Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Complete Care At Heritage Llc during CMS and state inspections, most recent first.
Staff failed to accurately code multiple MDS assessments, leading to missing and incorrect entries for medications, falls, behaviors, and treatments. Anticonvulsant and antianxiety medications documented on MARs were not captured in the high-risk drug classes section for several residents, while one resident was incorrectly coded as receiving hypoglycemic medication despite no such orders. A resident’s documented fall was not coded in the falls section, and another resident’s oxygen therapy was omitted from the special treatments section while hospice services and limited life expectancy were incorrectly coded without supporting documentation. In addition, a resident with clearly documented aggressive and combative behaviors was coded as having no physical or verbal behavioral symptoms on the MDS.
A resident who was alert and oriented reported that a nurse repeatedly entered the room despite the resident’s request to keep the door closed and to stop coming in. A GNA accompanied the resident back to the room and informed an LPN of the resident’s wishes, but the LPN stated he did not care and entered anyway to give meds to the roommate. The resident continued to ask the LPN to leave, the situation escalated into yelling, and both the resident and the LPN used expletive language. The LPN told the resident to hit him, stated the resident would not do anything, and threatened to beat the resident, which was witnessed and later confirmed as verbal abuse by supervisory staff and the administrator.
A resident who was alert, oriented, and able to express needs had standing orders for showers on specific days but, over a two‑month period, received only bed baths instead of the ordered showers. The resident and the responsible party both reported that no showers had been provided during this time, and facility documentation confirmed only bed baths with one documented refusal related to diarrhea. The resident was agreeable to occasional bed baths but expected to be offered showers on scheduled shower days, which did not occur.
A resident with acute prostatitis did not receive IV antibiotics as ordered by the physician. Hospital discharge instructions included daily Ertapenem through the end of the month, but the final scheduled dose was not administered according to the MAR. The antibiotic regimen was later changed to Meropenem every 8 hours, and a scheduled evening dose was also not documented as given. The DON confirmed that staff failed to administer these ordered antibiotic doses.
Two residents did not receive respiratory care in accordance with professional standards. One resident with obstructive sleep apnea had a hospital discharge summary directing continuation of BiPAP for sleep, but BiPAP was neither ordered nor documented as administered for the first three nights after admission. Another resident with COPD, asthma, chronic myeloid leukemia, and a history of acute on chronic hypoxic hypercapnic respiratory failure had intermittent oxygen use documented in vital signs, yet there were no physician orders for oxygen therapy, tubing changes, humidification, O2 saturation goals, or basic oxygen care, despite facility policy requiring a provider order specifying liter flow and delivery device; the DON confirmed the absence of related documentation on the MAR and TAR.
Facility staff did not provide necessary personal hygiene and bathing assistance to two totally dependent residents. One resident was found with neglected toenail care, and another had no documented showers or bed baths for several months, despite being fully dependent due to significant physical limitations. Documentation and staff interviews confirmed the lack of provided care and incomplete records.
Two residents experienced significant delays in receiving prescribed medications and wound care treatments. One resident's medications were repeatedly administered several hours late, primarily due to short staffing and reliance on agency staff, as confirmed by MAR review and staff interviews. Another resident did not receive wound care or IV antibiotics until days after admission, with no documentation of earlier treatment. Facility leadership acknowledged the lack of timely care and absence of supporting documentation.
A resident who was alert and oriented experienced severe, unrelieved pain for several hours without timely assessment or administration of pain medication. Although pain medications were reportedly ordered and administered, there was no documentation in the MAR to support this, and no pain assessment was recorded. Staff interviews confirmed that pain management and documentation protocols were not followed, resulting in a significant delay in addressing the resident's pain before hospital transfer.
A nurse, unfamiliar with the facility and distracted during medication pass, administered Methadone to a resident instead of the prescribed Methylphenidate by failing to verify the medication name, dose, and form. The nurse did not follow the five rights of medication administration, and the error was only discovered after the medication was given. The resident was later found unresponsive and the incident was reported to the Medical Examiner.
Inaccurate MDS Coding for Medications, Falls, Behaviors, and Treatments
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, resulting in omissions and inaccuracies in several MDS sections. For one resident receiving Gabapentin every eight hours for neuropathy, the anticonvulsant was not captured in Section N0415 (High-Risk Drug Classes) on two separate MDS assessments. Another resident experienced a documented fall, noted in the medical record as being found on the floor in a sitting position, but this fall was not coded in Section J1800 (any falls since admission/entry or prior assessment). A third resident had hypoglycemic medication use coded in Section N0415, despite the November MAR showing no hypoglycemic medications administered during that period. Additional inaccuracies were identified for a resident who received Lorazepam, an antianxiety medication, which was not captured in Section N0415 on a discharge MDS, and whose use of oxygen via nasal cannula was not coded in Section O (Special Treatments, Procedures, and Programs). The same resident was incorrectly coded in Section O as receiving hospice services and in Section J1400 as having a condition with a life expectancy of less than six months, despite no documentation supporting hospice services or such a prognosis. Another resident with documented aggressive and combative behavior, including agitation, psychosis, throwing objects at staff, and destroying property, was coded as having no physical or verbal behavioral symptoms in Section E0200. This resident was also receiving Gabapentin three times per day per the MAR, but the anticonvulsant was not captured in Section N0415. The MDS Coordinator confirmed these errors and noted that other staff had been filling in on MDS assessments during the primary coordinator’s leave.
Failure to Protect Resident From Verbal Abuse by Nursing Staff
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse by a staff member. An alert and oriented resident, admitted in 2025, approached the nursing station and reported that a nurse kept entering the resident’s room despite the resident’s request to keep the door closed and to stop coming into the room. A geriatric nursing assistant accompanied the resident back to the room and informed the nurse of the resident’s request. The nurse stated he did not care and entered the room anyway, stating he needed to administer medications to the roommate. The resident repeatedly told the nurse to leave the room, but the nurse refused, leading the resident to begin yelling. The geriatric nursing assistant reported that the situation became heated, with the nurse and the resident speaking to each other “like they were on the streets” and both using expletive language. The nurse told the resident to hit him and stated that the resident was not going to do anything, and that he would “beat the [expletive]” out of the resident. The nursing supervisor, after being notified by the geriatric nursing assistant, went to the scene and personally heard the nurse threaten to beat the resident. The supervisor stated that the nurse was being abusive and that he was afraid the situation was going to become physical. The facility’s administrator later confirmed that the facility substantiated verbal abuse of the resident by the nurse.
Failure to Provide Ordered Showers and Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to provide showers as ordered for a resident who required assistance with activities of daily living (ADLs). The resident had physician orders to receive showers on Tuesdays and Fridays during January and February 2026, but interviews and record review showed that these ordered showers were not provided. On 2/20/26, the resident’s responsible party reported that the resident had not received a shower in the prior two months, and the resident, who was alert, oriented, and able to express needs, confirmed not having had a shower during that period and expressed a desire for one. Documentation in the treatment and GNA records showed that the resident had only received bed baths, with one documented refusal of a shower/bed bath on a single occasion due to diarrhea, and there was no documentation that showers were offered on the scheduled shower days as ordered. The resident stated they were not opposed to receiving a bed bath occasionally but expected to be offered a shower on designated shower days rather than being given only bed baths. The surveyor’s review of records corroborated that showers were not provided in accordance with the care plan and orders for the months reviewed, and that the resident’s preference for showers on scheduled days was not honored, except for the one documented refusal related to diarrhea.
Failure to Administer Ordered IV Antibiotics as Prescribed
Penalty
Summary
Facility staff failed to administer ordered IV antibiotics as prescribed for a resident with acute prostatitis. The resident was admitted in December 2025 with a diagnosis including acute prostatitis, and the hospital discharge summary ordered Ertapenem 1 gm IV daily through 1/30/26. Review of the January 2026 Medication Administration Record showed the resident did not receive the ordered Ertapenem dose on 1/30/26. The resident’s antibiotic regimen was later changed by the physician to Meropenem 2 gm IV every 8 hours on 2/4/26. Review of the February 2026 Medication Administration Record revealed no evidence that the resident received the scheduled Meropenem dose on 2/15/26 at 10:00 PM. In an interview on 2/25/26 at 8:30 AM, the Director of Nursing confirmed that facility staff failed to administer the ordered antibiotic medications on both 1/30/26 and 2/15/26.
Failure to Provide Ordered BiPAP and Properly Order/Document Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services in accordance with professional standards of practice for two residents who required such care. One resident was admitted with a diagnosis that included obstructive sleep apnea and had a hospital discharge summary directing continuation of BiPAP for sleep. Review of the resident’s December Treatment Administration Record showed that the BiPAP was not ordered or documented as administered until three days after admission, resulting in three nights without the prescribed BiPAP therapy. In an interview, the Administrator confirmed that facility staff did not administer the resident’s BiPAP during those three nights following admission. For another resident, admitted with COPD, asthma, and chronic myeloid leukemia, the medical record documented use of oxygen at 3 LPM via nasal cannula and a history and physical noting acute on chronic hypoxic hypercapnic respiratory failure, COPD, asthma, and home oxygen use of 2–3 liters, as well as recent community-acquired pneumonia and acute hypoxic respiratory failure while hospitalized prior to admission. The vital sign section of the electronic medical record showed intermittent use of oxygen; however, review of the December and January physician’s orders revealed no orders for oxygen therapy, tubing changes, humidification, oxygen saturation goals, or basic care related to oxygen therapy. The facility’s oxygen therapy policy required verification of a medical doctor order including liter flow and type of O2 delivery device. During an interview, the DON confirmed that the MAR and TAR contained no documentation of oxygen usage, tubing changes, or humidification for this resident.
Failure to Provide Personal Hygiene and Bathing Assistance to Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary personal hygiene services to residents who were totally dependent on staff for activities of daily living (ADL). In one instance, a resident was observed to have long, yellowed, thickened, and misshapen toenails, with one toenail having fallen off. The resident’s Minimum Data Set (MDS) indicated total dependence on staff for personal hygiene. Interviews with staff revealed that toenail care was the responsibility of nurses or podiatry, but the resident had not been seen by podiatry until after the surveyor’s intervention, indicating a lack of timely care. Another resident, who was dependent for all ADLs due to diagnoses including muscular dystrophy and Friedreich ataxia, was reported by a family member to have not received a shower in years and to have a layer of filth on their head. Review of the resident’s medical record and facility documentation showed no evidence of showers or bed baths being provided over several months. The facility’s documentation systems, including Point of Care (POC) and paper shower sheets, lacked records of bathing or showering for this resident, except for two instances where refusal was documented. Staff interviews confirmed that showers were scheduled and assigned, but documentation was incomplete or missing. Both residents had care plans indicating total dependence on staff for personal hygiene and bathing, with goals for their ADL needs to be met. However, the lack of documented care and observations of poor hygiene demonstrated that the facility did not provide the required assistance with personal hygiene and bathing for these dependent residents.
Delayed Medication and Wound Care Administration
Penalty
Summary
The facility failed to provide timely medication administration and wound care treatment to two residents, as identified during a recertification and complaint survey. For one resident, multiple medications were administered 2-4 hours late on various days throughout the month, as confirmed by a review of the Medication Administration Records (MAR). The resident attributed the delays to agency staff frequently used by the facility, and a registered nurse confirmed that short staffing and lack of medication aides were common reasons for late medication passes. The Director of Nursing acknowledged awareness of the issue and stated that medication times had been adjusted in an attempt to address the problem, but late administration persisted. Another resident experienced a delay in wound care and IV antibiotic administration following admission. The wound treatment order was not placed until two days after admission, and there was no documentation of wound care prior to that order. Additionally, the resident's IV antibiotic, vancomycin, was ordered a day after admission, with the first dose administered later that day, and no evidence of earlier administration. Both the Director of Nursing and the Nursing Home Administrator confirmed there were no additional orders or documentation to support earlier treatment or medication administration.
Failure to Provide Timely Pain Management and Documentation
Penalty
Summary
A deficiency was identified when a resident experienced severe, unrelieved pain for an extended period without timely assessment or intervention. The resident, who was alert and oriented with a BIMS score of 15/15, began experiencing severe bilateral leg pain, rated at 10/10, starting in the evening and continuing into the following morning. Despite the resident's ongoing complaints and visible distress, there was no documented pain assessment or administration of pain medication during this time. Progress notes later indicated that pain medications and a lidocaine patch were ordered and reportedly administered, but the Medication Administration Record (MAR) did not reflect any such administration on the date in question. Staff interviews revealed that pain assessments are expected to be conducted every shift, and the DON confirmed that pain should be managed immediately with all interventions documented in the MAR. However, there was a five-hour gap between the initial documentation of severe pain and the resident's transfer to the hospital, during which no pain assessment or medication administration was documented. This failure to provide timely pain management and proper documentation constituted the identified deficiency.
Significant Medication Error: Methadone Administered Instead of Methylphenidate
Penalty
Summary
A significant medication error occurred when a registered nurse (RN), who was working their first shift at the facility as an agency nurse, administered Methadone to a resident instead of the prescribed Methylphenidate. The resident had been admitted with diagnoses including narcolepsy, muscle weakness, and recurrent falls, and was scheduled for discharge. The error happened when the RN, while administering medications, saw the letters 'M-E-T-H' on the medication administration record and assumed the medication was Methadone, without verifying the medication name, dosage, or form. The RN did not compare the medication pulled from the cart to the resident's medication administration record, did not confirm the medication, and did not check if the medication was in the correct form, resulting in the administration of a liquid Methadone dose instead of the prescribed tablet form of Methylphenidate. After realizing the error about an hour later, the RN assessed the resident, found them to be sleepy but with stable vital signs, and reported the incident to the nursing supervisor. The supervisor instructed the RN on documentation, contacting the on-call physician, and notifying the resident's family. The on-call provider was informed but was unable to obtain critical information from the RN, such as the resident's name, date of birth, and the exact dose of Methadone administered. The provider was told that the Methadone had been intended for another resident who was not currently admitted, and the RN could not locate the empty bottle or confirm the dose given. The provider relied on the RN's report that the resident was stable and did not recommend hospital transfer at that time. The RN admitted to not following the five rights of medication administration and reported being heavily distracted during the medication pass. The resident was found pulseless and without respirations by nursing staff later that evening, and the death was reported to the Medical Examiner's office. The facility's failure to ensure the resident was free from significant medication errors resulted in the identification of an Immediate Jeopardy situation by the Maryland Office of Health Care Quality.
Removal Plan
- Education of all nurses on medication administration with focus on the six-rights medication administration, opioid management, signs of opioid overdose, and in-house escalation protocol.
- Medicine Pass evaluations and competencies will be completed for all licensed nurses. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee's personnel file.
- Staff will be quizzed on their understanding of the opioid overdose management policy post education. The quizzes will cover key topics, including recognizing the signs and symptoms of opioid overdose, appropriate response protocols, and steps for escalation. Results will be reviewed, and any areas of concern will be addressed through additional training or clarification.
- Nursing staff will be quizzed on their understanding of the medication administration policy post education. The quiz will focus on the rights of medication administration. Any knowledge gaps identified will be addressed through additional training and support.
- Ongoing monthly medication evaluations will be conducted for all licensed nurses and Certified Medicine Aides by DON/designee. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee's personnel file.
- The results will be reported by the DON to the Quality Assurance Performance Improvement Committee until 100% compliance is achieved.
What surveyors are citing around you — mapped
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dundalk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Future Care Northpoint | 1 mi | — | 1 | 0 |
| Future Care Canton Harbor | 2.9 mi | — | 7 | 0 |
| Autumn Lake Healthcare Post-acute Care Center | 3.4 mi | — | 26 | 0 |
| Autumn Lake Healthcare At Riverview | 3.6 mi | — | 5 | 0 |
| Rossville Rehabilitation And Healthcare Center | 4.5 mi | — | 25 | 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.