Marley Neck Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Glen Burnie, Maryland.
- Location
- 7575 East Howard Road, Glen Burnie, Maryland 21060
- CMS Provider Number
- 215138
- Inspections on file
- 16
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Marley Neck Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
Staff failed to report an allegation of verbal abuse to the state agency after a resident emailed the Administrator and DON stating that two GNAs made comments about them while providing care and spoke as if the resident were not present. The email, sent during the night, was not seen or acted upon because the Administrator was out sick and the DON was away and then returning from vacation, and both reported they missed the message. As a result, the verbal abuse allegation was not reported as required, despite the facility’s stated practice of reporting abuse allegations promptly to the state and the Ombudsman.
A resident reported by email to the administrator and DON that two GNAs made comments about them as if they were not present while providing care. The administrator later acknowledged that the email was received but not reviewed because she was out sick and the DON was at a hearing, and both stated they missed the message. As a result, the resident’s allegation of verbal abuse was not addressed or investigated by facility staff.
A resident receiving Methadone and PRN Oxycodone for pain did not have a follow-up pain assessment documented after a PRN Oxycodone dose, and the follow-up pain score was later entered in the EHR by an LPN who had not administered the medication and had worked the prior shift. Facility staff interviews confirmed that standard practice is to document pre- and post-administration pain scores and to contact the provider if PRN pain medication is ineffective. In a separate event involving the same resident, documentation and a CRISP report showed that while the resident was in distress, their oxygen saturation dropped to 86%–87%, but oxygen therapy was not initiated, and the DON stated that the nurse did not recognize the decreased oxygen saturation despite contacting the provider.
Staff failed to ensure safe and appropriate wheelchair equipment for two residents. One resident requested footrests, but the Rehab Director reported difficulty finding compatible leg rests, relied on makeshift positioning of the resident’s legs on chairs during therapy, and had no documentation of efforts to obtain proper footrests beyond informal online searches. Another resident reported that their wheelchair brakes and armrest did not lock, causing them to feel unsafe during transfers to the commode; the Rehab Director acknowledged that wheelchairs were reused from other residents without a safety assessment, and that this wheelchair’s armrest mechanism and bent brake had not been properly evaluated before use.
Dietary staff used wet dome food covers during meal service, resulting in water dripping into plated meals for two residents, including one receiving pureed food. A surveyor observed a dietary aide placing dome covers with standing water over plates, leading to liquid in a pureed meal and on bacon and a plate, and also noted wet lids stacked near the tray line. In an interview, the aide reported assuming the lids were dry because they had been cleaned the previous night and was unaware they needed to be fully dry before use, as staff had only recently begun using the storage racks.
The facility failed to keep essential kitchen equipment in safe operating condition, leading to hot foods being served at improper temperatures. During lunch service, kitchen staff continued preparing trays after the last cart had left, and a test tray later showed ham, sweet potatoes, and collard greens all below appropriate hot-holding temperatures. A Certified Dietary Manager acknowledged the temperatures were not proper and reported that the plate warmer functioned correctly only briefly and that the pellet warmer, though initially reaching 135°F, cooled too quickly when taken out for use.
Facility staff failed to maintain a clean, safe, and well‑maintained kitchen environment, as evidenced by surveyor observations of different colored particles on the base of a food lid rack, copious black dust on the exhaust fan, and a detached front panel on a PTAC heat/air conditioning unit. The Maintenance Director reported reliance on a TELS app and scheduled inspections but acknowledged not identifying the observed issues during a recent kitchen inspection, while a Certified Dietary Manager stated that dietary staff are supposed to enter maintenance concerns into TELS but admitted seeing the problems and not reporting them due to being focused on other tasks.
Two residents did not receive timely assistance with incontinence care, as documented by GNA records and resident interviews. One resident was left in soiled briefs on multiple occasions, while another, who was cognitively intact, waited several hours for help after activating the call bell, but did not receive the needed care.
A resident with COPD and respiratory failure, who requires a CPAP machine for sleep apnea, did not consistently receive staff assistance to apply the device at night. The resident reported being unable to put on the CPAP independently and stated that staff did not always respond to call bell requests for help.
Surveyors found that food items in the kitchen and nutrition storage areas were not consistently labeled or dated after opening, including frozen omelets, seasoning, and a sandwich for a resident. Additionally, cold foods and beverages such as milk and juice were served above the required temperature, while hot foods like eggs and ham were served below the required temperature, contrary to facility policy. These deficiencies were acknowledged by the CDM and Administrator.
A resident did not receive all scheduled showers as required for ADL care, with documentation showing only 7 out of 13 scheduled showers were provided. Staff confirmed the resident was compliant and did not refuse care, and no reason was identified for the missed showers.
Two residents experienced unsafe transfers due to staff not following established care plans. One resident, requiring a two-person assist for bed mobility, was assisted by only one GNA and fell from the bed. Another resident, who needed a mechanical lift for transfers, was manually moved by a GNA without the lift, despite the resident's request and visible equipment. Both incidents involved staff not adhering to required protocols for safe resident handling.
A resident did not receive required nonpharmacological pain interventions prior to PRN pain medication administration, and PRN pain medication orders lacked specific pain parameters. Nursing staff did not document the use of nonpharmacological methods as required, and pain medication was given without clear guidance on pain levels, contrary to facility policy and professional standards.
A resident's discharge status was incorrectly coded on the MDS assessment as a transfer to an acute hospital, despite documentation and staff confirmation that the resident was discharged to an assisted living facility. The error was identified through record review and staff interviews.
Surveyors identified that care plans were not initiated for two residents receiving specific medications—one on antianxiety medication and another on anticoagulant therapy. Despite physician orders and ongoing administration of these medications, the facility did not develop or implement care plans to address these interventions until after the issue was raised during the survey. The DON confirmed the oversight following review and staff interviews.
A resident with foot drop and limited mobility did not receive the ordered application of a foot drop brace for contracture prevention. The brace was not in use for about a month, despite an active order, and staff were unaware of the order or any wounds on the resident's ankle. No documentation supported withholding the brace, and the brace was observed unused in the resident's room.
Two medication errors were observed when an LPN administered an incorrect dose of a nutritional supplement to one resident and only one puff of a prescribed inhaler instead of two to another resident. These errors resulted in a medication error rate above 5%, as confirmed by observation and MAR review.
Staff did not follow infection control protocols during medication administration, as an LPN failed to perform hand hygiene and did not disinfect shared medical equipment between use on two residents. Additionally, clothing intended for resident donations was stored uncovered in a dirty hallway, exposing it to contamination despite partial covering with blankets.
A resident was unable to activate the bathroom call system by pulling the cord after a fall, requiring them to manually operate the wall switch to alert staff. Surveyors and an LPN confirmed the pull cord was not functioning, while cords in other rooms worked as intended. The issue persisted during a follow-up observation, and audit records showed additional rooms with call device issues.
A resident, who was cognitively intact, reported being manually transferred from a wheelchair to a bed by a GNA without the use of a Hoyer lift, despite requesting it. The facility's investigation confirmed the incident but did not include interviews with other residents cared for by the same staff member, resulting in an incomplete investigation.
Failure to Report Resident’s Verbal Abuse Allegation to State Agency
Penalty
Summary
Facility staff failed to timely report an allegation of verbal abuse to the state agency after a resident complained that two GNAs spoke about them as if they were not present while providing care. During an interview, the resident stated they had emailed the Administrator and DON about the incident. The Administrator later confirmed that the resident had sent an email to both the Administrator and DON reporting that, during care the previous night, two GNAs were making comments about the resident. The email was sent in the early morning hours, but the Administrator stated she was out sick and the DON was at a hearing, and they missed the email and did not address the resident’s concerns. In a separate interview, the DON stated that the resident typically emailed or called when they needed to be changed and that she was not aware the resident had an issue with the GNAs because she had just returned from vacation and also missed the email. The DON reported that their usual practice is to report allegations of abuse immediately to the state within two hours and to the Ombudsman, but in this case the allegation of verbal abuse contained in the resident’s email was not reported to the state agency. This failure was identified in one of two abuse allegations reviewed during the complaint survey.
Failure to Investigate Resident’s Verbal Abuse Allegation Reported by Email
Penalty
Summary
Facility staff failed to investigate an allegation of verbal abuse after a resident reported that two Geriatric Nursing Assistants (GNAs) spoke about the resident as if they were not present while providing care. During an interview, the resident stated they had emailed Administrator #1 and DON #2 about this incident. Review of documentation showed the resident sent an email to both Administrator #1 and DON #2 reporting that, during care the previous night, GNA #16 and GNA #17 were making comments about the resident. Administrator #1 acknowledged receiving the email but stated she had been out sick and the DON was at a hearing, and that the email was missed and the resident’s concerns were not addressed. In a separate interview, the DON stated the resident typically emailed or called when they needed to be changed and that she was not aware the resident had an issue with the GNAs because the email had been missed. This failure to review and act on the resident’s email reporting staff comments during care resulted in the facility not responding appropriately to an alleged incident of verbal abuse, and no investigation of the allegation was initiated.
Failure to Document Pain Medication Effectiveness and Respond to Low Oxygen Saturation
Penalty
Summary
Facility staff failed to ensure that pain management services met professional standards for a resident receiving Methadone 10 mg PO BID and Oxycodone 10 mg PO q8h PRN. Review of the MAR showed that on 02/06 at 7:33 a.m., an LPN administered 10 mg of Oxycodone when the resident’s pain score was documented as 6, but there was no follow-up documentation in the EHR to verify whether the pain medication was effective. Interviews with an LPN and the DON confirmed that facility practice is to document pain scores before administration and a follow-up pain score 15–60 minutes after administration, and to contact the provider if the PRN medication is not effective. Further EHR review showed that a different LPN, who had worked the prior shift and had not administered the medication, documented the follow-up pain score for this dose, and the DON could not explain why this occurred. The facility also failed to meet professional standards in responding to a change in condition involving the same resident’s oxygen saturation. Review of the resident’s change in condition documentation and a CRISP report showed that while the resident was in distress, their oxygen saturation decreased to 86%–87%, but oxygen was not administered. The DON stated that during significant changes in condition, an in-house NP or on-call provider is notified for recommendations, and acknowledged that although the nurse contacted the provider, the nurse did not recognize the drop in oxygen saturation and that administering oxygen is a nursing judgment that was not exercised in this case.
Failure to Assess and Provide Safe Wheelchair Equipment
Penalty
Summary
Facility staff failed to ensure that residents received appropriate and safe wheelchair equipment in accordance with orders and resident preferences. For one resident, a concern form documented a request for footrests for the resident’s wheelchair. The Rehab Director reported difficulty finding leg rests that fit because the wheelchair prongs were wider than standard and the leg rests would not stay in place. The Rehab Director stated they tried modifications to keep the pieces together and that the resident’s legs were propped on chairs when their legs became tired during therapy. However, there was no documentation showing efforts to obtain appropriate footrests, and the Rehab Director acknowledged they were only searching online and had not contacted a supply company. For another resident, the resident reported that their wheelchair did not lock and that the armrest would not lock, and they verbalized feeling unsafe when transferring from the wheelchair to the commode. The Rehab Director stated that wheelchairs typically came from other residents and were turned over quickly, and acknowledged that this wheelchair had not been assessed for safety before being provided to the resident. The Rehab Director explained that the armrest release needed to be spun for the armrest to function properly and that the wheelchair brake appeared bent and had been bent back that morning. These observations and interviews showed that the facility did not assess wheelchair safety or ensure necessary equipment was available before use by the residents.
Wet Dome Food Covers Used During Meal Service
Penalty
Summary
Facility dietary staff failed to ensure dome food covers were dry before covering residents’ plated food, resulting in water dripping into meals during service. During a kitchen tour on 03/10/26 at 8:18 a.m., a surveyor observed a dietary aide placing dome food covers with visible standing water over the plated meals of Resident #6 and Resident #7. When the surveyor requested the covers be lifted, liquid was observed in Resident #6’s pureed food and on Resident #7’s bacon and plate. Wet dome-shaped food lids were also observed stacked on top of each other near the tray line. In a subsequent interview on 03/17/26 at 10:02 a.m., the dietary aide stated they believed the lids were already dry because they had been cleaned the night before and reported they were not aware the lids needed to be dry before use, noting that kitchen staff had only recently started using the racks. These observations and statements show that staff actions in using wet dome covers directly led to water contamination of plated food for at least two residents during meal preparation.
Failure to Maintain Kitchen Equipment Resulting in Improper Hot Food Temperatures
Penalty
Summary
The facility failed to maintain essential kitchen equipment in proper operating condition, resulting in hot foods not being held at appropriate temperatures during lunch service. On 03/11/26 at 11:43 a.m., the surveyor observed kitchen staff preparing lunch trays, with the last cart leaving the kitchen at 12:25 p.m., after which staff continued to prepare additional lunch trays that could not be placed in the cart due to lack of space. A test tray was prepared for the surveyor, and at 1:00 p.m. the surveyor measured the temperatures of the foods on a regular tray, finding the ham at 118.8°F, sweet potatoes at 121.3°F, and collard greens at 120.9°F, all below proper hot-holding temperatures. During an interview on 03/17/26 at 10:51 a.m., the Certified Dietary Manager acknowledged that none of the recorded temperatures were proper and reported that an electrician had been called to repair the plate warmer and pellet warmer; the plate warmer only worked properly for about an hour, and the pellet warmer initially read 135°F but cooled too quickly when pulled out for use.
Failure to Maintain Clean and Safe Kitchen Environment
Penalty
Summary
Facility staff failed to maintain a safe and sanitary environment in the kitchen area, as observed during a complaint survey. A surveyor noted different colored particles on the base of the food lid rack, copious black dust on the exhaust fan, and a detached front panel on the PTAC heat/air conditioning unit. These conditions were present in an area used for food service and environmental control, indicating that the kitchen environment was not being kept clean, intact, and in good repair for residents, staff, and the public. During interviews, the Maintenance Director stated that the facility uses an app called TELS for staff to submit maintenance concerns and that there is a monthly and weekly preventative maintenance schedule within TELS, with the kitchen typically coming up every month. The Maintenance Director reported that the kitchen had been inspected earlier in the week but he did not notice the detached PTAC front panel and stated that the exhaust fan was usually cleaned about once a month, and that maintenance would assume responsibility for cleaning the tray table rack, which had previously been cleaned by kitchen staff. The Certified Dietary Manager reported that dietary staff are supposed to enter maintenance issues into TELS using a computer in the office and acknowledged seeing the issues in the kitchen but being focused on something else, resulting in the issues not being reported or addressed.
Failure to Provide Timely Incontinence Care to Residents
Penalty
Summary
The facility failed to provide timely care and assistance with activities of daily living for two residents who were unable to do so themselves. One resident was left on multiple occasions with stool and urine in their brief, as documented on GNA records for both day and night shifts, with specific dates noted where no changes were recorded. Another resident, who was alert, oriented, and able to communicate needs, reported activating the call bell for assistance with changing, but after a GNA responded and stated they would return, no further assistance was provided, resulting in the call light remaining on for several hours without the resident being changed. These findings were based on incident reports, record reviews, and interviews with staff and residents, confirming that the facility did not consistently meet the needs of residents requiring assistance with incontinence care.
Failure to Provide Consistent CPAP Assistance
Penalty
Summary
A deficiency was identified when a resident with a history of COPD and respiratory failure, who had been ordered a CPAP machine for sleep apnea, did not consistently receive assistance to use the device as required. The resident, who is alert, oriented, and able to communicate needs, reported being unable to independently apply the CPAP machine and stated that assistance was not always provided when requested via the call bell. Medical chart review and interview confirmed that the CPAP was not placed on the resident every night as ordered.
Deficient Food Storage and Temperature Control Practices
Penalty
Summary
Surveyors identified multiple failures in food storage and handling practices within the facility's kitchen and nutrition storage areas. During an initial kitchen tour, frozen omelets were found in an open, unlabeled, and undated plastic bag in the freezer, and an opened container of Tajín seasoning was also found unlabeled and undated. Additionally, a sandwich in a Ziplock bag labeled with a resident's name was observed in the refrigerator without a date. The Certified Dietary Manager (CDM) confirmed that facility policy requires all opened and stored food items to be labeled with the date and, for resident food, with the resident's name and date of placement. These findings were acknowledged by the CDM and the Administrator. Further observations during breakfast service revealed that cold food items, such as milk and orange juice, were served at temperatures above the required 41 degrees Fahrenheit, with recorded temperatures of 49 and 50.5 degrees Fahrenheit, respectively. Hot food items, including fried eggs and hot ham, were found at temperatures below the required 135 degrees Fahrenheit, with readings as low as 126 degrees Fahrenheit. Facility policy explicitly requires cold foods and beverages to be maintained at 41 degrees Fahrenheit or below and hot foods at 135 degrees Fahrenheit or above. These temperature violations were confirmed by the CDM and Administrator during on-site observations.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident was provided scheduled showers as required for activities of daily living (ADL). Record review showed that the resident was scheduled to receive showers on Tuesdays and Fridays during the day shift, with a total of 13 opportunities for showers since admission. However, documentation indicated that the resident only received 7 out of the 13 scheduled showers during this period. There was no documentation or staff report indicating that the resident refused care or showers on the missed dates. Interviews with facility staff, including the Geriatric Nursing Assistant (GNA) who routinely cared for the resident, confirmed that the resident was compliant with care and did not refuse showers when offered. The GNA was unaware of any reason for the missed showers. The deficiency was identified during a re-certification survey following a complaint that the resident did not receive routine showers.
Failure to Provide Safe Transfers and Adequate Supervision
Penalty
Summary
The facility failed to provide safe transfer and adequate supervision for two residents, resulting in accident hazards. In the first incident, a resident who required a two-person assist for bed mobility, as documented in the Minimum Data Set (MDS) and care plan, was being changed by a single Geriatric Nursing Assistant (GNA). During the process, the resident rolled toward the GNA and slid off the bed. The GNA was unable to return the resident to the bed alone and had to call for assistance. The Director of Nursing confirmed that protocol was not followed, as the resident's care plan required two staff members for such assistance. In the second incident, another resident, who was care planned for mechanical lift transfers, was manually transferred from a wheelchair to a bed by a GNA without the use of a Hoyer lift. The resident reported the transfer was rough and that their request for the Hoyer lift was not honored. The GNA admitted to not checking the care plan and transferring the resident manually despite seeing the Hoyer pad. The facility's investigation substantiated the failure to follow the resident's care plan and transfer protocol.
Failure to Implement Nonpharmacological Pain Interventions and Specify PRN Pain Parameters
Penalty
Summary
The facility failed to implement nonpharmacological interventions for pain management and did not ensure that pain medications were administered according to professional standards of practice for one resident reviewed. Record review showed that the resident had active physician orders for PRN Oxycodone and Acetaminophen for pain, as well as orders and care plan interventions specifying the use of nonpharmacological methods such as repositioning, distraction, activity involvement, and other comfort measures prior to administering PRN pain medication. However, documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not show evidence that these nonpharmacological interventions were implemented or recorded as required. Additionally, the PRN pain medication orders for the resident did not include specific pain parameters to guide nursing staff on when to administer each medication based on the resident's pain level. Interviews with nursing staff and the DON confirmed that pain parameters were missing from the orders and that nonpharmacological interventions were not documented prior to medication administration. The facility's pain management policy required the use of appropriate pain scales and documentation of both pharmacological and nonpharmacological treatments, but these standards were not met in this case.
Incorrect Coding of Discharge Status on MDS Assessment
Penalty
Summary
The facility failed to accurately code a resident's discharge status on the Discharge Minimum Data Set (MDS) assessment. Specifically, a review of medical records showed that a resident was discharged to an Assisted Living Facility (ALF), as documented in the nurse's note, discharge summary by the nurse practitioner, social services note, and physician's order. However, the MDS Discharge Return Not Anticipated (DCRNA) assessment incorrectly coded the discharge status as a transfer to a short-term general hospital (acute hospital) instead of to the community/ALF. Interviews with facility staff confirmed the error. The social worker verified that the resident was discharged to an ALF and described the process for communicating discharge status changes to the interdisciplinary team. The MDS coordinator also acknowledged the resident was discharged to an ALF and that the discharge assessment should have reflected this. The Director of Nursing was notified of the concern.
Failure to Initiate Medication-Related Care Plans for Two Residents
Penalty
Summary
The facility failed to initiate care plans based on medication use for two residents during a recertification survey. For one resident, a physician order for busPIRone HCl 5 mg oral tablet to be administered every 8 hours for anxiety was present in the medical record, but no care plan addressing the use of antianxiety medication was initiated. The Director of Nursing (DON) confirmed that the care plan had not been started and acknowledged the oversight after being informed by the surveyor. The resident had a history of frequent admissions and discharges, but this was not documented as a reason for the lack of a care plan. Another resident was receiving Eliquis (Apixaban) 5 mg twice daily for deep vein thrombosis (DVT) as ordered by a physician, but there was no care plan in place to address the anticoagulant therapy. The DON confirmed that a care plan for anticoagulant therapy had not been initiated for this resident and acknowledged the concern when brought to her attention by the surveyor. Both deficiencies were identified through medical record review and staff interviews, indicating a failure to ensure care plans were developed and implemented for residents receiving specific medications.
Failure to Apply Ordered Foot Drop Brace for Contracture Prevention
Penalty
Summary
A deficiency was identified when a resident with a history of foot drop and limited mobility did not receive the ordered application of a foot drop brace (Ankle-Foot Orthosis, AFO) for contracture prevention. The resident reported not having worn the brace for about a month, and observations confirmed the brace was not in use, despite being present in the room. The resident's medical record included an active order for the brace to be worn at bedtime and removed in the morning, with skin checks at each application and removal. However, a new order to hold the brace due to impaired skin integrity was only placed recently, and there was no documentation of a wound or change in condition on the resident's left ankle prior to this order. Interviews with facility staff revealed a lack of awareness regarding the resident's need for the brace and the presence of any wounds on the ankle. The Rehab Director stated that the brace was withheld due to a supposed ankle wound, but no such wound was documented in the medical record or observed during a physical assessment. Additionally, the LPN responsible for the resident was unaware of the brace order and only knew of a sacral wound, not an ankle wound. The administrator was informed of the concern that the resident had not been wearing the ordered brace and that staff were not aware of the order.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors observed during medication administration for two out of six residents. Specifically, an LPN administered an incorrect dose of a nutritional supplement to one resident by providing 8 ounces instead of the prescribed 6 ounces. The LPN was unsure of the correct measurement method and used a plastic cup that held more than the ordered amount. This error was confirmed through observation and review of the resident's Medication Administration Record (MAR), which specified the correct dose. Additionally, the same LPN administered only one puff of Spiriva Respimat Inhalation Aerosol Solution to another resident, despite the order requiring two puffs for COPD management. The LPN acknowledged the error during an interview and confirmed understanding of the correct procedure. Review of the MAR corroborated that the order was for two inhalations. These two errors resulted in a medication error rate of 5.3% (2 errors out of 38 opportunities), exceeding the acceptable threshold.
Failure to Follow Infection Control Protocols During Medication Administration and Laundry Services
Penalty
Summary
The facility failed to ensure staff adherence to infection control protocols during medication administration and laundry services. During medication administration, an LPN was observed not performing hand hygiene before entering the rooms of two residents to administer medications. Additionally, the LPN did not disinfect shared medical equipment, specifically a blood pressure cuff and a pulse oximeter probe, between use on the two residents. The LPN acknowledged these lapses in infection control practices during an interview with the surveyor. In the laundry area, clothing intended for resident donations was found hanging on a rack in a dirty hallway, exposing the items to potential contamination. Although an attempt was made to cover the clothing with blankets, the items remained partially exposed and at risk for contamination due to the unclean environment. The Account Manager confirmed the clothing was for residents and understood the concern after it was explained by the surveyor.
Non-Functioning Bathroom Call System Identified During Survey
Penalty
Summary
A deficiency was identified when a resident reported falling in the bathroom and being unable to activate the call system by pulling the cord, as the cord was stuck and not functioning. The resident had to yell and physically maneuver to the wall switch to activate the call bell. During observation, the surveyor confirmed that the bathroom call cord was not working as intended; pulling the cord did not activate the call light, and the switch had to be manually slid to trigger the alert. The cord was observed to be hanging approximately 2 inches from the floor, with the switch located 40 inches from the floor. Additional testing by an LPN confirmed that the call cord in this bathroom was not functional, while cords in other rooms worked properly. The deficiency was further substantiated when the Nursing Home Administrator was unable to activate the call light by pulling the cord and acknowledged the malfunction. Despite being informed of the issue, a follow-up observation two days later revealed that the call cord was still not functioning. Audit records reviewed during the survey also indicated that other rooms had call devices with missing batteries, which were subsequently replaced. The ongoing malfunction of the bathroom call system in the resident's room was confirmed by both the surveyor and facility staff.
Failure to Thoroughly Investigate Resident Transfer Incident
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact with a BIMS score of 13 out of 15, reported being transferred from a wheelchair to a bed by a Geriatric Nurse Assistant (GNA) without the use of a Hoyer lift, despite the resident's request for mechanical assistance. The incident was corroborated by another resident's statement, confirming that the transfer was performed manually and not in accordance with the resident's care plan or preferences. The facility's investigation into the incident included obtaining statements from the involved staff, the victim, and witnesses. However, the investigation was incomplete as it did not include interviews with other residents who had been under the care of the alleged perpetrator. The facility substantiated the failure to honor the resident's request for a Hoyer lift but did not fully explore the potential scope of the issue by omitting interviews with additional residents.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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