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
Surveyors found that two residents did not receive care and treatment in accordance with professional standards, including lack of documentation before administering Nitroglycerin and inconsistent skin assessments leading to delayed wound care for a resident with MASD and a stage 3 pressure ulcer. Staff interviews confirmed documentation errors and delays in notifying practitioners and implementing wound care orders.
A resident with dementia and behavioral disturbances exhibited worsening agitation and wandering, but staff failed to assess or document these behaviors or implement behavior monitoring, relying instead on verbal reports. The DON confirmed that required documentation was missing from the medical record.
A resident with severe cognitive impairment and high elopement risk was able to access an unsecured mechanical/boiler room after staff failed to ensure laundry and mechanical room doors were locked when unattended. The resident was found on the floor with minor injuries, and staff and maintenance interviews indicated the doors were likely propped open, allowing unauthorized access.
Several residents who required assistance with ADLs and had limited mobility were found without access to a working call light system in their rooms and bathrooms. Despite facility policy requiring accessible call lights and prompt reporting of malfunctions, multiple work orders for broken call lights were left unresolved, and no manual call bells were provided. Staff and maintenance were aware of the ongoing issues, but residents remained unable to reliably summon help when needed.
Three residents experienced unsanitary and uncomfortable living conditions due to the facility's failure to replace a damaged, leaking commode toilet and to maintain cleanliness in resident rooms and bathrooms. Persistent odors, visible contamination, and delayed maintenance were observed, with staff and administration aware of the ongoing issues.
Multiple residents experienced prolonged periods of cold temperatures in their rooms and common areas due to ongoing heating system failures. Residents reported discomfort, needing extra blankets and clothing, and avoiding activities because of the cold. Staff interviews and documentation confirmed that heating repairs were delayed by incorrect parts and incomplete fixes, resulting in inadequate heating throughout the facility.
Multiple residents did not receive medications as ordered due to improper administration techniques, lack of medication availability, and inaccurate documentation. Staff were observed extracting insulin from pens using syringes instead of pen needles, using unlabeled medication containers, and failing to notify physicians when medications were unavailable. The DON was unaware of these practices, and the pharmacist confirmed that the methods used were not appropriate.
Three residents did not receive their prescribed medications as ordered, including a topical analgesic, a pain-relieving patch, an iron supplement, and an oral diabetes medication. In some cases, the correct medication was not available or was substituted with a different product, and in others, the nurse failed to administer the medication as ordered.
Surveyors identified an 11% medication error rate after observing multiple failures, including missed doses, incorrect medication administration, and improper handling of medications by nursing staff. Errors included not administering prescribed pain relief, antihypertensive, iron supplement, and diabetes medications, as well as substituting the wrong topical medication. Staff interviews confirmed these actions did not follow physician orders.
An opened Humalog insulin pen was found on a medication cart with only a handwritten room number and lacking required labeling such as patient name, physician name, and date opened. An LPN confirmed using the unlabeled pen for insulin administration, contrary to facility policy and pharmacy standards that require full labeling of all insulin pens.
Failure to Document Assessments and Timely Wound Care Interventions
Penalty
Summary
Surveyors identified deficiencies related to the facility's failure to accurately document assessments and ensure residents received treatment and care in accordance with professional standards. For one resident, Nitroglycerin was administered on multiple occasions without documentation of symptoms or assessments prior to administration. Interviews with the DON and an LPN confirmed that any change in condition, such as chest pain, should be documented in the electronic medical record, and that all steps taken in response to unusual symptoms should be recorded. However, the medical record lacked this required documentation. Another resident was found to have inconsistencies in skin assessment documentation within 24 hours of readmission. The admitting nurse documented intact skin, while subsequent assessments by the wound care nurse and nurse practitioner identified a stage 3 pressure ulcer and Moisture Associated Skin Damage (MASD) on the left buttock. The wound care nurse later explained that there was a user error in documentation, resulting in inaccurate records. Additionally, there was no evidence that the facility notified the resident's primary care practitioner of the wound upon readmission or that wound care treatment was initiated at that time, despite recommendations from the nurse practitioner. Wound care orders were not implemented until several days after readmission. Review of the GNA flowsheet and interviews with staff revealed further discrepancies, as documentation indicated no skin impairment for several days, despite clinical notes to the contrary. The facility's process for admission and wound care assessment was described by staff, but the records showed that required assessments and timely interventions were not consistently completed or documented. The DON confirmed that the hospital discharge summary did not indicate a wound, yet the resident developed significant skin impairment shortly after readmission, with delayed initiation of appropriate wound care.
Failure to Assess and Document Behavioral Health Needs
Penalty
Summary
The facility failed to assess or document the behaviors of a resident diagnosed with dementia with behavioral disturbance. Despite the resident exhibiting worsening agitation, wandering, and behaviors such as entering other residents' rooms and touching their belongings, there was no documentation or behavior monitoring order in the medical record. The resident was prescribed medications for behavioral health needs upon admission, but the facility did not implement or record any behavior monitoring as required. Interviews with facility staff revealed that information about the resident's behavioral issues was communicated verbally rather than documented. The Psychiatric Nurse Practitioner confirmed awareness of the resident's aggressive behaviors through verbal reports only, and the DON acknowledged that behavior monitoring should have been documented in the Treatment Administration Record. Upon review, the DON verified the absence of any assessment or documentation of the resident's behaviors in the medical record.
Failure to Secure Laundry and Mechanical Room Doors Resulting in Resident Injury
Penalty
Summary
Facility staff failed to ensure that the doors to the laundry room and mechanical/boiler room were locked when unattended, resulting in unauthorized access by a resident. On the evening of the incident, a Geriatric Nursing Assistant (GNA) was unable to locate a resident during evening care. After a search, the resident was found in the mechanical/boiler room, sitting on the floor near their wheelchair. The resident sustained a skin tear/laceration on the left shin and bruises on the left forearm and right elbow. The resident involved had a history of cognitive impairment, including diagnoses of Adjustment Disorder, Cognitive Communication Deficit, Delusional Disorders, and late-onset Alzheimer's Disease. The resident was assessed as high risk for elopement, with a severely impaired BIMS score. The resident used a wheelchair for mobility and had a care plan addressing elopement risk, wandering, and impaired safety. At the time of the incident, the resident could not recall how they entered the mechanical room and was disoriented, searching for a deceased spouse. Observations and interviews revealed that the laundry room doors were designed to lock automatically when closed, requiring a keypad code for entry, while the mechanical/boiler room door required a key from the laundry room side but did not automatically lock. Staff statements and maintenance inspection indicated that the doors were likely propped open, allowing the resident to access the unauthorized area. There was no evidence of mechanical malfunction with the door locks at the time of the incident.
Failure to Maintain Functional Call Light System in Resident Rooms
Penalty
Summary
The facility failed to provide a functioning call light system in resident bathrooms and bathing areas, as required by policy, for three residents. The policy mandates that each resident must have access to a call light at the bedside, toilet, and bathing area, with calls relayed directly to staff or a centralized location to ensure timely response. Staff are instructed to report any call light issues immediately and provide alternative solutions until repairs are made. However, multiple work orders for broken call lights remained unaddressed, and no manual call bells were provided in affected rooms. One resident, admitted with diagnoses including infectious gastroenteritis, congestive heart failure, and diarrhea, required assistance with activities of daily living (ADLs) due to limited mobility. This resident's call light was found detached from the wall, with no manual call bell available, making it difficult to summon staff when help was needed. Another resident, who was cognitively intact and dependent on staff for ADLs, reported that the call light in their shared room had not worked for four months, and no manual call bell was present. This resident also expressed concerns about staff responsiveness due to the ongoing issue. A third resident, also dependent on staff for ADLs and identified as a fall risk, was found in a room where both call lights were nonfunctional. Staff were unaware of the broken call lights until the time of observation and interview. The maintenance director acknowledged awareness of the issue and difficulties in obtaining replacement parts, while the administrator and DON were informed of the ongoing problems. Despite the facility's policy and the residents' needs, the lack of a working call system persisted, leaving residents without a reliable means to request assistance.
Failure to Maintain Sanitary and Functional Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for three residents. One resident, who was dependent on staff for all activities of daily living and had diagnoses including spastic quadriplegic cerebral palsy and spinal stenosis, was observed in a room with several dark spots, dried food droppings, and black and brown substances on the walls. The resident reported that the facility did not adequately clean the room or walls. Two other residents, one with unspecified dementia and chronic kidney disease requiring substantial to maximum assistance with personal hygiene, and another with end stage renal disease and a history of falls who was independent with ADLs, experienced ongoing issues with a damaged and leaking commode toilet in their shared bathroom. Both residents reported strong, persistent odors and visible contamination in the bathroom, including black and brown substances on the stool area, stained and discolored floor tiles, and a pervasive smell of urine and human waste. One resident stated the issue had persisted for over two months, leading them to use staff bathrooms instead. Interviews with the Housekeeping Director and Maintenance Director confirmed that the bathroom required significant repairs, including floor and toilet replacement, and that the odor could not be eliminated despite repeated cleaning. Both directors indicated that the administrator was aware of the ongoing plumbing and maintenance issues, which had been present for several months. A private plumber's work order documented repairs to the toilet bowl and recommended further replacement of toilet bolts and pipes.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures for multiple residents, as evidenced by observations and interviews. Temperatures in several resident rooms and common areas were recorded as significantly below standard comfort levels, with some rooms as low as 37.7 to 66 degrees Fahrenheit. Residents reported that the facility had been cold for an extended period, with some stating the issue had persisted since Thanksgiving and even over the past three years. Residents described needing to use extra blankets, wear hoodies, and avoid activities due to the cold conditions in their rooms and common areas. Interviews with residents confirmed ongoing discomfort, with several stating that the cold was unbearable and that they had to rely on family members to bring additional blankets or space heaters. The Resident Council president noted that activities were not being held because the activity room was too cold, and residents had to sleep in thick clothing and multiple blankets. Observations corroborated these statements, with residents seen bundled in blankets and expressing dissatisfaction with the facility's temperature. Staff interviews and documentation revealed that the facility's heating system had been malfunctioning, with one boiler out of service and issues with newly installed rooftop units. Delays in obtaining and installing the correct parts, as well as incomplete repairs, contributed to the prolonged period of inadequate heating. Temporary measures, such as rental heaters and providing hot beverages, were implemented, but these did not fully resolve the issue, as residents continued to report discomfort and low temperatures persisted in various areas of the facility.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to provide medication administration that meets professional standards for five of eight sampled residents. For one resident with diabetes, staff were observed extracting insulin from an insulin lispro kwikpen using an insulin syringe, rather than the manufacturer-recommended pen needles. Multiple nursing staff confirmed this practice, citing a lack of compatible safety needles in the facility. The insulin pens used were also not properly labeled with the resident's name, dose, or route, only displaying handwritten dates and room numbers. Staff interviews revealed that this practice had been ongoing for several months, and the central supply manager had instructed staff to use insulin syringes due to supply shortages. The facility pharmacist confirmed that extracting insulin from pens with syringes is not appropriate and can damage the pen, potentially leading to dosing errors. Another resident with a prescription for a topical analgesic did not receive the medication as ordered, despite documentation indicating it had been administered. The nurse responsible stated she thought she had given the medication but had not. For a resident prescribed amlodipine for hypertension, the nurse withheld the medication due to low blood pressure, placed the tablet in an unlabelled medicine cup, and stored it in the medication cart with only a room number written on it. The nurse later administered the medication without a new physician order and could not recall if the resident's blood pressure had increased. The medication administration record did not reflect that the medication was given as ordered. Two additional residents did not receive their prescribed medications (vitron-C and Jardiance) because the medications were not available in the facility. The nurse did not notify the physician about the missed doses. The Director of Nursing confirmed that the affected residents should have received their medications as ordered and that documentation should be accurate. The DON was not aware that staff were using insulin syringes to extract insulin from pens.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to administer medications as ordered by physicians for three residents. One resident with a history of seizures, hypertension, diabetes, and dysarthria did not receive a prescribed topical analgesic (Biofreeze) to the right shoulder as ordered. During observation, the assigned nurse did not administer the medication and later stated she thought she had done so. Another resident with polyneuropathy, diabetes, osteoarthritis, knee pain, vitamin D deficiency, and anemia did not receive a prescribed Salonpas pain relieving patch (lidocaine) to the knees or a Vitron-C tablet for anemia. The nurse on duty administered a different medication (lidocaine and prilocaine cream) instead of the prescribed patch and did not administer the Vitron-C tablet, citing unavailability of the medication. A third resident with diabetes, osteomyelitis, and peripheral vascular disease did not receive a prescribed Jardiance oral tablet for diabetes, as the medication was not available at the time of administration. Both the pharmacist and the Director of Nursing confirmed that these residents should have received their medications as ordered. The deficiencies were identified through record review, medication administration observations, and staff interviews.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11% with 5 errors out of 43 opportunities. Specific incidents included a nurse failing to administer a prescribed topical analgesic to a resident as ordered, and another nurse not administering an antihypertensive medication due to low blood pressure, subsequently storing the medication in an unlabelled cup in the medication cart and later administering it without confirming the resident's blood pressure status. Additionally, a nurse administered the wrong topical medication to a resident, substituting a lidocaine and prilocaine cream for a prescribed lidocaine patch. Two further errors involved the non-administration of prescribed medications (an iron supplement and a diabetes medication) due to unavailability, with staff confirming that the residents did not receive these medications as ordered. Interviews with staff and the pharmacist confirmed that all residents should receive medications as per physician orders, and the Director of Nursing also acknowledged this expectation. The observed failures included both omissions and incorrect administration of medications, as well as improper medication handling and storage practices, directly contributing to the elevated medication error rate identified during the survey.
Unlabeled Insulin Pen Found on Medication Cart
Penalty
Summary
Surveyors observed that an opened and used Humalog (insulin lispro) pen was stored on the West Wing Medication Cart without a label indicating the patient name, physician name, or date used. The only identifying mark on the insulin pen was a room number handwritten with a black marker. Staff Nurse #6 confirmed that he administered insulin using this unlabeled pen and believed that the room number was sufficient for identification. The facility's policy, as provided by the Director of Nursing, requires that insulin pens be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. Further interviews with the Director of Nursing and the pharmacy consultant confirmed that all insulin pens must be labeled with the patient's name, physician name, and date opened. The pharmacy consultant also stated that any opened, unlabeled insulin pens should not be used and that the facility should notify the pharmacy to order a new, properly labeled pen. The failure to label the insulin pen as required by both facility policy and professional standards led to the identified deficiency.
Some of the Latest Corrective Actions taken by Facilities in Maryland
- Educated all clinical nursing and agency staff to access active MOLST forms in Point Click Care during code events (J - F0678 - MD)
Failure to Honor Residents' Advance Directives for CPR Due to Inadequate MOLST Management
Penalty
Summary
The facility failed to have a process in place to ensure that residents' choices regarding cardiopulmonary resuscitation (CPR), as documented in their Maryland Orders for Life-Sustaining Treatment (MOLST) forms, were honored. This deficiency was identified through record review and staff interviews, which revealed that staff were unclear about where to locate the active MOLST forms in the electronic medical record. Multiple staff members reported different methods for determining code status, including checking the information bar, reviewing uploaded documents, or referencing daily assignment sheets. However, there was no standardized procedure, and it was noted that retrieving the correct information could be time-consuming. For one resident, two active MOLST forms were found in the medical record: one indicating full code status and another, more recent, indicating no CPR. The older form was not voided, and conflicting physician orders were present in the system. When the resident was found unresponsive, CPR was initiated by staff, and it was only after EMS arrived and reviewed the paperwork that the resident's wish for no CPR was discovered. Staff failed to document the time CPR was started, and interviews revealed a lack of recall about the incident and confusion regarding the correct code status at the time of the event. An audit following the incident identified other residents with multiple active MOLST forms and conflicting code status orders. A similar incident occurred with another resident who had an active MOLST indicating no CPR, but this document was not uploaded into the record until after a conflicting full code order had been entered and remained active. When the resident coded, CPR was initiated despite the resident's documented wishes. Staff interviews and review of statements failed to clarify where the nurse checked for code status before starting CPR, and it was confirmed that two active MOLST forms were present in the record at the time. These failures led to the declaration of Immediate Jeopardy due to the facility's inability to ensure residents' advance directives were followed.
Removal Plan
- The facility completed audit of all MOLST forms and code status orders to ensure they matched.
- Any discrepancies identified were corrected upon discovery.
- The audit was completed by the Assistant Director of Nursing.
- All clinical nursing staff in the facility, including agency staff, were educated on ensuring that when a code event occurs, they are to look in Point Click Care under documents and filter for category MOLST for the active MOLST.
- Any staff not available will be educated prior to beginning their next scheduled shift to include active agency staff.
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