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
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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