Sligo Creek Healthcare

In the surveyor’s words

From the most serious findings on record at Sligo Creek Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 21, 2025

  Based on observations, interviews and review of facility reports it was determined that the facility failed to prevent a cognitively impaired Resident with exit seeking behaviors from exiting the facility. This was found to be evident for 1 (resident #5) out of 1 Resident reviewed for an elopement. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy Past Non-compliance.The findings include: Brief Interview for Mental Status (BIMS) is a five-item screening that assesses memory and orientation by asking patients to recall words and state the current year, month, and day. […]

• No harm, potential for more than minimal, widespreadF812Feb 20, 2025

  Based on observation and interview it was determined that the facility failed to have an effective system in place to ensure temperature monitoring of unit refrigerators used to store resident food brought in from outside sources; and facility failed to ensure potentially hazardous food items were cooled according to acceptable standards. This was found to be evident for 3 out of 3 refrigerators observed in resident areas; and during the initial tour of the main kitchen and has the potential to affect all residents. The findings include: 1) Refrigerator temperatures for food storage should be kept at or below 41 degrees Fahrenheit (F). […]

• No harm, potential for more than minimal, widespreadF880Feb 20, 2025

  Based on observation, interviews, and review of medical records and facility policy and procedures it was determined that the facility failed to follow enhanced barrier precautions and perform hand hygiene when indicated; and failed to ensure linens were processed so as to prevent the spread of infection. This was found to be evident for 2 (Resident #19 and #66) out of 24 residents observed during the initial phase of the survey but has the potential to affect all residents. The findings include: 1a)Resident #19 has a care plan, initiated in April 2024, addressing the risk of infection due to the use of a feeding tube. […]

• No harm, potential for more than minimal, patternF812Jun 8, 2026

  Based on observation, and interview with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the kitchen tour of the annual survey. The findings include: A food-contact surface refers to any surface of equipment and utensils that typically comes into contact with food; or from which food may drain, drip, or splash onto food; or a surface that is usually in contact with food. On 06/02/2026 at 8:00 AM, the surveyor conducted a tour of the kitchen alongside the Food Service Director and identified the following deficient practices: The dish plate heating unit was nonfunctional. […]

• No harm, potential for more than minimal, patternF880Jun 8, 2026

  Based on observation, record review, and interview, it was determined that the facility failed to maintain effective infection control practices to prevent the potential spread of infection by 1) allowing clean and dirty laundry to be processed in the same room, and 2) ensuring appropriate infection control practices related to hand hygiene and the handling, storage, and maintenance of medical equipment and clinical devices. This was identified during the annual, recertification, and complaint survey processes and had the potential to affect all residents. […]