Marley Neck Rehab: CPAP Machine Left Off Nightly - MD
That's what a resident at Marley Neck Rehabilitation and Wellness Center told a federal inspector on October 15, who had come to the room to ask how the resident was being cared for. What the resident described was simple and specific: press the call bell, wait, and sometimes a nurse appears. Sometimes nobody does.
The resident had arrived at the facility nine days earlier, on October 6. They came with a history of COPD and respiratory failure. A physician had ordered a CPAP machine, a continuous positive airway pressure device, to treat sleep apnea by keeping the airway open during sleep. For a person already living with compromised lungs, missing nights on the machine is not a minor inconvenience. Sleep apnea left untreated raises the risk of heart disease and stroke. In a resident with COPD and a prior respiratory failure, the stakes are higher still.
The resident was alert and oriented and able to communicate their needs clearly. That made the situation more stark, not less. This wasn't a case where staff couldn't know what the resident needed. The resident was asking. The call bell was going unanswered.
When the surveyor asked what "when I can" meant, the resident explained: I cannot put the machine on by myself and need assistance, but when I call for assistance sometimes the nurse will come and other times no one answers my call bell.
The Director of Nursing was informed of the finding at 10 a.m. on October 15. Her response, as recorded in the inspection report, was that she would look into it.
Inspectors cited the facility under federal tag F0695, which covers safe and appropriate respiratory care. The violation was classified as causing minimal harm or potential for actual harm. One resident was reviewed for CPAP usage during the complaint survey. That one resident was the one going without the machine.
What the inspection report does not contain is any record of how many nights the resident lay in bed without the airway support their doctor had ordered. The resident had been there nine days. The phrasing, "sometimes the nurse will come and other times no one answers," does not suggest this happened once.
The Director of Nursing did not indicate that the facility had already identified the problem, or that corrective steps were underway before the surveyor arrived. She said she would look into it.
A CPAP machine sitting unused beside a bed is not a missing medication or a skipped dressing change. It requires someone to enter the room, fit the mask, and make sure the device is running. It is a nightly task. It requires showing up. For this resident, that was not reliably happening.
The resident's history of respiratory failure means their body had already been through a crisis involving the lungs. COPD is a chronic, progressive condition. Sleep apnea compounds the strain on the respiratory system. The CPAP order existed precisely because the physician judged the machine necessary, not optional.
The resident was not confused. They were not unable to advocate for themselves. They were pressing a call bell and waiting, and on the nights when no one came, they went to sleep without the device that was supposed to keep their airway open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marley Neck Rehabilitation and Wellness Center from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
Marley Neck Rehabilitation and Wellness Center in GLEN BURNIE, MD was cited for violations during a health inspection on October 15, 2025.
What the resident described was simple and specific: press the call bell, wait, and sometimes a nurse appears.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.