Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% better than Maryland average
Maryland average: 12.8 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Jan 31, 2025
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 resident dignity and respect, privacy of medical records, accuracy of resident assessments, appropriate treatment and care, respiratory care, bed rail use and safety, nurse aide performance reviews and training, medication error rates, food safety labeling, and bed frame and rail safety inspections.
Deficiencies (11)
Failure to ensure residents were treated with dignity and respect, evidenced by over-the-door organizers containing resident care items including briefs on 19 rooms.
Failure to keep residents' personal and medical records private and confidential; medication cart left unlocked with resident information visible.
Failure to update Minimum Data Set (MDS) assessments accurately to reflect residents' medical conditions for 3 residents during the annual survey.
Failure to provide appropriate treatment and care according to orders and resident preferences, including missed weekly skin checks for a resident.
Failure to provide safe and appropriate respiratory care, including oxygen orders not followed and lack of cautionary oxygen signage for residents.
Failure to obtain informed consent and document alternatives attempted prior to initiation of bed rails for 2 residents.
Failure to ensure staff received annual performance reviews for 4 of 5 GNAs reviewed.
Medication error rate exceeded 5%, with an 11.54% error rate observed during medication administration for 3 residents.
Failure to procure food from approved sources and properly label canned goods and opened food with expiration or use-by dates.
Failure to regularly inspect bed frames, mattresses, and bed rails for safety and entrapment risks for 2 residents.
Failure to ensure Geriatric Nursing Assistants completed required 12 hours of annual in-service training for 3 of 5 GNAs reviewed.
Report Facts
Medication error rate: 11.54
Medication count: 26
Medication bottle quantity: 30
GNA annual in-service training hours: 3
GNA annual in-service training hours: 5
GNA annual in-service training hours: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Supervisor #22 | Registered Nurse Supervisor | Named in medication error finding for Resident #236 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including medication errors, MDS assessments, respiratory care, and staff training |
| RN #23 | Registered Nurse | Observed administering medication with dosing errors |
| Unit Manager #5 | Nurse Unit Manager | Interviewed regarding wound care and medication error findings |
| MDS Coordinator #14 | MDS Coordinator | Interviewed regarding MDS assessment deficiencies |
| Quality Assurance Nurse #20 | Quality Assurance Nurse | Interviewed regarding skin condition and weekly skin checks |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding bed rail use and assessments |
| Director of Dietary Services #24 | Director of Dietary Services | Interviewed regarding food labeling deficiencies |
| Dietary Chef #25 | Dietary Chef | Interviewed regarding food labeling deficiencies |
| Director of Maintenance #13 | Director of Maintenance | Interviewed regarding bed rail safety inspections |
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 4
Date: Feb 28, 2020
Visit Reason
The inspection was conducted as part of the annual survey process to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in several areas including failure to clarify medication orders, failure to ensure safe resident transfers and environment, failure to provide ordered dietary interventions, and failure to maintain accurate medical records.
Deficiencies (4)
Facility staff failed to thoroughly clarify a medication order with the physician for Resident #228 regarding Hydralazine orders.
Facility staff failed to ensure the resident's environment was free from accident hazards and failed to provide adequate supervision to prevent accidents for Residents #12 and #14.
Facility staff failed to provide Resident #24 with dietary interventions as ordered by the physician, including use of divided plate and visual contrast for food.
Facility staff failed to maintain the medical record for Resident #12 in the most accurate and complete form by failing to obtain a physician's order to obtain weights.
Report Facts
Residents selected for review: 29
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Director | Interviewed regarding medication order clarification for Resident #228 | |
| Director of Nursing | Interviewed confirming failures in medication order clarification, accident prevention, dietary interventions, and medical record maintenance |
Inspection Report
Deficiencies: 3
Date: Aug 16, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, medication storage security, and timely laboratory testing in the facility.
Findings
The facility failed to administer medication (Levothyroxine) in a timely manner to a resident, failed to ensure medication carts were locked and secure, and failed to obtain laboratory tests (PT/INR) as ordered by the physician for another resident.
Deficiencies (3)
Facility staff failed to administer Levothyroxine medication in a timed manner as ordered to Resident #20.
Facility staff failed to ensure medication cart was locked and contents were not accessible to staff, residents, or visitors.
Facility staff failed to obtain PT/INR laboratory blood test as ordered by the physician for Resident #33.
Report Facts
Residents selected for review: 17
Medication carts observed: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed failures related to medication administration, medication cart security, and laboratory testing | |
| Geriatric Nursing Assistant #1 | GNA | Observed opening medication cart and removing hearing aid |
| Geriatric Nursing Assistant #2 | GNA | Observed locking medication cart |
| Facility staff nurse #1 | Nurse | Failed to administer Levothyroxine at the ordered time |
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