Solomons Nursing and Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Aug 29, 2024

  Based on resident and staff interviews, review of facility grievance logs, and resident medical records it was determined that the facility failed to protect residents from physical and verbal abuse. This finding was evident for 3 out of 9 residents (#58, #291, and # 18) 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 6:00 PM on 8/23/24. The facility submitted an abatement plan to remove the immediacy while surveyors were on site. The abatement plan was accepted by the OHCQ at 11:30 PM on 8/23/24. The findings include: 1. […]

• Actual harm, isolatedF689Jul 10, 2026

  Based on record review and staff interviews, the facility failed to ensure that the supervision and behavioral interventions implemented for Resident #11 were sufficient to prevent a resident-to-resident altercation. This was evident for 1 of 2 residents reviewed for accidents (Resident #11) and resulted in harm to Resident #9.The findings include:Review conducted on 7/8/26 at 2:06 p.m. of the facility-reported incident dated 3/27/26 revealed that witnesses observed Resident #11 push Resident #9 while Resident #9 was standing, causing Resident #9 to fall to the floor. […]

• Actual harm, isolatedF687Aug 29, 2024

  Based on record review, review of hospital records, and interviews, it was determined that the facility failed to provide adequate treatment for an identified foot concern that resulted in harm to the resident. This was found evident in 1 (Resident # 296) out of 1 resident reviewed for foot care. The findings include: On 8/14/24 at 12:22 PM, the surveyor reviewed Resident #296's medical record. The review revealed that Resident #296 was admitted to the facility in early 2017 and had a past medical history that included, but not limited to, type 2 diabetes mellitus with diabetic neuropathy (nerve damage), hyperlipidemia (too many lipids/fats in blood which can clog arteries) and dementia. […]

• No harm, potential for more than minimal, widespreadF804Feb 2, 2026

  Based on observations and interviews with facility staff, it was determined that the facility failed to ensure that meals were delivered to residents at safe and palatable temperatures. This was evident for 1 (Resident #6) out of 1 resident during test tray and tray service line temperature observations. This practice has the potential to affect all residents who receive meals prepared by the facility. The findings include: Hot food must be served at 135 F (57 C) or above. Cold food must be served at 41 F (5 C) or below. All foods must be stored, held, and served at these temperatures to ensure safety, prevent bacterial growth, and maintain palatability. […]

• No harm, potential for more than minimal, widespreadF812Feb 2, 2026

  Based on observations and interviews with facility staff, it was determined that the facility failed to store food in a manner consistent with professional standards for food service safety. This was evident in 2 of the 3 kitchen observations conducted during the recertification survey.The findings include: During the initial tour of the main kitchen conducted on 01/22/2026 at 8:028 AM the Surveyor and Food Service Director (FSD) observed the following expired food items in the dry storage area: 1 bottle Imperial Ground Allspice, expired 11/10/2020; 1 bottle Imperial Fancy Spanish Paprika, expired 9/14/2024; 2 bottles Imperial Ground Allspice, expired 1/12/2022; 1 bottle Italian Seasoning, expires 9/15/2025; 1 bottle Crushed Red Pepper, expired 1/31/2024; 6 packages Lemon Pudding Mix,… […]