Maryland Masonic Homes Ltd
Inspection history, citations, penalties and survey trends for this long-term care facility in Cockeysville, Maryland.
- Location
- 300 International Circle, Cockeysville, Maryland 21030
- CMS Provider Number
- 215361
- Inspections on file
- 14
- Latest survey
- July 15, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Maryland Masonic Homes Ltd during CMS and state inspections, most recent first.
Surveyors identified multiple infection control deficiencies, including staff failing to perform hand hygiene during medication administration and after handling a foley catheter, improper disposal of gloves, and lack of cleaning of shared equipment between residents. Additionally, the facility did not have a complete water management plan in place despite previous positive Legionella test results, and key staff were unaware of such a plan.
Surveyors found expired medications and medical supplies, including Oxycodone tablets for a resident and various IV supplies, in multiple medication storage areas. Additionally, an LPN and unit managers confirmed that narcotic lock boxes and medication refrigerators were left unlocked, contrary to facility policy. These deficiencies were confirmed by staff and discussed with facility leadership.
Surveyors found that the facility did not follow the planned menu or honor resident food preferences, as seven residents did not receive bread sticks they had ordered for lunch, and a resident's breakfast tray did not match their dietary ticket. These deficiencies were confirmed by dietary staff and discussed with facility leadership.
The facility did not ensure that GNAs received the required annual 12 hours of in-service training, as shown by missing documentation for three GNAs. Staff responsible for tracking and documenting this training were unaware of the regulatory requirement, and no records could be produced during the survey.
Surveyors found that three resident rooms had damaged walls, including scratches, peeling and flaking paint, and crumbling wall fragments in both bedroom and bathroom areas. These deficiencies were observed during the initial survey tour and confirmed by the maintenance supervisor.
A resident receiving multiple psychotropic medications, including an antidepressant, anxiolytic, and antipsychotic, did not have required side effect monitoring orders or documentation in place. Facility staff confirmed that monitoring should have been implemented during admission or with medication changes, but it was missed and not reflected in the medical record.
A resident reported an allegation of physical abuse to the Director of Social Services, and facility staff became aware of the incident in the afternoon. The required self-report to the Office of Health Care Quality was not submitted within the mandated two-hour window, as confirmed by the DON during the survey.
A resident reported both physical and verbal abuse, but the facility's investigation only addressed the physical abuse allegation. The investigation file lacked documentation of interviews or statements from the resident and the alleged perpetrator, and the DON confirmed that no attempts were made to obtain these statements or conduct interviews.
A quarterly comprehensive care plan was not reviewed or revised by all required interdisciplinary team members for a resident, as the attending physician and a responsible nurse aide did not participate in the process. This was confirmed by facility staff during the survey.
A resident dependent on staff for care was left unattended in a high, flat bed with a hoyer sling and a foley catheter bag placed on their thigh while staff left the room to retrieve equipment. The resident reported being left alone for several minutes, and staff who entered the room during this time did not address the unsafe positioning or catheter placement until concerns were raised by a surveyor. The incident was acknowledged by nursing and management staff.
A resident was administered an expired Oxycodone 5mg tablet after staff failed to properly reconcile and check expiration dates during medication administration and shift handoff. Staff interviews confirmed the expired medication was given, and records showed it was administered for pain management as ordered by the physician.
A nurse administered Benefiber powder to a resident using an unlabeled eating utensil spoon instead of a measurement-labeled device, failing to follow the prescriber's order and facility policy for accurate medication preparation. The DON confirmed that staff are expected to use proper measuring devices, but this protocol was not followed, resulting in a significant medication error.
Surveyors observed that expired food items brought in by family or visitors for a resident were stored in a central supply room refrigerator. Multiple containers, including smoked salmon cream cheese spread and cottage cheese with fruit, were found past their expiration dates. A unit manager confirmed these were resident items and that they were expired at the time of inspection.
A significant medication error occurred when a resident was administered a morphine dose ten times higher than ordered, leading to their death. The error stemmed from a miscommunication in a verbal order and incorrect entry in the electronic medical record. Despite the resident's decline and need for pain relief, the error was not identified until after administration. Staff interviews revealed ongoing reliance on verbal orders, contributing to the incident.
The facility administration failed to conduct thorough abuse investigations, as evidenced by four incidents involving residents. In one case, a resident's family reported verbal abuse, but the previous DON delayed the investigation. Another resident experienced a fall resulting in hospitalization, with an inadequate investigation conducted. Additional incidents involved reports of possible abuse by GNAs, which were not promptly addressed, and were dismissed as customer service issues. These deficiencies were reviewed with the current administration.
Facility staff failed to uphold resident dignity and rights in two incidents. A resident dependent on staff for meals was left with a breakfast tray without immediate assistance, contrary to their care plan. In another case, a cognitively alert resident reported rough treatment during a shower, including threats and physical mishandling, despite expressing a desire to refuse the shower. Staff did not follow protocol for handling care refusals, leading to violations of resident rights.
The facility failed to report allegations of abuse to the Administrator and State Agency within the required timeframe. In three cases, concerns of verbal abuse and poor treatment were either not investigated promptly or dismissed as customer service issues. The previous DON did not initiate timely investigations, and staff were not adequately trained on abuse reporting.
The facility failed to investigate allegations of abuse and injuries for several residents. A resident's family reported rude staff behavior, but the previous DON did not initiate an investigation. Another resident experienced multiple falls, with one resulting in a fracture, yet the investigation lacked interviews and conclusions. A resident reported rough treatment by a GNA, but the GNA continued to be assigned to the resident. An injury of unknown origin was reported without a thorough investigation.
A resident was administered a Morphine dose ten times higher than ordered due to a transcription error by an RN and a failure to verify the medication by an LPN. The incorrect dosage was administered, resulting in the resident's death from Morphine intoxication.
A resident with quadriplegia fell out of bed during ADL care due to inadequate supervision and lack of awareness of the two-person assistance requirement. The GNA, unaware of the resident's needs due to an incomplete Kardex, attempted to reposition the resident alone, resulting in a fall when the air mattress deflated. The resident experienced hip pain, and a suspected fracture was later ruled out. The Director of Nursing confirmed the Kardex did not include necessary assistance information.
A facility failed to monitor a resident's weight loss and nutritional status, resulting in significant weight loss and eventual hospitalization. The resident, who had swallowing difficulties and dehydration, was not referred to a dietitian despite being assessed by a CRNP. The CRNP was unaware of the resident's poor oral intake due to a lack of communication from nursing staff. The deficiency was reported to the facility's administrator and DON.
Two residents experienced inadequate pain management due to delays in communication and response from medical staff. One resident had a nearly 24-hour delay in receiving Morphine for severe pain, while another resident with a hip fracture was not promptly transferred to the hospital, receiving only Tylenol despite increased pain and swelling.
A facility failed to ensure 24-hour physician responsiveness, resulting in a significant delay in administering necessary medication to a resident experiencing a change in condition. The RN's urgent request for Morphine was delayed due to miscommunication and unavailability, leading to a nearly 24-hour wait before the resident received appropriate care.
A resident experienced significant weight loss due to swallowing difficulties and dehydration, but was not referred to a dietitian for nutritional support. Despite regular assessments by a CRNP, the resident's poor oral intake was not communicated by nursing staff, leading to the deficiency being identified during a complaint survey.
Infection Control and Water Management Deficiencies Identified
Penalty
Summary
Surveyors observed multiple deficiencies in infection prevention and control practices within the facility. One incident involved a resident left unattended in a high, flat bed with a hoyer sling underneath and a foley catheter bag placed on their thigh, while no staff were present in the room or hallway. The resident reported feeling helpless after being left alone for five minutes. When a Geriatric Nursing Assistant returned, they failed to perform proper hand hygiene after handling the catheter bag and exited the room wearing gloves, discarding them improperly on top of a trash and dirty linen container before using hand sanitizer only after surveyor intervention. Both the Licensed Practical Nurse and Unit Manager acknowledged the concerns when informed by the surveyor. Another deficiency was identified regarding the facility's water management program. Upon request, the Maintenance Supervisor provided only water testing results, which showed previous positive results for Legionella, and described some remedial actions taken. However, neither the Administrator nor the Infection Preventionist were aware of an existing water management plan, and only an incomplete template was later provided, missing critical information such as the water management team, system inventory, and monitoring procedures. The Administrator eventually produced a contract for a water management company to create a plan, but at the time of the survey, a comprehensive plan was not in place. Additional infection control lapses were observed during medication administration and equipment use. An LPN failed to perform hand hygiene before entering and after leaving a resident's room with Enhanced Barrier Precautions signage, and sat on the resident's bed to administer medications, replacing a dropped pill without hand hygiene. Similarly, an RN did not clean a vital sign machine between resident uses and failed to perform hand hygiene when entering and exiting another resident's room, despite posted requirements. These actions were confirmed by direct observation and staff interviews.
Expired Medications and Unsecured Narcotics Identified in Medication Storage Areas
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals during observation rounds, record review, and staff interviews. Expired medications and medical supplies were found in several medication storage areas, including a pack of Oxycodone tablets for a resident with an expiration date that had passed, as well as expired intravenous catheters, a sterile IV start kit, and a package of ArgiMent AT with Bimuno Prebiotic. In each instance, staff confirmed the items were expired when questioned by the surveyor. Additionally, surveyors observed that the narcotic lock box within the medication refrigerator, as well as the refrigerator padlock itself, were found to be open and unlocked in the medication supply room. Staff, including the unit manager and the Director of Nursing, confirmed that the expectation and policy is for these compartments to remain locked at all times. These findings were discussed with facility leadership during the exit conference.
Failure to Follow Menus and Meet Resident Food Preferences
Penalty
Summary
The facility failed to ensure that the menu was followed and that resident choices and preferences were met during meal service. On one occasion, seven residents who had ordered bread sticks for lunch did not receive them, as observed by the surveyor and confirmed by the Certified Dietary Manager (CDM). The bread sticks were not brought up from the kitchen to the unit, and the last meal tray was served without them. This issue was acknowledged by the CDM during the meal service and again during a review with the surveyor. Additionally, a resident's breakfast tray did not match the items listed on their dietary ticket, which included a beverage of choice, milk, bacon, Danish, and instructions to provide two cereals. Instead, the tray contained only a hot beverage cup, a tea bag, and a half-eaten bagel. The Dietary Supervisor confirmed that the expectation is to follow the dietary ticket, and the discrepancy was discussed during the survey. These findings were reviewed with facility leadership during the exit conference.
Failure to Provide Required Annual In-Service Training for GNAs
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received the required annual 12 hours of in-service training. During a personnel record review, it was found that three GNAs did not have documentation showing completion of this mandatory training. Interviews with the Human Resources Director and the Nursing and Health Services Educator/Infection Prevention Nurse revealed that neither was aware of the regulatory requirement for the annual 12-hour in-service training for GNAs, and no documentation could be provided to demonstrate compliance for the GNAs reviewed. The deficiency was identified during the facility's recertification survey, where the absence of training records for the GNAs was confirmed. The Director of Nursing was also informed of the lack of documentation. The findings were based solely on record reviews and staff interviews, with no mention of direct resident impact or specific patient conditions related to this deficiency.
Failure to Maintain Homelike Environment Due to Wall and Paint Damage
Penalty
Summary
Surveyors observed that the facility failed to maintain a homelike environment in three out of eighteen resident rooms during the initial tour of the recertification survey. Specifically, one resident's room had damage to the wall adjacent to the bed, with scratches and peeling, flaking paint. Another resident's bathroom had paint damage, brown streaking on the wall, and crumbling wall fragments at the base of the toilet. A third resident's room had scratches and peeling, flaking paint on the wall at the head of the bed. These deficiencies were directly observed by surveyors and confirmed during an interview with the Maintenance Supervisor, who acknowledged the presence of peeling, flaking, and scratched paint in resident areas. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
A deficiency was identified when a resident was found to have active medical orders for multiple psychotropic medications, including trazodone, buspirone, and zyprexa, without any corresponding side effect monitoring orders in place. Review of the resident's medical record and medication administration records confirmed that there was no documentation of side effect monitoring for these medications. The absence of such monitoring was noted during the facility's recertification survey. Interviews with facility staff, including the Unit Manager (RN) and the Director of Nursing (DON), revealed that the facility's process requires side effect monitoring orders to be placed during admission and whenever there is a medication change. Both staff members acknowledged that the expected monitoring was not present for this resident, and the DON confirmed that the deficiency was evident in the medical record. The concern was also discussed during the facility's exit conference.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the Office of Health Care Quality within the required two-hour timeframe. Documentation showed that the Director of Social Services received a verbal report of alleged physical abuse from a resident, and the facility became aware of the incident at 2:00PM. However, the initial self-report to the Office of Health Care Quality was not submitted until 4:10PM, exceeding the mandated reporting window. The Director of Nursing confirmed that the facility's expectation is to report such allegations within two hours, and acknowledged the delay when interviewed by the surveyor.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse as required. Specifically, for one of three facility-reported incidents reviewed during the recertification survey, a resident reported both physical and verbal abuse to the Director of Social Services. While staff were questioned regarding the physical abuse allegation, there was no documentation that staff were questioned about the verbal abuse allegation. Additionally, the investigation file lacked a written statement from the resident and did not include an interview or statement from the alleged perpetrator, a Geriatric Nursing Assistant. The Director of Nursing confirmed to the surveyor that no attempts were made to obtain these statements or conduct the necessary interviews, and no documentation could be provided to show otherwise.
Failure to Include All Interdisciplinary Team Members in Care Plan Review
Penalty
Summary
The facility failed to ensure that a quarterly comprehensive care plan was reviewed and revised by all required interdisciplinary team members for one resident. Review of the medical record showed that a quarterly care plan meeting and review was documented as completed by the interdisciplinary team; however, the attending physician and a nurse aide responsible for the resident did not participate in the review or revision of the care plan. This was confirmed by the Director of Social Services during an interview, who acknowledged that these team members were not involved in the care plan process for the resident on the specified date. The deficiency was identified during the facility's recertification survey, with findings discussed during the exit conference with the Administrator and Director of Nursing.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified when a resident was observed lying on their back in bed, which was positioned at its highest and flattest setting, with a hoyer sling underneath and a foley catheter bag resting on their right thigh. No staff were present in the room or nearby hallway at the time of observation. The resident reported that their nursing assistant had left to retrieve something and that they had been left in this position for five minutes, expressing feelings of helplessness. During this period, another staff member entered the room only to inform the resident about upcoming activities and then left without addressing the resident's position or the placement of the catheter bag. The assigned GNA later returned, at which point the surveyor shared concerns about the resident's safety. The GNA then adjusted the catheter bag to hang below the bladder and lowered the bed before leaving the room again. The incident was acknowledged by both the LPN and the Unit Manager, RN, who confirmed understanding of the concerns. The resident's care plan indicated complete dependence on staff for meeting their needs due to physical limitations. The sequence of events demonstrated a failure to ensure the resident was free from accident hazards and to provide adequate supervision to prevent accidents.
Expired Controlled Medication Administered Due to Inadequate Reconciliation
Penalty
Summary
The facility failed to ensure proper reconciliation and administration of controlled drug medications, specifically regarding the handling of expired narcotic medication for one resident. During observation and record review, a surveyor found that an expired Oxycodone 5mg tablet card was present in the narcotic lock box and had been administered to the resident after its expiration date. The narcotic count log and controlled drug receipt/record/disposition form confirmed that the expired medication was given by a registered nurse. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the expired medication was administered and that the expectation is for staff to verify both counts and expiration dates during the two-person handoff at each shift change, as well as during medication administration. Review of the resident's medical record showed a physician's order for Oxycodone 5mg for pain management, and the medication administration record indicated that the expired medication was given when the resident reported a pain level of 5.
Improper Measurement of Medication Dosage During Administration
Penalty
Summary
A deficiency occurred when a registered nurse prepared a resident's medication using an unlabeled white eating utensil spoon to scoop Benefiber powder from a bulk bottle, rather than using a measurement-labeled device as required. The nurse mixed two scoops of the powder in a measured cup before adding liquid, despite the physician's order specifying the administration of either one packet or two teaspoonsful of Benefiber powder dissolved in eight ounces of liquid. The use of an unmeasured utensil did not ensure the correct dosage was given, as the utensil was not marked for accurate measurement. The facility's policy and procedures for medication administration require that liquid medications be measured using a graduated medication cup or an appropriate measurement-labeled device. During interviews, the DON confirmed that staff are expected to use proper measuring devices for medication preparation. The surveyor's observations and record reviews confirmed that the nurse did not follow these protocols, resulting in a significant medication error for the resident.
Expired Resident Food Items Improperly Stored in Central Supply Refrigerator
Penalty
Summary
The facility failed to ensure the safe and separate storage of food items brought in by family or visitors for residents, as observed during a recertification survey. During observation rounds in the Central Supply room on Baltimore Hall #2, the surveyor, accompanied by a unit manager, found multiple expired food items, including containers of smoked salmon cream cheese spread, white soup containers labeled as visitor items, and various containers of cottage cheese with fruit, all past their expiration dates. The unit manager confirmed that these items were resident foods brought in by family and acknowledged that they were expired at the time of observation. The expired items were found in one of two refrigerators inspected during the survey.
Significant Medication Error Leads to Resident's Death
Penalty
Summary
The facility failed to adhere to the standard practice of verifying medication doses when ordering and administering medication, leading to a significant medication error. A resident was administered an inappropriate dose of morphine, which was ten times the ordered dose. The error occurred when RN #5 received a verbal order for morphine 5mg to be given every 2 hours, but mistakenly entered 2.5ml instead of 0.25ml in the electronic order. This resulted in a 50mg dose being administered instead of the intended 5mg dose. The error was compounded by LPN #6, who administered the incorrect dose from a 20 mg/ml concentration vial, leading to the resident's death. The incident was discovered during a review of a facility-reported incident involving the resident's decline and subsequent death. The resident had been experiencing dyspnea and agonal breathing, prompting a request for narcotic pain relief. Despite the facility's investigation and statements from staff, the error was not caught until after the medication was administered. Interviews with staff revealed that verbal orders from physicians were still being taken, which contributed to the medication error.
Removal Plan
- All controlled substance orders requiring written authorization will be reviewed to ensure controlled substance written order forms and electronic orders in the electronic medical record are correct.
- Education on medication administration to all licensed nursing staff.
- Controlled substance order forms requiring written authorization order forms will be reviewed.
- Daily checks of inventory records.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility administration failed to adhere to guidelines for abuse investigation, which included conducting thorough investigations and implementing appropriate interventions to prevent further occurrences of abuse. This deficiency was evident in four facility-reported incidents involving residents. In one case, a family member of a resident dependent on staff for meals reported verbal abuse, but the previous Director of Nursing (DON) did not initiate an investigation until six days later, dismissing the concern as not rising to the level of abuse. Another incident involved a resident who experienced a fall, the sixth in a month, resulting in hospitalization for a compression fracture. The facility's investigation was inadequate, with no staff or resident interviews conducted, and the report lacked conclusions or corrective actions. This was signed off by the previous DON without addressing the necessary preventive measures. Additional incidents included a resident reporting possible abuse by GNAs, which was not reported to the DON until four days later, and another resident expressing concerns about rough treatment by a GNA. The previous DON categorized these as customer service issues rather than potential abuse, failing to suspend the involved staff or implement preventive actions. These deficiencies were reviewed with the current administration during the survey.
Failure to Uphold Resident Dignity and Rights
Penalty
Summary
The facility staff failed to uphold the dignity and rights of residents, as evidenced by two separate incidents involving inadequate care. In the first incident, a family member reported that staff were rude when delivering breakfast trays to a resident who was dependent on staff for meals. The staff left the tray in front of the resident without assisting them immediately, despite the resident's care plan indicating they required help with eating due to poor intake and being a 'poor feeder.' This inaction was confirmed through interviews with the Director of Nursing (DON) and the facility administrator, who acknowledged the expectation for staff to assist residents with meals upon delivery. In the second incident, a resident reported experiencing rough treatment during a shower, including being threatened with being let fall, thrown against the wall, and having their feet stepped on by staff. The resident, who was cognitively alert, expressed that they did not want a shower, but the staff proceeded due to a family request. Interviews with the Geriatric Nursing Assistants (GNAs) involved revealed that one GNA insisted on continuing the shower despite the resident's protests. The DON stated that staff are trained to report refusals of care to a nurse, who should then attempt to persuade the resident to accept care, and if unsuccessful, document the refusal and try again later. However, this protocol was not followed, leading to the resident's rights being violated.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility staff failed to report allegations of abuse to the Administrator and the State Agency within the required timeframe of 2 hours after the allegation was made, and did not report the results of investigations within 5 working days. This deficiency was evident in three cases reviewed during a complaint survey. In the first case, a family member of a resident reported verbal abuse concerns to the previous Director of Nursing (DON), but the DON did not initiate an investigation, believing the concern did not rise to the level of abuse. It was only addressed during a care plan meeting six days later. In the second case, a resident reported possible abuse by GNAs to an LPN, but the concern was not reported to the DON until four days later. The issue was documented on a grievance form, and staff received customer service training instead of training on abuse or timely reporting. In the third case, a resident reported being treated poorly by a GNA, but the DON initially dismissed it as a customer service issue. The incident was not reported to the Office of Health Care Quality until two days later, despite the DON being aware of the incident on the day it occurred.
Inadequate Investigation of Abuse and Injuries
Penalty
Summary
The facility staff failed to thoroughly investigate allegations related to potential abuse and injuries of unknown origin for several residents. In one instance, a family member reported that staff were rude and did not assist a resident who was dependent on staff for meals. The previous Director of Nursing (DON) did not initiate an official investigation, as they did not consider the concern to rise to the level of verbal abuse. Another case involved a resident who experienced multiple falls, with one resulting in a compression fracture. The facility's investigation lacked staff or resident interviews, and no conclusions or preventative measures were documented. Additionally, a resident reported being treated poorly by a GNA, who was described as pushy and rough. Despite the complaint, the GNA continued to be assigned to the resident or nearby rooms on several occasions, with no evidence of suspension or preventative action. Another incident involved a resident with an injury of unknown origin, but the facility's investigation did not include interviews with staff or other residents. These deficiencies highlight a pattern of inadequate investigation and response to allegations of abuse and injuries.
Medication Error Leads to Resident's Death
Penalty
Summary
The facility staff failed to administer medication according to professional standards, resulting in a significant medication error. A verbal order for Morphine was incorrectly transcribed by an RN, leading to a dosage error. The order was intended for a concentration of 20mg/ml of Morphine to administer a dose of 0.25ml every 2 hours, equating to 5mg of Morphine. However, the RN transcribed the order as 2.5ml, which was ten times the intended dose. The medication administration record (MAR) reflected this incorrect dosage, and the medication was administered without verification by an LPN, despite discrepancies between the MAR and the medication provided by the pharmacy. The error resulted in the administration of a dose ten times higher than ordered, contributing to the resident's death from Morphine intoxication. The LPN on duty failed to verify that the delivered medication matched the ordered medication on the MAR, leading to the overdose. The RN who transcribed the order acknowledged the error and stated that she would have recognized the mistake if she had been on duty when the medication arrived. The incident highlights a critical lapse in medication management and verification processes within the facility.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility staff failed to provide adequate supervision while positioning a resident in bed, resulting in the resident falling out of bed. The resident, who had diagnoses including myalgia, osteoarthritis, pain, and quadriplegia, was totally dependent on staff for bed mobility and required assistance from two staff members. However, during the provision of activities of daily living (ADL) care, a Geriatric Nursing Assistant (GNA) attempted to reposition the resident alone, unaware of the two-person assistance requirement. This lack of awareness was due to the Kardex, which should have contained the necessary assistance information, not being updated with the resident's needs. During the incident, the resident was on an air mattress that deflated, causing the resident to fall to the floor. The resident complained of hip pain and was later found to have a suspected impacted femoral neck fracture, although no fracture or injuries were confirmed upon discharge from acute care. The Director of Nursing confirmed that the Kardex did not include the required assistance information, which contributed to the GNA's lack of knowledge about the resident's needs. The incident highlights a deficiency in ensuring adequate supervision and communication of care requirements for residents.
Failure to Monitor Resident's Weight Loss and Nutritional Status
Penalty
Summary
The facility failed to adequately monitor a resident's weight loss and nutritional status, as identified during a complaint survey. The resident, who was ordered to be weighed monthly, experienced a significant weight loss from 124 lbs to 104 lbs between June and July 2022. Despite this weight loss, there was no evidence in the medical records that the Certified Registered Nurse Practitioner (CRNP) #15, who assessed the resident twice a week in June 2022, noted the weight loss or referred the resident to a dietitian for nutritional supplementation. The resident had swallowing difficulties and dehydration, which were initially managed by encouraging oral intake of thickened liquids and later by IV hydration. The CRNP confirmed during an interview that the resident was being treated for COVID-19 and a urinary tract infection in June 2022, but was not informed by the nursing staff about the resident's poor oral intake, which contributed to the weight loss. The resident was eventually transferred to a hospital after a fall, where a nutritional assessment was conducted, and a PEG tube was placed to provide nutrition. The surveyor informed the facility's administrator and Director of Nursing about the deficient practice.
Inadequate Pain Management and Delayed Treatment
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents experiencing significant pain. In the first case, a resident exhibited signs of pain and discomfort, including removing oxygen and agonal breathing, prompting a request for narcotic pain relief. Despite the urgency, there was a delay in communication and response from the medical staff, resulting in a nearly 24-hour delay before the resident received the prescribed Morphine. This delay occurred despite multiple escalations and a verbal order being given, highlighting a breakdown in the facility's process for addressing acute changes in a resident's condition. In the second case, a newly admitted resident experienced an unwitnessed fall and reported pain, which was initially managed with Tylenol. However, the resident's condition worsened, with increased pain and swelling in the hip area, yet there was a delay in transferring the resident to the hospital. The resident was eventually diagnosed with a hip fracture at the hospital, over six hours after the fall. The facility's investigation revealed a failure to act promptly when the resident's pain increased and the x-ray technician was delayed, resulting in inadequate pain management and delayed treatment.
Failure to Ensure 24-Hour Physician Responsiveness
Penalty
Summary
The facility failed to ensure that a physician was responsive to the emergency needs of residents on a 24-hour basis. This deficiency was identified during the review of an incident involving a resident who exhibited a change in condition, including signs of pain, discomfort, and agonal breathing. The RN on duty contacted the on-call provider, MD, requesting an order for Morphine or a narcotic painkiller to alleviate the resident's discomfort. The request was marked with urgency, requiring a response within one hour. However, the MD redirected the RN to contact a CRNP, delaying the response. The RN escalated the request multiple times before receiving a response at 3:00 PM, nearly four hours after the initial request. Although a verbal order for Morphine was eventually given, the medication was not available and was not administered until the following day, almost 24 hours after the initial request. This delay in providing necessary medication highlights the facility's failure to ensure timely physician responsiveness to emergency situations, as evidenced by the prolonged period before the resident received appropriate care.
Failure to Refer Resident for Nutritional Support
Penalty
Summary
A facility provider failed to refer a resident's case to a dietitian when the resident required additional nutritional supplementation. The resident, who had a history of swallowing difficulties and dehydration, experienced significant weight loss from 124 lbs to 104 lbs between June and July 2022. Despite being assessed by a Certified Registered Nurse Practitioner (CRNP) twice a week during June 2022, there was no evidence of a referral to a dietitian for increased nutritional support. The resident was eventually given a PEG tube after a hospital readmission, but the initial weight loss and lack of referral were not addressed in a timely manner. The CRNP confirmed that the resident was being treated for multiple conditions, including COVID-19 and a urinary tract infection, during the month of June 2022. The CRNP also stated that the facility's nursing staff failed to inform him/her of the resident's poor oral intake, which contributed to the resident's weight loss. The deficiency was identified during a complaint survey, and the facility's administrator and Director of Nursing were informed of the deficient 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.
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