F0610

D

Failure to Thoroughly Investigate Abuse Allegations and Remove Alleged Abusers from Resident Care

Baltimore, Maryland Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

Facility staff failed to conduct thorough investigations into multiple resident abuse allegations and did not consistently remove alleged perpetrators from resident care during investigations. In one incident, a resident reported verbal abuse that allegedly occurred during a prior shift; the DON stated that staff and residents were interviewed and that another GNA had been present in the room during the alleged verbal abuse. However, the investigation file contained no written statement from that GNA, despite the DON acknowledging having spoken with the aide. In another case involving an allegation that an LPN called a resident a derogatory name during medication administration, the DON reported using open-ended questions with the nurse but did not directly ask whether the LPN had used the specific expletive alleged by the resident. The LPN later denied the allegation when directly questioned by the surveyor, and also stated they had not been aware of any problem with that resident.

The facility’s abuse, neglect, and exploitation policy defined any report by a resident, staff, or family as an abuse allegation requiring immediate investigation and indicated that room or staffing changes should be made as needed to protect residents from alleged perpetrators. In a separate incident, a resident reported to an RN that a GNA rolled them in bed and caused their head to hit the bedrail. The GNA’s timesheet showed that the aide continued working for approximately 2.5 hours after the allegation and returned to work the next morning before being suspended. The DON later stated that the RN had failed to notify her of the allegation immediately, which resulted in the GNA continuing to work with residents after the abuse allegation was made.