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.)
- 44
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
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.
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