Manokin Nursing and Rehab

Inspectors wroteBased on a review of complaint 2965994, observations during a dining experience, and interviews with facility staff, it was determined that staff failed to sit while feeding residents and failed to serve meals to all seated residents at the same time to provide a dignified dining experience. This was evident on 1 (Chase) of 2 nursing units observed during the dining experience of the complaint survey.

Inspectors wroteBased on review of complaints, observations, and interviews, it was determined that the facility failed to 1) provide maintenance services necessary to keep resident rooms and equipment sanitary and orderly and 2) ensure a resident's room was a safe, comfortable and homelike environment. This issue was observed on 3 of 5 nursing units reviewed for maintenance services and 1 of 4 resident rooms reviewed for safe, comfortable and homelike environment during a complaint survey.

Inspectors wroteBased on review of complaint 2965994, observation, and staff interview, it was determined the facility failed to follow infection control practices and guidelines to prevent the development and transmission of disease. This was evident for 3 of 5 nursing units observed during the complaint survey.

Inspectors wroteBased on review of complaint 2965994, observations, interviews, and documentation review, it was determined that the facility failed to maintain an effective pest control program, evidenced by numerous flies throughout the facility. This was evident on 2 of 2 days observed during a complaint survey.

Inspectors wroteBased on review of facility reported incident 3044296, documentation review, and interviews, it was determined the facility failed to report an alleged abuse immediately to the Nursing Home Administrator and within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #3) of 2 residents reviewed for 2 facility reported incidents during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to administer medications timely. This was evident for 1 (Resident #6) of 4 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to provide treatment/services to prevent/heal pressures ulcers as ordered for a resident. This was evident for 1 (Resident #4) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to assess and monitor a resident's nutritional needs and intervene in a timely manner. This was evident for 1 (Resident #4) of 4 residents reviewed for nutrition during a complaint survey.

Inspectors wroteBased on a review of facility reported incident 3044296, complaints 3044605, 3017702, 2980425, medical record review, and interviews, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 3 (Residents #3, #5, #7) of 8 residents reviewed for 9 intakes reviewed on a complaint survey.

Inspectors wroteBased 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 at 2:17 PM. [...]

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to ensure an allegation of resident abuse was reported to the state survey agency (SSA) within two hours for an allegation involving 1 (Resident #3) of 10 sampled residents reviewed for abuse.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interviews with facility staff and review of pertinent documentation, it was determined that the facility failed to employ a qualified social worker on a full time basis in a facility licensed with more than 120 beds. The facility is licensed for 135 beds. This deficient practice was found to be evident during the facility's recertification/complaint survey and has the potential to affect all residents.

Inspectors wroteBased on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received mandatory communication training. This was evident for 5 (GNA #3, GNA #18, GNA #22, LPN #33, RN #19) out of 5 direct care staff employees reviewed during the Extended Survey investigation portion of the facility's recertification survey. This deficient practice had the potential to impact all residents.

Inspectors wroteBased on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to provide mandatory Quality Assessment and Performance Improvement training to staff. This was evident for 7 (GNA #3, GNA #18, GNA #22, LPN #33, RN #19, DA #41, HA #42) out of 7 employees reviewed during the Extended Survey investigation portion of the facility's recertification survey. This deficient practice had the potential to impact all residents.

Inspectors wroteBased on observation, interview, and record review, it was determined that facility staff failed to treat residents with dignity. This was evident for 2 (#214, #97) of 27 residents that resided on the memory care unit and for 13 residents on the memory care unit that were in the dining/activity area on 1 of 3 days observed during a revisit survey.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to maintain a homelike environment for the residents, this was evident for 2 of 3 units observed during the recertification/complaint survey.

Inspectors wroteBased on medical record reviews and interviews, it was determined that the facility staff failed to provide appropriate care to residents when they had abnormally elevated blood pressure (BP). This was evident in 1 (Resident #6) out of the 45 residents reviewed for their care during this recertification/complaint survey.

Inspectors wroteBased on review of employee files and interviews with facility staff, it was determined that the facility failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was found to be evident for 2 (GNA #3, GNA #18 ) out of 2 GNA employee files reviewed during the Sufficient and Competent Nurse Staffing facility task for the facility's recertification survey.

Inspectors wroteBased on a review of records and interview with facility staff, it was determined that the facility failed to 1) ensure that drug records were maintained in a manner that allowed for reconciliation of dispensed and administered medication, and 2) complete controlled medication counts with two nurses. This was evident for four (Resident #44, #79, #96, #35) out of the six residents reviewed for administration of narcotic medication during this recertification/complaint survey.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to date and label drugs when opened with an open date. This was evident for 3 of 6 medication carts reviewed on the nursing units during the recertification/complaint survey.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to 1) ensure food items were stored under sanitary conditions by labeling and dating food items and 2) maintain proper freezer temperature for food items on the units. This deficient practice had the potential to affect all residents who consume food in the facility and was evident during the recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to implement an effective infection control program and the staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to complete tuberculosis (TB) screening for newly admitted residents. This was evident for 4 (Resident #17, #8, #3, and #77) of five residents for TB screening during this recertification/complaint survey.

Inspectors wroteBased on a record review and staff interview, it was determined that the facility staff failed to assess and document residents' vaccination status for influenza and pneumococcal vaccines and failed to provide education regarding the benefits and risks of the vaccines. This was evident for two (Resident #17 and #3) of the five residents reviewed for immunizations during the recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to maintain residents' and staff's COVID-19 vaccination status in their medical records. This was evident for five (Resident #3, #8, #17, #27, and #77) of 5 residents and one (Staff #19) out of five facility staff members reviewed for COVID-19 vaccinations status during this recertification/complaint survey.

Inspectors wroteBased on observation and interview, it was determined the facility failed to ensure the kitchen's freezer was in working order. This was evident during a revisit survey.

Inspectors wroteBased on surveyor observations, interviews with residents and facility staff, and review of pertinent documentation, it was determined that the facility failed to maintain an effective pest control program. This was found to be evident during the facility's recertification survey.

Inspectors wroteBased on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received compliance and ethics training. This was evident for 5 (GNA #18, GNA #22, RN #19, DA #41, HA #42) out of 7 employees reviewed during the Extended Survey investigation portion of the facility's recertification survey. This deficient practice had the potential to impact all residents.

Inspectors wroteBased on surveyor review of the clinical record and interviews it was determined that facility staff failed to honor the wishes of the guardian of Resident #21. This finding was evident for 1 out of 3 residents reviewed for behaviors during the recertification/complaint survey.

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to inform the responsible party on three separate dates when a new medication was ordered for a resident. This was evident for 1 (Resident #72) of 5 residents reviewed for unnecessary medications during the facility's recertification survey.

Inspectors wroteBased on medical record review and interviews with facility staff, it was determined the facility staff failed to notify the physician and the responsible party in a timely manner of a resident's significant change in condition. This was evident for Resident #113, one of the three closed records reviewed during this recertification/complaint survey.

Inspectors wroteBased on interview with residents and interviews with facility staff, it was determined that the facility failed to ensure that an allegation of abuse was reported to the State Survey Agency, the Office of Health Care Quality (OHCQ), in a timely manner. This was evident for 1 (Resident # 72) of 4 residents reviewed for abuse during the facility's recertification survey.

Inspectors wroteBased on surveyor review of the clinical record and interviews it was determined that facility staff failed to appropriately discharge Resident #21. This finding was evident for 1 out of 3 residents reviewed for behaviors during the recertification/complaint survey.

Inspectors wroteBased on surveyor review of the clinical record and interviews it was determined that facility staff failed to provide the guardian of Resident #21 with a notice of transfer or discharge 30 days prior to the transfer or discharge. This finding was evident for 1 out of 3 residents reviewed for behavior during the recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to ensure comprehensive care plans were developed and implemented. This was found to be evident for 2 (Residents #3 and #4) out of 6 residents reviewed for care plans during this recertification/complaint survey.

Inspectors wroteBased on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to hold interdisciplinary team care plan meetings for residents concurrent with their quarterly care plan revisions. This deficiency was observed in 2 (Resident #88 and #10) of 2 residents reviewed for care plan meetings during this recertification/complaint survey.

Inspectors wroteBased on observation, interview with staff, and medical record review, it was determined the facility failed to provide the level of assistance needed with feeding for dependent residents. This was evident for 3 (Resident #50, #55, and #97) of 7 residents reviewed for Nutrition during the recertification/complaint survey.

Inspectors wroteBased on observation, staff interview, and medical record review it was determined that the facility staff failed to provide 1 to 1 resident-centered activities to improve or maintain the resident's mental and psychosocial well-being. This was evident for 1 (Resident # 3) of 6 residents reviewed for activities during the recertification/complaint survey.

Inspectors wroteBased on observation, clinical record review, and staff interview it was determined that the facility staff failed to ensure medications were not left unattended on the locked unit. This was evident for 1 (#10) out of 45 residents that were part of the survey sample during the recertification/complaint survey.

Inspectors wroteBased on observation, medical record review and interviews. It was determined that the facility failed to label and date oxygen tubing to indicate when it was last changed. This was evident for 2 (Residents #66 and #41) of 2 residents reviewed for respiratory care during the recertification/complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the physician failed to enter progress notes and order medications in a timely manner for a resident (Resident #6). This was evident for 1 of 3 residents reviewed during a revisit survey.

Inspectors wroteBased on a medical record review and interview, it was determined that the facility staff failed to monitor and document residents' behavior for those who had mental disorders. This was evident for one (Resident #11) of the three residents reviewed for behavioral issues during this recertification/complaint survey.

Inspectors wroteBased on review of the medical record, interview with facility staff and review of facility policy, it was determined that the facility failed to ensure the physician reviewed and documented on the monthly pharmacy reviews and responded to the recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Resident #72) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident received medication as ordered. This was evident for 1 (Resident #10) out of the 5 residents reviewed for unnecessary medications during the recertification/complaint survey.

Inspectors wroteBased on resident interview, review of the medical record, and interviews with facility staff, it was determined the facility failed to screen/evaluate a resident for rehabilitative services. This was evident for 1 (Resident #72) of 2 reviewed for Rehab and Restorative services during the facility's recertification survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 1 (Resident #100) of 6 residents reviewed for medical record accuracy during the recertification/complaint survey.

Inspectors wroteBased on medical record reviews and staff interviews, it was determined that the facility failed to have key essential personnel present during their monthly quality assurance (QA) meetings. This was evident during a review of the facilities quality assurance program activities during the recertification/complaint survey.

Inspectors wroteBased on reviews and staff interviews, the facility failed to protect resident property and provide a safe environment by not maintaining an inventory of resident belongings and not investigating a lost item for one Resident (R28) of three sampled residents.

Inspectors wrote2. Record review of R35's face sheet showed an admission was dated 07/20/2022; diagnoses included Generalized anxiety disorder, Alzheimer's disease, and Major depressive disorder. R35's Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 03/15 indicating cognition was severely cognitively impaired. R35 care plan initiated 07/20/20/2022 documented the resident had Activities of daily Living (ADL) self- care deficit due to Alzheimer's. The care plan directed the staff to assist the resident with bathing and grooming. Record review of R35 nurse's notes dated 10/20/2023, revealed Licensed Practical Nurse (LPN)36 documented it was reported to her that R35 smacked GNA37 in the face and then GNA37 hit R35 back. LPN36 reported this information to the former administrator. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide adequate supervision and implement intervention to prevent multiple falls for one Resident (R31) of 3 sampled residents who was at high risk for falls.

Inspectors wroteBased 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.

Inspectors wroteBased 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. The abatement plan was accepted by the OHCQ at 8:48 PM on 8/7/23.

Inspectors wroteBased 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.

Inspectors wroteBased on staff interviews and record review, it was determined that the facility failed to ensure that the infection line lists were updated and proper hand hygiene was performed during a medication administration. This was evident for 3 of 3 monthly line lists reviewed and 2 (#13, #12) out of 2 staff observed for hand hygiene during medication administration.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure resident rooms were maintained in a homelike environment. This was found to be evident for 2 out of 10 rooms (# 100 and # 102) observed during the tour of the Antioch Nursing Unit.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to provide pharmaceutical services that met the needs of the residents. This was evident for 1 (#162) out of 68 residents in the survey sample.

Inspectors wroteBased on recorded review and interviews it was determined that the facility failed to have monthly medication regimen reviews by a licensed pharmacist and failed to have a process in place to ensure the medication irregularity reports were part of the resident's medical record. This was found evident of 2 of 5 (Resident # 74 & #62) residents reviewed for medication regimen review during a Medicare/Medicaid recertification and complaint survey.

Inspectors wroteBased on observation of medication administration it was determined that the facility staff failed to ensure medications were administered in a safe, appropriate, and timely manner. This was evident for 5 medications out of 31 administered.

Inspectors wroteBased on interviews and review of the facility's policies it was determined that the facility failed to have a qualified, full-time social worker employed to oversee the social service duties. This was found evident of 4 months in 2022 and 2 months in 2023.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility staff failed to ensure clarity regarding whether Advance Directives had been formulated by a resident. This was evident for 1 (#25) of 6 residents reviewed for Advance Directives during the annual survey.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident had baseline care plans created and initiated for a resident. This was evident for 1 (#162) out of 68 residents in the survey sample.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility staff failed to ensure that activities were provided that met a resident's needs. This was evident for 1 (#32) of 5 residents reviewed for activities during the annual survey.

Inspectors wroteBased on resident and staff interviews, observations, and medical record review, it was determined that the facility staff failed to provide a resident with a multi podus boot, as ordered. This was evident for 1 (#92) of 2 residents reviewed for positioning and mobility.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure that medication carts were locked and secured. This was evident for 1 of 3 nursing units.

Inspectors wroteBased on observation, record review, and interviews it was determined that the facility failed to provide routine dental services identified as need for a resident. This was found evident of 1 of 5 (Resident #91) residents reviewed for dental concern during an annual and complaint survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to keep complete and accurate medical records. This was found evident of 2 of 68 (Resident #106 and #66) residents reviewed during a recertification and complaint survey.

Inspectors wroteBased on staff interviews and record review, the facility failed to designate a qualified Infection Control Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Control and Prevention program. This was evident for 1 of 1 staff member reviewed for IP credentials.

Inspectors wroteBased on observation, staff interviews and record review, it was determined that the facility staff failed to ensure that a resident had a functioning call system. This was evident for 1 (#6) of 68 residents reviewed during the annual survey.

Inspectors wroteBased on the record reviews and interviews, it was determined that the facility failed to ensure that a Geriatric Nursing Assistant (GNA) received the required 12 hours of in-service training. This was found to be evident for 1 (GNA #34) out of 5 training records reviewed during the recertification survey.

Inspectors wroteBased on observations and interview of facility staff. it was determined that the facility staff failed to promote and enhance a resident's dignity while assisting the resident with their breakfast and lunch. This was evident for 1 of 2 residents reviewed during the annual survey process.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident and/or the resident representative. This was found to be evident for 2 out of 8 residents reviewed for a facility-initiated transfer during the investigative portion of the survey.

Inspectors wrote2. Review of the medical record for Resident #108 on 2/13/19 revealed Resident #108 had physician orders to obtain pre and post-dialysis vitals and weights. Monitoring a dialysis patient's weight helps the healthcare professional decide how much fluid needs to be removed from the body during dialysis. Maintaining a regular record of a patient's weight is necessary to avoid removing too much or too little fluid from the body. Review of Resident #108's Treatment Administration Record (TAR) revealed that post dialysis weights had not been obtained on 1/17/19 and 1/31/19. Review of Resident #108's Weight History showed no recorded weights on 1/17/19 and 1/31/19. Review of Resident #108's Dialysis Communication Forms from 1/17/19 and 1/31/19 showed no recorded weights by the facility. A Dialysis Communication Form is completed by both facility nurses and dialysis center nurses. [...]

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to administer oxygen to Resident #6 in accordance with the standard of practice. This was evident for 1 of 2 residents selected for review during the survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to conduct AIMs testing on Residents (# 65). This was evident for 1 of 1 resident selected for review during the survey process.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure staffing hours for nursing staff were posted and to ensure 18 months of posted nursing data were maintained. This was true for 3 out of 3 nursing units.