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F0609
D

Failure to Timely Report Abuse Allegations and Notify Law Enforcement

Baltimore, Maryland Survey Completed on 05-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report unusual occurrences and allegations of abuse in a timely manner, as well as to notify law enforcement as required. In one instance, a resident was found lethargic and difficult to arouse, requiring oxygen and Narcan administration before being sent to the ER. The incident, which occurred in the morning, was not reported to the Office of Health Care Quality (OHCQ) until four days later, and the facility leadership was unaware of the 24-hour reporting requirement for non-abuse incidents. In another case, a resident alleged sexual assault by another resident, but the incident was not reported to the appropriate agency within the required two-hour timeframe. Additionally, an allegation involving a nurse pulling a resident's mask, yelling, and taking a video without consent was reported to the state agency but not to law enforcement. The DON confirmed that the absence of a police investigation number indicated that law enforcement had not been notified, as required.

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