The Nursing And Rehab Center At Stadium Place

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

during an interview with the DON, the surveyor asked what the expected staff response time is for call bells.

The DON stated that she expects staff to respond to call bells within 15 minutes. She further stated that there are times when residents may wait longer than expected; however, her expectation is that call bells be answered within 15 minutes or less. The surveyor discussed call bell response times and staffing concerns for July 2025, and the DON acknowledged the issue. The findings were revealed to the Administrator on 10/17/25 at 11:30 AM.

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Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Nursing and Rehab Center at Stadium Place

1010 East 33rd Street Baltimore, MD 21218

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Based on record reviews and interviews, it was determined that the facility failed to ensure that the facility's assessment accurately reflected the facility's staffing requirements. This deficient practice was evident

during the complaint survey.The findings include: During an interview with the Director of Nursing (DON) on 10/16/25 at 11:54 AM, the surveyor reviewed the facility assessment with her. The DON stated that she participates in the facility assessment process. When asked if the assessment was up to date, she stated that she believed it was. The surveyor informed her that the date on the facility assessment was August 2024.The surveyor and the DON discussed the staffing requirements outlined in the facility assessment which indicated the following: one nurse and Geriatric Nursing Assistant (GNA) to each unit (4 units) on the day shift; one nurse covering two units and one GNA assigned on the evening shift; and one nurse with three GNA's splitting coverage across the units on the night shift. The DON stated the information on the facility assessment was incorrect. She reported that one nurse covers two floors during the day, evening, and night shift; one Certified Medication Aide (CMA) covers the entire building during the day and evening shifts, with no CMA coverage at night; and four GNAs are scheduled for day, evening and night shift. The surveyor informed the DON that based on the staffing numbers she provided, and staffing sheets reviewed for July 2025, the facility is operating below the staffing levels indicated in the facility assessment. The DON acknowledged this concern. During an interview with the Administrator on 10/16/25 at 12:38 PM, the surveyor reviewed the facility assessment he had provided earlier in the day. When asked if the facility assessment was up to date, the Administrator stated that it was. The surveyor informed him of the staffing ratios listed in the facility assessment, and the Administrator stated that the information was incorrect. The Administrator then provided the surveyor with a second copy of the facility assessment, which was also dated August 2024. However, the section regarding staffing requirements was blank on the second copy.

The Administrator stated that the staffing ratios reported by DON are the facility's current expected staffing requirement. The surveyor asked the Administrator if there was an updated facility assessment for 2025.

The Administrator stated that the most recent assessment available was dated August 2024.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Nursing and Rehab Center at Stadium Place

1010 East 33rd Street Baltimore, MD 21218

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of complaint #2611976, record reviews, and staff interviews, it was determined that the facility failed to ensure a resident's clinical record was accurately documented regarding the date and acquisition of pressure injuries. This was evident for 1 out of 2 complaints reviewed during the complaint survey.The findings include:Section M of the Minimum Data Set (MDS) is a part of the Resident Assessment Instrument used in long-term care facilities to document the risk, presence, appearance, and changes of skin conditions, primarily pressure ulcers. It also tracks other skin ulcers, wounds, lesions, and related treatments to ensure a comprehensive approach to skin care, prevention, and treatment. On 10/16/2025 at 9:50 AM, review of complaint #2611976 showed that on 09/09/2025, the resident's family filed a complaint with the State Agency stating concerns regarding Resident #301's wounds and care while the resident was at the facility.On 10/16/2025 at 10:12 AM, review of Section M of the Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated that Resident #301 had no pressure sores upon admission but was at risk for developing pressure ulcers and used a pressure-reducing device for the bed and review of Section M of the MDS assessment dated [DATE REDACTED] showed that the resident had unhealed pressure injuries that were unstageable and identified as Deep Tissue Injuries (DTI) to both heels.On 10/07/2025 at 10:21 AM, review of Resident #301's electronic medical record showed weekly skin assessments were completed from 07/28/2025 through 09/01/2025. The assessment dated [DATE REDACTED] documented the resident's skin as intact.

The next assessment, dated 09/08/2025, indicated the presence of unstageable pressure injuries to the right heel and deep tissue injury to the left heel.On 10/07/2025 at 10:41 AM, review of the wound assessment note dated 09/08/2025, completed by the Wound Nurse Practitioner (Staff #9), revealed documentation stating the wound was not acquired in house and listed the acquisition date as 07/19/2025.On 10/16/2025 at 1:13 PM, during an interview with the Director of Nursing (DON), she was asked whether Resident #301's wounds were avoidable. The DON stated that the wounds were unavoidable because Resident #301 was totally dependent upon admission and continued to decline.

When asked to clarify how and when the wounds were acquired, the DON stated that the wounds were acquired in the facility and were first noted on 09/08/2025, the same day the resident was transferred to the hospital upon the Responsible Party's request. When informed of the discrepancy between her statement and the wound documentation, the DON stated she would inform Staff #9.On 10/16/2025 at 1:20 PM, the surveyor requested to speak with Staff #9 and the DON provided the surveyor with a phone number. On 10/16/2025 at 1:25 PM, the surveyor attempted multiple calls to Staff #9 but received no answer and left a voicemail messageOn 10/16/2025 at 2:10 PM, the DON informed the surveyor that she had spoken with Staff #9 regarding the error in the wound documentation. The DON stated that Staff #9 acknowledged incorrectly documenting that the heel wounds were not facility-acquired and had entered an incorrect acquisition date of 07/19/2025. The DON further stated that Staff #9 agreed to write an addendum correcting the documentation to reflect that the wounds were facility-acquired with accurate dates.On 10/17/2025 at 8:08 AM, Staff #9 called the surveyor and stated that Resident #301 had incontinence-associated dermatitis (IAD) on the buttocks and pressure injuries to both heels. When informed that the acquisition and date of the wounds were incorrectly documented, Staff #9 confirmed that

the documentation error was hers and that she had written an addendum correcting the information following her discussion with the DON.On 10/17/2025 at 8:29 AM, the DON was informed that inaccurate wound documentation was a concern. The DON acknowledged the issue and stated that she would conduct a facility-wide audit of all residents with wounds to verify the accuracy of wound acquisition documentation and prevent future errors.

Event ID:

Facility ID:

If continuation sheet