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F0609
D

Failure to Report Allegation of Neglect to State Survey Agency

Baltimore, Maryland Survey Completed on 09-18-2025

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

Facility staff failed to report an allegation of neglect to the State Survey Agency after a resident's family expressed concerns about the resident's deteriorating condition. On the evening in question, the family requested that an LPN call an ambulance for the resident, but the LPN refused, instructed the family to call 911 themselves, argued with them, and did not check on the resident after the request. The family subsequently called 911 and sent an email to facility management and the Social Work Director, formally complaining about the LPN's refusal to assist and lack of concern for the resident's well-being. The email complaint was forwarded to the facility Administrator, but the allegation was not reported to the State Survey Agency as required. The Director of Nursing and Administrator confirmed during interviews that they did not report the incident, considering it a customer service issue rather than a reportable allegation of neglect. Medical record review confirmed that the family, not the nurse, called 911 following the change in the resident's condition. The failure to report the allegation of neglect constituted a deficiency in the facility's compliance with reporting requirements.

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