South River Rehabilitation And Wellness Center
South River Rehabilitation and Wellness Center in EDGEWATER, MD — inspection on May 28, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
facility failed to ensure appropriate wound assessment and timely specialist consultation.
This was
Ownership (CHOW) and complaint survey.
The findings include:On 5/26/26 at 11:33 AM, the surveyor reviewed complaint #3015772. It was revealed that the complainant expressed concern regarding Resident #1's wound care.A review of Resident #1's medical records revealed a history of multiple transfers and readmissions: the resident was initially admitted on [DATE], transferred to the hospital on 1/17/26, readmitted on [DATE], transferred again on 2/24/26, and readmitted on [DATE].The medical record review further revealed the following documentation gaps and discrepancies:-Initial admission [DATE] - 1/17/26): The Nursing admission Evaluation dated 1/08/26 documented that Resident #1 had pressure ulcers on the sacrum, coccyx, and groin.
However, there was no follow-up documentation regarding these wounds from the contracted wound specialist (Nurse Practitioner) until the resident was transferred to the hospital on 1/17/26.-First readmission [DATE] - 2/24/26): Following readmission on [DATE], the contracted wound specialist assessed the resident on 1/27/26, with a follow-up assessment on 2/10/26.
There were no wound care records for the first week of February.-Subsequent readmission and April/May Assessments: On 5/28/26 at 7:30 AM, a review of the medical records showed the wound NP evaluated the resident on 5/01/26.
The NP documented a left buttock unstageable pressure ulcer measuring 4 x 4.5 x 0.3 cm and a right buttock unstageable pressure ulcer measuring 1.5 x 2.5 x 0.2 cm.
Despite these severe findings, there was a total lack of specialized wound assessments during the last week of April.-Facility Assessment Discrepancies: A review of the facility's internal weekly skin assessments revealed conflicting data.
The facility recorded no new skin area noted on 4/29/26, a non-pressure new area noted on 4/30/26, and no new skin issue noted on 5/07/26.
During an interview with Resident #1's family member on 5/26/26 at 12:47 PM, the family member stated, [Resident #1] did not have a buttock wound during the hospital stay. No one updated us about his/her new wound.
During an interview with the Director of Nursing (DON) on 5/26/26 at 1:50 PM, she explained that the facility utilizes a contracted wound care company whose Nurse Practitioner (NP) visits twice a week: on Thursdays to evaluate all new admissions (regardless of whether they have an existing wound) and on Tuesdays to follow up on residents with existing wounds.
The DON also stated that the facility has a designated internal wound care nurse.The surveyor reviewed Resident #1's medical records with the DON, who validated the findings and acknowledged the lack of required wound assessments.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
215297 05/28/2026
South River Rehabilitation and Wellness Center 144 Washington Road Edgewater, MD 21037
was determined that the facility failed to monitor residents' nutritional status regarding body weight
residents reviewed for nutrition during this Change of Ownership (CHOW) and complaint survey.The findings include:On 5/26/26 at 11:33 AM, the surveyor reviewed complaint #3015772. It was noted that the complainant expressed concern regarding Resident #1's significant weight loss.A further review of Resident #1's medical records revealed that the resident was initially admitted on [DATE], transferred to the hospital on 1/17/26, readmitted on [DATE], transferred again on 2/24/26, and readmitted on [DATE].During a review of Resident #1's body weight on 5/26/26 at 1:00 PM, the resident's weight was noted and documented as follows:2/06/26: 171.0 lbs (pounds)3/26/26: 156.2 lbs3/27/26: 153.2 lbs4/07/26: 144.6 lbsResident #1's body weight documented on 3/26/26 was recorded 23 days after their readmission, following a 7-day hospitalization.
Additionally, the weight documented on 4/07/26 reflected an 8.6 lbs loss (5.6%) within a 10-day period.
During an interview with the Dietitian on 5/26/26 at 1:15 PM, she explained that facility staff are required to assess and monitor newly admitted residents' body weights weekly for four weeks, and monthly thereafter.
The surveyor reviewed Resident #1's weight records with the Dietitian, who verified that there was a lack of body weight documentation following the resident's most recent readmission on [DATE].
Furthermore, the Dietitian confirmed that no interventions or follow-up care were provided regarding the significant weight loss noted on 4/07/26.On 5/26/26 at 1:50 PM, the surveyor shared concerns with the Director of Nursing (DON) regarding the lack of monitoring of Resident #1's nutritional status and body weight, as well as the lack of interventions for the significant weight loss.
The DON validated the findings and acknowledged that the facility was aware of the issue.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.