Maryland Masonic Homes Ltd

In the surveyor’s words

From the most serious findings on record at Maryland Masonic Homes Ltd, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Oct 21, 2024

  Based on medical record review and interview it was determined that the facility failed to follow the standard of practice of verifying medication doses when ordering and administering medication. This was evident during the review of a facility reported incident where a resident was administered an inappropriate dose of morphine. This was evident for 1 of 3 Residents reviewed (#1) for deaths. This failure resulted in an Immediate Jeopardy for Resident #1. The facility implemented effective and thorough corrective measures following this incident. The facility's plan and action were verified during this survey, therefore this deficiency will be cited as past noncompliance. […]

• No harm, potential for more than minimal, widespreadF880Jun 2, 2025

  3) On 5/27/25 at 10:38AM the surveyor observed Resident #20 from the hallway to be laying on their back in their bed which was in a flat position and also in the highest position, with a hoyer sling situated under them and their foley catheter bag laying on top of their right thigh. No staff was observed by the surveyor to be present within the resident's room or within the hallway. On 5/27/25 at 10:40AM the surveyor conducted an interview of Resident #20 who reported to the surveyor that their nursing assistant had left to get something and they had been laying there for five minutes. Resident #20 stated to the surveyor: It makes me feel helpless. On 5/27/25 at 10:47AM the surveyor observed Geriatric Nursing Assistant (GNA) #25 in the hallway and shared concerns with them. […]

• No harm, potential for more than minimal, widespreadF656May 13, 2021

  Based on record reviews, observation, and staff interview, it was determined that the facility failed to develop and implement comprehensive person centered care plans that were resident specific, with measurable objectives and goals. This was evident for 8 (#57, #25, #31, #54, #369, #9, #36, #26) of 35 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. […]

• No harm, potential for more than minimal, widespreadF812May 13, 2021

  Based on observations of the facility's kitchen food services, and staff interview, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations. This was identified while observing the facility's dish washing machine in operation. The findings include. During the initial environmental kitchen food services inspection on 5/3/21, the Certified Dietary Manager (Staff # 12) in charge of the kitchen revealed that the facility was utilizing disposable dishware as the facility was currently in a COVID-19 outbreak. The trays that held the disposable dishware were the only items for washing in the dish washing machine. […]

• No harm, potential for more than minimal, widespreadF838May 13, 2021

  Based on review of facility records and interview with staff, it was determined the facility failed to revise and document an accurate up-to-date facility-wide assessment. This was evident during review of the sufficient and competent nurse staffing task of the annual survey. This had the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. […]