Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Blue Point Healthcare Center during CMS and state inspections, most recent first.
The facility did not provide necessary behavioral health care and services to residents who required them, as evidenced by a lack of appropriate assessment, planning, or delivery of behavioral health interventions.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
Surveyors found that two residents had medication cups with multiple pills left at their bedsides without documented assessments for self-administration. Both residents were cognitively intact and able to make their own medical decisions, but there was no evaluation in their records confirming their ability to self-administer medication without nursing supervision. LPNs reported that medications were given and residents were watched, but the required assessments were missing.
Facility staff did not inform the attending physician when a resident, admitted for IV antibiotics and substance use disorder treatment, repeatedly refused Suboxone doses. Despite documentation of multiple refusals and a physician note indicating the resident appeared high, neither the physician nor mental health services were notified prior to the resident experiencing a suspected overdose requiring Narcan.
A resident reported theft of personal funds after being transferred to a new room without being provided a lock box to secure valuables. The resident kept money unsecured in a drawer, and the DON confirmed that the lock box was not present in the new room, leading to the loss.
Facility staff failed to provide written notice and required documentation to two residents and their representatives during transfers to a hospital, including missing information about the transfer, lack of communication to the receiving institution, and absence of discharge and bed-hold policy notifications. The DON confirmed that only minimal documentation existed for these transfers.
The facility did not develop individualized care plans for residents with SUD, as evidenced by three cases where residents experienced unresponsiveness and required Narcan administration. Care plans lacked documentation of SUD-specific interventions such as group meetings, 1:1 support, and mental health services, despite residents' participation in these activities. Facility leadership did not provide explanations for these omissions.
The facility failed to intervene when a resident with a history of substance use disorder showed signs of relapse, including refusing Suboxone and being found unresponsive, without notifying mental health or the physician. Additionally, another resident admitted with multiple injuries did not have hospital wound care instructions implemented or documented, and the care plan did not address surgical wounds. These deficiencies were confirmed through record review and staff interviews.
The facility failed to consistently document and administer pain medications as ordered, did not provide adequate parameters for PRN pain medications, and did not ensure pain assessments or non-pharmacological interventions were completed prior to administering narcotics. Several residents with significant pain were affected, with missing documentation of pain levels, medication effectiveness, and appropriate interventions.
A deficiency occurred when a radiology report indicating a femoral neck fracture was not promptly reviewed or acted upon by the attending physician after being received by the facility. The delay in physician follow-up extended from the evening the report was received until midday the next day, despite recommendations for further imaging.
Facility staff did not ensure that a resident's court-appointed guardian was contacted, educated, or given the opportunity to consent or decline a COVID-19 vaccine booster, as required. Documentation only reflected the resident's refusal, despite the resident being unable to make decisions, and did not indicate guardian involvement.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. The lack of appropriate behavioral health care and services was directly related to the facility's inaction in assessing, planning, or delivering the necessary interventions for residents with behavioral health needs.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process to identify, review, and address quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
Failure to Assess Residents for Self-Administration of Medication
Penalty
Summary
Surveyors observed that the facility failed to assess residents for their ability to self-administer medications. During a tour of one unit, surveyors found medication cups containing multiple pills left at the bedsides of two residents. In one instance, a medication cup with seven pills was found on a bedside table, and the resident explained that the nurse left the medication there because the resident needed to use the bathroom. The resident then took the medication in the presence of the LPN. In another instance, a resident was found with a medication cup containing six pills at the bedside and stated they had been distracted and would take the medication now. Interviews with LPNs revealed that medications were given to residents and they were supposed to be watched while taking them, but no narcotics were left at the bedside. Review of the medical records for both residents showed they were cognitively intact and able to make their own medical decisions, but there was no documented assessment or evaluation in the records to determine their ability to self-administer medication without nursing supervision.
Failure to Notify Physician of Medication Refusals in Resident with Substance Use Disorder
Penalty
Summary
Facility staff failed to notify the attending physician when a resident was refusing prescribed Suboxone, a medication used as part of substance use disorder treatment. The resident, who was admitted for a minimum six-week course of intravenous antibiotics due to septic wounds and endocarditis suspected to be related to drug use, refused nine doses of Suboxone in January and five of eight doses in February. Despite these refusals, there was no documentation that the physician was informed of the missed doses. Additionally, after a note was made by a physician indicating the resident appeared high, there was no report to mental health services or a multidisciplinary meeting prior to the resident experiencing a suspected overdose that required Narcan administration. Interviews with facility staff confirmed that neither the physician nor mental health services were notified of the medication refusals or the concerning behavior prior to the overdose incident.
Failure to Provide Secure Storage for Resident Valuables After Room Transfer
Penalty
Summary
A deficiency was identified when a resident reported that $110.00 was stolen from their room. The facility's records indicated that the resident had previously been provided with a lock box to secure valuables. However, after being transferred to a new room, the resident did not have access to a lock box and was keeping valuables unsecured in a drawer. During an interview, the resident confirmed the absence of a lock box in the new room, and the DON acknowledged that the lock box had not been provided following the room transfer. This failure to provide a means for the resident to secure their valuables resulted in the misappropriation of the resident's personal funds.
Failure to Provide Required Transfer Documentation and Notifications
Penalty
Summary
Facility staff failed to provide written notice to a resident and their representative regarding a transfer to a local hospital for evaluation. Medical record review showed that the resident was treated for abnormal laboratory results by their primary provider, and nursing staff documented the resident's hospitalization the following day. However, there was no evidence in the medical record of documentation regarding the resident's change of condition or the transfer for treatment prior to the hospitalization. The Director of Nursing confirmed that nursing staff did not create or provide the required transfer documentation to the resident or their representative before the transfer occurred. Additionally, another resident's medical record indicated that the resident called 911 and was transported to the emergency room, but the record lacked documentation of the transfer location, reason for transfer, and required information provided to the receiving health care institution. There was also no evidence that the resident received a written discharge notice or information about the facility's bed hold and return policy. The record did not document the resident's orientation or physician notification. The Director of Nursing confirmed that the only documentation related to this hospital transfer was a nurse's note indicating the resident called 911, with no additional documentation available.
Failure to Individualize Care Plans for Residents with Substance Use Disorder
Penalty
Summary
The facility failed to develop and implement individualized care plans for residents with substance use disorder (SUD), as evidenced by medical record reviews of three residents. One resident with intact cognition and a diagnosis of SUD was found unresponsive and required emergency interventions including CPR, multiple doses of Narcan, and use of an AED. The care plan for this resident only included general monitoring and medication administration, omitting specific interventions such as participation in SUD group meetings, 1:1 support, and mental health or recovery services, despite the resident's involvement in these activities. There were also no documented notes from the social worker or evidence of interdisciplinary discussion regarding interventions in the quality assurance records. Another resident with SUD was found unresponsive in the courtyard and required Narcan administration before regaining consciousness. The care plan for this resident lacked documentation of SUD-specific interventions, such as group meetings or mental health services, even though the resident was receiving these services. A third resident with a history of opioid use and recent Narcan administration did not have an updated care plan reflecting behavioral health involvement, behavioral contracts, or references to SUD nurse practitioner visits or group participation. In all cases, interviews with facility leadership yielded no responses regarding the deficiencies in care planning.
Failure to Intervene for Substance Use and Address Hospital Wound Care Instructions
Penalty
Summary
The facility failed to provide appropriate interventions and care for two residents with significant medical needs. In the first case, a resident with a known history of substance use disorder was admitted following hospitalization for septic wounds and endocarditis related to suspected drug use. The resident had a central catheter and was prescribed Suboxone for opioid withdrawal, but repeatedly refused the medication. Staff documented that the resident appeared to be under the influence and was unavailable for medications and wound care on multiple occasions. Despite these observations and the resident later being found unresponsive and requiring Narcan administration, there was no evidence that mental health services were notified or that a multidisciplinary meeting occurred to address the relapse concerns. The physician was also not informed of the repeated Suboxone refusals. In the second case, another resident was admitted with multiple traumatic injuries and surgical wounds following a motor vehicle accident. The hospital discharge summary included specific instructions for wound care and follow-up appointments. However, the facility's admission assessment did not identify the presence or location of the surgical wounds, and there were no physician orders or documentation on the Treatment Administration Record (TAR) for wound care as outlined in the hospital instructions. The care plan addressed only the prevention of pressure ulcers and did not include the resident's surgical wounds or their care. The Director of Nursing confirmed that wound care orders should have been present upon admission, but no additional documentation was found. These deficiencies were identified through interviews, medical record reviews, and discussions with facility leadership, demonstrating failures to intervene appropriately for substance use concerns and to ensure continuity of care for surgical wounds as directed by hospital discharge instructions.
Failure to Provide Consistent and Documented Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for multiple residents, as evidenced by inconsistent documentation and administration of pain medications, lack of adequate medication parameters, and insufficient assessment and monitoring of pain. For one resident, Dilaudid (Hydromorphone) was ordered as needed for pain, but records showed that the medication was removed from the controlled lock box on several occasions without corresponding documentation in the Medication Administration Record (MAR) or evidence that the resident's pain level and the effectiveness of the medication were monitored. The Director of Nursing confirmed that staff did not ensure the medication was administered as ordered. Another resident with a history of dementia, chronic pain, and a previous hip fracture had orders for both Acetaminophen and Tramadol for pain, but the orders lacked clear parameters for when each medication should be used. Documentation showed that pain medications were administered without recording the location or source of pain, and there was no evidence that non-pharmacological interventions were attempted prior to giving narcotic pain medication. Pain assessments before and after medication administration were inconsistently documented, and the effectiveness of interventions was not always evaluated as required. A third resident experienced a right humeral fracture and was described as being in excruciating pain, but the MAR did not show that scheduled or as-needed pain medication was administered during the period of severe pain, except for a single dose. There was no documentation of further pain interventions prior to the resident's transfer to the emergency room, despite orders allowing for additional pain medication. These findings were confirmed through record review and interviews with facility leadership.
Delay in Physician Review of Radiology Report Following Resident Injury
Penalty
Summary
A deficiency was identified when the facility failed to ensure timely accessibility of a radiology report to the attending physician for a resident who sustained an injury of unknown origin. Medical record review showed that an x-ray was ordered and completed for the resident, revealing a right femoral neck fracture with a recommendation for further imaging. Although the radiology report was received by the facility in the evening, there was no documented response or follow-up by the attending physician until the following day at midday. The Director of Nursing was informed of these findings during the survey, and no additional information was provided regarding the delay in reviewing the x-ray report.
Failure to Obtain Guardian Consent for COVID-19 Vaccination
Penalty
Summary
Facility staff failed to ensure that the court-appointed guardian of a resident who was incapable of making decisions was provided with education and the opportunity to consent to or decline a COVID-19 vaccine booster on the resident's behalf. The resident's medical record confirmed the presence of a court-appointed guardian since 2017, yet the immunization record only showed electronic consent forms indicating that education was provided and the resident refused the vaccine. There was no documentation that the guardian was contacted, educated, or given the opportunity to provide or withhold consent for the vaccine. Interviews with facility staff, including the current and former Infection Preventionists (IPs), revealed that the established process required contacting the guardian, providing education, and obtaining consent or declination, either verbally or in writing. The electronic documentation system allowed for specifying whether the resident or guardian provided consent, but in this case, the records only reflected the resident's refusal, not the guardian's involvement. The Director of Nursing acknowledged that the electronic documentation did not reflect the required guardian contact.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Levindale Hebrew Ger Ctr & Hsp | 0.2 mi | — | 11 | 1 |
| Northwest Healthcare Center | 0.7 mi | — | 16 | 0 |
| Autumn Lake Healthcare At Arlington West | 1.3 mi | — | 0 | 0 |
| Roland Park Rehabilitation And Healthcare Center | 1.5 mi | — | 9 | 1 |
| Autumn Lake Healthcare At Alice Manor | 1.6 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.