Manokin Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Manokin Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Aug 11, 2023

  Based on observation and interview with facility staff, it was determined that the facility failed to remove expired food items and label opened stored food items and in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility kitchen. The findings include: Surveyors conducted an initial brief tour of the kitchen on [DATE] with and identified: - Three unopened 6-lb cans of marinara sauce without an expiration date - Five bags of unopened hot dog buns with an expiration date on [DATE] - 50 Resident food trays were rusty around the trim and cracked - 10 Blue domed plate covers, and plate holders, were cracked and missing pieces The surveyor conducted a second tour of the kitchen… […]

• Immediate jeopardy, isolatedF600Apr 1, 2026

  Based on interview, record review, document review, and facility policy review, the facility failed to protect a resident's right to be free from physical and verbal abuse by staff for 1 (Resident #3) of 10 sampled residents reviewed for abuse. It was determined the non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation, at a scope and severity of J.The IJ began on 02/05/2026 when the Administrator verbally and physically abused Resident #3.The survey team notified the Administrator and Director of Nursing of the IJ and provided the IJ template on 03/24/2026… […]

• Immediate jeopardy, isolatedF600Sep 26, 2025

  Based on the review of facility reported incident # 2602973, medical records, facility documentation, interview with facility staff, and observation, it was determined that the facility failed to 1) protect a cognitively impaired resident (Resident #50) from physical abuse by a resident (Resident #21) with a known history of verbal and physical aggression towards staff and residents. This was evident for 1 (Resident #50) of 4 residents reviewed for abuse during the annual survey. 2) In a separate occurrence, not Immediate Jeopardy, the facility also failed to prevent resident to resident physical abuse. This was evident for 1 of 3 (Resident #93) reviewed for behaviors during the annual survey. […]

• Immediate jeopardy, isolatedF600Aug 11, 2023

  Based on clinical and administrative record reviews, and interviews, the facility failed to protect residents' right to be free from physical abuse by other residents. The facility's failure to implement adequate interventions for a resident (#79) to prevent recurring resident-to-resident abuse placed residents at risk for serious harm. This finding was evident for 3 of 9 residents (#62, #22, and #6) reviewed for abuse. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 6:08 PM on 8/7/23. On 8/7/23 8:42 PM The facility submitted an abatement plan to remove the immediacy while surveyors were onsite. […]

• Actual harm, isolatedF689Aug 11, 2023

  Based on clinical record review and staff interviews, it was determined that the facility staff failed to ensure adequate supervision while positioning a resident in bed during the provision of care. This deficient practice resulted in harm for Resident #212. This was evident for 1 (#212) of 14 residents reviewed for accidents. The findings include: On 08/08/2023, a record review was conducted which revealed that Resident #212 had diagnoses which included, but were not limited to, left femur fracture, stroke and hemiplegia affecting his/her left non-dominant side. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body. The MDS (Minimum Data Set) is a screening tool that is utilized to ensure each resident's individual needs are identified. […]