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F0600
D

Failure to Protect Residents from Abuse and Report to Licensing Board

Berlin, Maryland Survey Completed on 07-23-2025

Penalty

Fine: $20,685
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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 protect residents from abuse, as evidenced by two separate incidents involving geriatric nursing assistants (GNAs) and residents. In the first incident, a resident reported being pushed by a GNA by the back of the neck, shoved onto the bed, and sustaining an arm injury. The investigation conducted by the acting DON confirmed the presence of a bruise consistent with the resident's account, and the GNA was found to have abused the resident. In the second incident, another resident accused a GNA of hitting their finger after the resident pointed at a meal tray and put their hand in the GNA's face. The facility's investigation substantiated that there was direct physical contact between the GNA and the resident, and the GNA admitted to pushing the resident's hand away. The incident was reported to local law enforcement, and the resident confirmed being physically abused. However, the facility did not file a required complaint with the Maryland Board of Nursing regarding the substantiated abuse by the GNA, as was mandated by facility policy and state regulations.

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