Inspection Reports for
Maryland Masonic Homes
300 International Circle, Cockeysville, MD, 21030
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Jun 2, 2025
Visit Reason
The inspection was conducted as part of the facility's recertification survey to assess compliance with regulatory requirements and ensure resident safety and care quality.
Findings
The facility was found deficient in multiple areas including maintenance of a homelike environment, psychotropic medication monitoring, timely reporting and investigation of abuse allegations, care planning, accident prevention, medication management, dietary services, infection control, and staff training. Several deficiencies were noted with minimal harm potential affecting few to many residents.
Deficiencies (13)
F 0584: The facility failed to maintain a homelike environment, evidenced by damaged walls with peeling and flaking paint in 3 of 18 resident rooms observed during the survey.
F 0605: The facility failed to ensure monitoring for side effects of psychotropic medications for Resident #50, with no side effect monitoring orders in place.
F 0609: The facility failed to timely report an allegation of abuse within the required two-hour timeframe for one incident.
F 0610: The facility failed to thoroughly investigate allegations of abuse, lacking statements or interviews from the resident and alleged perpetrator.
F 0657: The facility failed to include all required interdisciplinary team members in the quarterly care plan review for Resident #21.
F 0689: The facility failed to ensure accident hazard prevention and adequate supervision for Resident #20, who was left unattended in an unsafe bed position with a catheter bag improperly placed.
F 0755: The facility failed to ensure proper reconciliation of expired controlled medications, administering expired Oxycodone to Resident #33.
F 0760: The facility failed to follow prescriber's orders and manufacturer specifications during medication preparation, using an unlabeled spoon to measure Benefiber powder for Resident #13.
F 0761: The facility failed to maintain proper storage and reconciliation of expired medications and drugs, with expired items found in multiple medication storage areas and unlocked narcotic boxes.
F 0803: The facility failed to follow the menu and meet resident dietary preferences, with bread sticks not served despite orders and discrepancies in Resident #5's dietary tray.
F 0813: The facility failed to ensure safe and separate storage of food brought in by visitors, with expired food items found in the central supply room refrigerator.
F 0880: The facility failed to implement an effective infection prevention and control program, including improper hand hygiene during medication administration, failure to clean equipment between residents, improper glove use, and lack of a complete water management plan to address Legionella risks.
F 0947: The facility failed to ensure that Geriatric Nursing Assistants received the required annual 12 hours of in-service training, with no documentation for 3 GNAs reviewed.
Report Facts
Residents observed with room damage: 3
Residents reviewed for psychotropic medications: 5
Facility reported incidents reviewed: 3
Residents reviewed for care planning: 1
Residents reviewed for accidents: 2
Residents reviewed for medication storage: 6
Residents observed for medication administration: 4
Residents reviewed for dietary services: 2
Geriatric Nursing Assistants reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor #26 | Maintenance Supervisor | Discussed paint damage and water management plan |
| Registered Nurse #11 | Unit Manager, Registered Nurse | Interviewed regarding medication side effect monitoring and medication storage |
| Director of Nursing | Director of Nursing | Acknowledged concerns on multiple deficiencies including medication monitoring, abuse reporting, infection control, and staff training |
| Geriatric Nursing Assistant #23 | Geriatric Nursing Assistant | Alleged perpetrator in abuse investigation with no interview or statement obtained |
| Geriatric Nursing Assistant #25 | Geriatric Nursing Assistant | Observed improper catheter bag handling and glove use |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Observed medication administration and acknowledged concerns |
| Registered Nurse #27 | Registered Nurse | Administered expired medication to Resident #33 |
| Certified Dietary Manager #28 | Certified Dietary Manager | Acknowledged and confirmed dietary service concerns |
| Human Resources Director #12 | Human Resources Director | Interviewed regarding nurse aide in-service training documentation |
| Registered Nurse, Infection Preventionist #4 | Infection Prevention Nurse | Managed nurse aide training documentation and infection control program |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Oct 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by multiple allegations of abuse, neglect, medication errors, and failure to provide adequate care at Maryland Masonic Homes Ltd.
Complaint Details
The complaint investigation was triggered by multiple allegations including verbal abuse, neglect, medication errors, failure to report and investigate abuse timely, inadequate pain management, and failure to protect residents from accidents. Several residents (#1, #2, #6, #7, #10, #17, #25, #30) were involved in various incidents. Some allegations were substantiated, including medication errors leading to death and failure to investigate abuse.
Findings
The facility was found to have multiple deficiencies including failure to uphold residents' dignity, delayed and inadequate investigations of abuse allegations, medication errors resulting in a resident's death, failure to monitor nutritional status, inadequate pain management, and failure to provide adequate supervision to prevent accidents. The facility also failed to ensure timely physician response and proper delegation of tasks.
Deficiencies (11)
F550: Facility staff failed to maintain a resident's dignity by not assisting with meals promptly, risking violation of resident rights.
F609: Facility staff failed to timely report suspected abuse and results of investigations to proper authorities in 3 of 26 incidents reviewed.
F610: Facility staff failed to thoroughly investigate allegations of abuse and injuries of unknown origin in 5 of 30 incidents reviewed.
F658: Facility staff failed to appropriately review and administer medication orders, resulting in a resident receiving 10 times the ordered dose of morphine.
F689: Facility staff failed to ensure adequate supervision during care, resulting in a resident falling out of bed.
F692: Facility failed to monitor a resident's weight loss and nutritional status, and did not refer to a dietitian for supplementation.
F697: Facility failed to provide safe and appropriate pain management for residents, including delayed administration of morphine and inadequate response to pain after a fall.
F713: Facility failed to ensure 24-hour physician responsiveness to emergency needs, delaying morphine administration for a resident in distress.
F715: Facility failed to refer a resident to a dietitian for nutritional supplementation despite documented weight loss and swallowing difficulties.
F760: Facility failed to verify medication doses properly, resulting in administration of a morphine dose 10 times the ordered amount, causing resident death. Immediate Jeopardy was identified but corrected.
F835: Facility administration failed to conduct thorough abuse investigations and implement appropriate interventions, placing residents at risk for abuse.
Report Facts
Facility reported incidents reviewed: 30
Residents affected by deficiencies: 1
Medication overdose factor: 10
Fall incidents: 6
Days reviewed for abuse allegations: 26
Days Resident #10 was not with concerned GNAs: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Registered Nurse | Named in medication error finding related to morphine overdose |
| LPN #6 | Licensed Practical Nurse | Administered 10 times the ordered dose of morphine |
| RN #7 | Registered Nurse | Transcribed verbal order incorrectly for morphine dose |
| Director of Nursing (DON) | Director of Nursing | Named in multiple findings related to failure to investigate abuse and oversight |
| Geriatric Nursing Assistant (GNA) #17 | Nursing Assistant | Involved in shower care incident with Resident #4 |
| Geriatric Nursing Assistant (GNA) #18 | Nursing Assistant | Involved in shower care incident with Resident #4 |
| LPN #20 | Licensed Practical Nurse | Reported abuse concerns late to previous DON |
Inspection Report
Annual Inspection
Deficiencies: 25
Date: May 13, 2021
Visit Reason
Annual survey and inspection of Maryland Masonic Homes Ltd nursing facility to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found to have multiple deficiencies including medication administration errors, failure to notify physicians of abnormal blood pressure readings, inadequate resident privacy, failure to provide required notices to residents, incomplete care plans, failure to provide ordered treatments, inadequate infection control practices, and incomplete documentation of care and physician notes.
Deficiencies (25)
F0580: Facility staff failed to notify the physician of blood pressure readings outside of ordered parameters and failed to administer or hold medications accordingly for Residents #369 and #31.
F0582: Facility failed to provide residents notice of Medicare non-coverage and potential financial liability for services not covered for Residents #4 and #65.
F0583: Facility staff failed to maintain resident privacy by not providing privacy curtains in COVID isolation rooms for Residents #54 and #25.
F0609: Facility failed to timely report an injury of unknown origin and allegations of abuse to regulatory authorities for Residents #169, #15, and #120.
F0610: Facility failed to thoroughly investigate allegations of abuse for Residents #120 and #121.
F0623: Facility failed to notify residents or representatives in writing of transfers to hospital and failed to provide written transfer notices for Residents #54 and #39.
F0624: Facility failed to orient, prepare, and document resident preparation for hospital transfer for Resident #54.
F0625: Facility failed to notify residents or representatives in writing of bed hold policies upon hospital transfer for Residents #54 and #39.
F0641: Facility failed to ensure accurate Minimum Data Set (MDS) assessments for Residents #54, #71, and #36, including oxygen use, medication use, and discharge status.
F0656: Facility failed to develop and implement comprehensive, person-centered care plans for multiple residents including wound care, activity needs, medication administration, and isolation compliance.
F0684: Facility failed to provide appropriate treatment and care according to orders, resident preferences and goals for Residents #169, #9, #31, and #54, including vital signs monitoring, medication administration, feeding assistance, pain management, weight monitoring, and use of TED hose.
F0686: Facility failed to ensure dressing changes were completed as ordered for an open area on Resident #169's coccyx.
F0689: Facility failed to provide physician ordered safety devices (fall mats) and failed to thoroughly investigate unwitnessed falls for Resident #169 and #8.
F0695: Facility failed to provide safe and appropriate respiratory care for Resident #57 including false documentation of oxygen administration and failure to develop a person-centered respiratory care plan.
F0697: Facility failed to administer pain medication as ordered for Resident #169 on multiple occasions and failed to document medication removal from supply.
F0726: Facility failed to ensure staff competencies were assessed and maintained to provide care for residents.
F0732: Facility failed to post nurse staffing information daily in a clear, accurate, and readable format for residents and visitors.
F0757: Facility failed to ensure residents' drug regimens were free from unnecessary drugs by not assessing Resident #36's ability to self-administer inhaler and nasal spray medications and failing to develop a care plan.
F0759: Facility failed to ensure medication error rate was less than 5% with errors including wrong dose, failure to administer medication, and false documentation for Residents #57, #49, and #44.
F0760: Facility failed to ensure residents were free from significant medication errors related to blood pressure medication administration for Residents #369 and #31.
F0761: Facility failed to ensure drugs and biologicals were stored in locked compartments as medication carts were observed unlocked and unattended.
F0808: Facility failed to procure food from approved sources and maintain food service equipment to ensure sanitary operations, including failure to maintain dishwasher temperatures.
F0838: Facility failed to conduct and document an accurate facility-wide assessment including staff competencies and impact of COVID-19 pandemic.
F0842: Facility failed to safeguard resident-identifiable information and maintain accurate medical records including incomplete GNA documentation and incorrect resident identification.
F0880: Facility failed to provide and implement an effective infection prevention and control program including failure to keep isolation doors closed, improper PPE use, and lack of isolation signage for residents.
Report Facts
Medication administration errors: 3
Medication administration error rate: 11.11
Blood pressure readings outside parameters: 13
Days with missing dishwasher temperature logs: 8
Days without activity documentation: 12
Weight loss percentage: 10
Weight loss percentage: 5
Medication doses not documented removed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Medication administration errors and interview about blood pressure medication |
| LPN #4 | Licensed Practical Nurse | Medication administration errors including failure to administer Lasix |
| CMA #5 | Certified Medicine Aide | Medication administration errors including failure to administer nasal spray |
| RN #33 | Registered Nurse | Interview about blood pressure medication notification |
| CRNP #16 | Certified Registered Nurse Practitioner | Interview about blood pressure medication and oxygen therapy |
| DON | Director of Nursing | Multiple interviews and responses regarding deficiencies |
| Staff #14 | Infection Control Practitioner | Interview about infection control signage and PPE |
| Staff #17 | Lobby Receptionist | Observed not wearing mask properly |
| Staff #20 | Medical Records Coordinator | Interview about missing physician notes and incorrect resident name |
| Staff #25 | Human Resources | Interview about lack of documentation for employee termination |
| Staff #31 | Business Office Manager | Interview about failure to provide ABN notices |
| Staff #36 | Nurse | Interview and documentation related to fall investigation |
| Staff #39 | Director of Life Enrichment | Interview about activity care plans |
| Staff #44 | Resident | Interview about medication administration |
| Staff #57 | Resident | Interview and observation related to oxygen therapy |
| Staff #169 | Resident | Multiple interviews and record reviews related to falls and medication |
| Staff #22 | Culinary Services Manager | Interview about dishwasher temperatures |
| Staff #29 | Rehab Director | Interview about physical therapy orders |
| Staff #4 | Nurse | Interview about medication administration and inhaler use |
| Staff #13 | Nurse | Interview about fall mats and medication cart |
| Staff #27 | Shift Supervisor Nurse | Interview about fall investigation |
| Staff #6 | Nurse | Interview about fall and resident condition |
| Staff #12 | Certified Dietary Manager | Interview about diet orders and dishwasher |
| Staff #9 | Licensed Practical Nurse | Interview about resident care and hipsters |
| Staff #8 | Geriatric Nursing Assistant | Interview about resident care and hipsters |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Oct 12, 2018
Visit Reason
The inspection was conducted as part of an annual re-certification survey and investigative portion of the survey to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights, inadequate notification of room changes and transfers, insufficient personal hygiene care, failure to obtain ordered dermatology consults and weekly weights, inadequate nutritional assessments, medication administration delays, failure to document blood pressures for medications with parameters, unsafe sanitary conditions, and malfunctioning resident call bell systems.
Deficiencies (10)
F 0550: Facility staff failed to honor a resident's right to a dignified existence by calling Resident #42 by an undesired nickname despite requests to use the resident's first name.
F 0559: Facility failed to provide written notice to Resident #38 or representative before a room change occurred on 09/21/18.
F 0623: Facility failed to provide timely written notification to Resident #70 and representative regarding transfer to an acute care hospital and rationale for transfer.
F 0677: Facility staff failed to ensure dependent Resident #42 received scheduled showers, providing only one shower since admission despite scheduled twice weekly.
F 0684: Facility nursing staff failed to obtain a dermatology consult for Resident #36 and weekly weights for Resident #8 as ordered by the physician.
F 0692: Facility staff failed to recognize and evaluate nutrition needs for Residents #13, #29, and #51, including failure to obtain timely weights and accurate nutritional assessments.
F 0755: Facility and pharmacy failed to provide medications as ordered for Resident #7, including delayed administration of Mobic and lack of Synthroid delivery documentation.
F 0757: Facility staff failed to document blood pressures for Resident #29 when administering Lisinopril as ordered with parameters to hold for low blood pressure.
F 0880: Facility staff failed to maintain safe and sanitary conditions in Resident #51's bathroom, including uncovered toothbrushes, used gloves on floor, and soiled equipment improperly stored.
F 0908: Facility failed to maintain the resident call bell system in safe operating condition, with call bell plates pulled away from walls exposing wires in multiple rooms.
Report Facts
Residents reviewed: 30
Residents reviewed: 31
Days: 136
Weight loss: 36
Weight loss: 18.8
Weight loss percentage: 11.34
Medication administration delay: 2
Blood pressure documentation failures: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Made aware of multiple deficiencies including medication errors, notification failures, and care issues |
| Unit Manager | Unit Manager | Confirmed GNA task documentation did not specify if showers or bed baths were provided |
| Dietitian | Registered Dietitian | Acknowledged failure to obtain current weights for nutritional assessments |
| Facility Administrator | Administrator | Made aware of multiple concerns including resident rights, sanitary conditions, and call bell system issues |
| Social Worker | Facility Social Worker | Confirmed Resident #38 did not receive written notice of room change |
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