MARYLAND BAPTIST AGED HOME
Non profit - Church related
29 Beds
Independent
Data: November 2025
Trust Grade
63/100
#115 of 219 in MD
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Maryland Baptist Aged Home has a Trust Grade of C+, which means it is slightly above average but still has room for improvement. It ranks #115 out of 219 nursing homes in Maryland, placing it in the bottom half, and #13 out of 26 in Baltimore City County, indicating there are better options available nearby. The facility's trend is worsening, with the number of issues increasing from 19 in 2022 to 20 in 2025. Staffing is a relative strength, with a 4 out of 5 star rating and a turnover rate of 27%, which is well below the state's average. However, there have been some concerning incidents noted, such as expired food items in the kitchen, inconsistent RN coverage on weekends, and incomplete assessments regarding resident care capabilities. Overall, while there are strengths in staffing and financial management, families should be aware of the facility's ongoing issues and the need for improvement in certain areas.
- Trust Score
- C+
- In Maryland
- #115/219
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 27% annual turnover. Excellent stability, 21 points below Maryland's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Maryland facilities.
- Skilled Nurses ✓ Good
- Each resident gets 45 minutes of Registered Nurse (RN) attention daily — more than average for Maryland. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
63/100
Bottom 48%
No red flags
19 → 20 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2022: 19 issues
2025: 20 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (27%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (27%)
21 points below Maryland average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
3-Star Overall Rating
Near Maryland average (3.0)
Meets federal standards, typical of most facilities
The Ugly 44 deficiencies on record
Jun 2025
20 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on medical record review and interviews it was determined that the facility staff failed to provide residents with showers and get residents out of bed. This deficient practice was evidenced in ...
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Based on medical record review and interviews it was determined that the facility staff failed to provide residents with showers and get residents out of bed. This deficient practice was evidenced in 2 (#1 & #22) of 2 residents assessed for choices during the recertification survey.
The findings include:
On 05/28/25 at 9:28 AM during observation rounds the surveyor asked Resident #22 how often he/she gets out of bed (OOB). Resident #22 verbalized they don't get OOB although they would like to. The surveyor observed a Gerry chair in the shared bedroom. Resident #22 verbalized the chair was used for their roommate.
On 05/29/25 at 1:27 PM a review of Resident #1 and Resident #22 electronic health records (EMR) to verify if the residents had a shower; there was no documentation to verify whether the residents had a shower. A review of the shower list revealed Resident #1 was scheduled to have a complete bed bath (CBB) on Monday and Friday during the 3 PM - 11 PM shift. Resident #22 was scheduled to have a CBB on Monday and Friday during 11 PM - 7 AM shift.
On 05/29/25 at 2:06 PM the surveyor asked Geriatric Nursing Assistant (GNA) #17 to show the surveyor in the electronic medical record (EMR) PointClickCare (PCC) documentation to verify Resident #22 had a shower. There was no place in the EMR for GNA #17 to document whether the resident had a shower. The surveyor asked GNA #17 if there is another place to document that a resident had a shower. GNA #17 verbalized, no.
On 05/29/25 at 2:11 PM the surveyor made the Director of Nursing (DON) aware that Resident #22 had not had a shower since being admitted to the facility in October 2023 and there was no documentation to verify that Resident #1 or Resident #22 had a shower. Also, the surveyor observed both residents were in bed the past two days. The surveyor and DON went to Resident #22's room and the resident verified they had not had a shower since being admitted and they do not get OOB.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on medical record review and interviews, it was determined that the facility staff failed to provide a copy of the Notice of Medicare Non-Coverage to a resident's representative prior to being d...
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Based on medical record review and interviews, it was determined that the facility staff failed to provide a copy of the Notice of Medicare Non-Coverage to a resident's representative prior to being discharged from the facility. The deficient practice was evidenced in 1 (#4) of 1 resident record reviewed for NOMNC compliance during the recertification survey.
The findings include:
On 05/29/25 at 1:36 PM the surveyor received the list of residents who were discharged from the facility within the past 6 months. Three residents transitioned, five residents remained in the facility, and one resident went to an assisted living facility (ALF).
On 05/29/25 at 2:32 PM during an interview with Social Worker #4 and the Administrator, the surveyor asked, Did Resident #4's responsible party (RP) receive a Notice of Medicare Non-Coverage prior to the resident's discharge? The surveyor received a copy of Resident #4 Notice of Medicare Non-Coverage dated 05/16/25. The resident representative's signature was not on the form; a note was typed on the form indicating that Resident #4's responsible party (RP) was notified via telephone on 05/16/25. The resident was discharged on 05/23/25. The Masters of Social Work (MSW) staff provided an envelope addressed to the RP. Social Worker #4 was unable to verify when the letter was mailed or if the RP received the letter. Social Worker #4 verbalized the facility had not received a signed copy from the RP.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with facility staff, it was determined the facility failed to ensure that th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with facility staff, it was determined the facility failed to ensure that the resident receiving psychotropic medications were necessary and justified when staff failed to complete behavioral and mood monitoring documentation for the conditions that the psychotropic medications were prescribed for. This was evident for 1 (Resident # 6) of 4 residents reviewed for unnecessary psychotropic medications.
The findings include:
Psychotropic medications, also known as psychiatric or psychoactive medications, are drugs that affect the mind, emotions and behavior. They are primarily used to treat mental health disorders, and can be divided into several categories, including antidepressants, antipsychotics, antianxiety, and hypnotics.
On 05/29/25 at 08:36 AM, a record review was conducted. Resident # 6 was admitted to the facility on [DATE]. He/She had the diagnosis of Paranoid Schizophrenia; Major depressive disorder; anxiety disorder unspecified; Dementia with behavioral disturbance. Upon further review, he/she was taking psychotropic medications such as, Quetipine fumarate 200 mg tablet 1 tablet by mouth twice a day together with Quetipine fumarate 50 mg tablet 1 tablet by mouth twice a day to equal 250 mg tablet. There was no indication for the Quetipine in the Physician order. Additionally, he/she was taking Valproic acid 250 mg/5 ml solution given 10 ml by mouth twice daily for Schizophrenia. He/She was also given Trazodone 50 mg tablet 1 tablet by mouth at bedtime for Insomnia and Lorazepam 1 mg tablet 1 tablet by mouth twice daily for anxiety.
Further review of the medical record was done; it was found that there was no behavior and mood monitoring documentation in his/her record.
Additionally, the care plan for Resident # 6 was reviewed, Resident # 6 had a history of exhibiting behavioral outburst such as persistent yelling and screaming at others. He/She has the potential to be verbally aggressive. One of the interventions was to monitor behavior every shift, document the behavior and attempted intervention.
On 05/29/25 at 09:58 AM, an interview with the Director of Nursing (DON) was conducted. This surveyor asked if they were doing the behavior monitoring for any resident who was taking psychotropic medications? The DON responded yes, we do it on paper. It was in front of the medication administration binder on top of the medication cart. The DON instructed staff # 10 (Registered Nurse) to pull it from the binder. Staff # 10 were not able to find the behavior monitoring flowsheet and instead provided the Treatment Administration Record for the month of May 2025. This surveyor asked Staff # 10 if they had the behavior monitoring record and she had no response.
In addition, the DON was asked for medication regimen review process, the DON stated that the pharmacy consultant comes once a month to conduct the medication review and upon completion of the review, a report will be provided to her.
On 06/02/25 at 10:26 AM, a record review was done for the medication regimen review. It was found that on March 26, 2025, Staff # 15 (Pharmacy Consultant) reported as follows: Resident # 6 has received Trazodone 50 mg at bedtime since 12/22/2023 for Insomnia. A recommendation to attempt a gradual dose reduction (GDR) of Trazodone 25 mg at bedtime. The psychiatry provider visited Resident # 6 on 3/26/2025 and 4/30/2025 respectively and there was no documentation that this recommendation was addressed.
On 6/2/2025 at 11:45 AM, The findings were shared to the DON. No comment was noted.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews it was determined that the facility staff failed to notify a resident's representa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews it was determined that the facility staff failed to notify a resident's representative in writing of the reason why the resident was transferred to the hospital and failed to provide a copy of the bed-hold policy to the resident representative. This deficient practice was evidenced in 1 (#17) of 2 resident records reviewed for transfer/discharge practices during the recertification survey.
The findings include:
On 05/28/25 at 2:01 PM a review of Resident #17 electronic medical record (EMR) revealed the resident was hospitalized in February and April 2025. The surveyor was unable to find documentation in the EMR indicating why the resident was hospitalized .
On 05/29/25 at 9:15 AM the surveyor along with the Director of Nursing (DON) reviewed Resident #17's paper medical record located at the nurse's station. The transfer summaries dated 2/26/25 and 04/27/25 indicated the resident's family/responsible party was notified by telephone of the hospitalizations. There was no documentation to verify that Resident #17's responsible party was notified in writing of the hospital transfers.
On 05/29/25 at 1:22 PM during an interview with Social Worker #4 the surveyor asked did they send a copy of the Bed-Hold Policy to Resident #17's responsible party when the resident was hospitalized on [DATE] and 04/27/25. Social Worker #4 verbalized the facility only provides a copy of the Bed-Hold Policy upon admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on resident record review and staff interview it was determined that the facility failed to complete a Minimum Data Set (MDS) assessment within 14 days of a significant change of the resident's ...
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Based on resident record review and staff interview it was determined that the facility failed to complete a Minimum Data Set (MDS) assessment within 14 days of a significant change of the resident's physical or mental condition. This was evident for 1 (Resident #20) of 1 resident reviewed for Hospice during an annual survey.
The findings include:
The Minimum Data Set (MDS) is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.
A significant change means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.
On 5/29/25 at 12:16 PM a record review revealed that Resident #20 was admitted to hospice services on 5/9/25. However, the MDS significant change assessment was started on 5/19/25 and remained incomplete as of 5/30/25.
On 5/30/25 at 12:37 PM a phone interview was conducted with the MDS Coordinator, and he confirmed that the resident was admitted to hospice on 5/9/2025. The MDS Coordinator also acknowledged that the significant change assessment for Resident # 20 was still in process as of 5/30/25. The Coordinator agreed that a MDS assessment should be updated within 14 days of a significant change, and the electronic records were not updated in a timely manner.
The Nursing Home Administrator, Director of Nursing, Social Worker, Chief Financial Officer and other pertinent staff were made aware of these findings during the exit conference on 6/2/25.
Cross Reference F640
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on record review and interviews it was determined that the facility staff failed to complete and transmit a Minimum Data Set assessment within the required 14-day timeframe. This deficient pract...
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Based on record review and interviews it was determined that the facility staff failed to complete and transmit a Minimum Data Set assessment within the required 14-day timeframe. This deficient practice was evidenced in 1 (#1) of 2 resident MDS assessments reviewed for timely completion during the recertification survey.
The findings include:
On 05/30/25 at 12:27 PM a review of Resident #1 quarterly MDS assessment revealed the assessment review date (ARD) was 04/05/25 and the assessment was signed on 04/25/25 which was outside of the 14-day window to complete and transmit the assessment.
On 05/30/25 at 12:47 PM during a telephone interview with the MDS Coordinator the surveyor asked why Resident #1 MDS assessment was completed outside of the required 14-day timeframe. The MDS Coordinator verbalized that the assessment was not completed within the required timeframe because the staff who needed to complete Section E & Section Q did not complete their assessments in a timely manner. After the facility staff completed their portion of the assessment, the assessment was submitted. The surveyor asked, were the Director of Nursing or Administrator made aware he/she was having difficulty with the staff completing Section E & Section Q in a timely manner. The MDS Coordinator verbalized, no.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on medical record review and interview it was determined that the facility staff failed to complete a narcotic count when a registered nurse assumed control over the nursing assignment. The defi...
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Based on medical record review and interview it was determined that the facility staff failed to complete a narcotic count when a registered nurse assumed control over the nursing assignment. The deficient practice occurred during the recertification survey.
The findings are:
On 05/29/25 at 8:40 AM a review of the Controlled Drug Count Verification form revealed on 05/18/25 7AM - 3 PM shift a nurse signed the form as the incoming nurse. The outgoing nurse's signature 3PM - 11PM was different from the incoming nurse's signature. On 05/19/25 3PM-11PM shift the incoming nurse's signature and the outgoing 11PM- 7 AM shift was different. The surveyor could not verify if the narcotic count was completed by the nursing staff if another nurse completed the shift other than the incoming nurse.
On 05/29/25 at 9 AM during an interview with the Director of Nursing the surveyor reported concerns about the nurse's completing the narcotic count as a nursing professional standard of practice. When the surveyor asked was the narcotic count completed when the nurse assumed control of the nursing assignment on 05/28/25 during 7 AM - 3 PM shift, the DON could not verify the narcotic count was completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and observation it was determined that the facility staff failed to ensure the use of a hand spl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and observation it was determined that the facility staff failed to ensure the use of a hand splint as stated in the care plan. This was true for 1 (Resident # 9) out of 29 residents reviewed during the annual survey.
The findings include:
The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.
On 5/29/2025 at 2:17 PM, A record review was conducted. Resident # 9 was admitted to the facility on [DATE]. He/She had hemiplegia affecting the left non dominant side and left-hand contracture.
On 5/30/2025 at 11:38 AM, a review of Resident # 9's medical record was conducted, there was no documentation of any rehabilitation screening or evaluation. Minimum Data Set (MDS) quarterly assessment with the reference date of 4/7/2025 Section GG0115 was coded to have a limitation with the range of motion of the upper and lower extremity, one sided.
On 05/30/25 at 11:52 AM, Resident # 9 was observed in his wheelchair with the contracture of his left hand.
On 6/2/2025 at 8:49 AM, Review of the medical record revealed that Resident #9 was seen by Occupational Therapy from 4/1/2024 until 8/21/2024 and was treated for improvement of his/her activities of daily living and safety to decrease the risk for falls. There was no further occupational therapy screen or evaluation documentation found after 8/2024. Further review found to have no treatment or intervention for the contracture of his/her left hand in the Treatment Administration Record (TAR).The care plan for Resident # 9 revealed Resident has an alteration in musculoskeletal status of the left hand related to contracture one of the interventions was stated as: Staff to assist the resident with the application of supportive devices splints and check for skin checks every shift and as recommended. This was initiated on 12/14/2016 and was revised on 10/21/2024.
On 06/02/25 at 09:18 AM, the surveyor observed Resident # 9 in his room and showed his/her left hand and stated I cannot completely open my hand. There was no splint, or any devices observed on his left hand.
On 06/02/25 at 10:59 AM, all the findings were shared with the Director of Nursing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that the facility staff failed to consistently provide Activities to residents who were unable to participate in communal Activities. This defici...
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Based on record review and interview it was determined that the facility staff failed to consistently provide Activities to residents who were unable to participate in communal Activities. This deficient practice was evidenced in 2 (#1 & #22) of 2 resident records reviewed for staff providing Activities to bedbound residents during the recertification survey.
The findings include:
On 05/28/25 at 9:25 AM while speaking with Resident #22 the surveyor asked does someone come to the room and do Activities with him/her. Resident #22 verbalized a lady used to come to their room and do Activities with him/her, but the lady no longer works there, and it stopped.
On 05/29/25 at 2:24 PM during a review of Resident #1 Activities Log revealed the last documented activity session was on 05/01/25. A review of Resident #22's Activities Log revealed the last documented Activity session was 04/28/25. During an interview with Activities Director #6 he/she was unable to verbalize why the resident's were not receiving Activities regularly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, it was determined that the facility failed to: 1.) properly label medications and dated once opened, and 2). Remove expired medications from the medication ca...
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Based on observation and staff interview, it was determined that the facility failed to: 1.) properly label medications and dated once opened, and 2). Remove expired medications from the medication cart. This was evident for 2 of 2 medication carts reviewed during the annual survey.
The findings include:
1.) On 5/30/2025 at 08:58 AM, a medication observation was conducted in the presence of staff # 8 (Certified Medication Aide) and revealed for medication cart 1 to have 2 eye drops, Dorzamide and Latanoprost eye drops for Resident # 8 both opened without a date they were opened. Resident # 20 had Dorzamide eye drops and found to be not dated. Upon further observation, medication cart 2 was noted to have 2 bottles of Nystatin powder for Resident # 14 with no date when both bottles were opened. It was also found to have 2 tubes of Duoderm Hydroactive gel without any label and not dated. Staff # 8 acknowledged the findings.
Upon further medication storage observation, a canister of blood glucose strip was found in medication cart 2 without the date when it was opened. This was acknowledged by Staff # 13 (Registered Nurse) and immediately disposed of the blood glucose strips.
2.) Further medication observation was conducted. In medication cart 2 revealed for Resident # 21, had a tube of Nystatin cream that expired on 7/16/2024. It was immediately taken by Staff # 12 to be discarded.
On 6/2/2025 at 10:35 AM, all findings were shared to the Director of Nursing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, clinical record review and observation, it was determined that the facility failed to provide an Oc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, clinical record review and observation, it was determined that the facility failed to provide an Occupational Therapy evaluation for 1 (Resident # 9) out of 29 residents reviewed during the annual survey.
The findings include:
The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.
On 5/28/2025 at 09:39 AM, an initial interview was conducted, Resident # 9 stated, I don't have any therapy.
On 5/29/2025 at 2:17 PM, a record review was conducted. Resident # 9 was admitted to the facility on [DATE]. He/She had hemiplegia affecting the left non dominant side and left-hand contracture.
On 5/30/2025 at 11:38 AM, a review of Resident # 9's medical record was conducted, there was no documentation of any rehabilitation screening or evaluation. Minimum Data Set (MDS) quarterly assessment with the reference date of 4/7/2025 Section GG0115 was coded to have a limitation with the range of motion of the upper and lower extremity, one sided.
On 05/30/25 at 11:52 AM, Resident # 9 was observed in his wheelchair with the contracture of his left hand.
On 6/2/2025 at 8:49 AM, Review of the medical record revealed that Resident #9 was seen by Occupational Therapy from 4/1/2024 until 8/21/2024 and was treated for improvement of his/her activities of daily living and safety to decrease the risk for falls. There was no further occupational therapy screen or evaluation documentation found after 8/2024. Further review found to have no treatment or intervention for the contracture of his/her left hand in the Treatment Administration Record (TAR). The care plan for Resident # 9 revealed Resident has an alteration in musculoskeletal status of the left hand related to contracture one of the interventions was stated as: Staff to assist the resident with the application of supportive devices splints and check for skin checks every shift and as recommended. This was initiated on 12/14/2016 and was revised on 10/21/2024.
On 06/02/25 at 09:18 AM, The surveyor observed Resident # 9 in his room and showed his/her left hand and stated I cannot completely open my hand. There was no splint, or any devices observed on his left hand.
On 06/02/25 at 10:59 AM, all the findings were shared with the Director of Nursing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews it was determined that the facility staff failed to have an effective system in place to i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews it was determined that the facility staff failed to have an effective system in place to identify, report, track, investigate, and analyze information relating to adverse events that occur within the facility. This deficient practice was discovered during the recertification survey.
The findings include:
On [DATE] at 10:26 AM after reviewing the Quality Assurance Performance Improvement (QAPI) plan the surveyor interviewed the Director of Nursing (DON). The surveyor informed the DON that the QAPI plan was ineffective because it lacked a systematic approach that identify problems, track, investigate, and analyze data. The DON verbalized the team meets monthly, and they were instructed to do review problems in the areas that needed to be approved. Their major concern was staffing. At first they were not using agency but started to meet the needs of the residents. The surveyor asked for documentation to show how they were monitoring that the building was properly staff. There was no data available to review and there were no notes to verify that they were monitoring the staffing issues.
On [DATE] at 10:45 AM part of the QAPI plan indicated all the nursing staff were not cardiopulmonary resuscitation (CPR) certified. The surveyor asked to review the documentation when the issue was discovered, how they are monitoring the problem, what the team did to rectify the issue, and all else data. The requested data was not in the QAPI book for review.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on record review and interviews it was determined that the facility staff failed to include the Infection Preventionist in the Quality Assurance Performance Improvement (QAPI) meetings. This def...
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Based on record review and interviews it was determined that the facility staff failed to include the Infection Preventionist in the Quality Assurance Performance Improvement (QAPI) meetings. This deficient practice was discovered during the recertification survey.
The findings are:
On 05/30/25 at 2:42 PM the surveyor reviewed the sign-in sheets for QAPI meetings held on 01/31/25, 02/19/25, 03/19/25 and the Infection Preventionist's name or signature was not included on any of the sign-in sheets.
On 05/30/25 at 2:56 PM during a telephone interview with Infection Preventionist #3 the surveyor asked did he/she attend any QAPI meetings. IP #3 verbalized they did not attend the QAPI meetings in person but was present via telephone. IP #3 was made aware that their name was not included as attending the meetings in person or by telephone. The surveyor asked when the last time he/she participated in a meeting. IP #3 was not able to provide the information requested.
On 05/30/25 at 3:13 PM the Director of Nursing was made aware the Infection Preventionist is required to attend QAPI meetings; and verbalized understanding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and interviews with facility staff, it was determined that the facility failed to ensure that they had an adequate emergency water supply and were unaware of the building's water ...
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Based on observation and interviews with facility staff, it was determined that the facility failed to ensure that they had an adequate emergency water supply and were unaware of the building's water system and unable to provide a description of it, a diagram and no testing of the water had been done for legionella and/or other opportunistic waterborne pathogens.
The findings include:
On 05/28/25 at 10:27 AM the surveyor spoke with two housekeeping staff and the Director of Maintenance (Staff #1) regarding water testing and emergency water supply. Staff #1 said the city took care of water testing and would notify the facility if there was a problem. The surveyor informed him that the City provided the water up to the facility, but that the facility was responsible for the water system inside the building including testing for Legionella and other waterborne bacteria. He was completely unaware that the facility was responsible for testing the water and stated that they had not tested it anytime during the 2 years he had been employed in the facility. He also stated that they had not change the aerators in the residents' rooms and had not engaged a plumber to do any maintenance on the water system except for emergency breakdowns.
One of the housekeeper's ( Staff #2), accompanied the surveyor to check the basement area while checking the laundry and the emergency water supply. There were 11-5 gallon containers of water and 4 empty containers observed in an alcove of the basement between the laundry and a storage area. The surveyor made Staff #1 aware that the recommended emergency water supply was a gallon of water a day per resident and staff for 3 days. The facility has the capacity of 29 residents and schedule 10 staff per day for a total of 39. That would require 117 gallons to be onsite at all times. When the surveyor asked about the empty bottles, Staff #1 said the water was the emergency supply and used by the facility day to day. He stated that they had a contract with a water supplier and that last week 10 bottles were ordered but only 3 were delivered. The surveyor informed the Director of Maintenance (Staff #1), Staff #2 and the Nursing Home Administrator (NHA), that the facility's emergency water supply was significantly below the 117 gallons that they were supposed to have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility staff failed to apply for a room waiver for rooms less ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility staff failed to apply for a room waiver for rooms less than the required square footage. This deficient practice was discovered during the annual survey.
The findings include:
On 05/28/25 at 8:33 AM during the entrance conference with the Director of Nursing (DON) the surveyor asked did the facility have any waivers. The DON verbalized the facility had a waiver for rooms that are less than the required size. The surveyor requested a copy of the waiver.
On 05/29/25 at 9:15 AM the surveyor reviewed a document received after the entrance conference. The document indicated rooms [ROOM NUMBERS] was less than the required square footage. The surveyor asked the Administrator for a copy of the waiver. The Administrator verbalized they were told not to apply for a waiver unless the survey team asked for the waiver. The surveyor made the Administrator aware the waiver should have been available prior to the survey to avoid noncompliance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on staff interviews and record review it was determined that the facility failed to have an Registered Nurse (RN) on duty 24 hours a day for 7 consecutive days.
The findings include:
The PBJ St...
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Based on staff interviews and record review it was determined that the facility failed to have an Registered Nurse (RN) on duty 24 hours a day for 7 consecutive days.
The findings include:
The PBJ Staffing Data Report listed that on Saturday, 10/05/2024, Saturday, 11/02/2024, Sunday, 12/01/2024, Saturday, 12/07/2024, Saturday, 12/14 /2024, Saturday, 12/21/2024, and Wednesday, 12/25/2024 there weren't any RNs on duty for the full 24 hours. The facility provided 2 weekends of scheduling (5/24-5/25/2025) and (5/31-6/1/2025) and consistently on Saturdays and Sundays there weren't any RNs on duty for the entire day.
During an interview with the Administrator on 05/29/25 at 10:22 AM , she was asked about the dates targeted in the PBJ report. She stated that there was not an RN on duty on those dates. The Administrator stated that the facility was unable to find RN staff for weekends and holidays either from staff or agency. For the 2 week staffing schedule that was provided, there weren't any RNs working on the weekends (weekends of 5/24-5/25 and 5/31-6/1).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on record review and interviews it was determined that the facility assessment did not accurately reflect the services provided by the facility. This deficient practice was discovered during the...
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Based on record review and interviews it was determined that the facility assessment did not accurately reflect the services provided by the facility. This deficient practice was discovered during the recertification survey.
The findings include:
On 05/30/25 at 4:30 PM the surveyor reviewed the facility assessment provided by the Director of Nursing. A review of the assessment revealed it was documented the facility had an average of 10 resident admissions during the weekday. The assessment failed to include they have the capacity to admit residents who had infectious diseases such as COVID-19, MRSA, and/or Clostridium Difficile. The portion of the assessment regarding caring for residents with conditions not listed was incomplete. The assessment indicated that the facility is equipped to care for residents with a tracheostomy, although there are no current residents within the facility. Showers were not listed for assistance provided for activities of daily living.
On 06/02/25 at 11:21 AM during an interview with the Director of Nursing and Administrator the surveyor reported the concerns about the inaccuracy of the Facility Assessment. The Director of Nursing verbalized it's been a while since they had a skills lab for the nurses. There are no competencies to verify the staff have been trained to care for residents with a tracheostomy or gastrostomy tube. The Administrator verbalized the area of the assessment that indicated the facility had an average of 10 admissions during the week was an error.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews it was determined that the facility's governing body and/or executive leadership failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews it was determined that the facility's governing body and/or executive leadership failed to ensure the Quality Assurance Performance Improvement (QAPI) program identified & prioritized problems that reflected the organizational process, functions, and services provided to residents based on performance indicator data, resident and staff input, and other information. This deficient practice was discovered during the recertification survey.
The findings include:
On [DATE] at 10:26 AM after reviewing the Quality Assurance Performance Improvement plan the surveyor interviewed the Director of Nursing (DON). The surveyor informed DON that the QAPI plan was ineffective because it lacked a systematic approach that identified problems, tracked, investigated, and analyzed data. When the surveyor asked the DON, was there oversight of the QAPI processes by a governing body and the DON verbalized, No.
On [DATE] at 10:45 AM the Administrator verbalized Chief Financial Officer #14 provided oversight of the QAPI process. When the surveyor asked has CFO #14 attended any of the QAPI meetings and provided input to determine if the QAPI process was effective. The surveyor's question was not answered.
On [DATE] at 12:23 PM during a telephone interview with CFO #14 the surveyor asked do they provide oversight of the QAPI process. CFO #14 verbalized the Administrator, and the Director of Nursing keeps them abreast with what was going on with the QAPI process and they try to attend some of the morning calls. The surveyor asked what was discussed during the most recent QAPI meeting. CFO #14 verbalized they discussed a couple of resident passings, and they always discuss staffing; he/she is part of the governing body. They just went to the facility to see how the survey was going, but did not review the QAPI book. The surveyor asked CFO #14 were they aware some of the nursing staff were not certified in cardiopulmonary resuscitation (CPR) as a provider, which was identified by the QAPI committee. CFO #14 verbalized, No.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
Based on observations and staff interview it was determined that the facility staff failed to: 1) ensure a call device was installed in shower areas and 2) a cord used to turn on/off a call light was ...
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Based on observations and staff interview it was determined that the facility staff failed to: 1) ensure a call device was installed in shower areas and 2) a cord used to turn on/off a call light was attached to the call system in the toilet stalls. This was evident for 2 of the 2 environmental observations during the annual survey.
The findings include:
On 5/28/25 at 10 AM the surveyor conducted a tour of the facility and observed the bathroom on the long hall without a call device in the shower area, and no string attached to the call device in the toilet stall. The shared bathroom on the short hall was without a call device in the shower area and two of the 3 toilet stalls were without strings attached to the call device.
On 5/29/25 at 11:01 AM a subsequent tour of the facility with the Nursing Home Administrator (NHA) and Maintenance Director revealed the bathroom on the long hall without a call device in the shower area, and no string attached to the call device in the toilet stall. The shared bathroom on the short hall was without a call device in the shower area and two of the 3 toilet stalls were without strings attached to the call device. The Maintenance Director confirmed that the call device strings would be installed right away and installation of the call devices for the showers will be done as soon as approval to purchase is received from the NHA.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record review, it was determined that the facility failed to: 1) maintain proper labeling, dating, and expiration practices for food items, and 2) did not consis...
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Based on observations, interviews, and record review, it was determined that the facility failed to: 1) maintain proper labeling, dating, and expiration practices for food items, and 2) did not consistently meet the manufacturer-recommended range of Quaternary Ammonium Compounds (QACs) for dish sanitization. This was found to be evident during the initial kitchen visit of the annual recertification survey.
The findings include:
1) During a Kitchen tour on 5/28/25 at 8:17 AM, Staff #8 was unable to identify the correct expiration date on a box of hot sauce, noting conflicting and possibly expired dates. Cereal dispensers (Raisin Bran, [NAME] Krispies, Frosted Flakes) were all labeled 2/14/25. Staff #8 was unsure if this was the date the cereal was put in the dispenser or the expiration date. Expired spices were found Poultry Seasoning (exp. 9/27/2019) and Allspice (exp. 8/10/2023).
On 5/28/25 at 8:35 AM, Staff #7 and Staff #8 could not consistently identify or date items in the Unit 2 freezer due to lack of labeling. Conflicting dates were given for chicken and ground beef, and Staff #7 acknowledged the need for proper labeling of frozen goods received. An unlabeled container of potato salad in Unit 1 refrigerator was shown to Staff #8 and was discarded by Staff #8 due to uncertainty about its expiration.
On 5/28/25 at 8:53 AM, two unlabeled zip lock bags of spreadable butter were found in the Unit 4 freezer without an expiration date. Staff #7 acknowledged the need to label all received food items with a received date and an expiration date going forward.
Quaternary ammonium compounds (QACs) are a large class of chemicals used as antimicrobials for cleaning and disinfecting food processing equipment, food contact surfaces and utensils. Bartavation is the brand of QAC that the facility used. According to Bartovation Quaternary Ammonium (QAC, Multi-Quat) Sanitizer Test Paper strips, the target range for effective sanitization of dishes is 200-400 ppm (parts per million).
2) On 5/29/25 at 10:04 AM, Staff #9 and Staff #8 were shown the May 2025 temperature/sanitizer log. Staff #9 was unsure of the correct QAC concentration range. The May 2025 temperature/sanitizer log showed readings of 100, which Staff #9 and Staff #8 did not recognize as being outside of the proper range. Staff #7 was informed that 100 ppm was too low and needed to be between 200-400 ppm for proper sanitization. Staff #7 verbalized understanding of the correct range.
Jun 2022
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #9's medical record on 6/28/2022 at 9:30 AM revealed a nurses note dated 6/21/2022 at 8:30 AM stating a GN...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #9's medical record on 6/28/2022 at 9:30 AM revealed a nurses note dated 6/21/2022 at 8:30 AM stating a GNA (geriatric Nursing assisant) reported that Resident #9 was found with bleeding/clotting from the rectum and the nurses notified the CRNP (Certified Nurse Practitioner) and then called 911.
Further review of the medical record revealed a document titled: Maryland Baptist Aged Home Concurrent Review Follow- Up Evaluation Form that stated: resident transported via [NAME] to Hospital ER and the surrogate was notified. The identity of the surrogate notified was not located on the document nor in any of the nurses' notes in the medical record.
An interview was conducted with the Social Worker, Staff #9, on 6/29/2022 11:45 AM. Staff #9 confirmed that the resident was discharged on 6/21/2022 and sent to the Emergency Room. Staff# 9 stated that Resident #9's RP (Responsible Party) was notified by phone call about the change of condition and transfer.
On 6/30/2022 at 10 AM an interview was conducted with Staff #9 and the DON (Director of Nursing). Staff #9 stated that they only notify the resident or responsible party by phone call and do not have written notifications that are sent out to the resident/responsible party upon transfer or discharge of a resident. Staff #9 and the DON state that they will now adopt the process of sending written notifications to the resident or responsible party in addition to the phone call notifications currently in place.
The concern regarding failure to notify the resident/resident representative in writing of a transfer/discharge of a resident was again addressed with the Administrator and DON on 6/30/2022 at 1:30 PM.
Based on medical review the facility failed to notify Resident # 21 and the resident's responsible party in writing of the reason for the transfer to the hospital and send a copy to the Ombudsman. This was evident for 2 (resident #9 and resident # 21) of 3 residents reviewed during the closed record review portion of the survey.
The findings include:
1. On 06/27/22 at 10:08 AM a medical record review was conducted for Resident # 21. The resident had been sent to the hospital on 2 different occasions.
On 4/7/22-4/15/22, Resident #21 was sent to the hospital due to a change in mental status. Resident # 21 was found to be lethargic and unresponsive. He has a history of cognitive impairment, Chronic obstructive pulmonary disease (COPD), cerebrovascular accident (CVA) and tachycardic. The resident was placed on antibiotic therapy and an appointment was made to follow up with the urology clinic for staghorn calculus. He was also placed with a urinary catheter for retention.
On 5/25/22 Resident #21 was sent to the hospital for a complicated UTI (Urinary tract infection). The Guardian was notified of the transfer to the hospital, however the guardian was not notified in writing of the reason for the transfer, nor was a copy sent to the Ombudsman. This surveyor spoke with the Nursing Home Administrator and the Director of Nursing.
The DON on 6/28/22 at 12:05 PM, stated that they were unaware that they had to send the reason for the transfer to the hospital notification in writing to the Responsible Party or Guardian and Ombudsman. Both the Administrator and the DON acknowledged that they now understood this requirement is.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on resident medical record review, the facility failed to develop a care plan for Resident # 21 who has a history of urinary track infections and kidney stones in addition to retention of urine....
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Based on resident medical record review, the facility failed to develop a care plan for Resident # 21 who has a history of urinary track infections and kidney stones in addition to retention of urine. This was evident for 1 out of 3 residents reviewed for care plans.
The findings include:
On 06/27/22 at 10:08 AM a medical record review was conducted for Resident # 21. The resident had been sent to the hospital on 2 different occasions.
On 4/7/22-4/15/22 the resident was sent to the hospital due to a change in mental status. Resident # 21 was found to be lethargic and unresponsive. He has a history of cognitive impairment, COPD, CVA and tachycardia. Resident was placed on antibiotic therapy and a appointment was made to follow up with urology clinic for staghorn calculus. He was also placed with a urinary catheter for retention.
On 5/2522 Resident #21 was sent to the hospital for a complicated UTI (Urinary tract infection) associated with catheter use. Resident has surgery (ureteroscopy) on 6/3/22 to remove staghorn calculus. Resident # 21 was also placed on Cefdinir 300 mg 2 times per day until 6/5/22.
On 6/12/22 Resident 21 was ordered cipro750 mg by mouth every 12 hours for UTI x 7 days . A urine culture and sensitivity was conducted on 6/10/22 and the physician was made of results. The resident had no complaints of pain. Resident #21 was consuming water and eating well. He is fed by staff. All incontinence care given. There was no care plan on the chart for UTI or former catheter use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview, and medical record review, it was determined that the facility staff failed to follow physician orders regarding nutrition for a resident exclusively dependent on gast...
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Based on observation, interview, and medical record review, it was determined that the facility staff failed to follow physician orders regarding nutrition for a resident exclusively dependent on gastrostomy tube (also called a G-tube, is a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding and ensure that s/he was fed all scheduled and ordered tube feeding nutrition. This was evident for 1 of 1 residents (#14) in the facility that were ordered gastrostomy tube feedings.
The findings include:
During an interview on 6/29/2022 at 7:35 AM with the night and day shift staff, Licensed Practical Nurse (LPN) #6, and LPN #3 respectively. The Surveyors inquired as to the next scheduled time that Resident #14 was to receive his/her g-tube feeding. The facility staff both simultaneously stated that Resident #14 received g-tube feeding 3 times a day and that s/he will not be due again until 2:00 PM.
The Surveyors continued with their review of Resident #14's medication administration record (MAR) and paper chart as part of the closed record review portion of the survey. During the review of the MAR the surveyors noted that there was an order from 10/1/2019 that remained current for bolus tube feeding 5 times a day. According to the MAR, staff was signing off that this was completed, however staff LPN #3 and #6 just reported that they were only completing this task 3 times a day.
During medication pass on 6/29/2022 at 8:30 AM with staff LPN #3 with Resident #14, the MAR for his/her tube feeding was reviewed. Staff LPN #3 stated that she would have to review the actual physician order and that she was not aware that it was supposed to be 5 times a day. It should be noted that staff LPN #3 and #6 both worked for the past 3 days and provided care to Resident #14.
On 6/29/2022 at 9:35 AM during an observation pass with another staff member, staff LPN #3 approached the surveyors and stated that she confirmed the order and will now be feeding Resident #14 at 10:00 AM as ordered in addition to the 2:00 PM shift.
The concern that there was an order for Resident #14 to be fed 5 times a day and was only fed 3 times a day confirmed by staff LPN #3 and #6 who were signing off the MAR and not completeing the task, was reported to the facility Registered Dietician on 6/29/2022 at 10:53 AM. This was also reported to the DON and Administrator throughout the survey and again during the survey exit on 7/1/2022.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on medical record review and interview with facility staff, it was determined that the facility failed to: 1. complete a discharge summary on a resident to include a recapitulation of the reside...
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Based on medical record review and interview with facility staff, it was determined that the facility failed to: 1. complete a discharge summary on a resident to include a recapitulation of the resident's medication and 2. Provide a resident with discharge instructions at discharge. This was evident in 1 of 3 residents (#26) reviewed for discharge.
The findings include:
Review of the closed medical record on 6/29/2022 at 12:31 PM for Resident #26 revealed a discharge from the facility on 4/4/2022 according to his/her electronic health record (EHR), specifically the nursing progress notes that documented the resident was discharged home on 4/4/2022 at 5:40 PM. This progress note though did not address any training or review any medications the resident was to be discharged home on. In addition during this review no physician discharge summary was located in the residents closed chart.
A social work note completed on 4/1/2022 documented that medications were reviewed with the resident on 4/1/22 at a care plan meeting, however there was no documentation in the chart that the prescriptions and discharge summary were given to the resident upon discharge.
On 6/29/2022 at 1:00 PM the Director of Nursing (DON) was notified that there was no discharge physician summary located in the closed chart.
On 6/30/2022 at 8:21 AM the DON provided the surveyor with a copy of the physician discharge summary completed on 4/4/2022 at 1:37 PM. There was also a fax stamp on the paperwork for 6/29/2022. The DON was asked if the paperwork was just faxed yesterday from the physician's office, and she stated, 'yes.'
Review off the physician discharge summary revealed an area where 14 medications were listed for the resident to continue taking at discharge with directions. Again, it was reviewed with the DON that there was no documentation that this information was provided to Resident #26 upon discharge and that there was no physician discharge summary located on the chart timely after Resident #26's discharge.
The findings were reviewed with the DON on 7/1/2022 prior to the survey exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview with facility staff, it was determined that the facility failed to arrange a follow up appointment for a resident's venous stasis ulcer. This was evi...
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Based on observation, record review, and interview with facility staff, it was determined that the facility failed to arrange a follow up appointment for a resident's venous stasis ulcer. This was evident for 1 (Resident #23) of 1 resident reviewed for wounds.
The findings include:
On 6/28/22 at 10:27 AM, the surveyor observed Resident #23 in his/her room. During the observation, the resident was noted to have a wound to his/her right leg. There was an intact bandage on the leg wound. The resident was unable to be interviewed.
On 6/30/22 at 8:13 AM, the surveyor reviewed Resident #23's medical record. The record showed that the resident's right leg wound was present on admission in 2021 and improved as of a physician's note written on 10/31/21. However, a note was found from a vascular surgery appointment on 1/19/22 that indicated Resident #23's right leg venous wound had reopened. The note indicated that the resident should be ordered compression dressing, should elevate the extremities, should wear compression stockings, and will need to continue to be followed by a vascular surgeon.
On 6/30/22 at 8:45 AM, the surveyor interviewed the Director of Nursing (DON). During the interview, the DON confirmed that Resident #23's wound had been healing earlier in his/her stay but that recently it had been worsening. The DON attributed some of this worsening to the resident's behaviors, saying that the resident was highly noncompliant with treatment, would refuse to wear his/her ordered compression stockings, would remove the wound's dressing, would not elevate the extremity when seated, and had a behavioral habit of inserting crayons into his/her sock where they were in contact with the exposed wound. The DON described the resident's behaviors as having worsened in recent months. Historically, the resident could be redirected from removing his/her dressing with incentives to draw and create art, but that had to be limited because the art was impacting other residents. When asked if the resident had an appointment scheduled with the vascular surgeon, the DON stated that there should be such an appointment coming up. The DON stated that she would check with the scheduler.
On 6/30/22 at 8:30 AM, the surveyor interviewed the Scheduler. During the interview, the Scheduler stated that she makes appointments for residents. She said that there was no vascular surgery appointment scheduled for Resident #23
On 6/30/22 at 10:02 AM, the surveyor was notified by the DON that no vascular surgery appointment had been previously scheduled for Resident #23. The DON said that an appointment had now been made for mid-July.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and medical record reviews, it was determined that this facility failed to follow Physician Orders regarding management of Tube Feeding for a resident totally depend...
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Based on observations, interviews, and medical record reviews, it was determined that this facility failed to follow Physician Orders regarding management of Tube Feeding for a resident totally dependent on gastrostomy tube feeding.
The findings include:
During tour of the facility on 6/28/2022 at 8:55 AM Resident #14 was observed in his/her room asleep. Observation of Resident #14's room revealed the presence of a 60-cc syringe used for gastrostomy tube feeding on the resident's bedside table.
On 6/29/2022 during review of the medication administration record (MAR) for Resident #14, surveyor noted that s/he was scheduled for feeding via the gastrostomy tube at 10:00 AM. Surveyor interviewed staff Licensed Practical Nurse (LPN) #3 and #4 regarding when Resident #14 was scheduled to be fed again and they both stated not until 2 PM and further that s/he only is fed 3 times a day.
On 6/29/2022 at 9:00 AM, while observing staff LPN #3 on Medication Pass, LPN # 3 was interviewed on, how many times each day, Resident #14 is fed. LPN# 3 answered three times. This Surveyor asked her to review the MAR which showed that Resident # 14 has as order for feeding five times each day, which LPN #3 has signed off on. Nurse # 3 replied that she was not aware and will check the Physician's order sheets to verify exactly how many times a day s/he is supposed to receive the tube feeding.
The concern that there was an order for Resident #14 to be fed 5 times a day and was only fed 3 times a day confirmed by staff LPN #3 and #6 who were signing off the MAR and not completing the task, were reported to the facility Registered Dietician on 6/29/2022 at 10:53 AM. This was also reported to the DON and Administrator throughout the survey and again during the survey exit on 7/1/2022.
cross reference with F658
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected 1 resident
Based on medical record review and interview with facility staff it was determined that the facility staff failed to document an accurate overview of the resident during a physician visit. This was ev...
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Based on medical record review and interview with facility staff it was determined that the facility staff failed to document an accurate overview of the resident during a physician visit. This was evident during 1 of 3 physician record reviews. (R #12)
The findings include:
Review of the medical record for Resident #12 on 6/29/22 at 8:26 AM revealed a physician visit note dated 3/26/2022 documenting 11 medications in the resident's profile, with one medication listed 3 times and two different medications referred to twice. A review of the resident's concurrent medication administration record revealed Resident #12 was only 12 medications, however, only 9 of the medications that were listed in the physician note. Two of the medications listed; Aricept and Abilify were not documented as administered since before December 2021.
These medications were also listed on the physician progress notes for 4/9/22 and 5/14/22, 6/11/22 and 6/19/22.
These concerns were reviewed with the facility Director of Nursing throughout the survey and again on 7/1/2022 at 9:30 AM and again during the survey exit from the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on record review and staff interviews, it was determined that the facility failed to ensure that a nurse aide had no less than twelve hours of in-service education per year. This was evident for...
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Based on record review and staff interviews, it was determined that the facility failed to ensure that a nurse aide had no less than twelve hours of in-service education per year. This was evident for 1 (Staff # 16) of 3 Geriatric Nursing Assistants (GNAs) reviewed during the Sufficient and Competent Staffing Review portion of the survey.
The findings include:
During review of Staff #16's personnel file On 6/30/2022 8:30 AM , it was revealed that the most current GNA training was completed by Staff #16 on 5/29/2020.
On 6/30/2022 9:45 AM an interview was conducted with the DON. During the interview the DON stated: the file we submitted is our current in-service and training record for Staff #16.
The concern regarding failure to ensure a nurse aide had no less than twelve hours of in-service education per year was addressed with the Administrator and DON on 6/30/2022 1:30 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews it was determined that the facility failed to ensur:e 1) appropriate temperature maintained...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews it was determined that the facility failed to ensur:e 1) appropriate temperature maintained for the medication refrigerator, 2) expired medications were properly disposed, 3) ensure medications were kept in secured locations, and 4) food items were not kept in medication storage room. This was found to be evident in 1 out of 1 medication storage rooms observed during the recertification survey.
The findings include:
1) On 06/30/22 at 10:43 AM the surveyor and Director of Nursing (DON) conducted an observation of the medication storage room. The surveyor and DON found the medication refrigerator thermostat temperature at 50 degrees Fahrenheit. The medication refrigerator log stated minimum temperature of 36 degrees Fahrenheit and a maximum of 46 degrees Fahrenheit.
2) On 06/30/2022 at 10:45 AM the Surveyor and DON observed the inside of the medication refrigerator and found 3 Latanoprost eye drops that expired on 2/25/2022 and 3 Trulicity insulin pens that expired on 4/17/2022. The DON stated he/she would discard and replace the expired medications, have maintenance check the refrigerator and replace the thermostat for the medication refrigerator. Observation of the cabinet revealed 2 unopened boxed of Refresh Plus single use eye drops that had an expiration date of 2/2020.
3) On 06/30/2022 at 10:52 AM the surveyor and DON observed an unlocked cabinet that had an interim medication cart inside. The interim medication cart had 4 out of the 5 drawers unlocked with multiple medications in each drawer. The DON stated he/she would get a new interim medication cart and will have a lock placed on the cabinet.
4) During an observation of the medication storage room on 06/3/2022 at 10:52 AM the surveyor and DON found 2 jars of opened peanut butter, 1 opened bottle of mustard, 1 opened jar of grape jelly,1 container filled with packets of salt, pepper and Chinese duck sauce, 1 opened bottle of Parmesan Cheese, 1 can of unopened fruit mix, 1 unopened can of diet Pepsi, 1 unopened pack of hot chocolate , 25 unopened bottles of in house docusate in unlocked cabinets
5) Medication Storage and Labeling
06/29/22 10:33 AM
6/29/22 7:35 AM review of narcotic log- night shift staff P. [NAME] present (staff #6 LPN) and day shift LPN Kya [NAME] (staff #3) present. Noted that the narc log for this morning 7-3 was signed off for the night shift staf but not the day shift. asked if they had completed the narc count and they stated 'no.' confirmed the signature with the nightshift staff and he stated that they were getting ready to but have not yet and he confirmed his signature.
Paperwork reviewed and noted multiple holes for the month of june to April for shift to shift or a single staff would sign this was reviewed with the ADmin and DON on 6/29/22 at 745 AM.
06/29/22 10:40 AM request for schedule for following days with noted holes over multiple shifts to see if there were staff that worked mulitple shifts or staff just did not sign or if there was a pattern in the same staff.
3/28
4/25
4/29
5/19
5/31
6/7
6/12
6/22
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, interview, and medical record review, it was determined that the facility failed to provide dental services and assessments within a reasonable time frame. This was found to be e...
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Based on observation, interview, and medical record review, it was determined that the facility failed to provide dental services and assessments within a reasonable time frame. This was found to be evident for 1 out of 4 residents (Resident #10) reviewed for dental.
The findings include:
During a tour conducted on 06/27/2022 at 11:55 AM surveyor observed resident #10 with missing teeth and a broken tooth on the left side of the resident's mouth.
During an interview conducted on 06/27/2022 at 11:56 AM, resident #10 stated he/she had not seen a dentist since he/she had resided at the facility and currently had a sore mouth from his/her broken teeth. The Resident stated he/she had not told the facility about the mouth pain.
On 6/28/22 at 02:26 PM a record review of the physical chart was conducted. The surveyor located 1 dental/oral assessment conducted on 07/17/2019. The assessment documented the resident #10 had a total of 6 teeth in his/her mouth.
During an interview conducted on 06/28/2022 2:32 PM Medical Records #13 reviewed the resident's chart and confirmed the resident had one dental assessment in the chart and it was dated 07/17/2019.
During an interview conducted on 06/28/2022 02:42 PM, the Director of Nursing (DON) stated the facility's policy is to conduct an inhouse oral assessment annually. The DON reviewed the resident's physical chart and confirmed the resident did not receive an annual oral assessment; the last oral assessment was dated 07/17/2019. The DON also stated residents are sent out for routine and emergency dental services to the Druid Hill dental clinic, residents also have an option to go to a personal dentist through private pay. The DON confirmed the resident was not offered dental services because he had not complained of oral pain. The surveyor advised the DON of the resident's complaint of oral pain. The DON stated he/she would speak with the resident.
On 06/29/2022 at 10:19 AM the DON advised the dental policy has been revised to now provide oral assessments quarterly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
Based on interview with facility staff, it was determined that the facility failed to ensure that leftover foods were cooled in a safe and sanitary manner. This practice had the potential to affect al...
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Based on interview with facility staff, it was determined that the facility failed to ensure that leftover foods were cooled in a safe and sanitary manner. This practice had the potential to affect all residents.
The findings include:
During a tour of the kitchen that took place on 6/28/22 at 12:40 PM, the surveyor interviewed the Certified Dietary Manager (CDM). During the interview, the CDM was asked if the facility maintains any leftover food after it has been prepared. The CDM stated yes, the facility does keep leftover foods in small quantities after some meals. The surveyor asked if the facility tracks the cooling temperatures of potentially hazardous cooked foods to ensure that they cool from 135°F to 70°F within 2 hours and from 70°F to 41°F within 4 hours. The CDM indicated that there was not such a process, stating that there was no expectation that staff take the temperature of cooling foods prior to refrigeration. The CDM denied having any cooling log of potentially hazardous leftovers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interview with facility staff, it was determined that the facility failed to ensure that food service was operated in a clean and sanitary manner. This practice had the potent...
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Based on observation and interview with facility staff, it was determined that the facility failed to ensure that food service was operated in a clean and sanitary manner. This practice had the potential to affect all residents.
The findings include:
The surveyor conducted a tour of the kitchen on 6/28/22 at 12:40 PM. The tour revealed the following findings:
- the surveyor noted a used scoop for serving sugar and flour that was being kept inside the bin for the sugar and flour, exposing the food to the contaminated handle.
- the surveyor noted approximately 8-10 seasoning containers with heavily soiled lids. The containers were placed next to the steam trays and had evidence of being contaminated by splash from food preparation. The lids all had thick brown crust on their tops and sides. The Certified Dietary Manager (CDM) indicated that the containers were reused because of their smaller size, and that staff refilled them from larger storage containers of the respective spices. The CDM indicated that she would obtain new smaller spice containers.
- the surveyor identified a red sanitation container with clear fluid in it. The container was designated for containing sanitizer at a specific concentration to allow for the sterilizing of cooking surfaces during food preparation. The CDM tested the level of sanitizer in the presence of the surveyor using a test strip specific to the sanitizing chemical. Based on the CDM's test level of sanitizer was below a detectable level.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected 1 resident
Based on review of facility documentation and interview with facility staff, it was determined that the facility failed to maintain a facility-wide assessment of necessary resources for resident care ...
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Based on review of facility documentation and interview with facility staff, it was determined that the facility failed to maintain a facility-wide assessment of necessary resources for resident care and review and update the assessment at least annually. This practice has the potential to affect all residents in the facility.
The findings include:
On 6/30/22 at 9:50 AM, the surveyor interviewed the Administrator. During the interview, the administrator stated that she recalled completing a 2 page document that she thought served as a viable facility assessment. The Administrator couldn't say when it was last reviewed or seen, but stated that she expected to find it in the survey resource binder.
During a follow up interview that took place on 6/30/22 at 10:05 AM, the Administrator stated that she had reviewed the facility resource binder and couldn't locate the facility assessment there or anywhere else.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined the facility failed to ensure the appropriate staff attended the Quality Assurance and Performance Improvement (QAPI) committee meeting. This was...
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Based on record review and interview it was determined the facility failed to ensure the appropriate staff attended the Quality Assurance and Performance Improvement (QAPI) committee meeting. This was found to be evident for 5 out of 5 QAPI meetings held.
The findings include:
On 06/27/2022 at 11:25 AM a record review of the Quality Assurance and Performance Improvement (QAPI) meeting attendance sheets revealed the Medical Director was not in attendance for meetings held January, February, March, April, and May 2022.
During an interview conducted on 06/27/2022 at 12:27 PM the Director of Nursing (DON) stated he/she had taken the role to conduct the QAPI meetings since the last person left in December of 2021. The Administrator confirmed the Medical Director was not listed as an attendee because the Medical Director attended the QAPI meetings by telephone. The Surveyor requested supportive documentation to confirm the Medical Director attendance.
On 06/27/2022 at 1:35 PM the surveyor reviewed the QAPI meeting notes and was for January, February, March, April, and May 2022 and was unable to confirm the Medical Director attended the QAPI meetings.
On 06/27/2022 at 2:33 PM the survey advised the DON he/she was unable to confirm the Medical Director's attendance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on previous room measurements, observations and interviews, it was determined that the facility failed to provide at least...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on previous room measurements, observations and interviews, it was determined that the facility failed to provide at least 80 square feet of floor space per resident in 2 of the 11 residents rooms.
The findings include:
As previously determined the floor space for rooms [ROOM NUMBERS] is calculated to be 75.5 square feet of floor space per resident. Both rooms are equipped to house two residents each. The Nursing Home Aadministrator had acknowledged that rooms 101, and 102 did not meet the floor space requirement during environmental rounds conducted on 6/27/22 at 11 AM. The Administrator also presented a waiver to the survey team.
During the survey, there were 2 residents in 101 and 102. The residents in these rooms had no issue with the size of the rooms. The calculated room size did not meet the 160 square foot requirements for a 2 person room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that handrails were secure to provide a safe environment. This...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that handrails were secure to provide a safe environment. This was found to be evident for 1 out of 5 handrails observed during the re-certification survey.
The findings include:
During a tour of the facility conducted on 06/27/2022 at 8:32 AM, the surveyor observed a handrail hanging in a downward position away from the wall located in the hallway between resident room [ROOM NUMBER] and the restroom.
During an interview conducted on 06/27/2022 at 8:35 AM the Maintenance worker #2 stated he/she would repair the handrail. The Surveyor observed Maintenance worker #2 attach the handrail to the wall.
On 06/27/2022 at 9:05 AM the surveyor advised the Administrator of the findings during an interview.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 06/28/22 06:56 AM the surveyor observed that the shower curtain on the short hall was dirty, and the ceiling tiles had bro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 06/28/22 06:56 AM the surveyor observed that the shower curtain on the short hall was dirty, and the ceiling tiles had brown water stains located in the long hall.
On 06/28/22 06:59 AM the surveyor observed a bucket of trash in the shower; sharp edges on the baseboard radiator cover. Against the wall in the toilet stall; there were 3 full 16 oz water bottles stored in the sink in the toilet room opposite room [ROOM NUMBER].
On 06/28/22 10:50 AM the surveyor toured all units, the baseboard heater covers were damaged/broken/frayed, exposing radiator coils in room [ROOM NUMBER] and room [ROOM NUMBER].
Based on observations of the facility on 6/27/22, the facility failed to provide maintenance services to keep the resident's environment safe and in good repair. This was evident in all resident rooms and hallways. In addition, it was determined that the facility failed to ensure that resident rooms were kept in a home like environment. This was found to be evident for 1 out of 3 (affecting Residents #10, #16 and #22) resident rooms observed during the re-certification survey.
The findings include:
1. An environmental tour was conducted by three surveyors at 10 AM on 6/27/22. Another tour of the facility was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 6/29/22 at 11 AM.
It was noted that the floor in the hallways was uneven with gouges and separation in the tile with mix matched tiles as a temporary fix to the floor. In the bedrooms mix matched tiles throughout the rooms was observed with exposed rough, uneven edges. The floor tiles were also loose and/or missing in room [ROOM NUMBER]. The NHA said that she had been working on hiring a contractor floor vendor to fix the flooring in the hallways, but that the bedrooms would have to wait.
In all the bedrooms, hallways, and shower rooms the baseboard heating needs to be replaced. The baseboards were old and rusty, with chipped paint and rough, sharp edges on the baseboard. The baseboard heaters were also not attached to the wall. Sharp jagged edges were observed on the bottom of the baseboard surface. It was observed that Rooms 101, 102, 105, 109, 110, 111, 112, 108, 106, 101, and 104 all needed repair/replacement.
Also, observed and noted was that the furniture in all the bedrooms were scratched and dented. The color on the surface of the furniture was worn off.
In room [ROOM NUMBER] an empty bed was positioned directly next to the baseboard heater.
During a tour conducted on 06/27/2022 at 09:22 AM by Surveyor 42783 of residents #10, #16, & #22's Room, the surveyor observed missing pieces of floor tiles throughout the residents' room. The Surveyor also observed three deep cuts in the wall about 6 inches long behind Resident #10's bed. The residents' furniture paint/stain had peeled away and showed bare wood.
During an interview conducted on 06/27/2022 at 10:15 AM by Surveyor # 42783, the Administrator stated that he/she was aware of the condition of the resident's furniture and floors but not the damaged deep cuts in the wall. The Administrator further stated that he/she would have maintenance repair Resident #10's wall. The observed damage to the floors and furniture had not been contracted out for repair in order to keep the residents safer from exposure to COVID-19. According to the Centers of Disease Control (CDC) COVID-19 is a respiratory disease caused by SARS-CoV-2, a coronavirus discovered in 2019. The virus spreads mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks.
.
On 06/30/22, 9:30 AM a tour was conducted by Surveyor 42783, the surveyor observed that the window ledge was damaged. There were sections of Resident #14's window ledge missing.
During an interview conducted on 06/30/2022 at 9:42 AM, the Administrator and Surveyor #42783 observed that Resident #14's window ledge was damaged. The Administrator stated he/she would notify Maintenance for repair. The Administrator and the Director of Nursing were made aware of the findings again on 6/30/22 at 9:42 AM prior to the survey exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation, staff interviews, and documentation review, it was determined the facility failed to post the daily nurse staffing hours and ratios at the beginning of each shift. This was evide...
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Based on observation, staff interviews, and documentation review, it was determined the facility failed to post the daily nurse staffing hours and ratios at the beginning of each shift. This was evident for nursing assignments posted from June 28, 2022, to June 30, 2022.
The findings include:
During tour of the facility on 06/28/22 6:40 AM the surveyor observed staff assignments posted on the whiteboard opposite the nurses' station which read: Date: 6/27/2022 Shift:7 AM to 3 PM. Actual staffing hours and staffing ratios worked by licensed and unlicensed staff not found.
On 6/28/2022 at 6:45 AM Staff #6, stated he worked the 6/27/2022 3 PM to 11 PM shift as well as the overnight shift 11 PM to 7 AM.
During a subsequent tour of the facility on 06/29/22 at 6:13 AM the surveyor observed staff assignments posted on the whiteboard opposite the nurses' station which read: Date: 6/28/2022 7 AM to 3 PM Shift. Actual staffing hours and staffing ratios worked by licensed and unlicensed staff not found.
On 6/29/2022 at 6:55 AM Staff #7, stated that she worked the 6/28/2022 11 PM to 7 AM shift as well as the overnight shift 11 PM to 7 AM.
On 6/29/2022 at 12:30 PM the surveyors made the Administrator and the DON aware of the incorrect posted nursing staffing data for 6/28/2022 and 6/29/2022.
On 6/30/2022 at 7:20 AM the surveyor observed staff assignments posted on the whiteboard opposite the nurses' station which read: Date: 6/29/2022 Shift:7 AM to 3 PM. Actual staffing hours and staffing ratios worked by licensed and unlicensed staff not found.
During an interview on 6/30/2022 at 7:30 AM with the DON and the Business Office Manager, surveyor requested licensed and unlicensed staff schedules and schedules of actual staff that worked for all shifts spanning the months of May 2022 and June 2022.
On 6/30/2022 at 8:20 AM the Business Office Manager submitted the facility's proposed staffing schedule and the actual schedules for May 2022 and June 2022 all shifts to the surveyor. Review of these documents revealed the total daily nursing staff ratios and total hours were not found.
On 6/30/2022 at 10:30 AM the Administrator and DON were made aware of the requirement to post nursing staff information on a daily basis and to include total daily nursing hours and staff ratios.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on review and observation of medical records, Controlled Drug Count Verification sheet and interview with staff it was determined that the facility failed to: 1. ensure that an account of all co...
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Based on review and observation of medical records, Controlled Drug Count Verification sheet and interview with staff it was determined that the facility failed to: 1. ensure that an account of all controlled drugs was completed with two licensed nurses at the change of each shift. This was evident for 1 of 1 available narcotic count logs.
The findings include:
During the first observation of medication pass on 6/29/2022 at 7:35 AM, surveyors started by reviewing the medication administration logs of the current residents to see when medication pass times were scheduled for and the different medications that would be scheduled. During review and as part of the medication storage task, the narcotic log was reviewed.
The nightshift slot for the 7-3 shift was signed off as of 7:37 AM and the corresponding day shift signature was not. The day shift LPN, staff # 3 and the night shift LPN, staff #6 were present at the nursing desk. Staff #6 was asked if they had completed the narcotic count for the change of shift. He stated 'no, they were getting ready too.' He was then shown the book to confirm his signature and stated 'yes,' that it was his, that he already signed the narcotic book. The Surveyor continued to review the narcotic log and noted multiple holes from 3/28/2022 to the present date in the signing out from shift to shift. Surveyor requested copies of the narcotic log from the end of March to the present date.
The identified concerns of the holes in the narcotic log and the observation of staff #6 signing out the log prior to counting the narcotics was reviewed with the Administrator and the DON on 6/29/22 at 7:45 AM.
On 6/29/22 at 10:40 AM the Surveyor requested the schedule for specific days from March to June that were noted on the narcotic log where there were holes over multiple shifts to verify if staff worked over multiple shifts in a row. According to the schedules provided to the survey team, no staff worked multiple shifts on the days noted with holes on the log. According to the facility policy that is used, last revised in 2013, Inventory of Control and Controlled Substances; 1.2 Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications .at the change of each shift or at least once daily and document the results on the Controlled Drug Count Verification Log.
The identified concerns were reviewed with the DON and the Administrator throughout the survey and again during the survey exit on 7/1/2022.
Apr 2019
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the 4/3/2019, observation of resident bedrooms and bathrooms, it was revealed that there was evidence of unattended mai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the 4/3/2019, observation of resident bedrooms and bathrooms, it was revealed that there was evidence of unattended maintenance necessary to maintain a clean, comfortable and homelike environment. This was evident for 3 of 18 residents selected for review during the survey process.
The findings include:
During the initial tour of the facility on April 3, 2019, the survey team observed the following evidence of unattended maintenance and/or housekeeping concerns:
1. room [ROOM NUMBER] was found with the base board molding to the right of the door, approximately 2 feet long pulled away from the wall. In addition, there was a missing floor tile next to the night stand.
2. On 4/3/2019 at 11:30 AM Resident #20's wheel chair padding on both arms was torn.
3. On 4/3/2019 at 11:00 AM Resident #21's wheel chair was repaired with grey duct tape.
4. All nursing homes must assure that adequate housekeeping and maintenance services were provided as necessary to maintain a sanitary, orderly, and comfortable environment of care.
In an interview on 04/09/19 at 9 AM, the Director of Nursing was made aware of these concerns.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based upon resident interview, staff interview and medical record review it was determined that facility staff failed to assist a resident in obtaining routine and emergency dental care. This was evid...
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Based upon resident interview, staff interview and medical record review it was determined that facility staff failed to assist a resident in obtaining routine and emergency dental care. This was evident for 1 of 2 residents (Resident #21,) during the investigative portion of the survey.
The findings include:
1. An interview was conducted with Resident #21 on 4/3/2019 at 8:30 AM. When asked if the resident was experiencing any dental or oral issues the resident responded I have missing teeth and tooth pain. I told them I wanted to see a dentist.
Medical record review reveals an evaluation of oral/dental status on 8/8/2018, at that time the Resident requested to be seen by a Dentist 2nd to missing teeth.
Further, medical record review reveals a Physician order on 3/16/19 to start amoxicillin 500mg by mouth every 12 hours, times 7 days for tooth ache/abscess.
Interview with the Director of Nursing on 4/8/19 at 9:30AM, confirmed the facility staff failed to obtain the dental consult. Following surveyor intervention, a dental consultation was scheduled for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview with staff it was determined that the facility failed to maintain all essential mechanical, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview with staff it was determined that the facility failed to maintain all essential mechanical, electrical, equipment in safe operating condition.
The findings include:
On 4/3/2019 at 8:30 AM, during an initial tour of the facility's the following observations was made:
1. Resident's room [ROOM NUMBER]A has a call bell cord attached to the wall with expose wires.
2. Observation of the laundry on 4/8/19 at 12 Pm, revealed that there were multiple issues in evidence of unattended maintenance. The dryer room revealed lint attached to the walls, floor and covering the exhaust fan.
These findings were acknowledged by the Director of Nursing on 4/9/19 at 9 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
Could have caused harm · This affected 1 resident
Based on observation and staff interview it was determined that the facility staff failed to ensure all of the rooms met the requirement for square footage.
The findings include:
The Administrator was...
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Based on observation and staff interview it was determined that the facility staff failed to ensure all of the rooms met the requirement for square footage.
The findings include:
The Administrator was asked on 4/3/19 if the facility had any waivers. She informed the team that she had a waiver for the square footage of two of the rooms, 101 and 102. The floor space was calculated to be 75.5 square feet of floor space per resident for both rooms. Both rooms are equipped to house two residents each. The nursing home administrator confirmed that the rooms do not meet the requirement and informed me that a waiver request had been faxed to OHCQ on 2/18/19. There are two residents currently living in each room. None of the residents complained about the room size.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on observation and staff interview it was determined that the facility staff failed to ensure the privacy of medical information.
The findings include:
This surveyor observation of the outside ...
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Based on observation and staff interview it was determined that the facility staff failed to ensure the privacy of medical information.
The findings include:
This surveyor observation of the outside of the facility on 4/9/2019 at 12:00 PM revealed:
1. The back of the facility revealed 11 overflowing boxes of varies medical and staff information including a Resident to Resident investigation dating back to 2009.
2. The back of the facility revealed 4 overstuffed, blue duffle bags that was not completely closed and had current medical information including empty medication packages.
3. The fence around the facility needed repair and was unsecure. Anyone in the back of the facility had visible to the medical information.
The Director of Nursing and Administrator was interviewed on 04/09/19 at 12:44 PM, revealed that the company Shred-It was to come out today and pick- up the bags to be destroy. The Administrator stated that she understood the findings of unsecure medical information.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Maryland facilities.
- • 27% annual turnover. Excellent stability, 21 points below Maryland's 48% average. Staff who stay learn residents' needs.
Concerns
- • 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 63/100. Visit in person and ask pointed questions.
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About This Facility
What is Maryland Baptist Aged Home's CMS Rating?
CMS assigns MARYLAND BAPTIST AGED HOME an overall rating of 3 out of 5 stars, which is considered average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Maryland Baptist Aged Home Staffed?
CMS rates MARYLAND BAPTIST AGED HOME's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 27%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Maryland Baptist Aged Home?
State health inspectors documented 44 deficiencies at MARYLAND BAPTIST AGED HOME during 2019 to 2025. These included: 44 with potential for harm.
Who Owns and Operates Maryland Baptist Aged Home?
MARYLAND BAPTIST AGED HOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 29 certified beds and approximately 22 residents (about 76% occupancy), it is a smaller facility located in BALTIMORE, Maryland.
How Does Maryland Baptist Aged Home Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, MARYLAND BAPTIST AGED HOME's overall rating (3 stars) is below the state average of 3.0, staff turnover (27%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Maryland Baptist Aged Home?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Maryland Baptist Aged Home Safe?
Based on CMS inspection data, MARYLAND BAPTIST AGED HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Maryland Baptist Aged Home Stick Around?
Staff at MARYLAND BAPTIST AGED HOME tend to stick around. With a turnover rate of 27%, the facility is 19 percentage points below the Maryland average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was Maryland Baptist Aged Home Ever Fined?
MARYLAND BAPTIST AGED HOME has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Maryland Baptist Aged Home on Any Federal Watch List?
MARYLAND BAPTIST AGED HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.