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Health officials find Sykesville nursing home failed to isolate residents during COVID-19 outbreak, notify staff

A Sykesville nursing home faces a $315,000 fine after the state found conditions at the facility in July posed “immediate jeopardy” to the safety of residents.

A 45-page report issued by the Maryland Department of Health, Office of Health Care Quality includes the findings of on-site visits to Brinton Woods Nursing and Rehabilitation Center and follow-up investigation. The Office of Health Care Quality inspects nursing homes for the state.


Sixty-four nursing homes in Maryland failed to take sufficient infection control measures to protect residents from the coronavirus, according to state inspection records provided to The Baltimore Sun.

At the height of the Brinton Woods outbreak, 38 residents and six staff members tested positive (two of which are Carroll residents), resulting in 11 residents' deaths, according to Carroll County Health Department data.


According to the Office of Health Care Quality report, a Brinton Woods resident who had been exposed to COVID-19 by their roommate was moved to a shared room June 2 with a resident who tested negative. The exposed resident tested positive June 22 and died, and their new roommate also tested positive. By moving an exposed resident into a room with a negative resident, the facility failed to follow Centers for Disease Control and Prevention guidelines, inspection records state. A potentially exposed resident should have been isolated and observed for 14 days.

“In fact, based on observations, interviews, and record reviews it was evident that the facility failed to properly implement infection control practices to prevent COVID-19 and was not following infection control safety practices and guidance recommended by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC), during a COVID-19 pandemic,” the report states.

The surveyor encountered a number of practices deemed concerning.

Four newly admitted residents with unknown COVID-19 status were not isolated, despite there being 16 open beds as of July 9.

The door to a COVID-19 positive resident’s room was left open as other residents roamed the hall — one roaming resident was found without a mask and barefoot July 6.

No personal protective equipment (PPE) was available near the entrance of a positive resident’s room that had the door open July 6 and on a follow-up visit July 8. On July 6, there was no sign posted at the room’s door to inform staff that the occupant was positive. The infection preventionist said staff would be told verbally at the start of their shift who tested positive. The facility also lacked signage about donning and taking off PPE July 8.

Some staff did not know there were cases of COVID-19 in the facility. The first floor was dedicated to COVID-19 positive residents while the ground floor served as an observation unit for new admissions, the infection preventionist/assistant director of nursing told the Office of Health Care Quality surveyor. One staff member said they were assigned to both floors and did not know if there were COVID-19 positive residents. Three other staff members said they did not know of any positive cases July 6 and 8, at which point 35 residents and six staff had tested positive, according to the Carroll County Health Department.

The names of COVID-19 positive residents were to be posted at the nurses station, according to the director of nursing, but when the surveyor visited there was no posting because a staff member had thrown the paper away July 3. The director of nursing and a staff member looked through a cardboard box and retrieved a handwritten paper dated June 23 that included the names of 16 residents under isolation, which was out of date.


“At that time, the [director of nursing] confirmed that there was no current written notification of residents who were positive for COVID and staff would only know if a resident was positive for COVID by word of mouth,” the report reads.

The surveyor determined residents’ health were in immediate jeopardy July 10 and notified staff to make changes right away.

Brinton Woods responds

A spokesperson issued a statement on behalf of Brinton Woods but did not respond to specific questions and a request to discuss the circumstances surrounding the outbreak.

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There are no cases at Brinton Woods as of Sept. 10, LifeBridge Health spokesperson Sharon Boston wrote in an email. LifeBridge took full ownership of the nursing home in April. Carroll County Health Department considered the outbreak there closed as of Sept. 8, meaning 14 days had passed since the onset of the most recent case.

“The care and safety of our residents is paramount at Brinton Woods," Boston wrote. "There are currently no COVID positive residents at our facility, and there have been no positive cases since early August. While we look to appeal some of the findings, any concerns identified were immediately addressed and corrected. We are now further analyzing the State’s survey and putting together a comprehensive action plan, including implementing resources and coordination with leaders at LifeBridge Health long-term care facilities.”

Of nursing homes fined in Maryland, Brinton Woods faces one of the heftier fines. Fines for 10 nursing homes range from $70,000 to $380,000, The Baltimore Sun reported. Forty-five facilities received smaller fines for not completing mandatory testing and not reporting records to the state.


In addition to the fine, Brinton Woods may not operate a nurse aide training program for two years.

Next steps

Brinton Woods has the right to appeal and request a hearing before an administrative law judge of the U.S. Department of Health and Human Services, Departmental Appeals Board. The appeal has to be filed within 60 days of receiving MDH’s letter, which was dated Aug. 21.

The Office of Health Care Quality outlined steps Brinton Woods must take moving forward. The facility has to:

  • Provide evidence of current infection control policy and procedures to include the guidance related to COVID-19 from Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention.
  • Train staff in cohorting, social distancing and wearing of face masks. Training must be conducted by a clinician certified in infection control and be documented.
  • Provide evidence of a plan for managing new residents or residents readmitted in regard to COVID-19. This includes completing an infection control self-assessment.
  • Conduct a “Root Cause Analysis” with help from the infection preventionist, Quality Assurance and Performance Improvement (QAPI) committee and Governing Body. The analysis should be incorporated into the intervention plan.

Brian Compere and Meredith Cohn contributed to this story.