Westgate Hills Rehab & Healthcare Ctr

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

about the wound care process at the facility. She explained that a wound care Nurse Practitioner (NP) and

the facility's wound care nurse conducted weekly wound rounds for residents with existing wounds. The facility's wound care nurse will also conduct a monthly sweep for residents who don't have wounds. If a resident was newly admitted and available when the weekly wound rounds are being done, the wound care team would see the newly admitted resident as well. If the resident was admitted on off-hours the floor nurse would be responsible for the initial skin assessment and then the wound care nurse would follow up

on Monday. The surveyor asked the DON what type of treatment would be offered to a resident with moisture associated skin damage (MASD) and she explained that a barrier cream after incontinent care and watching the wound closely would be standard practice. However, if the wound nurse practitioner assessed the wound, they may provide other wound care orders for us to follow.

The DON was notified of the following concerns: inconsistency with Resident #2 skin assessment documentation less than 24 hours after admission (the resident's admitting nurse documented: skin intact on10/2/2025; the facility's wound care nurse documented: pressure ulcer stage 3 on left buttock on 10/3/2025 and the NP documented MASD on 10/3/2025). There was also no indication that the wound care treatment was initiated upon admission. The resident wound care treatment was started on 10/12/2025, which potentially contributed to a decline in the resident skin integrity. The DON stated that she will review resident's hospital records.

On 12/31/2025 at 3:53 pm, the DON stated that she reviewed the resident's hospital record which did not indicate that the resident had a wound upon discharge from the hospital.

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

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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

12/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Westgate Hills Rehab & Healthcare Ctr

10 North Rock Glen Road Baltimore, MD 21229

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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Based on a review of records and interviews, it was determined that the facility failed to assess or document residents' behaviors regarding mental illness. This was evident for one resident (Resident #7) out of eight residents reviewed during this complaint survey. The findings include: On 12/30/25 at 1:50 PM, the surveyor conducted a phone interview with the complainant for case #2659413. During the interview, the complainant reported that they were not informed of Resident #7's worsening agitation, wandering, and/or behaviors, such as entering other residents' rooms and touching their belongings. The complainant stated that when the resident was ready to be readmitted to the facility, management resisted, claiming that Resident #7 had worsening behavioral issues that resulted in the facility increasing its budget to address

the problems.The surveyor reviewed Resident #7's medical records on 12/30/25 at 2:15 PM. The review revealed that the resident had resided at this facility since October 2025 with a diagnosis of dementia with behavioral disturbance. Additionally, the resident was prescribed medications (Risperidone, Divalproex, and Trazodone) for those diagnoses upon admission; however, there was no order/documentation for behavior monitoring.During a phone interview with the Psychiatric Nurse Practitioner (Staff #5) on 12/30/25 at 5:23 PM, she recalled Resident #7's condition as aggressive, including making false accusations and wandering.

The surveyor asked how Staff #5 became aware of the resident's condition. She stated, It was a verbal report; there was no documentation that I referred to.In an interview with the Director of Nursing (DON) on 12/30/25 at 5:49 PM, she stated that Resident #7's behavioral issues were documented in the care plan and that behavior monitoring for every shift should have been documented in the Treatment Administration Record. The surveyor reviewed Resident #7's medical records with the DON. The DON verified that there was no assessment or documentation of the resident's behavior.

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