Citations in Maryland T

Penalty

No penalty information released

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 protect and value residents’ right to religious freedom by not providing an accurate list of Catholic residents to an outside eucharistic minister. A complaint from the eucharistic minister stated that he or she had been unable to provide communion to Catholic residents for approximately two years because the facility did not supply an accurate list of Catholic residents. The eucharistic minister reported attempting since October 2025 to obtain an accurate list, typically emailing the Administrator and Activity Director about four days before visits, and alleged that since March 2025 the lists received were inaccurate, preventing the provision of communion. The eucharistic minister further alleged that, when the Administrator was contacted about this issue, the Administrator acknowledged seeing the email but stated that he or she did not believe the list of Catholic residents was important at the time. During the survey, the Activity Director provided a list of Catholic residents, which, upon review and comparison with the most recent annual activity preference forms, was found to be inaccurate. Residents identified on the list as Catholic did not indicate Catholicism on their most recent activity preference forms, all of which had been signed and reviewed by the Activity Director. The Activity Director stated that residents receive an assessment of activity preferences at admission, upon changes, at readmission, and annually, and that the list of Catholic residents is supposed to be updated based on changes to these forms. The Activity Director indicated that assistants normally update the list, and, after reviewing the specific residents’ preference forms presented by the surveyor, admitted that the list of Catholic residents was inaccurate. The DON and Administrator were informed by the surveyor that the list was inaccurate based on the most recent activity preference forms.

Penalty

No penalty information released

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

Surveyors identified a deficiency in the facility’s failure to provide activities to meet a resident’s needs and interests as outlined in the comprehensive care plan. An anonymous complaint reported that Resident #32 felt bored at the facility. Record review showed that the resident was admitted in 2025 and had an Activity Preferences Interview dated 7/12/2025 indicating interest in a wide range of activities, including animals, group activities, sports, religion, cards, bingo, games, audio books, reading, writing, music, TV, movies, outdoor activities, talking, and parties. The resident’s comprehensive care plan, initiated on 7/15/2025, documented that the resident was dependent on staff for activities and engagement, with interventions to encourage attendance, invite the resident to scheduled activities, and provide activity materials of interest such as books, puzzles, and magazines. Despite these documented interests and care plan interventions, review of the resident’s activity logs from July 2025 through January 2026 showed that the resident was offered activities on relatively few days each month. Specifically, the logs showed the resident was offered an activity on 10 of 31 days in July, 7 of 31 days in August, 7 of 30 days in September, 9 of 30 days in November, 8 of 31 days in December, and 5 of 28 days in January (as of the review date). During interview, the Activities Director stated that the expectation was that residents would be offered all scheduled activities and that offers, attendance, and refusals would be documented on the activity log, and acknowledged awareness that the resident’s activity log reflected that the resident had not been offered nor attended many activities during the reviewed months. The DON was informed of these findings and indicated understanding.

Penalty

No penalty information released

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 maintain a complete and accurate medical record for a resident who alleged physical abuse and was found on the floor. According to the facility’s own incident reporting and investigation for a facility-reported incident, the resident alleged that a staff member answered the call bell and hit the resident on the head. Witness statements obtained during the facility’s investigation indicated that the resident was later found sitting on the floor of the room at approximately 11:40 PM. The allegation was reported to the State Agency and local police, and the facility conducted an investigation and submitted a follow-up report, but they were unable to verify that the resident was struck on the head as alleged. When surveyors reviewed the resident’s medical record, there was no documentation of the resident’s allegation of physical abuse, no notation that the resident had an unwitnessed fall or was found sitting on the floor, and no related assessments or interventions documented in response to these events. An incident report dated the same night indicated the resident was observed sitting on the floor next to the bed, but this document was labeled as privileged, confidential, and not part of the medical record. A skin assessment completed the following day documented no current tissue injury and no skin issues, but did not indicate the reason the assessment was performed. Thus, the medical record lacked required entries regarding the allegation of abuse, the fall event, and any clinical assessments or interventions associated with those events.

Penalty

No penalty information released

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 deficiency involves the facility’s failure to assess a resident for behavioral health needs, specifically suicidal ideation, following a change in behavior. Intake documentation showed that the resident was transported to the hospital for a behavioral emergency. A social services progress note, entered late and dated two days before the hospital transfer, documented that social services visited the resident due to staff concerns about the resident’s welfare and behavior. During that visit, the resident was described as calm, pleasant, and redirectable, and there was no documentation that a suicide ideation assessment interview was completed. Subsequent review of clinical documentation revealed that a late-entry nursing note, written several days after the events, indicated that a nursing assistant had reported the resident stated they wanted to die. This late-entry note, referring to an earlier date, was not available in the record at the time the social worker evaluated the resident, and the social worker reported being unaware that the resident had voiced a desire to die. Later documentation showed that the resident was found lying on the floor with a plastic bag over their head and was assessed and transported to the hospital, with police, physician, and family notified. Review of the facility’s suicide precaution management policy showed that a brief suicide ideation assessment was required for any current resident who voiced or indicated suicidal ideation in any manner, but such an assessment was not completed for this resident.

Penalty

Fine: $21,665

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 deficiency involves the facility’s failure to identify a cognitively impaired resident as an elopement risk and to implement interventions to prevent elopement, resulting in the resident leaving the building unsupervised. The facility had an elopement and wandering policy requiring residents to be assessed for elopement risk on admission and throughout their stay, with high‑risk residents to receive an alarm bracelet and an individualized care plan. On admission, the nursing elopement assessment for this resident was completed by an LPN, who marked the resident as unable to ambulate; this locked the remainder of the elopement assessment and resulted in the resident being deemed not at risk for elopement. This determination was made despite hospital records showing that prior to admission the resident had been living at home, driving, and working, and that during the hospital stay the resident could ambulate with a rolling walker and assistance. Following admission, multiple clinical findings and events indicated that the resident’s condition and behavior had changed in ways relevant to elopement risk, but the facility did not reassess the resident for elopement until after the elopement occurred. Progress notes documented that the resident fell twice in the early morning of one day when attempting to get out of bed and walk, with staff noting the resident was unsteady. A care plan was initiated for noncompliance with using a walker. A Brief Interview for Mental Status determined the resident had severe cognitive impairment, and both the attending physician and a nurse practitioner documented that the resident was incapable of comprehending information and making decisions due to a hemorrhagic stroke. Therapy notes showed that the resident’s mobility improved, including ambulating 70 feet with a rolling walker and minimal assistance, which constituted a change in condition. Staff interviews later revealed that the resident frequently talked about going home, became more worked up when family prepared to leave, walked unassisted despite being unsteady, wandered without clear purpose, and had poor safety awareness. On the day of the elopement, the resident was observed by the receptionist walking down the hallway carrying a wash basin with items and a shoebox, then exiting through the front door; the receptionist was unsure if the individual was a resident and did not intervene before the resident left the building. The resident’s assigned LPN and GNA reported they were passing dinner trays and checking blood sugars and did not see the resident leave the unit. A visitor arriving for a Thanksgiving event later found the resident lying on the ground in the visitor parking lot in dark, cold weather, still carrying the basin and shoebox. Another LPN leaving the facility also saw the resident on the ground behind a parked car and initially did not recognize the person as a resident until noticing an adult brief. When interviewed, the resident stated they had gone outside to go home. The facility’s own investigation concluded that the resident left the facility, was outside for several minutes, and was found lying in the parking lot, and that staff had not previously identified or care planned the resident as an elopement risk despite documented behaviors and functional abilities that met the facility’s own criteria for elopement risk. The facility’s investigation file also showed that, prior to the incident, staff education on the elopement policy and elopement assessments had been started but not completed for all staff. Interviews with the interim DON and other staff confirmed that elopement assessments were expected on admission, quarterly, and with changes in condition or behavior, and that the resident’s behaviors—such as repeatedly talking about going home, packing belongings, and exit‑seeking—should have triggered reassessment. The NHA acknowledged that the resident was not being monitored as an elopement risk because the admission assessment had categorized the resident as not at risk, even though the NHA identified behaviors like wanting to go home and packing belongings as high‑risk indicators. These combined assessment failures, lack of reassessment after clear changes in condition and behavior, and lack of effective supervision and response to observed exit‑seeking behavior led to the resident’s elopement and subsequent fall in the parking lot, where the resident sustained an abrasion to the right side of the face and scrapes on both hands.

Removal Plan

• Resident #6 no longer resides in the facility.
• Complete updated elopement evaluations for all current residents to determine if any residents are at risk for elopement.
• Complete updated elopement evaluations by the Unit Managers and DON.
• Recheck alarm bracelets for proper placement and function for all residents determined to be at risk for elopement.
• Place any resident identified at increased risk for elopement on appropriate elopement precautions and update the care plan.
• Educate all facility licensed staff on the elopement policy and procedure, including the elopement risk evaluation process, to ensure elopement risk is reassessed.
• Educate all licensed nurses.
• Educate any licensed staff member unable to attend scheduled education upon arrival to the facility, and ensure education is provided prior to beginning their shift.
• Continue to educate all non-clinical staff on elopement policy and procedures, including identifying elopement risk signs and symptoms and reporting to appropriate clinical staff.
• Educate any facility staff member unable to attend scheduled education upon arrival at the facility, and ensure education is provided prior to beginning their shift.
• Validate education by administering quizzes randomly with 10% of staff weekly.
• Conduct audits monthly.
• Report findings at the monthly QAPI meeting to monitor progress towards improvement and recommendations.

Penalty

Fine: $21,665

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 administration allowed a nephrology nurse practitioner (NP #13) to provide consultation services to residents without an established contract in place and without physician orders authorizing these consultations, contrary to facility policy. For Resident #16, a nephrology consult was completed on 1/13/26 and not uploaded until 1/15/26, and there was no physician order for this resident to be seen by a nephrologist or consultant. Within that consult, NP #13 documented a medication error on the resident’s medication administration record but did not notify facility staff; the error was instead brought to the DON’s attention by the survey team on 1/21/26, eight days after NP #13 identified it. The facility’s policy on Provision of Physician Ordered Services, revised 2/18/25, states that no diagnostic tests or consultation requests will be performed without specific orders from a physician, PA, NP, or CNS in accordance with state law. Further record review of four additional randomly selected residents showed that all had been seen by the same nephrology NP consultant beginning around 11/9/25, with consultation notes uploaded days after the visits and no corresponding physician orders for nephrology consultations. NP #13 was reportedly seeing every new admission based on lists provided by unit managers when she arrived. The facility medical director stated that the process for nephrology consultation should involve residents with a diagnosed need and an order from their attending physician, and acknowledged that the contract for this consultant was not signed until 1/27/26, despite her seeing residents since at least November 2025. He also stated that he was not the resource following up on NP #13’s consultations and that this should be an actual nephrologist, and there was no nephrologist signing off on NP #13’s consultations.

Penalty

Fine: $21,665

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 ensure that geriatric nursing assistants (GNAs) received annual performance evaluations of their skills, as required to identify weaknesses and provide targeted training. Record review on 1/22/26 showed that GNA #37, hired in 11/2018, had no documented performance evaluation within the last 12 months. Similarly, GNA #14, hired in 2/2019, and GNA #36, hired in 4/2023, also had no evidence of a performance evaluation in the preceding year. In an interview on 1/22/26 at 12:21 PM, the DON and NHA acknowledged that the facility had no process in place to ensure that nurse aides received annual performance evaluations. This deficiency was cross-referenced to F947, indicating it related to training and competency requirements for staff.

Penalty

Fine: $21,665

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 develop and implement an effective training program for new and existing staff, contracted staff, and volunteers, as required by regulation and based on the facility assessment. Review of the facility’s orientation PowerPoint on 1/22/26 showed that behavioral health topics were not included, despite the requirement that such topics be based on the behavioral health needs identified in the facility assessment for the resident population. Although the list of computer-based training modules included required topics such as effective communication, Resident Rights, Elder Abuse, QAPI, Infection Control, Compliance and Ethics, and Behavioral Health, the infection control module did not include the facility’s own infection prevention and control policies and procedures. During interview, the NHA reported she did not have a copy of the previous NHA’s facility assessment and had not completed a new assessment since returning to the position in 8/2025, resulting in training topics not being aligned with the facility’s assessed needs. Review of individual staff computer-based training transcripts on 1/22/26 showed multiple staff members were not current with required trainings. One GNA had completed only four computerized training modules in 2024, with abuse being the only required topic listed, and had no completed trainings between 2021 and those 2024 modules. An LPN had last completed computerized training modules in 2022, and two other GNAs had not completed computerized training modules since 2024. A laundry aide had not completed Resident Rights training since 2023 and had not completed infection control training that included the facility’s policies and procedures. The Corporate Clinical Resource Nurse, who had served as interim DON and was acting as Nurse Practice Educator, stated that corporate determined and assigned annual computer-based training topics, but the facility had no system to ensure staff actually completed the assigned modules. When these concerns were reviewed with the NHA, she offered no rationale for the deficient practice.

Penalty

Fine: $21,665

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 develop and implement a nurse aide training program that ensured each nurse aide received 12 hours of annual training, including competencies and education in dementia care and abuse prevention, and that training addressed weaknesses identified during annual performance evaluations. Record review on 1/22/26 showed that the personnel file for GNA #37, hired in 11/2018, contained no evidence of a performance evaluation or 12 hours of training with competencies in the last 12 months. Similarly, the file for GNA #14, hired in 2/2019, and the file for GNA #36, hired in 4/2023, lacked documentation of a performance evaluation or 12 hours of competency-based training in the last 12 months. Review of computer-based training transcripts for these three GNAs also failed to show completion of 12 hours of training with competencies in the last 12 months. On 1/16/26, review of the facility’s nurse aide training program/plan revealed it consisted only of a list of computer-based training modules and did not include skills competencies. The NHA and Corporate Clinical Resource Nurse Staff #3 confirmed that this list was their nurse aide training program, and the acting Nurse Practice Educator (Staff #13) stated that the facility had not developed and implemented a training program for nurse aides. These findings were cross-referenced with F730.

Penalty

Fine: $21,665

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 deficiency involves the facility’s failure to timely report allegations of abuse, neglect, and injuries of unknown origin to the State Agency (SA) within required timeframes after staff became aware of them. For one incident, a resident reported to a GNA that someone had been in the room and touched the resident inappropriately at 6:45 AM. The on‑call Unit Manager acknowledged being aware of the allegation before 9:30 AM but did not notify the Nursing Home Administrator (NHA) until 9:30 AM, and the report to the SA was not sent until 10:47 AM. The NHA, who was involved in abuse investigations and review of final reports, could not explain the discrepancy between the time the allegation was known and the time it was reported to the SA. In another incident, an injury of unknown origin involving discoloration and bruising to a resident’s right knee and shin was known to staff earlier than what was reported to the SA. A family member reported a bruise on the resident’s right knee on one evening, and an RN documented this in the progress notes the following day, which would have required reporting to the SA within 24 hours. However, the facility’s investigation file indicated that management did not recognize the injury of unknown origin until two days later in the morning, and the SA was not notified until late that morning. The RN involved stated she knew injuries of unknown origin should be reported to the NP and supervisor and that suspected abuse should be reported to the NHA within 2 hours, but she had no rationale for not reporting this injury when first made aware. The Corporate Clinical Resource Nurse confirmed the RN’s earlier awareness, and the NHA again could not explain the discrepancy in the reported awareness time. Additional deficiencies occurred when staff failed to promptly report allegations of abuse and improper care involving other residents. In one case, a respiratory therapist was documented as having loud, aggressive interactions with a ventilator‑dependent resident, including statements about tying the resident down or sending the resident out, and a statement that patients who hit the therapist would be hit back. A GNA described the resident as anxious with arms up blocking the therapist, and the LPN on the unit acknowledged knowing the abuse policy and recognizing the behavior as inappropriate but only texted the unit manager hours later; the facility did not report the allegation to the SA until approximately five hours after the start of the therapist’s documented aggression. In another case, a resident reported pain and an inappropriate transfer by a GNA during a move to a bedside commode, and the resident’s daughter later called to reiterate the resident’s pain and allegation. Although the GNA was reassigned and management was notified, no further action was taken until two days later when the resident continued to voice concerns and left AMA, and the SA was not notified of the allegation until that same day, well beyond the required reporting timeframe. The NHA acknowledged understanding that this reporting was late.