Citations in Maryland
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Maryland.
Statistics for Maryland (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Maryland
A resident who was fully dependent on staff for self-care due to Multiple Sclerosis did not receive necessary ADL care during an evening shift. Despite being cognitively intact and assessed as needing total assistance, the assigned GNA failed to change the resident after a bowel movement, and this lapse was only discovered by the next shift when a strong odor was noted and the resident reported not being cared for.
A resident who was admitted without pressure ulcers developed a Stage III ulcer and a DTI. Despite wound care orders for the right heel and a recommendation for x-rays, staff did not administer the ordered treatments or complete the diagnostic testing before discharge, as confirmed by staff interviews and record review.
Nursing staff failed to document a resident's heart rate and did not hold a cardiovascular medication as ordered when the pulse was below a specified threshold. Additionally, staff did not accurately record the route of administration for the medication, continuing to indicate oral administration despite the resident receiving care via a feeding tube. The DON was unaware of these issues until identified during the survey.
Nursing staff failed to keep medication carts locked and secure on multiple nursing units. Several medication carts were observed unlocked and unattended, with one cart also having a medicine cup containing tablets left on top. These lapses were identified during a complaint survey across three different units.
Multiple residents with cognitive and physical impairments experienced repeated falls and injuries due to inadequate supervision, incomplete adherence to care plans, and insufficient investigation of incidents. One resident suffered a severe leg laceration during an improper transfer by a single staff member, while another resident with a history of falls was left unsupervised multiple times, resulting in several injuries. Staff interviews revealed gaps in supervision, documentation, and the effectiveness of interventions for high-risk residents.
The facility did not develop or document a written action plan to address repeated falls, despite reviewing fall incidents in QAPI meetings and recording a high number of falls among residents. Nursing staff were not involved in QAPI activities or performance improvement projects, and interventions were communicated verbally without systematic tracking or evaluation of their effectiveness.
The facility did not consistently report allegations of abuse, neglect, or injuries of unknown origin to the state survey agency within the required timeframe. Multiple incidents involving residents with cognitive and physical impairments, including altercations and unexplained injuries, were either reported late or not reported at all. Staff confusion about what constituted a reportable event and delays caused by waiting for corporate guidance contributed to these failures, impacting resident safety and regulatory compliance.
Multiple deficiencies occurred when the facility did not thoroughly investigate alleged abuse, neglect, or injuries of unknown origin, failed to document staff and resident interviews, and did not immediately remove an LPN accused of abuse from the premises. In several cases, incidents were not reported to the state agency or the Administrator, and required investigative steps were not followed, affecting several residents with cognitive impairment and complex medical needs.
A resident admitted with multiple medical conditions, including a pressure ulcer and who sustained a fall with a skin tear, was inaccurately coded on the 5-day MDS assessment as having no falls and no pressure ulcers. Despite documentation and care planning addressing these issues, the MDS Coordinator did not clarify or accurately code the events, resulting in an assessment that did not reflect the resident's true condition.
A resident with multiple comorbidities and on anticoagulant therapy experienced a fall, after which staff failed to perform a thorough assessment or communicate critical information, such as the fall and vomiting, to the provider. The resident continued to receive anticoagulant medication, and changes in vital signs were not fully recognized or reported. Incomplete documentation and communication led to a lack of appropriate response to the resident's deteriorating condition, resulting in the resident being found unresponsive and expiring.
Failure to Provide Required ADL Care to Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to provide necessary activities of daily living (ADL) care to a resident who was totally dependent on staff for self-care. The resident, admitted in 2017 with a diagnosis including Multiple Sclerosis, was assessed as cognitively intact and fully dependent for self-care according to the most recent MDS assessment. On the evening in question, the resident's nurse identified that the resident needed to be changed after a bowel movement and instructed the assigned geriatric nursing assistant (GNA) to provide care. However, the GNA did not perform the required care, only emptying the resident's urinary catheter and failing to recognize the need for further assistance. The lapse in care was discovered when the next shift's GNA entered the resident's room and noted a strong odor, with the resident reporting that the previous GNA had not provided the necessary care. Facility investigation and interviews confirmed that the resident did not receive the required ADL care during the 3 PM to 11 PM shift. The administrator acknowledged that staff failed to provide the needed care for the resident during this time period.
Failure to Provide Ordered Pressure Ulcer Treatments and Timely Diagnostic Testing
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident who was admitted without any pressure ulcers. The resident developed an open area on the left buttock, which progressed to a Stage III pressure ulcer, and also developed a deep tissue injury (DTI) on the right heel. The wound nurse practitioner ordered specific treatments for the right heel, including cleansing with wound cleanser, application of skin prep twice daily, and use of offloading foam heel boots. Additionally, an x-ray of the left buttock and sacrum was recommended to rule out osseous changes. Despite these orders, a review of the resident's physician orders and treatment administration records revealed that the right heel DTI treatments were neither ordered nor administered from the time of the initial wound nurse practitioner's order through the resident's discharge. Furthermore, the x-ray recommended by the wound nurse practitioner was not completed prior to discharge, with the order for the x-ray not being placed until several days after the recommendation. These failures were confirmed through interviews with facility staff, including the x-ray staff and the Director of Nursing.
Failure to Follow Physician Orders and Document Medication Administration
Penalty
Summary
Nursing staff failed to follow physician orders regarding the administration of a cardiovascular medication for a resident who was totally dependent on staff for care, ventilator dependent, had a tracheostomy, and received nutrition and hydration via a feeding tube. The physician's order specified that Propranolol Hydrochloride, 10 mg, should be administered every 8 hours by mouth for tachycardia, but to hold the medication if the resident's heart rate was less than 100 beats per minute. However, review of the medication administration records for September and October showed that staff documented administration of the medication without recording the resident's heart rate or confirming whether the heart rate was below the threshold specified in the order. Additionally, the nursing staff did not accurately document the route of administration for the medication. Although the resident was receiving nutrition and hydration through a gastrostomy tube, the medical record continued to indicate that the medication was being given by mouth, rather than through the feeding tube. The Director of Nursing was unaware of these documentation and administration errors until the time of the survey.
Medication Carts Found Unlocked and Unattended
Penalty
Summary
Facility nursing staff failed to maintain medication carts in a locked and secure manner, as required for the storage of drugs and biologicals. During the initial tour, one medication cart on the second-floor nursing unit was found unlocked and unattended, with a medicine cup containing two cherry-colored oval tablets left on top of the cart. Additionally, on the fourth-floor nursing unit, two medication carts were observed unlocked and unattended, and on the third-floor nursing unit, two more medication carts were found in the same unsecured and unattended state. These observations were made during a complaint survey and involved three of four nursing units in the facility. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by multiple incidents involving several residents. One resident, who had a history of muscle weakness, difficulty walking, and moderate cognitive impairment, required two staff for safe transfers according to their care plan and Kardex. Despite this, the resident was transferred by a single staff member, resulting in a severe laceration to the leg that required 15 sutures. The injury was caused by the resident's leg hitting an uncapped edge of the bed frame during the improper transfer. The staff member involved did not follow the care plan, and the incident was reported as an injury of unknown source before the cause was determined. Another resident with severe cognitive impairment, a history of falls, and dependence on staff for mobility experienced multiple unwitnessed falls over several months. The care plan included interventions such as keeping the call light within reach, frequent checks, and supervision at the nurses' station. However, the resident was repeatedly found alone in their room or in other areas without adequate supervision, leading to several falls, some resulting in injuries such as skin tears and a possible clavicle fracture. Staff interviews revealed that the resident was unable to use the call light effectively and could not remember instructions, yet was left unsupervised on multiple occasions. Staff also acknowledged that interventions like visual cues and education were ineffective due to the resident's cognitive status. Incident reports and post-fall investigations were often incomplete, lacking details about the circumstances leading to the falls, when the resident was last seen, and what interventions were in place at the time. Staff interviews confirmed that required documentation and witness statements were not consistently obtained, and that there was no clear assignment of responsibility for supervising high-risk residents at the nurses' station. These failures in supervision, adherence to care plans, and thorough investigation contributed to an environment where accident hazards were not minimized, directly resulting in harm and repeated incidents for multiple residents.
Failure to Implement Effective QAPI Plan for Falls
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement (QAPI) program effectively implemented a plan to address quality deficiencies related to falls. Documentation from QAPI meetings over several months showed that falls were reviewed, and in one month, 25 falls involving 22 residents were recorded, with two residents accounting for five of those falls. However, there was no evidence in the facility's records of corrective actions being developed or implemented to address the high number of falls, nor was there documentation of a good faith effort to resolve the issue. Interviews with nursing staff revealed that they had not been involved in QAPI meetings or performance improvement projects, and their input on fall prevention was not solicited in a structured manner. Further interviews with the Director of Nursing (DON) and the Administrator indicated that while falls were discussed in meetings and some interventions, such as increased rounds, were verbally communicated, there was no written action plan or systematic tracking of interventions and their effectiveness. The DON expected a written plan with measurable goals and tools to assess outcomes, but was not involved in follow-up or action items. The Administrator acknowledged that interventions were discussed verbally and corrections were made on an individual basis, but there was no formal, documented plan to address the ongoing issue of falls.
Failure to Timely Report Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report multiple allegations of abuse, neglect, and injuries of unknown origin to the state survey agency within the required timeframe, as outlined in their own policy and federal regulations. Several incidents involving resident-to-resident altercations, injuries of unknown origin, and alleged staff abuse were either not reported at all or were reported late. In some cases, staff and leadership were unclear about what constituted a reportable event, leading to delays or omissions in reporting. For example, altercations between residents, such as one resident attempting to dump another from a wheelchair or a resident grabbing another by the shirt collar, were not reported to the state agency as required. In other cases, injuries of unknown origin, such as a resident's acute wrist fracture, were reported more than two hours after discovery, contrary to policy requirements. The report details that staff, including LPNs, RNs, and DONs, sometimes failed to recognize or escalate incidents as reportable abuse or altercations. In several instances, staff deferred to corporate guidance before submitting reports, which contributed to delays. There were also communication breakdowns, with some administrators and regional staff not being informed of incidents in a timely manner. For example, after a resident was found with a new fracture, the DON waited for corporate input before reporting, resulting in a late submission. In another case, a DON instructed staff not to report a resident-to-resident altercation, classifying it as a behavioral issue instead, despite staff concerns that it met the criteria for abuse. Residents involved in these incidents often had significant cognitive impairments, dementia, or physical limitations, making them particularly vulnerable. The lack of timely reporting prevented prompt investigation and intervention, as required by both facility policy and regulatory standards. The facility's failure to consistently recognize, document, and report these events as abuse, neglect, or injuries of unknown origin led to noncompliance with reporting requirements and affected the safety and well-being of multiple residents.
Failure to Investigate and Protect Residents Following Alleged Abuse and Injuries
Penalty
Summary
The facility failed to conduct thorough investigations and maintain evidence of investigations into multiple alleged incidents of abuse, neglect, and injuries of unknown origin. In several cases, the facility did not obtain or document staff and resident interviews, body audits, or other investigative steps as required by policy. For example, after an alleged altercation between two residents, there was no evidence of an investigation or documentation, and the incident was not reported to the state agency. In another case, a resident sustained rib fractures, but the facility's investigation lacked interviews with staff or residents and did not include body audits to rule out abuse or other causes. The facility also failed to protect residents from potential further abuse by not immediately removing alleged abusers from the premises. In one incident, an LPN accused of being rough and verbally abusive to a resident was allowed to continue working and interacting with the resident for several hours after the allegation was reported. Documentation showed the LPN continued to perform neurological checks on the resident and remained in the building until the end of the shift, contrary to facility policy requiring immediate suspension and removal of the accused staff member. Additionally, the facility did not consistently report alleged violations to the state survey agency or notify the Administrator as required. In several incidents involving resident-to-resident altercations or injuries of unknown origin, there was no evidence of timely reporting, comprehensive documentation, or assessment of all involved parties. The lack of thorough investigations and failure to follow established protocols affected multiple residents with varying degrees of cognitive impairment and complex medical histories.
Inaccurate MDS Assessment Coding for Fall and Pressure Ulcer
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one resident. The resident, who was admitted with a history of dysphagia, aphasia following a stroke, chronic obstructive pulmonary disease, and congestive heart failure, had a documented pressure ulcer on the coccyx and sustained a fall resulting in a skin tear to the right hand shortly after admission. Despite these documented conditions, the 5-day MDS assessment indicated that the resident had no falls since admission and no pressure ulcers. The MDS Coordinator, who completed and signed the assessment, did not accurately code these events, as confirmed by interviews and record reviews. The facility's policy required staff to certify the accuracy of each portion of the MDS, and the CMS RAI Manual provided clear coding instructions for falls and pressure ulcers, which were not followed in this case. Further review of the resident's care plan and progress notes confirmed the presence of a pressure ulcer and a fall, both of which were addressed in care planning and interventions. Interviews with the DON, MDS Coordinator, and Administrator revealed that the MDS Coordinator did not clarify the pressure ulcer information with nursing staff and failed to code the fall, despite being aware of both incidents. The inaccuracy of the MDS assessment had the potential to affect the resident's care and care planning, as the assessment did not reflect the resident's actual status.
Failure to Assess and Respond to Change in Condition After Fall
Penalty
Summary
Staff failed to accurately assess and respond to a resident's change in condition following a fall. The resident, who had a history of dysphagia, aphasia, stroke, gastrostomy tube, COPD, atrial fibrillation, atherosclerotic heart disease, and congestive heart failure, was found on the floor after a fall, had vomited twice, and was on anticoagulant therapy. Despite these risk factors, there was no evidence that nursing staff performed a thorough assessment, such as auscultating the lungs or assessing the abdomen, and critical information about the fall and vomiting was not communicated to the provider. Documentation and communication lapses were evident throughout the incident. The nurse practitioner was contacted but was not informed of the resident's fall, and the SBAR form was incomplete, omitting key details such as the fall and the resident's anticoagulant use. The resident continued to receive anticoagulant medication after the fall, and neurological checks were performed, but changes in vital signs and the significance of vomiting were not fully recognized or reported. Multiple staff interviews revealed assumptions that the provider was already aware of the fall, and there was a lack of clarity regarding who was responsible for communicating critical changes. The facility's policies required detailed assessment and prompt, complete communication with providers in the event of an acute change in condition, especially for residents on anticoagulants who experience a fall. However, these protocols were not followed. The resident's deteriorating condition, including elevated pulse, low oxygen saturation, and repeated vomiting, was not adequately addressed, and the provider was not given the necessary information to make informed decisions. Ultimately, the resident was found unresponsive and expired, with staff and providers acknowledging in hindsight that the resident should have been sent to the hospital and that the anticoagulant should have been held.
Some of the Latest Corrective Actions taken by Facilities in Maryland
- Educated all current employees on abuse-investigation procedures to reinforce proper reporting and investigative practices (K - F0610 - MD)
- Educated nurse managers and social workers on conducting abuse investigations to strengthen oversight and response capabilities (K - F0610 - MD)
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse involving four residents. In one instance, a resident with intact cognition and a history of falls reported that a registered nurse physically abused them by grabbing their head and squeezing their arm after a fall. Although staff were informed and some statements were collected, the Director of Nursing (DON) did not initiate a comprehensive investigation, did not suspend the accused nurse, and did not report the incident to the State Survey Agency as required. Witnesses were not fully interviewed, and documentation was incomplete. Another resident alleged that a housekeeper pushed them, an incident witnessed by staff. However, the facility did not perform a skin audit or trauma assessment on the resident, nor did it obtain a written statement from the resident or interview other potential witnesses. The investigation relied on a summary of staff interviews and did not include direct input from the resident or other residents in the area at the time of the incident. A third resident reported that another resident attempted to touch them inappropriately and that subsequent retaliation occurred. Despite the resident self-isolating and reporting the incident to multiple staff members, the facility did not conduct an investigation into the allegation. Additionally, an allegation of verbal abuse made by another resident was not thoroughly investigated, as the facility failed to obtain written statements from staff or residents related to the claim. These failures were contrary to the facility's own policies, which require comprehensive investigation and documentation of all abuse allegations.
Removal Plan
- Obtain statements from involved residents #41, #22 and #33
- Assess residents #41, #22, and #33 to ensure no injuries, physical or psychological, are present
- Suspend RN #20 and Housekeeper #28
- Suspend the administrator and director of nursing
- Obtain statements from the accused employees #20 and #28
- Social Services to meet with involved residents #41, #22 and #33 to address any psychosocial concerns
- Notify responsible parties of residents #41 and #33 of the allegations
- Notify police of the allegations of physical and sexual abuse
- Notify Maryland Department of Health of the allegations of physical and sexual abuse
- Notify Medical Directors of the allegations of physical and sexual abuse for residents #41 and #33
- Notify Ombudsman of the allegations of physical and verbal abuse
- Complete trauma informed evaluations for identified residents #41 and #33
- Educate all current employees regarding investigation of abuse
- Educate nurse managers and social workers on abuse investigation
Elopement of Cognitively Impaired Resident Due to Unsecured Exit
Penalty
Summary
A cognitively impaired resident with a Brief Interview for Mental Status (BIMS) score of 5, indicating severe impairment, and a documented history of exit-seeking behaviors, was able to elope from the facility. The resident had previously been assessed as an elopement risk and was wearing a wanderguard bracelet. Despite these precautions, the resident was observed on camera footage moving from the second floor to the first floor, attempting to exit through a locked door, and then accessing an unlocked service hallway via double doors. The resident subsequently entered an unlocked laundry room, where an exit door without a lock, wanderguard sensor, or alarm provided direct access outside. The laundry door had been left unlocked by a staff member, and at the time, could only be locked with a key. The resident was last seen in the facility around 10 AM after receiving medication. The facility became aware of the elopement only after being notified by the resident's family member, who had been contacted by a bus driver at a nearby metro station. The resident, found at the bus terminal, expressed confusion about their location and requested assistance in returning home. The resident left the bus terminal before the family member arrived and was later located at a hospital in another district, having traveled a significant distance from the facility. Interviews and record reviews confirmed that the resident's care plan included interventions for wandering, such as providing diversions and structured activities. However, the physical security measures in place were insufficient, as the resident was able to bypass locked doors and exit through an unsecured area. The incident was determined to meet the federal definition of Immediate Jeopardy Past Non-compliance due to the facility's failure to prevent the elopement of a resident assessed as high risk.
Removal Plan
- Replaced the laundry entry door with a self-locking door.
- Bolted shut the exit door located inside of the laundry room where the Resident exited the facility.
- Reassessed all elopement risk residents and tested the wanderguard functionality on all residents with wanderguard bracelets.
- Completed in-service education for all staff on elopement, wandering, and monitoring.
- Environmental Service Director (EVS) completed in-service on safety procedure in laundry area.
- Ordered a maglock to secure and lock the double doors of the service hallway and installed it.
- Random audits to be performed on elopement risk residents and staff implementing interventions, with findings submitted to the QAPI committee for review and further recommendations.
- Director of Nursing (DON) and/or Assistant Director of Nursing (ADON) will audit for proper transcription of the wanderguard orders, elopement risk assessment presence, and care plan update for new residents identified to be a risk, with findings submitted to the QAPI committee for review and further recommendations.
- Engineering Director will audit the exit doors to ensure they are always locked, with findings submitted to the QAPI committee for review and further recommendations.
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