Deficiencies (last 3 years)
Deficiencies (over 3 years)
17.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 19
Aug 8, 2025
Visit Reason
The facility underwent a recertification/complaint annual survey to assess compliance with regulatory requirements, including complaint investigations and routine inspections.
Findings
The survey identified multiple deficiencies including failure to respond timely to call bells, lack of posting survey results, failure to notify physicians and family of changes in condition, unaddressed resident grievances, failure to provide bed-hold policy upon hospital transfer, incomplete baseline and quarterly care plans, inadequate hearing services, delayed wound care treatments, unsafe use of Hoyer lift and inadequate supervision on locked dementia unit, failure to provide appropriate catheter care, medication administration errors, missing dialysis clamps, improper food labeling, infection control lapses, inadequate antibiotic stewardship, malfunctioning call bell system, and insufficient nurse aide training.
Complaint Details
The survey included complaint investigations related to call bell response, grievance handling, catheter care, wound care, supervision, and infection control.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Level of Harm - Potential for minimal harm: 2
Deficiencies (19)
| Description | Severity |
|---|---|
| Facility failed to attend to and answer call bells in a timely manner for dependent residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to post notice of availability of survey results in a prominent, publicly accessible location. | Level of Harm - Potential for minimal harm |
| Facility failed to notify resident's physician and/or responsible party following an accident/change in condition related to Foley catheter. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to address grievances from Resident Council meetings and inform staff and residents of grievance process. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide written notification of bed-hold policy to residents transferred to acute care. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure baseline care plans were completed and provided to residents or representatives within 48 hours of admission. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to hold interdisciplinary care plan meetings at time of quarterly revision for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide services to maintain hearing for a resident requesting ENT consultation. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to implement wound care consults timely resulting in missed wound treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure safe use of Hoyer lift and supervision of residents on locked dementia unit. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide appropriate care for resident with indwelling urinary catheter including proper catheter insertion and monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide appropriate pain management and monitoring for a resident with pain. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to have emergency dialysis clamps in residents' rooms as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure controlled substance medications were accurately monitored with complete documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure medication refrigerator maintained proper temperature. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to respond timely to pharmacist recommendations for unnecessary medication. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure call bell system operated correctly for each resident's room. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure proper labeling of stored food items to prevent contamination. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to follow infection control practices including proper bagging of soiled linens and appropriate precaution signage. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Duration call bell active: 113
Missed antibiotic doses: 4
Medication administration errors: 2
Training hours: 1.73
Training hours: 11.53
Training hours: 6.43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #14 | Nurse | Confirmed call bell active for 113 minutes |
| Staff #26 | Geriatric Nursing Aide | Communicated with non-verbal resident about call bell |
| Director of Nursing | DON | Validated call bell concern and other findings |
| LPN #17 | Licensed Practical Nurse | Found Foley catheter on floor, notified day nurse but did not notify provider or RP |
| LPN #4 | Licensed Practical Nurse | Day nurse who was informed of Foley catheter incident and attempted reinsertion |
| Nurse Practitioner #41 | NP | Ordered voiding trial and assessed Foley catheter issues |
| Staff #51 | Geriatric Nursing Assistant | Operated Hoyer lift during resident incident |
| Staff #3 | Nurse Practitioner | Responded to Hoyer lift incident and performed CPR |
| Staff #52 | Respiratory Therapist | Observed Hoyer lift incident and assisted with airway |
| Assistant Director of Nursing | ADON | Observed resident unattended off locked dementia unit |
| Dialysis Transporter #48 | Transporter | Left resident unattended in hallway |
| Staff #59 | Nurse | Acknowledged gaps in controlled substance logbook |
| Staff #62 | Dietary Aide | Acknowledged unlabeled food items in kitchen |
| Staff #28 | Food Service Director | Committed to re-educate staff on food labeling |
| Infection Preventionist | IP | Validated infection control concerns and antibiotic stewardship issues |
| Staff Developer/Educator | Staff Developer | Confirmed nurse aide training deficiencies |
| Assistant Director of Nursing | ADON | Interviewed about antibiotic stewardship and resident supervision |
Inspection Report
Complaint Investigation
Deficiencies: 9
May 15, 2025
Visit Reason
The inspection was conducted based on complaints alleging failure to meet residents' needs including wheelchair availability, notification of weight loss, abuse reporting, and care plan deficiencies.
Findings
The facility failed to ensure a custom-made wheelchair was available for a resident, failed to timely notify physicians and dieticians of significant weight loss and changes in condition, failed to report abuse allegations within required timeframes, failed to maintain wheelchairs properly, failed to accurately complete Minimum Data Set (MDS) assessments, failed to hold quarterly care plan meetings, and failed to provide appropriate care and neuro checks after falls.
Complaint Details
The complaint survey reviewed 28 residents and found multiple deficiencies related to wheelchair availability, notification failures, abuse reporting delays, MDS inaccuracies, care plan meeting omissions, and inadequate care provision.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure a custom-made wheelchair was available for Resident #4 during transport to an appointment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely notify Resident #10's physician of low blood pressure and failed to timely notify physician, responsible party, and dietician of significant weight loss for Resident #22. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide maintenance services to keep wheelchairs sanitary, comfortable, and well-maintained. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to report allegations of abuse to the regulatory agency within 2 hours for Residents #6, #1, and #18. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Minimum Data Set (MDS) assessments were accurately coded for Residents #22, #24, #18, and #3. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have quarterly care plan meetings for Resident #12 and failed to document care plan meeting details. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care including toileting, turning, and positioning for Resident #37 requiring extensive assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care to meet physical, mental, and psychosocial health needs for Residents #10 and #13, including failure to address consultant recommendations and perform neuro checks after a fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to recognize Resident #22's weight loss and notify physician and dietician promptly. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for complaints: 28
Residents reviewed for facility reported incidents: 13
Residents reviewed for MDS accuracy: 46
Weight loss: 25.8
Weight loss percentage: 20
Wheelchair missing armrest count: 4
Neuro checks missed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geriatric Nursing Assistant #37 | Provided statements about Resident #4 sliding from wheelchair and repositioning | |
| LPN #39 | Nurse Supervisor for 2 West | Interviewed about Resident #4's transport and wheelchair availability |
| Nursing Home Administrator | NHA | Interviewed regarding missing wheelchairs and wheelchair maintenance |
| Director of Nursing | DON | Confirmed failures in notification, care plan meetings, abuse reporting, and neuro checks |
| Physician #29 | Consultant | Expected timely notification of weight loss for Resident #22 |
| Geriatric Nursing Assistant #16 | Alleged physical abuse incident with Resident #18 | |
| Staff #35 | Housekeeping | Confirmed wheelchair cleaning schedule and condition of wheelchair cushions |
| MDS Coordinators | Confirmed errors in Minimum Data Set assessments |
Inspection Report
Complaint Investigation
Deficiencies: 14
Aug 23, 2022
Visit Reason
The inspection was conducted based on complaint investigations and routine oversight to assess compliance with regulatory requirements related to resident rights, safety, care, medication management, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure advance directives and MOLST forms were properly documented, unsafe and unclean environment conditions, failure to implement grievance policies, misappropriation of resident property, failure to protect residents from abuse, inadequate notification of transfers and bed hold policies, inaccurate assessments and care plans, medication administration errors, failure to provide appropriate activities, incomplete medical records, medication errors, unsafe use of bed rails, and inadequate infection control screening procedures.
Complaint Details
The complaint investigation revealed multiple concerns including failure to follow advance directive orders, unsafe environment, failure to report grievances, misappropriation of property, abuse allegations, inadequate transfer notifications, inaccurate assessments and care plans, medication errors, and infection control deficiencies.
Deficiencies (14)
| Description |
|---|
| Failure to ensure orders for life-sustaining treatment were made in accordance with residents' advance directives and proper documentation of Physicians' Certification of Incapacity. |
| Failure to provide a safe, clean, homelike environment including stained walls, dirty vents, broken windows, and unsafe shower room conditions. |
| Failure to implement a grievance policy as staff failed to report resident concerns to a supervisor. |
| Failure to recognize, report, and investigate a resident's missing wheelchair as misappropriation of resident property. |
| Failure to protect residents from a staff member accused of abuse who continued to work with vulnerable residents. |
| Failure to provide timely notification in writing to residents and representatives of transfer or discharge reasons and bed hold policies. |
| Failure to ensure Minimum Data Set (MDS) assessments and care plans were accurate and reflected residents' needs and preferences. |
| Failure to develop and implement baseline and comprehensive care plans that meet residents' needs including activities and diabetes management. |
| Failure to provide ongoing resident-centered activities that reflect resident interests and preferences. |
| Failure to ensure medication administration according to orders including access to interim medications, administration of pain medications, and medication error documentation. |
| Failure to ensure physician progress notes were written, signed, and dated at each required visit. |
| Failure to ensure all medications and biologicals were stored and labeled properly including undated opened containers and medications left at bedside. |
| Failure to establish and maintain an infection prevention and control program including accurate COVID-19 screening and monitoring. |
| Failure to assess residents for safety risks related to bed rails, educate residents and representatives on risks and benefits, obtain informed consent, and ensure proper mattress fit. |
Report Facts
Medication administration opportunities: 34
Screening temperatures below 96.9 F: 58
Screening temperatures below 96.9 F: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #38 | Licensed Practical Nurse | Named in medication administration error for Calcium Carbonate Vitamin D dosage. |
| Staff #39 | Licensed Practical Nurse | Named in medication administration error for crushing Potassium Chloride ER. |
| Staff #59 | Certified Nursing Assistant | Named in abuse allegation and failure to suspend staff member. |
| Staff #60 | Certified Nursing Assistant | Named in training deficiency related to waiver expiration. |
| Staff #26 | RN, MDS Coordinator | Named in MDS assessment accuracy concerns. |
| Staff #23 | LPN, Unit Manager | Named in multiple findings including wandering resident, wheelchair footrest issue, and medication irregularities. |
| Staff #6 | Activity Director | Named in failure to provide resident-centered activities and care plans. |
| Staff #4 | Unit Nurse Manager | Named in concerns regarding missing advance directive certification and wandering resident. |
| Staff #5 | RN | Named in pharmacist irregularity report response. |
| Staff #14 | LPN | Named in medication cart storage concerns. |
| Staff #43 | LPN | Named in medication cart storage concerns. |
| Staff #27 | Maintenance Assistant | Named in shower room storage and cleaning concerns. |
| Staff #12 | Housekeeping Manager | Named in shower room cleaning process concerns. |
| Staff #37 | RN, Unit Manager | Named in medication cart storage and wheelchair footrest concerns. |
| Staff #66 | LPN | Named in fall risk bed observation. |
| Staff #62 | LPN | Named in fall risk bed observation. |
| Staff #11 | Social Worker Associate | Named in resident activity and personal laptop concerns. |
| Staff #9 | Social Service Director | Named in personal laptop and advance directive certification concerns. |
| Staff #40 | Unknown | Signed resident's personal property inventory list. |
| Staff #57 | Social Worker | Named in care plan meeting note. |
Inspection Report
Annual Inspection
Deficiencies: 10
Dec 9, 2019
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy, incomplete care plans, failure to follow physician orders, inadequate behavioral monitoring for psychotropic medication use, incomplete medical record documentation, infection control deficiencies, failure to provide required immunizations, and unsafe equipment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide personal privacy and confidentiality of patient information by discarding patient names and medication labels in the common trash. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to identify discharge plans in the comprehensive care plan for 4 of 34 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop the complete care plan within 7 days of the comprehensive assessment and failed to include residents or their representatives in care plan meetings. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care according to physician orders for 2 residents, including incorrect oxygen settings and failure to apply wound treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assist a resident in gaining access to vision services; no appointment scheduled despite known need. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement behavioral monitoring and non-pharmacological interventions for 10 of 11 residents on psychotropic medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document a resident's negative medical change leaving the clinical record incomplete. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and implement an infection prevention and control program including failure to label oxygen and nebulizer tubing with date of first use and failure to review and revise IPCP policies annually. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement policies and procedures for flu and pneumonia vaccinations; residents did not receive immunizations and were not offered them. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to keep all essential equipment working safely; resident's bed controller cord was frayed and intermittently working. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care plans: 34
Residents affected by privacy deficiency: 4
Medication carts reviewed: 5
Residents affected by psychotropic medication deficiency: 10
Residents reviewed for respiratory care: 3
Residents affected by infection control deficiency: 2
Residents selected for immunization review: 7
Residents affected by immunization deficiency: 2
Rooms observed: 93
Residents affected by equipment deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding deficiencies and findings |
| Unit Manager RN Staff #7 | Unit Manager RN | Interviewed regarding wound care orders and deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding infection control policies and labeling |
| Administrator | Administrator | Interviewed regarding various deficiencies and findings |
| Attending Physician | Attending Physician | Interviewed regarding documentation of resident capacity |
| Staff #5 | Nursing Staff | Interviewed regarding immunization administration |
| 2 [NAME] Unit Manager | Unit Manager | Interviewed regarding vision appointment scheduling and oxygen labeling |
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