Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 24, 2025
Visit Reason
The inspection was conducted as part of the recertification survey to assess compliance with regulatory requirements.
Findings
The facility failed to report an allegation of misappropriation of property in a timely manner. Specifically, the facility delayed reporting a missing resident's ring to the Office of Health Care Quality beyond the required 24-hour timeframe.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to proper authorities within the required timeframe.
Report Facts
Number of residents sampled: 3
Number of residents cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the delay in reporting the incident |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 4, 2024
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulations regarding resident transfer notifications, bed hold policies, and discharge summary completeness.
Findings
The facility failed to provide timely written notification to residents and their representatives about hospital transfers and bed hold policies for residents transferred to hospitals. Additionally, the discharge summary for one resident was incomplete and inaccurate.
Deficiencies (3)
F 0623: The facility failed to provide written notification to residents and their representatives about hospital transfers, as evidenced by two residents lacking such notices.
F 0625: The facility failed to provide written bed hold policy notices to residents and their representatives within 24 hours after hospital transfer for two residents.
F 0661: The facility failed to ensure that a discharge summary was complete and accurate, missing medication details and accurate documentation of discharge initiation for one resident.
Report Facts
Residents reviewed for hospitalization: 3
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed failures to provide written notifications and bed hold policy notices |
| Licensed Practical Nurse #18 | Licensed Practical Nurse | Reported transfer forms and bed hold policies were given to EMS staff, not residents or representatives |
| Licensed Practical Nurse #19 | Licensed Practical Nurse | Reported transfer forms and bed hold policies were given to EMS staff, unaware if given to residents or representatives |
| Social Worker #6 | Social Worker | Interviewed regarding resident discharge initiated by family |
| Attending Physician | Attending Physician | Interviewed regarding incomplete discharge summary documentation |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jun 4, 2024
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including maintaining a homelike environment, timely notification of hospital transfers and bed hold policies, baseline care plan provision, completeness and timeliness of care plans, discharge summary accuracy, nurse staffing postings, and pneumococcal vaccination policies and administration.
Deficiencies (9)
F 0584: The facility failed to ensure residents had a homelike environment, with multiple rooms showing black marks on walls and peeling shower grip strips.
F 0623: The facility failed to provide timely written notification of hospital transfers to residents and their representatives for 2 of 3 residents reviewed.
F 0625: The facility failed to notify residents or their representatives in writing about the bed hold policy within 24 hours after hospital transfer for 2 of 3 residents reviewed.
F 0655: The facility failed to provide baseline care plans to residents and their representatives within 48 hours of admission for 2 of 4 residents reviewed.
F 0656: The facility failed to develop and implement complete care plans that included individualized dialysis-related interventions and precautions for Resident #10.
F 0657: The facility failed to measure resident-centered objectives, ensure interdisciplinary care plan reviews, and hold quarterly care plan meetings for Residents #10 and #40.
F 0661: The facility failed to ensure discharge summaries were complete and accurate, missing medication details and discharge initiation information for Resident #42.
F 0732: The facility failed to post nurse staffing information daily in an accurate, clear, and readable format as required.
F 0883: The facility failed to develop and implement policies and procedures to ensure residents were offered pneumococcal vaccinations according to national standards, affecting 2 of 5 residents reviewed.
Report Facts
Residents reviewed for hospitalization: 3
Residents reviewed for baseline care plans: 4
Residents reviewed for care planning: 5
Residents reviewed for discharge summary: 3
Residents reviewed for pneumococcal vaccinations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #6 | Social Worker | Named in care plan meeting and communication deficiencies |
| Staff #4 | Assistant Director of Nursing / MDS Coordinator | Named in care plan evaluation and vaccination record review |
| Director of Nursing | Interviewed regarding multiple deficiencies including transfer notification, care plans, and discharge summaries | |
| Licensed Practical Nurse #18 | LPN | Interviewed regarding hospital transfer notification process |
| Licensed Practical Nurse #19 | LPN | Interviewed regarding hospital transfer notification process |
| Unit Manager Staff #17 | Unit Manager | Named in baseline care plan review delay |
| Infection Preventionist | IP | Interviewed regarding vaccination policy and resident vaccination records |
| Attending Physician | Interviewed regarding discharge summary documentation |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 7, 2019
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with care plan implementation and activities of daily living for residents.
Findings
The facility failed to implement a comprehensive person-centered care plan and did not follow a physician's order to insert a resident's hearing aids daily at 8 AM. This was evident for one resident reviewed during the survey.
Deficiencies (2)
F 0656: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The facility failed to implement a comprehensive person-centered care plan for Resident #36, who did not have hearing aids applied as ordered.
F 0677: Provide care and assistance to perform activities of daily living for any resident who is unable. The facility failed to follow a physician order to insert Resident #36's hearing aids daily at 8 AM, with hearing aids found still in the medication cart at 2:44 PM.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Discussed findings at time of exit and produced documentation regarding hearing aid insertion. | |
| Staff #3 | Interviewed regarding Resident #36's hearing aids and care plan. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Feb 9, 2018
Visit Reason
The inspection was conducted as a complaint investigation to determine compliance with regulations related to resident notification of hospital transfers, bed hold policies, care planning, bed rail safety, medication management, infection control, and documentation of life-sustaining treatment orders and fall monitoring.
Complaint Details
The complaint investigation focused on issues including resident transfer notifications, bed hold policies, care planning, bed rail safety, medication management, infection control, MOLST documentation, and fall monitoring. Findings were substantiated with multiple deficiencies identified.
Findings
The facility was found deficient in multiple areas including failure to provide written notification to residents or representatives about hospital transfers and bed hold policies, incomplete and untimely care planning, lack of routine assessments and maintenance for bed rails, failure to timely address psychiatrist medication recommendations, inadequate infection control practices in the kitchen, and improper documentation of MOLST forms and fall monitoring.
Deficiencies (8)
F 0623: The facility failed to provide written notification to the resident or representative about hospital transfer and the reason for transfer for Resident #244.
F 0625: The facility failed to provide written notification of the bed hold policy to the resident or representative upon transfer to hospital for Resident #244.
F 0655: The facility failed to complete an interim care plan within 48 hours of admission and provide a copy to the resident or representative for Residents #244 and #41.
F 0657: The facility failed to update care plans to reflect falls and pressure ulcers for Residents #39 and #22.
F 0700: The facility failed to perform routine assessments and maintenance of bed rails and assess resident appropriateness for ongoing use for Resident #3.
F 0757: The facility failed to timely address a psychiatrist's recommendation to discontinue an antidepressant medication for Resident #27.
F 0812: The facility failed to maintain proper infection control by not wearing hairnets in the kitchen during meal preparation.
F 0842: The facility failed to correctly document MOLST forms for Residents #39 and #9 and failed to document 24-hour monitoring after a fall for Resident #22.
Report Facts
Residents reviewed for care planning: 3
Residents reviewed for unnecessary medications: 5
Residents reviewed for MOLST documentation: 2
Residents affected by deficiencies: 1
Residents affected by bed rail deficiency: 1
Residents affected by medication deficiency: 1
Residents affected by infection control deficiency: 4
Residents affected by MOLST and fall monitoring deficiency: 3
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