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 did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Surveyors found that the facility failed to develop and implement comprehensive care plans for two residents. One resident used a motorized wheelchair and had a documented safety assessment and an ED note describing a leg injury that occurred while using the device, yet the care plan contained no documentation or interventions related to motorized wheelchair use. Another resident had a documented diagnosis of PTSD and a history of childhood sexual abuse, and while the care plan noted trauma as a focus, it listed no specific interventions to address PTSD or the trauma history.
Surveyors identified that the facility failed to revise person-centered care plans after significant changes in two residents’ conditions. For one resident, the MOLST and paper chart were updated from Full Code to DNR-B with No CPR and palliative/supportive care orders, but the care plan continued to list the resident as Full Code. For another resident who sustained a fall with injuries and was sent to the ER, the existing fall-prevention care plan was not updated to reflect the incident or any new interventions, and no timely review was documented. During interviews, the rehab director reported that therapy provides recommendations after falls but does not revise care plans, and the DON and regional administrator confirmed that no care plan revisions or fall investigation documentation were available.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Develop Comprehensive Care Plans for Motorized Wheelchair Use and PTSD
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive care plans for two residents. For one resident who used a motorized wheelchair, interviews with the DON, Administrator, and Occupational Therapist confirmed that the resident had a power mobility device and that a safety assessment for its use had been completed by therapy. The resident’s medical record included an Emergency Department physician note documenting the resident’s report that they were in their motorized wheelchair when they sustained a leg skin tear or laceration after running into their bed. The facility’s matrix and records showed the resident had been admitted and later discharged, and a power mobility indoor driving assessment dated several months prior was provided. Despite this information and the confirmed use of a motorized wheelchair, review of the resident’s care plan showed no documentation addressing the resident’s use of a motorized wheelchair. For another resident, record review showed documentation in the facility matrix and in a Quarterly MDS that the resident had a medical diagnosis of post-traumatic stress disorder (PTSD) and a history of trauma related to childhood sexual abuse. The resident’s care plan focus reflected this trauma history; however, the only listed intervention for that focus was the word “trauma,” with no specific interventions identified to address the PTSD diagnosis or trauma history. During an interview, the Nursing Home Administrator was informed that the resident had a PTSD diagnosis, but the surveyor could not locate any detailed interventions in the care plan beyond the generic trauma notation.
Failure to Revise Care Plans After Code Status Change and Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure person-centered care plans were timely updated and revised by the interdisciplinary team following significant changes in residents’ status and events. For one resident, a social services note documented that the Maryland MOLST was reviewed and changed from Full Code to DNR-B on a specified date, and the paper chart contained a MOLST form with orders for No CPR, Option B, Palliative and Supportive Care. However, the resident’s care plan still contained a focus stating that the resident’s Full Code MOLST would remain in place through the review date, and this care plan was not revised to reflect the updated code status. During record review with the Nursing Home Administrator, it was confirmed that the MOLST had been updated but the care plan had not been revised accordingly. The deficiency also includes the facility’s failure to revise a resident’s care plan after a fall event. A progress note by an LPN documented that another resident experienced a fall, sustained several injuries, and was transferred to the emergency room. Review of this resident’s care plan showed that no revisions were made to the existing fall interventions in response to the fall, and the care plan was not documented as reviewed and revised until a later date. During interviews, the Director of Rehabilitation stated that therapy makes recommendations and sees residents after falls but does not revise the care plan and was unsure if nursing was responsible for care plan revisions. The DON and Regional Administrator confirmed that no care plan revisions had been made in response to the fall and that there was no recollection or documentation of a fall investigation.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Some of the Latest Corrective Actions taken by Facilities in Maryland
- Implemented a Leave of Absence (LOA) pink form process requiring the front desk to be notified before a resident left the building to strengthen monitoring of resident exits (J - F0689 - MD)
- Re-educated staff on elopement prevention protocols and the LOA form process to reinforce required prevention steps (J - F0689 - MD)
- Reviewed and reinforced elopement policies and procedures with all staff to support consistent implementation of prevention measures (J - F0689 - MD)
- Conducted ongoing audits of the elopement binder for accuracy to ensure at-risk residents were correctly identified and tracked (J - F0689 - MD)
- Conducted ongoing reviews of LOA documentation for compliance to verify adherence to the resident-leave notification process (J - F0689 - MD)
- Conducted random resident audits to ensure elopement risk assessments and interventions were in place (J - F0689 - MD)
- Reviewed audit results in the QAPI program and addressed identified issues promptly with corrective action to provide ongoing oversight and system response (J - F0689 - MD)
Failure to Supervise Exit-Seeking Resident Resulting in Unnoticed Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implement appropriate interventions to prevent elopement for a resident with known exit-seeking behaviors. On nursing admission, the resident was documented as exhibiting exit-seeking behavior, and later assessments showed dementia with a low BIMS score of 5, impaired communication, unsteady gait, muscle weakness with difficulty walking, and dependence on staff for most ADLs while using a wheelchair for locomotion. Despite this, the resident’s care plan did not address wandering behaviors until more than two months after admission, and the facility’s elopement prevention policy called for interdisciplinary planning, environmental modifications, monitoring, and identification of at-risk residents, which were not effectively implemented for this resident prior to the incident. On the date of the elopement, the resident, who frequently moved up and down the hall in a wheelchair and often expressed a desire to go home, asked an Environmental Service Aide (ESA) to go outside. The ESA, who had been employed less than two weeks and had not been trained in elopement prevention, opened a door and allowed the resident to exit the building. The resident later reported calmly to the NP that they had waited at the back door until an opportunity arose and left when the person nearby stepped away, and also reported losing balance and falling while leaving the building. Staff interviews confirmed that the resident was able to self-propel in a wheelchair but could not walk long distances without it. Following the resident’s departure, facility staff were unaware that the resident had eloped and there was no documentation indicating that the resident was unaccounted for over an approximate eight-hour period between early afternoon and late evening. The resident ultimately ended up at a local police department after being found by a citizen near a busy street and was then sent to a hospital. The DON acknowledged that the last progress note for that day only documented the resident’s lunch and independent eating, with no entries reflecting the resident’s absence during the subsequent hours. Interviews with the Maintenance Director and other staff confirmed that the resident often tried to leave and wanted to go home, yet the supervision and interventions in place did not prevent the elopement event.
Removal Plan
- Implemented a 100% headcount immediately following the elopement incident.
- Assessed Resident #16 immediately upon return from the hospital.
- Placed Resident #16 on 1:1 supervision.
- Ordered labs for Resident #16.
- Completed a full-body skin assessment for Resident #16.
- Placed a wander guard on Resident #16's right wrist.
- Updated the order to reflect wander guard use for Resident #16.
- Updated Resident #16's care plan.
- Updated the elopement binder to include Resident #16.
- Reviewed and revised Resident #16's elopement risk assessment to ensure accuracy and appropriate interventions.
- Completed an elopement drill on each shift.
- Educated staff regarding elopement and obtained staff statements.
- Reviewed all residents for elopement risk.
- Completed and/or updated elopement assessments for current residents.
- For residents identified at risk: obtained wander guard orders, applied wander guards, updated care plans, and initiated behavior monitoring.
- Audited and updated the facility elopement binder to ensure all at-risk residents are accurately identified and tracked.
- Implemented system-wide interventions, including applying wander guards to identified at-risk residents.
- Implemented a Leave of Absence (LOA) pink form process requiring the front desk to be notified before a resident leaves the building.
- Re-educated staff on elopement prevention protocols and the LOA form process.
- Reviewed and reinforced elopement policies and procedures with all staff.
- Conducted ongoing audits of the elopement binder to ensure accuracy.
- Conducted ongoing reviews of LOA documentation for compliance.
- Conducted random resident audits to ensure elopement risk assessments and interventions were in place.
- Reviewed audit results in the QAPI program and addressed identified issues promptly with corrective action.
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