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F0609
E

Failure to Timely Report Abuse Allegations and Injuries of Unknown Origin

Frostburg, Maryland Survey Completed on 08-13-2025

Penalty

Fine: $25,475
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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 immediately report allegations of abuse and injuries of unknown origin to the state office as required. In one instance, a resident's roommate reported that a GNA used a paper towel to wipe the resident's peri area, causing the resident to cry due to pain. This concern was reported to the DON, who only cautioned the staff member about their communication and did not report the incident to the state office. A second, similar grievance was also reported by the same roommate, indicating repeated behavior by the same GNA, but the DON considered it a repetition and did not take further action or report it. Additionally, another resident voiced concerns about a GNA being rough and touching them in an unwelcome manner during care. This concern was brought to the attention of the DON and the Nursing Home Administrator, but again, there was no immediate report to the state office. The report also details an incident where a resident was found on the floor with a head laceration and required hospital treatment. The injury was of unknown origin, and although the DON was notified shortly after the incident, the report to the Office of Health Care Quality was not made until two days later. The DON acknowledged the delay in reporting and could not provide a reason for the late submission. These findings were based on record reviews and staff interviews, which confirmed that the facility did not follow required procedures for timely reporting of abuse allegations and injuries of unknown origin.

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