findings suggests ongoing challenges in clinical care and facility environment, with no clear improvement trend in recent years.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
12.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1% better than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 25, 2025
Visit Reason
The inspection was conducted based on a complaint intake regarding pressure ulcers on Resident #142, with concerns about whether the ulcers were facility-acquired and related to the resident's death.
Complaint Details
Complaint intake #310260 involved Resident #142 having bedsores with uncertainty if they were facility acquired and if they contributed to the resident's death.
Findings
The facility failed to accurately complete the resident's skin assessment sheets and did not follow physician orders for wound treatment. Nurses did not sign off on treatment administration records, and wound treatments were ordered late or not documented properly.
Deficiencies (1)
Failure to accurately complete resident's skin assessment sheet and follow physician's order for wound treatment.
Report Facts
Number of wound areas: 15
Deficiencies cited: 1
Dates wound treatment not signed off: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding skin assessment sheets and wound treatment documentation; validated deficiencies. |
Inspection Report
Recertification/complaint Survey
Deficiencies: 9
Date: Jul 25, 2025
Visit Reason
The inspection was conducted as a recertification and complaint survey to assess compliance with regulatory requirements and investigate specific complaints.
Complaint Details
The survey included complaint investigations related to cleanliness, care planning, medication administration, wound care, respiratory care, pain management, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and homelike environment, incomplete and inaccurate care plans, medication administration errors, inadequate wound care, improper respiratory care labeling, failure to monitor vital signs prior to medication administration, and lapses in infection control practices in the laundry room.
Deficiencies (9)
Failed to ensure a resident's room was clean, comfortable, and homelike, with strong urine odor and rusty vent observed.
Failed to develop and implement a complete care plan that meets all the resident's needs, including impaired mobility.
Failed to review and revise interdisciplinary care plans to reflect accurate and current interventions for residents.
Failed to provide appropriate treatment and care according to orders, resident’s preferences and goals, including medication administration errors and delayed lab follow-up.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, including incomplete skin assessments and unsigned treatment records.
Failed to label oxygen tubing when oxygen therapy was initiated.
Failed to develop and implement a person-centered comprehensive care plan addressing pain management.
Failed to adequately monitor resident's blood pressure and heart rate prior to administering medication as ordered.
Failed to maintain infection control practices in the laundry room, with cleaning supplies and ice water found on clean linen folding table.
Report Facts
Residents reviewed for care plans: 33
Residents reviewed for medication administration: 50
Residents reviewed for pressure ulcers: 1
Residents reviewed for respiratory care: 50
Residents reviewed for pain management: 33
Residents reviewed for unnecessary medications: 5
Medication administration delays: 4
Wounds documented on admission: 3
Wounds areas: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #7 | Licensed Practical Nurse (LPN) | Named in findings related to urine odor and communication with residents |
| Staff #4 | Maintenance Director | Interviewed regarding rusty vent and urine odor |
| Staff #16 | Housekeeper | Interviewed about cleaning frequency and urine odor |
| Staff #14 | Environmental Services (EVS) Manager | Interviewed about cleaning efforts and ordered mattress covers |
| Director of Nursing (DON) | Director of Nursing | Interviewed multiple times regarding care plans, medication administration, and infection control |
| Nursing Home Administrator (NHA) | Nursing Home Administrator | Interviewed regarding urine odor and cleaning efforts |
| Unit Manager (UM #5) | Unit Manager | Interviewed regarding communication with Resident #126 and care plan updates |
| Registered Nurse (RN #17) | Registered Nurse | Interviewed about medication administration policy and delays |
| Unit Manager #21 | Unit Manager | Interviewed about lab results follow-up and wound care |
| Licensed Practical Nurse (LPN #22) | Licensed Practical Nurse | Interviewed about tube feeding pump and syringe changes |
| Speech Therapist (ST #20) | Speech Therapist | Interviewed about communication board use |
| Registered Nurse (RN #18) | Registered Nurse | Interviewed about oxygen tubing labeling |
| Staff #19 | Laundry Assistant | Interviewed about laundry process and infection control training |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on allegations regarding failure to notify a resident's representative of a significant change in condition, failure to develop a person-centered Hospice care plan, medication errors, and incomplete medical records.
Complaint Details
The complaint investigation was triggered by allegations that Resident #11's representative was not notified of a significant change in condition and oxygen treatment; Resident #12's Hospice care plan was not individualized; Resident #16 experienced medication errors due to delayed medication availability; and incomplete medical records were maintained for Resident #12.
Findings
The facility failed to notify a resident's representative of a significant change in condition and treatment plan, failed to develop a person-centered Hospice care plan reflecting individual needs and preferences, failed to ensure timely availability of medications resulting in medication errors, and failed to maintain complete and accurate medical records for a Hospice resident.
Deficiencies (4)
Facility staff failed to notify the resident's representative when there was a significant change in the resident's condition and treatment plan.
Facility failed to develop a person-centered Hospice plan of care with individualized needs and preferences.
Facility failed to keep residents free from significant medication errors by failing to ensure medication was available in a timely manner for administration.
Facility staff failed to maintain complete and accurately documented medical records for a Hospice resident.
Report Facts
Residents reviewed for complaint: 22
Residents affected: 1
Residents affected: 1
Residents affected: 1
Oxygen saturation: 68
Oxygen liters: 6
Medication administration times signed with code 9: 9
Blood sugar result: 343
Blood sugar result: 275
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Director of Social Services | Interviewed regarding Hospice Services and Care Plan development |
| Staff #6 | Nurse Practitioner | Notified regarding unavailability of Novolog insulin |
| Nursing Home Administrator | Acknowledged concerns regarding notification failure and medication errors | |
| Director of Nurses | Acknowledged concerns regarding notification failure and medication errors |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Nov 17, 2022
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with federal regulations regarding resident rights, safety, care, medication administration, environment, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to notify residents of rule changes after ownership transition, inadequate maintenance of a homelike environment, failure to respond adequately to resident grievances, substantiated abuse incidents, delayed reporting of abuse, incomplete and untimely resident assessments, failure to initiate CPR as required, medication administration errors including missed and late medications, inadequate pain management documentation, and poor ventilation on the second floor.
Deficiencies (12)
Failed to ensure residents were aware of current facility rules and regulations after change in ownership.
Failed to maintain a homelike environment; holes in baseboards, urine odor, missing tiles, and water leaks observed.
Failed to give adequate responses to resident grievances regarding staffing and dietary services.
Failed to prevent abuse by employees; substantiated incidents of physical abuse involving residents #78 and #79.
Failed to timely report suspected abuse to authorities for Resident #68.
Failed to complete timely MDS assessment for hospice resident #59.
Failed to submit significant change MDS assessment timely for hospice resident #59.
Failed to initiate CPR on resident #167 who had no pulse, violating resident's wishes; immediate jeopardy cited but corrected.
Failed to administer medications as ordered for residents #3 and #42.
Failed to document administration and assess effectiveness of pain medication for resident #26.
Failed to administer medications according to physician orders and had significant late medication documentation for resident #164 and others.
Failed to have adequate ventilation on the 2nd floor; ventilation duct filters were dirty and never cleaned in 8 years.
Report Facts
Residents reviewed: 56
Residents reviewed for abuse allegations: 18
Residents affected by abuse: 2
Late medication administrations: 73
Late medication administrations: 35
Late medication administrations: 47
Late medication administrations: 2
Late medication administrations: 11
Late medication administrations: 24
Late medication administrations: 23
Late medication administrations: 20
Late medication administrations: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #21 | Geriatric Nursing Assistant | Removed from facility after substantiated abuse of Resident #79 |
| Staff #24 | Geriatric Nursing Assistant | Removed from facility after substantiated verbal and physical abuse of Resident #78 |
| Staff #27 | Nurse | Failed to initiate CPR on Resident #167; terminated |
| Staff #19 | MDS Coordinator | Acknowledged failure to complete pain assessment and submit significant change MDS for Resident #59 |
| Staff #23 | LPN | Witnessed verbal altercation between Resident #78 and Staff #24 |
| Staff #34 | LPN | Reported medication administration error for Resident #114 |
| Staff #36 | Physician | Ordered medication refill leading to medication error for Resident #114 |
| Staff #17 | Unit Manager RN | Interviewed regarding medication error and CPR incident |
| Staff #1 | LPN | Failed to report abuse incident timely for Resident #68 |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Dec 11, 2018
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements including resident care, medication management, infection control, staffing, and facility operations.
Findings
The facility was found deficient in multiple areas including confidentiality of medical records, timely notification of resident transfers, care planning, assistance with activities of daily living, pain management, medication labeling and storage, dietary staff certification, food storage, facility-wide assessment, medical record maintenance, and infection prevention and control.
Deficiencies (12)
Failed to keep residents' personal and medical records private and confidential, with medication carts left unattended exposing resident information.
Failed to provide timely notification to the resident's responsible party before transfer to hospital.
Failed to notify resident or representative in writing about bed hold policy during hospital transfer.
Failed to develop a comprehensive care plan for a resident prescribed medication for depression.
Failed to provide consistent shaving assistance to a resident as per care plan and resident preference.
Failed to clarify pain definitions and document pain location/type prior to administering as needed pain medications.
Failed to label and store drugs and biologicals properly and secure medication carts and medication rooms.
Failed to ensure dietary managers had required certified dietary manager (CDM) certification.
Failed to properly store food and other items in the kitchen, including unlabeled juices and spilled dry goods.
Failed to include required staff competencies and education in the facility-wide assessment plan.
Failed to obtain physician's order for resident transfer and failed to ensure required nurse signatures on hemodialysis communication logs.
Failed to ensure personal hygiene equipment was stored and labeled appropriately in a shared bathroom.
Report Facts
Residents reviewed for care plans: 33
Residents transferred to hospital: 4
Medication carts inspected: 6
Medication rooms checked: 1
Residents affected by confidentiality deficiency: 2
Residents affected by notification deficiency: 1
Residents affected by bed hold policy deficiency: 1
Residents affected by care plan deficiency: 1
Residents affected by shaving assistance deficiency: 1
Residents affected by pain management deficiency: 1
Residents affected by medication labeling deficiency: 3
Residents affected by medical record maintenance deficiency: 3
Residents affected by infection control deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Mentioned in relation to medication cart confidentiality observation | |
| Staff #2 | Mentioned in relation to medication cart confidentiality observation | |
| Unit Manager #3 | Unit Manager | Interviewed about confidentiality of resident records |
| Director of Nursing | Director of Nursing | Interviewed and made aware of multiple deficiencies including notification, care planning, and medical record issues |
| Unit Clerk #5 | Unit Clerk | Confirmed absence of bed hold policy documentation |
| Unit Manager #4 | Unit Manager | Confirmed shaving assistance responsibility and infection control findings |
| Staff #6 | Acting Dietary Manager | Interviewed about dietary manager certification |
| Staff #7 | Dietary Manager | Interviewed about dietary manager certification and kitchen food storage |
| Unit Manager #9 | Unit Manager | Made aware of medication labeling and storage deficiencies |
| Administrator | Administrator | Informed of multiple deficiencies including confidentiality, dietary certification, medication issues, and medical record concerns |
| Staff member #9 | Verified medical record concerns during interview | |
| Nurse Educator | Nurse Educator | Verified medical record concerns during interview |
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