Maryland Gardens Post Acute

In the surveyor’s words

From the most serious findings on record at Maryland Gardens Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF600Jul 2, 2026

  Based on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of 7 of 15 residents sampled (#6, #19, #22, #65, #66, #76, and #77) to be free from physical and verbal abuse between residents. The deficient practice could result in resident injury, psychological, or behavioral harm as well as continued resident to resident abuse.Findings include:Regarding Resident #66 and Resident #65:-Resident #66, the alleged victim, was re-admitted [DATE] with diagnoses that included major depressive disorder, mood disorder, cerebral infarction, aphasia, vascular dementia with behavioral disturbances, Schizoaffective disorder depressive type, and bipolar II disorder. […]

• No harm, potential for more than minimal, patternF684Jul 2, 2026

  Based on clinical record review, resident and staff interviews, facility documentation, and policy review, the facility failed to ensure one resident (#27) received pain medication per physician ordered parameters. The deficient practice placed the resident at risk for receiving medication outside physician-prescribed parameters, which could result in unnecessary medication exposure and adverse drug reactions. The universe was 18 and the sample size was 6.Findings include:Resident #27 was admitted on [DATE], with diagnoses including rheumatoid arthritis, extrapyramidal and movement disorder, muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility.A physician order dated June 18, 2025, revealed an order for Sulindac Tablet 200 mg, one tablet by mouth two times a day at… […]

• No harm, potential for more than minimal, patternF812Jul 2, 2026

  Based on observations, staff interviews, and facility policy, the facility failed to ensure multiple food items were stored, labeled, and dated in accordance with professional standards, and failed to wash, rinse, and sanitize dishware in accordance with the manufacturer's instructions. The deficient practice places residents at risk for complications from foodborne illness. The universe was 79. Findings include:An initial observation of the kitchen was conducted on June 29, 2026, at 8:11 A.M with the Dietary Manager (Staff #57). […]

• No harm, potential for more than minimal, patternF920Jul 2, 2026

  Based on dining observations and interviews, the facility failed to have sufficient space to accommodate all dining activities. The deficient practice resulted in residents not having a dining area that accommodates residents' physical needs. The census was 79.Findings include:An observation was conducted on June 29, 2026 between 11:52 A.M. and 12:25 P.M. The facility had one dining room for residents residing in the long-term care unit. The dining area had one small area to accommodate six residents who needed assistance with their eating. Within this small space, there was one large dining table to accommodate the six residents sitting across from each other and one on each end. The table sat approximately 2 feet from the kitchen counter where staff picked up resident meals. […]

• No harm, potential for more than minimal, patternF558Dec 4, 2024

  Based on observations, clinical record reviews, interviews and policy review, the facility failed to ensure an accessible bathroom was readily available for resident use for two residents (#34 and #46); and, failed to ensure that the bathroom of two residents (#23 and #28) were not used by other residents. The deficient practice could result in residents not receiving necessary assistance to help maintain their independence. The Census was 55. Findings include: -Resident #34 was admitted on [DATE] with diagnoses of hypertension, cerebrovascular accident, depression and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. […]