Westgate Hills Rehab & Healthcare Ctr

Based on record review and interview, it was determined that the facility failed to report an injury of unknown origin to the State Agency (SA) within the required time frame of discovering the incident, as required by regulation.

This was evident for 1 out of 6 facility reported incidents during the complaint survey.The findings include:On 10/08/2025 at 8:20 AM, the surveyor reviewed the facility's investigation packet for intake #2605804, which revealed the facility reported an injury of unknown origin for Resident #203 on 09/02/2025.On 10/08/2025 8:23 AM, further review of the initial self-report sent to the State Agency (SA) revealed that the facility became aware of Resident #203's injury of unknown origin on 09/02/2025 at 7:20 AM and reported it to the state Agency (SA) on 09/02/2025 at 11:02 AM.

The elapsed time between identification of the injury and the facility's report to the SA was approximately 3 hours and 42 minutes, exceeding the required two-hour reporting timeframe.On 10/08/2025 at 12:48 PM, during an interview with the Nursing Home Administrator (NHA), when asked when an allegation of an injury of unknown origin should be reported to the State Agency (SA), she stated the facility had a two-hour window period to report such incidents.

When informed that the facility reported the incident nearly four hours after discovery, the NHA acknowledged awareness of the late reporting and stated she was implementing measures to prevent recurrence.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Westgate Hills Rehab & Healthcare Ctr

10 North Rock Glen Road Baltimore, MD 21229

SUMMARY STATEMENT OF DEFICIENCIES

The surveyor asked the Administrator how she was able to reach an inconclusive finding without conducting and documenting pertinent interviews.

The Administrator stated that interviews were conducted using questionnaire but acknowledged that the interviews were not documented.

She further explained that two residents reported the verbal abuse, and two staff members denied the verbal abuse, therefore she was unable to verify the allegations.

The surveyor requested evidence supporting the staff member statements that GNA #17 did not curse at Resident #215, the Administrator stated that she did not have any documents to support the statement.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Westgate Hills Rehab & Healthcare Ctr

10 North Rock Glen Road Baltimore, MD 21229

SUMMARY STATEMENT OF DEFICIENCIES

Based on interviews and record reviews it was determined that facility staff failed to provide care to a resident who was dependent on staff for personal hygiene and incontinence care.

This deficient practice was evident for 1 (#201) resident reviewed for ADL care during the complaint survey.

The findings include:On 10/07/25 at 10:30 AM, a review of the Facility Reported Incident (FRI) # 2590945 revealed that the complainant alleged that Resident #201 and other residents were often left wet and soiled.

During a phone interview with the complainant on 10/08/25 at 12:45 PM, they further explained that Resident #201 was observed unbathed and soiled with urine and bowel movement on their gown on 07/04/25 and 07/25/25.

During an interview with Geriatric Nursing Assistant (GNA) #4 on 10/07/25 at 10:45 AM, the surveyor asked about the process for documenting resident's baths, showers, and personal hygiene.

The GNA explained that GNA's are responsible for documenting on the computer whether the resident received a shower.

She further stated that GNAs must also record the resident's shower or refusal in the unit's shower logbook.

Additionally, the GNA also stated that if a resident refuses a shower or bed bath, the GNA must inform the resident's nurse. On 10/07/25 at 11:16 AM, during an interview with Assistant Director of Nursing (ADON)/Unit Manager, she explained that residents are assigned shower days, and staff are expected to provide showers on those designated days.

Staff are required to document the completed or refusal of the shower in the resident's electronic medical record, as well as in the unit's shower logbook.

The ADON further states that GNAs must report any shower refusals to the nurse.

The nurse is expected to follow up with the resident and document the resident's refusal. A review of Resident #201's electronic medical records on 10/08/25 indicated that the resident was scheduled to receive showers on Tuesday and Saturdays during the 3:00 PM to 11:00 PM shift.

Further review of the records failed to show a nursing note documenting the residents' refusal of shower or bed bath.On 10/08/25, the surveyor requested to review the shower logbooks for both units 1 & 2 for the month of July 2025. A review of both shower logs revealed that Resident #201 received a bed bath on 07/03/25, and 07/14/25.

Based on the resident's shower schedule, there should have been nine shower logbook entries documented for the month of July, however, only two entries were recorded for the resident. On 10/08/25 at 12:59 PM, a review of documentation report for Resident #201 for July 2025 revealed that bladder incontinence and bowel incontinence care were documented as provided on 07/04/25 at 5:36 PM.

The next entry was documented on 07/05/25 at 3:32 AM.

Further review showed that on 07/25/25 these same care activities were documented at 12:33 AM, with the next entry documented at 2:21 PM.

During an interview with the Administrator and DON on 10/08/25 at 1:30 PM, the surveyor discussed the shower logbook and incontinence care provided to Resident #201.

The surveyor requested any paper or electronic documentation verifying that the resident received showers and incontinence care more frequently than documented.

Both the Administrator and DON stated that the facility was unable to provide documentation to confirm that the resident did not go an extended period without receiving incontinent care and showers as ordered.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Westgate Hills Rehab & Healthcare Ctr

10 North Rock Glen Road Baltimore, MD 21229

SUMMARY STATEMENT OF DEFICIENCIES

Based on record review and staff interviews, it was determined that the facility failed to prevent an avoidable pressure injury.

This was evident for 1 (Resident #208) out of 2 residents reviewed for pressure injuries.

Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.

The findings include. On 10/6/2025 at 9:39 AM, a review of Complaint #2616868 was completed.

The complainant alleged that the facility was not treating and preventing pressure injuries for Resident #208. On 10/6/2025 at 9:54 AM, a review of Resident #208's records was conducted. In the Skin and Wound evaluation on 9/12/2025, Staff #6 documented, Right knee brace removed to assess entire skin when both wound [Nurse Practitioner] and writer noticed an indentation to right lateral knee noted as a traumatic wound [Related to] the brace. In the Skin and Wound note on 9/12/2025, the Wound Nurse Practitioner (Staff #16) provided the following recommendations: Check daily underneath brace to ensure there are no wounds.

Recommend follow up with ortho regarding new Right lateral knee wound caused by knee brace, and see if there is a different brace [the resident] can wear that won't rub on this area, or if [the resident] can go without the brace now.

Betadine wet to dry dressing to the wound, and extra padding to prevent trauma from brace. On 10/6/2025 at 10:59 AM, a review of Resident #208's Orders was conducted. An order for the patient to don R hinge-knee brace locked into extension at all times. No ROM allowed through R knee was placed on 8/4/2025 and discontinued on 9/16/2025. An order to assess the skin under the brace and report abnormalities was placed on 7/29/2025 and discontinued on 8/1/2025. On 10/6/2025 at 12:25 PM, An interview with Staff #9 and Staff #10 was conducted.

When asked what is the standard for assessing resident's with braces or orthopedic devices.

Nurses should assess the resident's skin before and after placement of device.

When asked how often these skin checks are completed, they stated that they would assess the skin every 4 hour or as long as the order indicated.

When asked what if the order stated to keep a device on at all times, the staff indicated that ideally the skin and resident would be assessed every 2 hours.

When asked if there needed to be an order to complete a skin check under these devices, they stated that orders for assessment are usually placed but that it was an expectation that skin under the devices be checked regardless of being an order or not.On 10/6/2025 at 12:42 PM, a review of the resident's care plan was conducted. A care plan for skin impairment and wounds had an intervention to Please check right knee skin under immobilizer Q shift.

Notify MD/NP for any abnormality. No documentation for intervention was found in progress notes or treatment administration record after 8/1/2025 and prior to 9/12/2025.On 10/06/2025 at 12:55 PM, the Director of Nursing was made aware of concern regarding Resident #208's pressure injury found under knee brace.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Westgate Hills Rehab & Healthcare Ctr

10 North Rock Glen Road Baltimore, MD 21229

SUMMARY STATEMENT OF DEFICIENCIES

Based on record review, interviews and observations, it was determined that the facility failed to ensure fall prevention interventions were in place to prevent future falls.

This was evident for 1 (Resident #213) of 2 residents reviewed for falls during a complaint survey.The findings include: On 10/06/2025 at 8:03 AM A review of the complaint #328732 sent to the state agency was conducted.

The complainant reported that the facility was not implementing interventions to prevent future falls for Resident #213.On 10/06/2025 at 9:47 AM An interview with the complainant was conducted.

The complainant reported that Resident #213 had several falls in March 2025 and that not all fall prevention interventions were put in place.On 10/06/2025 at 10:21 AM Further review of the record indicated that the resident had several falls in March

• The Resident had a fall on 3/6/25, 3/7/25, 3/19/25 and 3/24/2025.Further review of the records

indicated that the resident had been identified as a high risk for falls.

The interventions documented on the care plan included frequent rounding on the resident, bilateral fall mats, and a call pad should be near reach, and to be placed on the bed on the side the resident frequently falls on.On 10/07/2025 at 9:07 AM During unit round, the surveyor observed Resident #213 lying on the right side of the bed.

The call pad was not near reach and not on the resident's bed.

The call pad was placed on top of a suctioning container that was on the bedside table.On 10/07/2025 at 1:35 PM Another observation was made by the surveyor. At this time, the call pad was also not on the resident's bed.

During this observation, Resident #213's representative was at the bedside.

The representative stated that they've observed the call pad not near reach.

The resident representative showed the surveyor a picture that was taken on 10/4/2025, which showed the call pad on top of the oxygen humidifier machine. On 10/07/2025 at 1:37 PM The Assistant Director of Nursing (ADON) was summoned to the resident's room and was shown the placement of the resident's call pad.On 10/07/2025 at 1:39 PM A brief interview with the ADON was conducted.

When asked what fall intervention measures should be in place for Resident #213, the ADON stated the fall mats, bed in low position and that the call pad should be on the right side of the bed because the resident falls on that side.

The ADON confirmed that the call pad was neither near reach nor on the right side of the resident's bed.

She acknowledged that the care plan interventions indicated to prevent future falls were not all in place.

The ADON was notified that this will be a concern.On 10/07/2025 at 2:10 PM The administrator and the Director of Nursing (DON) were made aware of the concerns regarding fall prevention interventions.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Westgate Hills Rehab & Healthcare Ctr

10 North Rock Glen Road Baltimore, MD 21229

SUMMARY STATEMENT OF DEFICIENCIES

Based on record review and staff interviews, it was determined that the facility failed to maintain accurate resident records.

This was evident for 1 (Resident #202) out of 18 residents reviewed during the complaint survey.

The findings include: On 10/7/2025 at 9:09 AM, A review of Complaint #2561490 was conducted.

The complainant alleged that Resident #202 was not being cleaned after incontinent episodes. On 10/7/2025 at 9:52 AM, A review of Resident #202's medical record was conducted. A review of the Documentation Survey Report for the month of June indicated that the resident had bladder and bowel incontinent episodes on 6/8/2025, 6/25/2025, and 6/27/2025 during the night shift but the Geriatric Nursing Assistant (GNA) documentation noted Not Applicable (NA) for the Toileting Hygiene task during the night shift. On 10/07/2025 at 10:47 AM, an interview with the Director of Nursing was conducted.

When asked what the expectation was for GNA documentation in regard to toileting hygiene? The GNA's should document if care was provided and document any refusals.

The GNA documentation found for Resident #202 in the month of June 2025 was presented to the DON.

When asked what documenting NA in the Toileting Hygiene task signified, the DON stated the GNA was probably trying to document that the resident refused because the resident had refusing behaviors.

When asked if it was the expectation that that staff document Resident Refused (RR) for resident refused rather than NA, The DON stated that if the GNAs have the option to document RR in the chart then they should document it as refused. On 10/7/2025 at 11:48 AM, GNA #18 was interviewed.

When asked what the documentation of NA under Toileting Hygiene indicated, the GNA stated that if the care or task does not apply to the resident they will document NA.

When asked for the specific case where the GNA documented NA for Resident #202 in Toileting Hygiene and the resident had incontinent episodes, the GNA stated that they meant to document RR but were unable to so they documented NA.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Westgate Hills Rehab & Healthcare Ctr

10 North Rock Glen Road Baltimore, MD 21229

SUMMARY STATEMENT OF DEFICIENCIES

The surveyor went to the nurses' station where there were 3 staff members talking.While standing at the nurses' station, the surveyor showed the Assistant Director of Nursing (ADON) that the call light sign was on for room [ROOM NUMBER].

The surveyor then asked the ADON if she heard any audible call sound at the nurses' station or the hallways, the ADON replied no, that she did not hear any call bell sound.

The surveyor notified the ADON that the call bell system was expected to have visual signal and the sound was supposed to be audible enough for staff to hear.

The ADON stated that she would notify the maintenance director.0n 10/08/2025 2:10 PM The administrator provided the surveyor with a document that indicated the facility had placed a work order request to an external facility to repair the call bell system on the second floor.On 10/09/2025 at 9:59 AM An interview with the Maintenance Director was conducted. He reported that no one had reported that the call bell system had no audible sound. He acknowledged that the second-floor call bell system sound was significantly lower compared to the first floor. He also reported that this was a new problem because he had inspected the call bell system sound last month and had no issues then.On 10/09/2025 at 10:55 AM The Administrator was notified of the call bell system concerns.

Facility ID: