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
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severe cognitive and physical impairments, who required staff assistance for mobility, was injured after falling from a wheelchair that lacked leg rests during staff transport. The absence of leg rests, contrary to facility policy, allowed the resident's feet to become caught under the wheelchair, resulting in a forward fall and head injury. The facility did not complete a full investigation or root cause analysis following the incident.
A review of the facility's abuse policy and staff interviews revealed that the policy did not address all required elements, including misappropriation of resident property, abuse prevention, staff training, QAPI coordination, and timely reporting requirements. The policy also failed to prohibit retaliation for reporting suspected abuse, and there was no posted signage informing employees of their rights regarding retaliation.
Surveyors found that the facility did not consistently develop or implement comprehensive, person-centered care plans for three residents. One resident's need for ADL assistance was not addressed in their care plan, another resident's discharge planning lacked documentation of assistance with ALF placement and necessary supplies, and a third resident's urinary incontinence was not included in their care plan despite assessment triggers. The DON and social services staff confirmed these omissions during interviews.
The facility did not report multiple allegations of abuse, neglect, or theft to the state agency or law enforcement within the required timeframes. In several cases, residents reported incidents to staff, but there were delays in notifying facility leadership and external authorities, despite facility policy and regulatory requirements. Interviews confirmed that staff were aware of the reporting requirements, but documentation showed repeated failures to comply.
Staff failed to respond to resident call bells within the facility's required timeframe, with numerous instances of delays exceeding 30 minutes and some over an hour. Additionally, a resident with a PEG tube did not receive prescribed site care, as the order was not documented on the TAR or MAR, and care was not provided as directed by the physician.
A resident who required staff assistance for showering did not receive the scheduled number of showers, with records showing only one shower provided over nearly two months. The resident expressed a desire for more frequent showers, and staff confirmed the lack of documentation for additional showers during this period.
Facility staff did not determine if a resident had an advance directive upon admission, nor did they provide information or assistance regarding advance directives. Later, after the resident was found to lack decision-making capacity, the facility failed to document or identify a surrogate decision maker.
Three residents experienced deficiencies in care: one received an incorrect dose of Carvedilol due to a transcription error and lack of proper admission checks, resulting in hypotension and hospitalization; another was given an antiemetic instead of prescribed nitroglycerin for chest pain, with no assessment or provider notification; and a third did not have required weights obtained or documented as ordered, with no explanation for the omissions.
A resident with a history of blood clots was lowered to the floor by staff, who did not report the incident as a fall. The resident later exhibited swelling and inability to bear weight, leading to hospital transfer and diagnosis of a hip fracture. The responsible party was not notified of the incident until the resident was hospitalized.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Prevent Avoidable Fall Due to Missing Wheelchair Leg Rests
Penalty
Summary
A deficiency was identified when a resident with dementia, polyarthritis, muscle contracture, and severe cognitive impairment experienced a fall resulting in actual harm. The resident was dependent on staff for activities of daily living, including mobility and personal care. The care plan indicated the need for staff assistance and escort to activities. On the day of the incident, the resident was being pushed in a wheelchair by a GNA after breakfast, when the resident fell forward from the wheelchair, sustaining a laceration to the forehead and requiring hospital evaluation. The medical record and staff interviews confirmed that the wheelchair did not have leg rests attached at the time of transport, contrary to facility policy and staff expectations for safe resident transport. Further review revealed that the facility did not complete a summary of the investigation, witness statements, or a root cause analysis for the fall. Interviews with the Director of PT and the DON confirmed the requirement for leg rests when staff transport residents in wheelchairs, but neither could recall the specific incident. The GNA involved could not remember if leg rests were in place and reported that the resident's feet went under the wheelchair, causing the fall. The lack of proper wheelchair equipment and supervision directly contributed to the resident's avoidable fall and subsequent injury.
Abuse Policy Lacks Required Components and Protections
Penalty
Summary
The facility failed to ensure its abuse policy addressed all required regulatory components, as determined by a review of the policy and interviews with staff. The policy lacked a date of initiation or review and, while it included definitions of various types of abuse and some signs of abuse, it did not address misappropriation of resident property. Additionally, the policy did not include provisions for abuse prevention, staff training, or coordination with the Quality Assurance Performance Improvement (QAPI) program. The reporting section of the policy did not meet federal requirements, as it did not specify that allegations of abuse must be reported immediately, but not later than two hours after the allegation is made, to the nursing home administrator and other officials. Furthermore, the policy failed to address the prohibition and prevention of retaliation against individuals reporting suspected abuse. Observations throughout the facility, including employee break areas, revealed that there was no posted signage informing employees of their rights related to protection from retaliation for reporting suspected crimes. The nursing home administrator confirmed the absence of such signage and acknowledged that the abuse policy provided to staff was incomplete in these areas.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for three residents, as evidenced by medical record reviews and staff interviews. One resident, who required assistance with activities of daily living (ADLs) as documented in the Minimum Data Set (MDS), did not have these needs addressed in their care plan. The Director of Nursing (DON) confirmed that the care plan was not comprehensive and did not capture the resident's ADL needs. Another resident, admitted for therapy and with a goal of discharge to an assisted living facility (ALF), had a care plan that only included staff discussing discharge needs with the family. There was no documentation in the care plan regarding assistance with identifying an appropriate ALF placement or obtaining necessary supplies and services for discharge, despite the responsible party's stated goals and the social worker's reported practices. A third resident, who was occasionally incontinent of urine according to the admission MDS assessment, had triggered a care area assessment (CAA) for urinary incontinence, with a decision to address this in a care plan. However, review of the care plans revealed that urinary incontinence was not addressed. The DON confirmed that the care plan did not include interventions for urinary incontinence, despite the CAA indicating it should be addressed. These findings demonstrate that the facility did not consistently develop or implement care plans that addressed all identified resident needs.
Failure to Timely Report Allegations of Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft in a timely manner for multiple residents, as evidenced by record review and staff interviews. In several cases, allegations were either not reported to the state agency within the required timeframe or not reported to law enforcement as appropriate. For example, one resident with complex medical needs, including hydrocephalus and chronic kidney disease, reported an incident involving a blood draw that was perceived as abusive. The DON was notified by the resident’s family, but the incident was not reported to the state agency until two days later, exceeding the required reporting window. Another instance involved a cognitively intact resident who reported theft of money to a receptionist, who then informed the DON. The DON initiated an internal investigation and interviewed staff, but the incident was not reported to the state office until the following day, and law enforcement was not notified. Additional cases included residents reporting abuse or missing money to staff, with delays in both internal notification to facility leadership and external reporting to the state agency. In one case, a resident’s allegation of abuse was reported to an LPN, but the NHA was not notified until two days later, and the state agency was not informed until four days after the initial report. Facility policy required allegations to be reported to the administrator within 24 hours and to state agencies as per regulations, which in some cases is within two hours. Interviews with the NHA and DON confirmed awareness of these requirements, but documentation and investigation records showed repeated failures to meet the mandated reporting timelines. These deficiencies were identified for five residents out of fifteen reviewed for abuse allegations.
Failure to Respond Timely to Call Bells and Provide PEG Tube Site Care
Penalty
Summary
Facility staff failed to provide timely responses to resident call bells and did not ensure proper gastrostomy tube (PEG) site care for a resident. Review of call bell logs over a one-week period revealed 114 instances where call bells were left unanswered for more than 30 minutes, with 31 of those occasions exceeding one hour. The facility's policy required all staff to respond to call lights within a reasonable timeframe, defined by the DON as within 15 minutes, or up to 25 minutes if staff were with another resident. Despite this policy, staff did not consistently meet these expectations, and the facility was unable to demonstrate effective monitoring or identification of trends related to call bell response times. Additionally, a resident with a PEG tube did not receive documented site care as ordered by the physician. The order to cleanse the PEG tube site with soap and water and cover with dry gauze every night shift was not transcribed onto the Treatment Administration Record (TAR) or Medication Administration Record (MAR) for July or August, and no new order was written upon the resident's return from the hospital. Interviews with nursing leadership confirmed that PEG tube care should have been documented and performed according to physician orders, but this was not done, resulting in the resident's PEG tube site being left uncleaned on multiple occasions.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A resident who required staff assistance with activities of daily living, specifically showering, was not provided with the scheduled number of showers. The resident, who had been in the facility since June 2025, expressed a desire for more frequent showers during an interview. Review of the Minimum Data Set (MDS) assessment confirmed the resident's need for staff assistance with showering. Documentation from July to August 2025 showed no showers in July and only one shower in August, despite the resident being scheduled for two showers per week. Staff interviews confirmed the resident's shower schedule and the lack of documentation for showers provided during this period. The Director of Nursing acknowledged that only one shower was documented between July 1 and August 25, 2025.
Failure to Determine Advance Directive Status and Identify Decision Maker
Penalty
Summary
Facility staff failed to determine on admission whether a resident had an advance directive and did not provide information about the right to formulate one. The admission record for the resident showed the section for advance directives was left blank, and there was no documentation indicating that staff had informed the resident of their rights or offered assistance in establishing an advance directive. The resident was noted as being cognitively intact at admission, with a BIMS score of 14, and was listed as their own responsible party. Subsequently, the resident experienced increased confusion and was assessed by two physicians, who determined that the resident lacked capacity to make informed medical decisions. Despite this change in condition, the medical record did not identify who was responsible for making decisions on the resident's behalf or how a surrogate decision maker was determined. When requested, the facility administrator was unable to provide documentation regarding advance directives or the identification of a decision maker for the resident.
Failure to Provide Care According to Physician Orders and Professional Standards
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure, atrial fibrillation, and hypertension was admitted following a hospitalization for dyspnea. Upon admission, the facility transcribed a hospital order for Carvedilol incorrectly, entering it as 25 mg twice daily instead of the intended 12.5 mg (half tablet) twice daily. This error resulted in the resident receiving double the prescribed dose for four administrations, leading to hypotension, acute kidney injury, and a transfer to the hospital. The facility's admission process was not followed, as the required admission checklist and second nurse review were not completed, and the error was not identified by the pharmacist during the admission medication review. Another deficiency was identified when a resident with a history of unstable angina and an order for sublingual nitroglycerin for chest pain reported chest pain during the night. Instead of administering the prescribed nitroglycerin, staff gave the resident an antiemetic (Zofran) and did not assess the resident for a change in condition or notify the attending provider. The resident later requested transfer to the hospital for evaluation of a possible heart attack due to their medical history. A third deficiency involved a resident admitted after a hospitalization, for whom the facility failed to obtain and document weights as ordered. The resident's care plan and physician orders required weights to be taken on admission, on day two, and weekly for four weeks. Documentation showed that weights were not obtained or recorded on the required days, and there was no evidence that attempts were made to obtain the missing weights. The DON was unable to account for the missing documentation or explain why the required weights were not obtained.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the responsible party after a resident experienced a fall. On 8/23/24, a staff member lowered the resident to the floor, but did not consider this a fall and therefore did not report the incident. The resident, who had a history of blood clots, was later observed by a family member to have a swollen left ankle and was unable to stand or put pressure on the foot. Medical assessments, including an x-ray and venous doppler, were performed, and the resident was eventually sent to the hospital where a left hip fracture was diagnosed and surgically repaired. The responsible party was not informed of the fall until several days later, when the resident was already at the hospital.
Some of the Latest Corrective Actions taken by Facilities in Maryland
- Instituted continuous 24/7 visual monitoring of front entrance and inter-level exit doors by designated staff to prevent unauthorized resident elopement (J - F0689 - MD)
- Conducted staff education on the new door-security process changes to ensure all disciplines follow proper exit-control procedures (J - F0689 - MD)
- Initiated daily audits of front-entry and inter-unit door monitoring by the NHA or designee to verify sustained compliance (J - F0689 - MD)
- Established QAPI review of audit results for ongoing recommendations and corrective actions (J - F0689 - MD)
- Consulted a security company and obtained senior-technician assessment of door-security options to enhance alarm and notification systems (J - F0689 - MD)
Failure to Prevent Elopement of Cognitively Impaired Residents Due to Ineffective Monitoring and Alarm Systems
Penalty
Summary
The facility failed to maintain an effective system to prevent residents with cognitive impairments from leaving the premises without appropriate supervision. Two residents with known exit-seeking and elopement behaviors were able to leave secure areas of the facility undetected. One resident, who had a history of severe cognitive impairment and multiple prior elopement incidents, was able to exit the building after dinner and was found outside near the facility van. The WanderGuard system, which was intended to alert staff and prevent such incidents, did not trigger an alarm when the resident exited, and only recorded an event when the resident was escorted back inside. Staff documentation for this incident was also found to be mixed with records from a previous year, and no new elopement evaluation was completed after the incident. Another resident, also with severe cognitive impairment and a history of wandering, was found in the assisted living library after having previously eloped from the nursing home building. This resident had a WanderGuard bracelet in place, but the system failed to alarm when the resident passed through a monitored door. The alarm only activated when the resident was brought back through the door by staff. Interviews with facility leadership and maintenance staff revealed that the WanderGuard alarm system's audio alert was faint and not easily heard from a distance, and that the system was not integrated with staff phones, relying instead on pagers for notification. Observations confirmed that the physical environment outside the main entrance posed multiple hazards, including active roadways and parking areas. The facility's elopement evaluation process was found to be inadequate, as it was only used to determine the need for a WanderGuard and not updated after each incident. Staff interviews confirmed a lack of understanding regarding the need for post-incident evaluations. The combination of ineffective monitoring, unreliable alarm systems, and insufficient post-incident assessment contributed to the failure to provide adequate supervision and prevent accidents for residents at high risk of elopement.
Removal Plan
- A team member will be present monitoring the front entrance doors at nursing desk and the door exiting the healthcare center level of living and entering assisted level of living 24 hours a day, 7 days a week to ensure constant visual monitoring of individuals exiting the community until a mechanism is installed to create immediate notification to community staff for unauthorized exits.
- Install a mechanism to create immediate notification to community staff for unauthorized exits.
- Consult a security company to explore solutions to increase door security related to unauthorized exits and have a senior technician assess the situation.
- Educate current community staff of all disciplines on the immediate process change related to door security.
- Audit the front entry door monitoring and door between assisted living and nursing home daily by NHA or designee.
- Submit audit results for review and recommendation to the Quality Assurance Performance Improvement Committee.
Explore Popular Searches
