Lorien Nursing & Rehab Ctr - Elkridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkridge, Maryland.
- Location
- 7615 Washington Boulevard, Elkridge, Maryland 21075
- CMS Provider Number
- 215357
- Inspections on file
- 18
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Lorien Nursing & Rehab Ctr - Elkridge during CMS and state inspections, most recent first.
A resident’s family member reported that a GNA told her that residents and their representatives were not allowed to speak directly with state surveyors who were on site. Instead of bringing the family member to a surveyor, the GNA provided contact information for the state oversight agency to file a complaint. The family member subsequently filed a complaint, and record review confirmed the complaint submission, demonstrating that the resident’s representative was discouraged from and not permitted to communicate directly with surveyors.
A resident with hemiplegia, muscle weakness, impaired coordination, and documented need for one-person assistance with transfers and partial to moderate assistance for toilet transfers experienced prolonged delays in call bell response when requesting toileting help. The resident reported long waits, attempted to toilet without assistance, and had multiple falls. Review of call bell logs showed several response times exceeding the facility’s stated 20-minute expectation, including one response over 24 minutes. A GNA reported inadequate staffing to meet care needs, and the resident’s family reported new episodes of incontinence since admission, which they associated with prolonged call bell response times.
Facility staff did not conduct an investigation after a resident's family reported missing personal items, including a puzzle and an electronic sound amplifier device. The resident's medical record lacked an inventory sheet for these items, and the DON confirmed that no investigation was performed.
Nursing staff did not document ADL care for a resident on three separate shifts, as confirmed by the DON during a complaint survey. This lack of documentation was identified after a family complaint regarding care and the development of a preventable wound.
A resident with left-sided hemiparesis, requiring total care, fell from bed during ADL care due to inadequate assistance, resulting in a humeral neck fracture and hematoma. Despite care plans indicating the need for two-person assistance, a GNA attempted care alone, leading to the incident. Subsequent evaluations revealed the extent of injuries, and staff interviews confirmed the resident's dependency on two-person support for ADL care.
A resident with one-sided impairment and dependent on staff for toileting reported long wait times for call bell responses over a weekend. The facility's policy requires call bells to be answered within 20 minutes, but logs showed delays of 28 and 55 minutes. The Second Floor Supervisor confirmed the expectation for timely responses but could not explain the delays.
A resident with a history of ischemic CVA and requiring total care experienced a medical event involving excessive sweating and a distended abdomen. The physician was notified, and an x-ray was ordered, but the Responsible Party (RP) was not informed until after the resident's passing. The delay in notification was acknowledged by the DON, who confirmed that the RP should have been updated on changes in the plan of care.
A facility failed to thoroughly investigate a missing credit card incident reported by a resident. The investigative file lacked documentation of staff and resident interviews or evidence from the bank about fraudulent use. The DON confirmed no additional documentation was available, indicating an incomplete investigation.
A facility failed to document staff training on the application of a sling for a resident with a humeral fracture. Despite the family's concerns and the DON's acknowledgment of the need for training, there was no evidence of an in-service being conducted. Interviews revealed inconsistencies and lack of documentation regarding the training, contributing to the deficiency identified by the surveyor.
A resident experienced a delay in receiving necessary x-ray services after an incident where their legs slid out of bed, resulting in a bruise. Despite orders for x-rays of the left rib, humerus, and shoulder, the facility failed to obtain the services in a timely manner, leading to the resident being transferred to the hospital for evaluation. The facility has since changed its radiology service provider.
A facility failed to involve a resident's guardian in the initial care planning process, violating the resident's rights. The resident, with a history of schizophrenia, epilepsy, and edema, was incorrectly designated as their own representative. The baseline care plan lacked a written summary and signatures from the resident or their representative. Despite a hospital discharge summary indicating updated decision-making capacity, this information was not in the facility's records. The Social Work Director acknowledged speaking with the guardian, but the Nursing Home Administrator noted that staff should have been aware of the guardianship status.
The facility failed to assist two residents in formulating or obtaining advance directives, as revealed during an annual survey. Both residents lacked documentation indicating whether they had advance directives or were offered assistance in creating one. The social director confirmed the oversight, acknowledging that the residents were not provided with the opportunity to formulate advance directives.
A facility failed to complete a Significant Change in Status MDS within 14 days for a resident enrolled in hospice care. The resident was admitted to hospice, but the MDS did not reflect this change, as confirmed by the MDS Coordinator during a survey review.
The facility staff inaccurately coded the MDS assessments for two residents. One resident was incorrectly marked as having natural teeth, while another resident's Foley catheter was not documented, leading to inaccurate coding of urinary incontinence. The errors were acknowledged by the MDS Coordinator.
A facility failed to complete a comprehensive baseline care plan for a resident with a history of disorientation, malnutrition, and diabetes. The care plan lacked specific details in dietary and therapy sections, and there was no documentation of the resident's dietary preferences or goals. Interviews revealed that multiple disciplines did not document initial goals or care plans, leaving the resident uninformed about the services to be provided.
A facility failed to conduct timely care plan meetings for a resident following quarterly assessments, as required for effective care planning. Despite an audit identifying missing meetings for multiple residents, documentation for the resident in question remained incomplete, indicating a lapse in the facility's care planning process.
The facility failed to document and provide activities that meet the needs of two residents, as observed during an annual survey. One resident was unable to recall any activities and had no documentation of participation for several months, while another resident reported not being offered activities despite expressing interest. The Activities Director cited staffing shortages and admitted to incomplete assessments and documentation, leading to a deficiency in meeting the residents' needs for socialization and engagement.
A facility failed to have physician orders for a resident's foley catheter care, despite the resident's history of sepsis, UTIs, and obstructive uropathy. The absence of orders led to no documented foley care in the Treatment Administration Record. The DON confirmed the oversight, noting that without an order, the task was not assigned.
A resident with a stage 2 pressure ulcer on the heels was not consistently provided with protective boots as ordered, despite having a care plan indicating the need for pressure relief interventions. Observations showed the resident without boots in bed, and the TAR lacked documentation for these interventions. An LPN and the DON confirmed the boots should have been applied, highlighting a deficiency in pressure ulcer care.
A resident experienced issues with bowel regularity, and the facility failed to follow its bowel protocol. Despite having an order for MiraLax to treat constipation, it was not administered, and bowel movements were not documented on several days. The facility's protocol required specific steps to address constipation, which were not followed, leading to the deficiency.
The facility failed to ensure timely certification for nurse aides in training (NAITs), as three NAITs did not obtain Geriatric Nursing Assistant (GNA) licensure within the required timeframe. One NAIT was reassigned until licensure was obtained, another continued working until resignation, and a third was employed beyond the permissible period without proper enrollment records. The HR Director acknowledged the issue and confirmed discrepancies in employment status.
The facility failed to maintain professional standards in food service safety, with multiple instances of unlabeled and improperly stored food items observed. Unlabeled spices, cheese, meat, and eggs were found, along with missing dishwasher temperature log entries and improperly stored wet bowls. Further inspections revealed continued issues with unlabeled and undated food items, indicating non-compliance with food safety standards.
The facility failed to maintain medical records according to professional standards, as evidenced by incomplete documentation for two residents. One resident's COVID-19 test result lacked a date, and another resident's MOLST form was incomplete, with discrepancies in the code status between the electronic medical record and the care plan.
A facility failed to maintain infection control practices, including a foley catheter drainage bag left on the floor, discrepancies in PICC dressing change documentation, and a GNA handling soiled linen without gloves or hand sanitization.
Resident Representative Discouraged From Speaking Directly With State Surveyors
Penalty
Summary
The facility failed to permit a resident’s representative to speak directly with state surveyors during a recertification survey. During an interview, the family member of Resident #14 reported that a Geriatric Nursing Assistant (GNA #23) told her that residents and their representatives were not allowed to speak directly with state surveyors who were on site. Instead of facilitating contact with the surveyors, GNA #23 provided the family member with contact information for the Office of Health Care Quality (OHCQ) to file a complaint. Complaint record review confirmed that the family member subsequently filed a complaint with OHCQ. This conduct resulted in the resident’s representative being discouraged from and not permitted to communicate directly with the state surveyors who were present in the facility. No additional medical history or clinical condition for the resident was provided in the report.
Failure to Provide Timely Assistance With Toileting and Call Bell Response
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), specifically toileting, to a resident who required staff help. The resident, admitted in January 2026 with hemiplegia and hemiparesis affecting the left non-dominant side, muscle weakness, difficulty walking, and lack of coordination, reported long wait times for staff to respond to the call bell when needing restroom assistance. Due to these delays, the resident stated they attempted to use the restroom without assistance and fell on multiple occasions. Record review showed the resident had unwitnessed falls in January and February 2026, and the baseline care plan from January 2026 documented a need for one-person assistance with transfers. An MDS from January 2026 indicated upper and lower extremity impairment and a need for partial to moderate assistance with toilet transfers. The care plan documented a fall on 01/21/2026 and included a goal initiated on 01/22/2026 for the resident to use the call bell and wait for staff assistance. During an interview, the Administrator stated that staff are expected to respond to call bells immediately, but no longer than 20 minutes. Review of the call bell response log for the resident’s room between January and February 2026 revealed multiple instances where response times exceeded 20 minutes. On 02/09/2026, the call bell was activated at 6:59 PM and staff responded 24.31 minutes later. A GNA reported that the facility was not adequately staffed to meet residents’ care needs. The resident’s family member reported that the resident, who was continent of bowel and bladder at admission, had episodes of incontinence attributed to prolonged call bell response times. These findings were reviewed with the Administrator on 02/11/2026.
Failure to Investigate Missing Personal Items Complaint
Penalty
Summary
Facility staff failed to thoroughly investigate a complaint regarding missing personal items belonging to a resident. The resident's family reported that an adult puzzle and an electronic sound amplifier device were missing from the resident's room. Upon review, there was no evidence in the resident's medical record of an inventory sheet listing these items. Additionally, the Director of Nursing confirmed that no investigation into the missing items had been conducted, despite the complaint being reported and the items being identified as missing during a room search.
Failure to Document ADL Care in Resident Medical Record
Penalty
Summary
Facility nursing staff failed to accurately document activities of daily living (ADL) care in the medical record for a resident on three separate shifts. Specifically, there was no documentation of ADL care provided on the day shift of 1/15/25, the evening shift of 1/20/25, and the night shift of 1/23/25. This deficiency was identified during a complaint survey following a family report that the resident did not receive necessary ADL care, which allegedly contributed to the development of a preventable wound. The Director of Nursing (DON) confirmed during an interview that the nursing staff did not document the required ADL care for the resident on the specified dates.
Failure to Provide Adequate Assistance Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adequately assess and assist a dependent resident during Activities of Daily Living (ADL) care, resulting in a fall from bed and actual harm to the resident. The resident, who was admitted in early 2023, had left-sided hemiparesis and required total care, being unable to participate in medical decision-making. The care plan initially required 1-2 staff for bed mobility, but was revised to require 2 staff by July 2023. Despite this, a Geriatric Nursing Assistant (GNA) attempted to perform care alone, leading to the resident's fall. The incident occurred when the GNA was providing afternoon care and attempted to roll the resident onto their side, causing the resident's legs to slide out of bed while the upper torso remained in bed. Although initially no injuries were noted, subsequent medical evaluations revealed a humeral neck fracture and a muscular hematoma, necessitating a blood transfusion due to anemia. The resident's care plan and assessments consistently indicated the need for extensive assistance and two-person support for bed mobility, which was not adhered to during the incident. Interviews with staff, including the GNA involved and the LPN responsible for care planning, confirmed that the resident required a two-person assist for all ADL care. The facility's investigation report highlighted that the Nursing Assistant in Training (NAT) involved in the incident had received training on safe resident lifting and transfers, which emphasized the need for two staff members for repositioning in bed. The Director of Nursing (DON) acknowledged the discrepancy in the care plan and confirmed that it was adjusted post-incident to reflect the need for two-person assistance for all ADL care.
Delayed Call Bell Response for Dependent Resident
Penalty
Summary
The facility failed to answer call bells in a timely manner to attend to the needs of dependent residents, specifically for one resident on the Second Floor Nursing Unit. During an interview, the resident reported that over the weekend, they used the call bell to request assistance to the bathroom, but it took a long time for the staff to respond. The resident expressed difficulty in waiting for assistance when needing to use the bathroom. A review of the resident's electronic medical record revealed that the resident has an impairment on one side and is dependent on staff for toileting and transferring needs. The surveyor requested and reviewed the call light response time log for the resident, which confirmed that on a specific date, the call light was on for 28 minutes and later for 55 minutes and 51 seconds. The facility's Call Light Policy states that call lights should not be ignored, and the Routine Resident Checks policy specifies that call bells should be answered within 20 minutes. The Second Floor Supervisor confirmed the expectation for call lights to be answered within 20 minutes and acknowledged the delay in response time but was unable to determine the reason for the prolonged wait.
Failure to Timely Notify Responsible Party of Treatment Changes
Penalty
Summary
The facility failed to inform the Responsible Party (RP) of Resident #70 about the need to alter treatment in a timely manner. Resident #70, who had a history of ischemic CerebroVascular Accident (CVA) with left-sided hemiparesis and required total care, was admitted to the facility in early 2023. On a particular day, the resident was noted to have excessive sweating and a distended abdomen with hypoactive bowel sounds. The physician was notified, and an abdominal x-ray was ordered. However, the RP, identified as the resident's granddaughter, was not informed of these developments until later in the afternoon. The delay in notifying the RP was documented by LPN #28, who noted that the call to the RP was delayed due to pending abdominal x-ray results. Despite the physician being updated and an x-ray being ordered, the RP was not informed of the morning events until after Resident #70 had passed away at 3:10 PM. The Director of Nursing (DON) confirmed that the RP should have been notified of changes in the plan of care and acknowledged the delay in notification as documented by the LPN.
Incomplete Investigation of Missing Credit Card
Penalty
Summary
The facility failed to maintain documentation that a Facility Reported Incident (FRI) was thoroughly investigated for one resident out of thirteen during the annual survey. The deficiency was identified when a resident reported a missing credit card months prior, and the surveyor found that the facility's investigative file lacked comprehensive documentation. The file contained initial and follow-up report forms submitted to the Office of Health Care Quality, but there were no records of interviews with facility staff, other residents, or evidence from the bank regarding fraudulent use of the credit card. The Director of Nursing confirmed that no additional documentation was available, indicating an incomplete investigation into the reported incident.
Failure to Document Staff Training on Sling Application
Penalty
Summary
The facility failed to provide necessary education for the application of a sling device after a knowledge deficit was identified among staff. This deficiency was observed in the case of a resident who had been admitted to the facility in early 2023. The resident had suffered a fall resulting in a mildly impacted humeral neck fracture and a left pectoral muscular hematoma, requiring nonoperative management with a sling. Despite the physician's note indicating the family's concern about staff's ability to manage the sling and the Director of Nursing's (DON) acknowledgment of the need for an in-service training, there was no documentation to confirm that such training was conducted. Interviews with the DON and the Occupational Therapist (OT) revealed inconsistencies and lack of documentation regarding the in-service training. The OT recalled conducting an in-service on the standard sling but could not confirm the attendance or documentation of the training. The DON was unable to provide any evidence of the training being completed, and no documentation was found in the medical record or elsewhere to indicate that staff had been adequately trained to manage the resident's sling. This lack of documentation and follow-through on training contributed to the deficiency identified by the surveyor.
Failure to Provide Timely Radiology Services
Penalty
Summary
The facility failed to provide timely radiology services for Resident #70, who was admitted in early 2023. On July 15, 2023, a Licensed Practical Nurse (LPN) documented an incident where the resident's legs slid out of bed while a Geriatric Nursing Assistant (GNA) was providing care, resulting in a bruise. The LPN communicated this observation to a provider on July 17, 2023, who requested lab tests and clarification of the fall. On July 18, 2023, the Nurse Supervisor sought further clarification and inquired about the need for an x-ray. The resident's physician and Medical Director ordered x-rays for the left rib, humerus, and shoulder later that day. Despite the order, the x-ray was not completed at the facility. On July 19, 2023, the Medical Director noted that staff had been unable to obtain an estimated time of arrival from the radiology service. Due to the resident's pain and the possibility of a fracture, the resident was transferred to the hospital's emergency room for evaluation. The Director of Nursing confirmed that the x-ray order was placed on July 18, 2023, and was scheduled for completion on July 19, 2023, but the radiology company did not fulfill the order. The facility has since changed its radiology service provider.
Failure to Involve Guardian in Care Planning
Penalty
Summary
The facility failed to involve a resident's guardian in the initial care planning process, which is a violation of the resident's rights. The deficiency was identified during a review of the medical records and interviews conducted by the surveyor. Resident #162 was admitted to the facility with a history of schizophrenia, epilepsy, and edema. The baseline care plan incorrectly designated the resident as their own representative, and there was no written summary or signatures from the resident or their representative on the care plan. The Social Work Director and Nurse Supervisor signed the document, but the guardian's involvement was not documented. Further investigation revealed that a hospital discharge summary indicated the resident's capacity to make care decisions was updated prior to admission, but this information was not included in the facility's records. During interviews, the Social Work Director acknowledged speaking with the resident's guardian and requesting guardianship paperwork, but the Nursing Home Administrator stated that admissions and nursing staff should have been aware of the guardianship status. The incorrect assessment of the responsible party led to the failure to involve the guardian in the care planning process.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to assist residents in formulating or obtaining an advance directive, as evidenced by the cases of two residents during an annual survey. Resident #54 was admitted in late August 2024, and a social worker assessment was completed on August 22, 2024. However, the assessment did not indicate whether the resident had an advance directive or if they were offered assistance in formulating one. During an interview, the social director confirmed that the necessary documentation was missing, and the resident was not offered help in creating an advance directive. Similarly, Resident #162, admitted in early September 2024, also lacked documentation regarding advance directives. A social worker assessment completed on September 6, 2024, failed to show whether the resident had an advance directive or was offered assistance in formulating one. The social director acknowledged the oversight during an interview, confirming that the resident was not provided with the opportunity to create an advance directive. These findings highlight the facility's failure to comply with regulations regarding residents' rights to formulate advance directives.
Failure to Complete Significant Change MDS for Hospice Enrollment
Penalty
Summary
The facility failed to accurately assess and complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days of a resident's enrollment into a hospice program. This deficiency was identified during an annual survey for one resident who was investigated for hospice care. The MDS is a comprehensive assessment tool used to evaluate a resident's functional, medical, psychosocial, and cognitive status to develop a personalized care plan. A Significant Change in Status MDS is required when a resident enrolls in a hospice program, which provides specialized care for individuals with a life expectancy of six months or less. The surveyor discovered that the resident was admitted to a hospice program on June 7, 2024, as indicated by a physician's order. However, during a review of the Significant Change in Status MDS with an assessment reference date of June 17, 2024, it was found that the enrollment into the hospice program was not addressed in the assessment. MDS Coordinator #5 confirmed that the resident's enrollment in hospice should have triggered a Significant Change in Status MDS, which was not completed as required. This oversight was confirmed during an interview with the MDS Coordinator and a review of the assessment documentation.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility staff failed to accurately code the Minimum Data Set (MDS) assessments for two residents during the annual survey. For one resident, the MDS assessment incorrectly indicated that the resident was not edentulous, despite observations confirming the resident had no natural teeth. The MDS Coordinator acknowledged the error during an interview and confirmed that the coding was incorrect. For another resident, the MDS assessment failed to document the presence of an indwelling Foley catheter, despite the resident's medical history and care plan indicating its use due to obstructive uropathy. The MDS Coordinator admitted to missing this detail, as he primarily relied on physician orders and nursing assessments, which did not include an order for the Foley catheter. This oversight led to the resident being inaccurately coded as always having urinary incontinence.
Failure to Complete Baseline Care Plan for Resident
Penalty
Summary
The facility failed to adequately include and review all initial healthcare information and goals in the baseline care plan for a resident. Upon admission in early July 2024, the resident had a medical history of disorientation, protein-calorie malnutrition, and diabetes. Despite being alert and oriented to self, the resident was not oriented to place or time. The baseline care plan, completed shortly after admission, lacked specific details in several sections, including dietary and therapy orders, functional goals, and therapy services. Additionally, there was no documentation of the resident's dietary preferences, risks, or goals, and the section for the resident or representative's signature was left blank. Interviews with the Social Work Director and the Nursing Home Administrator revealed that the responsibility for completing the baseline care plan was divided among different disciplines. However, several disciplines failed to document initial goals or the care to be provided, leaving the resident uninformed about the plans and services to be rendered. The lack of a comprehensive baseline care plan and the absence of a care plan meeting contributed to the deficiency identified by the surveyor.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to facilitate timely care plan meetings for a resident following their quarterly assessments, which is a requirement to ensure the resident and their representative can participate in the care planning process. This deficiency was identified during an annual survey, where it was found that care plan meetings were not held after several MDS assessments, including quarterly and annual assessments. Specifically, for one resident, care plan meetings were documented on only a few occasions, despite multiple assessments being conducted over the period. The Social Services Director confirmed the absence of timely care plan meetings and acknowledged that an audit had previously identified this issue for multiple residents. Despite the audit and efforts to rectify the situation, documentation for the resident in question was still lacking. The deficiency highlights a failure in the facility's process to ensure regular and documented care plan meetings, which are crucial for evaluating the effectiveness of the resident's care.
Deficiency in Meeting Residents' Activity Needs
Penalty
Summary
The facility failed to evaluate and document activities that meet the needs of residents, as evidenced by the cases of two residents during an annual survey. Resident #38 was observed in bed with outdated activity calendars and was unable to recall any activities provided by the facility. The resident's care plan indicated a need for assistance with activities and a preference for group activities, but there was no documentation of participation in activities for several months. The Activities Director acknowledged the lack of documentation due to staffing shortages and confirmed that no records showed the resident's engagement in activities. Resident #54 reported not being offered activities and expressed interest in participating. The resident's medical record showed an admission in late August 2024, but there was no documentation of activities being offered or provided. The MDS assessment indicated preferences for reading materials, music, and group activities, among others. However, the Activities Director admitted that no Home and Lifestyle Assessment was completed, and there was minimal documentation of activities offered, with only a beverage and nail care recorded for September 2024. The surveyor's investigation revealed significant gaps in the documentation and provision of activities for both residents, highlighting a deficiency in meeting the residents' needs for socialization and engagement. The lack of documentation and assessment of residents' preferences contributed to the failure to provide appropriate activities, as required by the residents' care plans and preferences.
Lack of Physician Orders for Foley Catheter Care
Penalty
Summary
The facility failed to have physician orders written to ensure proper care and treatments were in place for a resident with a foley catheter. This deficiency was identified during a survey when reviewing the medical records of a resident who was readmitted to the facility after a hospital stay. The resident had a history of sepsis due to MRSA, urinary tract infections, and obstructive uropathy, which necessitated the use of a foley catheter. Despite the presence of a care plan for bladder elimination issues, there were no physician orders documented for the foley catheter or its care. The surveyor's review of the Treatment Administration Record (TAR) for September 2024 revealed no documentation of foley care. During an interview, the Director of Nursing confirmed the absence of orders for the foley catheter and acknowledged that without an order, the task was not assigned to the TAR. This oversight resulted in the lack of documented care for the resident's foley catheter, highlighting a gap in the facility's process for ensuring necessary medical orders and care documentation.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate services to promote the healing of a pressure ulcer. This deficiency was identified for one resident who was observed multiple times without protective boots while in bed, despite having orders to elevate and float heels and apply off-loading boots for pressure relief. The resident had a care plan indicating a risk for pressure ulcers, which was later revised to include a stage 2 pressure ulcer on the heels. However, the protective boots were not consistently applied as required. The surveyor noted that the Treatment Administration Record (TAR) for the resident did not include documentation for pressure relief interventions. During an interview, an LPN confirmed that the resident should have been wearing the boots while in bed and acknowledged the presence of wounds on the resident's feet. The Director of Nursing also confirmed that the boots should have been applied according to the orders and that any refusal by the resident should have been documented. This lack of adherence to the care plan and physician orders contributed to the deficiency in pressure ulcer care.
Failure to Follow Bowel Protocol for Resident
Penalty
Summary
The facility failed to provide appropriate treatment for constipation and maintain bowel continence for a resident. The resident, who was readmitted to the facility after a hospital stay, reported issues with bowel regularity. The medical record review revealed that the resident had an order for MiraLax to be administered as needed for constipation, but it was not given despite several days without a documented bowel movement. The facility's bowel protocol, which included steps to address constipation, was not followed. The surveyor noted that the resident's bowel movements were not recorded on multiple days, and the prescribed MiraLax was not administered according to the protocol. The facility's protocol required an abdominal assessment and the administration of prune juice and MiraLax if no bowel movement occurred within specified timeframes. However, these steps were not taken, leading to the deficiency. The Director of Nursing was informed of the concern that the bowel protocol was not adhered to for the resident.
Failure to Ensure Timely Certification for NAITs
Penalty
Summary
The facility failed to ensure that nurse aides in training (NAITs) obtained appropriate certification within the required timeframe, as evidenced by the cases of three NAITs. NAIT #24 was hired during the pandemic waiver period and was required to obtain Geriatric Nursing Assistant (GNA) licensure by the end of the waiver period. However, the licensure was not obtained in time, leading to her reassignment to the Assisted Living side of the facility until she obtained her licensure. NAIT #25 also did not obtain licensure within the required timeframe and continued to work as a NAIT until her resignation. The Human Resources (HR) Director acknowledged the issue and stated that a process is now in place to track educational progress for all NAITs. Additionally, NAIT #26 was hired as a dietary aide and there were no records indicating her enrollment in a nurse-in-training program. Despite completing her training and obtaining certification, she was employed as a NAIT beyond the permissible period and was incorrectly coded as a GNA for her last two days of employment. The HR Director confirmed these discrepancies, indicating a failure in the facility's process to ensure timely certification and proper employment status for NAITs.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. During an initial kitchen tour, several items, including bottles of Oregano, Italian Seasoning, and Old Bay, were found unlabeled regarding their opening and discard dates. Additionally, unlabeled cheese, a meat patty, a bag of meat, and an opened scrambled egg carton were identified. The Dietary Team Lead acknowledged that labeling might have been missed. A dishwasher temperature log was found with missing entries, and wet bowls were improperly stored upright, preventing proper drainage. Further observations revealed ongoing issues with food labeling and storage. On a subsequent visit, a refrigerator on the second floor contained an open pudding container and other resident food items that were unlabeled and undated. The process for labeling food was unclear among staff, as indicated by the responses from a Unit Secretary and a Registered Nurse. During a kitchen revisit, a container of egg salad was found past its labeled expiration date, and jars of mayonnaise and mustard were without labels or dates, indicating continued non-compliance with food safety standards.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards, as evidenced by deficiencies found in the records of two residents. For one resident, the surveyor discovered incomplete documentation related to a COVID-19 test. The paper medical record contained a point-of-care COVID antigen test result that was positive, but the form lacked a date indicating when the test was performed. This incomplete documentation was brought to the attention of the Director of Nursing. Another deficiency was identified in the medical records of a second resident, where the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form was incomplete. Although the first page of the MOLST form was filled out, signed, and dated with a Do Not Intubate (DNI) code status, the second page was incomplete. Additionally, there was a discrepancy in the resident's electronic medical record, which showed a care plan with a code status of Do Not Resuscitate, Intubate (DNR A-1), conflicting with the physician's order of DNI A-2. This inconsistency was confirmed by the Assistant Director of Nursing.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain infection prevention practices, as evidenced by several observations. In one instance, a resident's foley catheter drainage bag was observed lying on the floor, which could increase the risk of infection. Despite being informed by a Geriatric Nursing Assistant (GNA) that the clip was broken, the Licensed Practical Nurse (LPN) did not address the issue promptly, leaving the bag on the floor for approximately an hour. This delay in response was acknowledged by the Director of Nursing (DON) during a review of the concern. Another deficiency was noted when a Registered Nurse was observed changing a resident's Peripherally Inserted Central Catheter (PICC) dressing. The dressing was labeled with a date that did not match the documented change date in the Medication Administration Record (MAR). The DON confirmed that the dressing had not been changed as documented, due to the resident being at therapy, and acknowledged that the documentation was completed prior to the actual dressing change. Additionally, a GNA was observed handling soiled linen without gloves and subsequently touching a clean linen cart without sanitizing hands, which was later acknowledged by the GNA as a lapse in infection control practice.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
