The incident at Marley Neck Health and Rehabilitation Center occurred on an evening in October when the cognitively intact resident pressed his call button at 7:30 PM requesting to be changed. A geriatric nursing assistant responded and acknowledged his need but said she would return shortly.
She didn't come back. The call light remained on until 11:30 PM.
Federal inspectors documented the case during an October 15 complaint investigation that found the facility failed to provide basic hygiene care to residents who couldn't manage it themselves.
The resident, identified as Resident #6 in the inspection report, scored 14 out of 15 on a cognitive assessment, indicating he was alert and oriented and could clearly communicate his needs. During an interview with inspectors at 9:45 AM on October 15, he explained that while he normally didn't have problems getting changed, the previous evening's experience was different.
When the Director of Nursing learned about the incident, she told inspectors she would "look into the matter and educate staff if needed."
A second case involved documentation showing another resident went unchanged for entire shifts. Family members of Resident #5 filed a complaint on August 16, stating their relative had been left "on several occasions with stool and urine in his/her diaper."
Records from March and April 2025 supported the family's concerns. Geriatric nursing assistant documentation sheets showed the resident wasn't changed during both day and night shifts on March 28. The same pattern occurred during the night shift on March 31.
The Director of Nursing, when made aware of these documentation gaps during the inspection, said she would investigate.
Both cases emerged during a complaint survey conducted by federal inspectors, who reviewed records for six residents and found problems with basic hygiene care for two of them. The violations fell under federal regulations requiring nursing homes to provide care and assistance with activities of daily living for residents unable to manage them independently.
Inspectors classified the violations as causing "minimal harm or potential for actual harm" but noted they affected "few" residents at the facility.
The facility operates at 7575 East Howard Road in Glen Burnie. Federal records show the inspection was completed on October 15, 2025, following the family complaint filed two months earlier.
For Resident #6, the four-hour wait represented a failure of the most basic nursing home function: responding when residents call for help. His cognitive scores showed he understood his situation and could clearly communicate his needs, yet staff left him in soiled conditions despite his direct request for assistance.
The documentation problems for Resident #5 revealed systematic gaps in care tracking. Nursing assistant logs are supposed to record when residents receive hygiene care, but the March records showed entire shifts passing without any documented brief changes.
Federal nursing home regulations require facilities to help residents maintain dignity and comfort through proper hygiene care. When residents cannot change themselves, staff must provide timely assistance to prevent skin breakdown, infections, and the psychological distress of remaining in soiled conditions.
The inspection findings will require the facility to submit a plan of correction to continue participating in Medicare and Medicaid programs. The Director of Nursing's promises to investigate and educate staff suggest the facility acknowledges the problems but hasn't yet implemented specific solutions.
For the families involved, the violations represent fundamental failures in their relatives' daily care. One family felt compelled to file a formal complaint after witnessing repeated incidents of their loved one being left in soiled conditions. The other case involved a resident who could clearly ask for help but was ignored for hours.
The cognitive assessment score for Resident #6 underscores the particular cruelty of his situation. Unlike residents with dementia who might not fully understand their circumstances, he was completely aware that staff had promised to return and then abandoned him with his call light flashing through the evening.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marley Neck Health and Rehabilitation Center from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
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