Bayleigh Chase Inc

F-F609

31982

4. Facility reported incident #MD00185366 was reviewed on 1/8/25 at 10:15 AM. The facility reported that on 10/31/22, Resident #901, a resident with severe cognitive impairment, reported to his/her daughter that the previous morning he/she called an employee a bitch and the employee smacked him/her on the mouth and told him/her not to call her names. The Director of Nursing (DON) reported the incident to the state agency and began an investigation. Written statements were obtained from 5 staff. The statement written by GNA (Geriatric Nursing Assistant) #10 revealed that Resident #901 reported to her on 10/28 that s/he was slapped twice on the face during the day by someone in the TV room, but she forgot to report it.

The documentation failed to reveal that the facility expanded or began a new investigation after they became aware of the earlier abuse allegation in Staff #10's statement.

Staffing schedules revealed that 26 nursing staff worked on the unit where Resident #901 resided from 10/28/22 - 10/30/22. However, written statements were only obtained from 5 nursing staff. There were no statements from non-nursing staff including but not limited to activities, maintenance, laundry, dietary or housekeeping personnel, in an effort to collect information potentially useful to their investigation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0610 5. Facility reported incident #MD00182604 was reviewed on 1/9/25 11:30 AM. The report indicated that on 4/25/22 at approximately 11:30 PM, GNA#7 pulled Resident #905, a wheelchair bound resident, by his/her Level of Harm - Minimal harm or collar, pulled his/her hair, grabbed him/her by the neck, rushed at the resident and punched him/her in the potential for actual harm abdomen. Per her written statement, LPN (Licensed Practical Nurse) #3 witnessed the event. GNA#6 was also present during part of the incident and, per her statement, witnessed some of the same events. Residents Affected - Few GNA#7's time punch records were reviewed on 1/9/25 at approximately 4:00 PM. They revealed that GNA#7 continued to work approximately 8 hours and 20 minutes, from 11:30 PM on 4/25/22 until 7:51 AM on 4/26/22. She returned at 2:57 PM on 4/26/22 and worked an additional 3 hours until sent off duty at 6:03 PM by the DON.

During an interview on 1/9/25 at 4:30 PM the DON was asked to clarify when GNA#7 was suspended after

the incident. She indicated that when she came in to work the next day 4/26/22, she was made aware of the incident, she informed the nurse on duty to obtain a statement from GNA#7 and send her home pending the outcome of the investigation. She confirmed that GNA#7 was not sent off duty on 4/25/22 immediately after

the incident. When asked why, she indicated that GNA#6 did not report the incident and LPN#3 was an agency staff member and did not report it immediately.

The facility failed to protect the residents by failing to ensure that GNA#7 was removed from the facility pending the outcome of the abuse allegation.

Cross reference F 600.

43050

Review of a policy provided by the facility titled Abuse, Neglect, Involuntary Seclusion, Exploitation, and Misappropriation of Property Prevention, dated 07/2023 indicated . The investigative summary report must include sufficient detail to document the facility conducted a thorough investigation and shall include: Date and time of the alleged incident; Resident's full name and room number; Details of the allegation and any injury; Name(s) of the accused and any witnesses; Name of the facility staff member(s) who investigated the allegation; Any corrective action taken by the facility (i.e., disciplinary actions, staff training, etc.); The results of the investigation (i.e., was the allegation substantiated or unsubstantiated). 1. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed Resident R24 was admitted to

the facility on [DATE REDACTED] with diagnoses which included dementia and major depressive disorder.

6. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/13/24 in

the EMR under the MDS tab revealed Resident R24 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of zero out of 15.

Review of the facility investigation provided by the facility for an injury of unknown origin, revealed Resident R24 had a bruise on the face with no known fall. Progress note dated 08/22/24 at 7:34 AM stated, Resident noted to have bruise 6x4 on left side of face by eye which was noted at shift change. Left eye puffy. Resident in no distress.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0610 During an interview on 01/09/25 at 7:35 AM with Geriatric Nurse Assistant (GNA) 4 on revealed I took care of

the resident during the 11-7 shift and no incident occurred. I do not know how she received the bruise. Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Nursing (DON) who completed the investigation revealed, This was

an injury of unknown origin. Resident R24 had bruising to the left side of her face. A complete skin assessment was Residents Affected - Few not done. The entire body should have been assessed since it was an injury of unknown origin. When asked if Resident R24 hit her head, the DON did not know. When the DON was asked if other residents were interviewed or all staff that had been working during the night shift, the DON stated No other residents were interviewed or staff. This was an incomplete investigation.

7. Review of Resident R45's Face Sheet located in resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE REDACTED] with diagnoses which included Major Depressive Disorder, Mild Cognitive Impairment, Hallucinations, Unspecified Dementia, and anxiety disorder.

Review of Resident R45's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. Further review revealed no behaviors were indicated.

Review of Resident R45's Care Plan, dated 11/30/22 and located in the residents' EMR under the Care Plan tab, revealed I use psychotropic medications related to depression, anxiety, insomnia, dementia (I have hallucinations, delusions/paranoia at times). Interventions in place were Resident continues with hallucinations and delusions/paranoia at times. Resident re-directed and re-oriented to reality when having those episodes. Mood does appear improved 05/22/24. Further interview revealed no care plan related to making false allegations.

During an interview on 01/07/25 at 11:25 AM, Resident R45 said Geriatric Nursing Assistant (GNA)1 hates him/her just because s/he is him/her. Resident R45 said GNA1 mouths off to him/her and when s/he reports something about GNA1 to administration GNA1 gets even with him/her by reporting something false about Resident R45. Resident R45 said s/he believed she killed his/her dog, and that GNA1 ignores her job duties. Resident R45 said GNA1 called him/her an (expletive). S/he said s/he reported it to the DON who told Resident R45 that it was unacceptable behavior. S/he said GNA1 was still currently employed. Resident R45 said GNA1 did not care about the care she provided to him/her. Resident R45 said GNA1 and GNA2 would gang up on him/her and talk about him/her in the hall because s/he could hear them. S/he said they said they were not going to do the right thing.

During an interview on 01/07/25 at 11:45 AM the allegations by Resident R45 about GNA1 were reported to the Administrator and the DON. The DON stated she was aware of the allegations about the dog, but this was

the first time she heard that Resident R45 alleged that GNA1 called him/her an (expletive). The DON said this was never reported and that Resident R45 has never had a dog on the facility grounds.

During an interview on 01/08/25 at 12:27 PM the DON she had a discussion with the Administrator after they became aware of the allegations by Resident R45 but that was as far as it's gone. She stated they have reported it to

the state and that she was waiting to discuss it with Regional Clinical Nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0610 During an interview on 01/08/25 at 12:42 PM the Administrator consulted with the DON, and he spoke to the Medical Director. He said that they decided there was no validity to the allegation based on the fact that s/he Level of Harm - Minimal harm or never had a dog here, and that GNA2 has not worked here for a long time. He said this was not reported to potential for actual harm the state and that he did not interview the resident or any staff before making this conclusion. He stated after

an allegation is made they decide if it's valid before they report it to the state. If they investigate they will Residents Affected - Few interview the resident and any staff that was identified and that any staff who was named as an alleged perpetrator would be suspended during the investigation. He stated that he did not investigate the allegation, and the staff was not suspended.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51678 Residents Affected - Few Based on interview, record review, and policy review, the facility failed to ensure one resident (Resident (R)52) of two residents reviewed for falls out of a total sample of 27 residents had root cause analysis and a thorough investigation completed to determine if additional interventions were warranted when the resident had 11 falls, one resulting in harm when the resident sustained a left hip fracture requiring surgery. This had

the potential for the resident to continue to have falls with possible major injuries.

Findings include:

Review of the facilities revised November 2020 Fall Reduction and Management Policy revealed Strive to identify residents at risk for falls and reduce the incidence of falls by identifying environmental, interpersonal, and/or functional triggers and causes of fall and implementing person-centered interventions to reduce risks. To strive to ensure that the resident environment remains as free of accident hazards as is possible; and that each resident receives adequate supervision, functional support, and assistance devices to prevent and/or minimize accidents. Recommendations for prevention of future occurrences will be incorporated into the resident's care plan.

Review of Resident R52's Electronic Medical Record (EMR) under the Census tab revealed the resident was admitted to the facility on [DATE REDACTED].

Review of Resident R52's diagnoses located in the EMR under the Diagnosis tab revealed a diagnosis of Alzheimer's Dementia.

Review Resident R52's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an assessment reference date (ARD) of 10/15/24 Brief Interview for Mental Status (BIMS) of five out of 15, which showed s/he had severe cognitive impairment. The MDS showed the resident required limited assistance of one staff for transfers, toileting, and ambulation.

Review of Resident R52's Care Plan located under the Care Plan tab a fall focus area revealed I am a fall risk r/t [related to] deconditioning, Gait/balance problems, Incontinence, Unaware of safety needs, Alzheimer's/Dementia started on 09/22/23. A goal revealed I will be free of minor injuries started on 09/22/23. Interventions started after 09/22/23 included Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility started on 07/09/24 and Call bell pad to alert nursing of movement and to reduce the risk of falls initiated on 12/11/24. There were no new interventions added to potentially prevent further falls from 09/22/23 until 07/09/24.

Review of Resident R52's EMR Progress Notes located under the Progress Notes tab revealed he had at total of 11 falls; on 10/20/23, 10/28/23, 11/25/23, 01/01/24, 01/04/24 (two falls), 03/30/24, 05/20/24 (two falls), 06/27/24, and 07/01/24. The fall on 07/01/24 resulted in a fracture to his left hip.

Review of Resident R52's Progress Notes located in the EMR under the Progress Note tab revealed the following falls:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0689 1. Details of a fall on 10/20/23 at 10:40 PM revealed an Aide went into the resident's room to pick up his/her dinner tray. She found him/her on his/her knees next to the bed. Fall mats were down and s/he was actually Level of Harm - Actual harm kneeling on the fall mat. Resident said s/he was trying to get to his/her desk to get some toothpicks.

Residents Affected - Few 2. Details of a fall on 10/28/23 revealed the resident was found on the fall mat kneeling next to his/her bed. S/he had the upper part of his/her body resting on the bed. S/he was unable to tell staff what s/he was trying to do. S/he did not have any c/o pain or discomfort. His/her skin is intact with no bruising or skin tears noted

3. Details of a fall on 11/25/23 revealed the resident's family hired aide had called staff to the room. When staff arrived in the room the resident was sitting on the floor in front of his/her recliner. The aide said the resident told her s/he could walk so she had attempted to transfer the resident from his/her bed to the recliner and s/he landed on the floor. No injuries were noted. Caregiver was made aware that the resident required a hoyer lift for transfers and when needing assistance to please notify staff.

4. Details of a fall on 01/01/24 revealed the resident was observed lying on his back in his/her bathroom beside his/her wheelchair. Resident attempted to transfer to the toilet without calling for assistance. Resident obtained a skin tear to his/her left forearm. No other injuries were noted.

5. Details of a fall on 01/04/24 revealed the resident was found on the floor. S/he was on the floor next to his/her bed lying on his/her back. His/her head was at the end of the bed where the footboard was. S/he had

a skin tear on the resident's lower left extremity. S/he denied any pain or discomfort.

6. Details of the second fall on 01/04/24 revealed the resident was heard calling from his/her room. S/he was found lying on his/her left side in front of the recliner. S/he could not tell us why s/he had gotten out of bed. S/he had no complaints of pain or discomfort. No new skin issues. Resident reminded to use call bell if s/he needs to get out of bed.

7. Details of a fall on 03/30/24 revealed the resident was observed sitting on the floor beside his/her bed near his/her recliner. Resident was attempting to transfer out of bed to his/her recliner without assistance. Resident obtained a skin tear to his/her lower left leg and right elbow.

8. Details of a fall on 05/20/24 revealed A Geriatric Nursing Assistant (GNA) found the resident lying on his back on the floor mat next to bed. Resident has no injuries noted. The resident participated in therapy.

9. Details of a second fall on 05/20/24 revealed the resident was observed sitting on his/her buttocks in front of his/her recliner. Resident was attempting to transfer without calling for assistance to his/her wheelchair. No injuries noted.

10. Details of a fall on 06/27/24 revealed the resident was found on floor in the resident's room, lying on his/her left side. A skin tear was noted to the left hand. Resident was alert, awake and oriented to baseline.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0689 11. Details of a fall on 07/01/24 revealed the resident was observed lying on his/her back in his/her bathroom beside his/her wheelchair. Resident attempted to transfer to the toilet without calling for assistance. Resident Level of Harm - Actual harm obtained a skin tear to his/her left forearm. Resident denied hitting his/her head. No other injuries noted. The resident was escorted out to the common area after having dinner in the dining area. The resident Residents Affected - Few complained of pain in the upper left leg. Tylenol given for pain. [physician] notified of c/o pain. An x-ray was ordered. The x-ray indicated the resident had a fracture of his/her left hip and had a left hemiarthroplasty (surgery).

Review of Resident R52's Fall Risk Evaluations completed on 09/21/23, 12/22/23, 12/28/23, 03/28/24, 07/09/24, 07/30/24, and 10/30/24 revealed scores had been based on level of consciousness/mental status, history of falls in the past three months, ambulation/elimination, vision, gait/balance, systolic blood pressure, medications, and disease processes. His/her scores indicated s/he was at high risk for falls.

Review of Resident R52's Fall Incident Reports completed after each fall and provided by the facility included a review of the residents' diagnoses, medications including psychoactive, anticoagulants, steroids, antihypertensives, and new medications in the last seven days. Any changes in mental status, unsteady gait, combative or agitated, continent, or incontinent. Other areas reviewed including what type of equipment the resident used, if their call light was near or on, footwear, use of a walker/cane/wheelchair, use of a bed or chair alarm, use of side rails, and the condition of the room. Those areas were filled out however, under the Fall Huddle Investigation Worksheet that was completed with staff working at the time of the falls revealed there were no new interventions listed other than monitoring. The Root Cause of Fall section had not been completed for any of the falls.

During an interview on 01/10/25 at 1:30 PM with the Director of Nursing (DON) confirmed the Fall Intervention Form only had monitoring as the intervention. She also agreed the Root Cause of Fall section had not been completed, and it could have brought more ideas for effective fall prevention interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or 30428 potential for actual harm Based on medical record review and interview with facility staff, and after the review of multiple facility Residents Affected - Few reported incidents, it was determined that the facility failed to administer and document pain medication for residents with reported pain. This was evident during the review of 2 of 3 residents with reported falls and pain. (#903 and #902)

The findings include:

1. Review of the medical record on 1/10/25 at 7:47 AM for Resident #903 noted admission diagnosis including unspecified dementia and abnormalities of gait.

Resident #903 was assessed on 12/19/23 as having a brief interview of mental status (BIMS) of 5, meaning that s/he had severe cognitive impairment. Nursing progress notes documented that s/he would ambulate with either a walker or wheelchair throughout the unit.

During the review of a facility reported incident (FRI) occurring on 5/10/24, Resident #903 was documented that s/he was found on the bathroom floor and had complaints of left hip pain. Nursing documented that Tylenol was administered at 9:50 PM for the pain.

A concurrent review of the resident's medication administration record (MAR) failed to reveal that any Tylenol was administered, though the residents' pain was documented as a '6' prior to the resident's transfer to the hospital.

.

2. Review of the facility reported incident on 1/10/25 at 7:47 AM for Resident #902 noted admission diagnosis including unspecified dementia and abnormalities of gait.

Resident #902 was found on their back in their room on 7/12/23, nursing progress notes and corresponding MAR documented that the resident was medicated with Tylenol.

On 7/12/23 at 11:15 PM nursing documented that Resident #902's arm was swollen, and s/he was unable to straighten arm and reports pain to elbow when touched.

According to the corresponding MAR reviewed on 1/14/25 at 9:00 AM, no further Tylenol was administered, though the physician order was for every 6 hours as needed, and Resident #902 was complaining of pain.

Resident #902 had an x-ray completed and was diagnosed with an Olecranon (elbow) fracture.

On 7/15, 7/16, 7/17 and 7/18, nursing progress notes all documented that Resident #902 had complaints of pain on the left arm and was given routine Tylenol. However, concurrent review of the MAR failed to reveal that any Tylenol was administered except one time on 7/17. The progress notes all repeated the same information verbatim.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0697 The concern that the resident was not medicated for pain, or was not appropriately and thoroughly assessed was reviewed with the facility DON and NHA on 1/13/25. Level of Harm - Minimal harm or potential for actual harm b. Resident #902 also had a noted injury on 8/19/23 according to nursing progress notes, reviewed on 1/14/25. At 5:14 AM, nursing documented that the resident complained of pain in the upper part of the right Residents Affected - Few leg and had a bruise on [his/her] right cheek. However, according to the MAR, no Tylenol or any pain medication was signed off until 3:58 PM that afternoon.

This concern was reviewed with the facility DON on 1/13/25.

RN#4 was interviewed on 1/14/25 at 11:15 AM. She was asked how she assesses a resident's pain. She reviewed the process according to the facility policy and confirmed that there are different assessments for residents on different cognitive levels and that are unable to state pain on a 1-10 pain scale. Those assessments include looking at the residents for physical signs of pain such as grimacing and not solely relying on a numerical scale. She also stated that that information gets documented at that time and progress notes are never copied over from the day prior.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 31982 potential for actual harm Based on review of staff records and interview with facility staff, it was determined that the facility failed to Residents Affected - Many ensure Geriatric Nursing Assistants (GNAs) received a performance review at least once every 12 months.

This was evident for all GNA's working in the facility since 2022 and has the potential to affect all residents.

Failure to perform performance reviews prevents the facility from providing regular in-service education that is based on the outcome of these reviews.

The evidence includes:

The employee file of GNA#7 was reviewed on 1/13/25 at 9:30 AM, during review of a facility reported incident (#MD00182604) related to abuse. No performance reviews were found in the file. Upon request, the Director of Nursing (DON) provided the last 3 reviews for GNA#7 which were dated 1/27/09, 9/4/09 and 10/26/11.

On 1/13/25 at 10:35 AM the DON was informed that the documentation she provided did not contain performance evaluations after 2011. She indicated that she came to the facility as the DON in 2020 during COVID, and she did not do evaluations. She was asked when she began doing performance evaluations again. She paused then stated: I only do evaluations of my ADON (Assistant Director of Nursing).

On 1/13/25 at 1:30 PM The DON was asked to clarify who was responsible for completing the performance evaluations for the other nursing staff. She stated, they're not done.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or 30428 potential for actual harm Based on staff interview and medical record review, it was determined that the facility administration failed to Residents Affected - Some provide effective oversight activities for the facility to ensure that resources were used effectively to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards, as evidenced by 1. Failure to have a system in place to effectively complete investigations related to injuries of unknown origin, 2. Failure to address abuse and further identify/address potential/alleged abusers, and 3. Failure to ensure that all staff received required training for abuse.

The administration's failure to ensure processes were in place that could identify and correct deficient practice in care had the potential to adversely affect the health and safety of all the residents in the facility in addition resulted in an immediate jeopardy for abuse related to the failure to identify and address actual abuse of a resident.

The findings include:

1. On 1/7/25 at approximately 10:30 AM the survey team provided the Director of Nursing (DON) with a list of facility reported incidents for review and requested the corresponding facility investigations.

At 2:00 PM on 1/7/25 the investigations for 2 of 8 of the requested facility reports were provided. The DON was immediately questioned about the investigations as they only consisted of 2 and 3 pages respectively.

She stated at that time that the investigations were easy because they knew what had happened.

The first report reviewed was for Resident #903, related to an unwitnessed fall that resulted in a fracture, consisted of only 3 pages. The first page was the actual self-report that was submitted to the Office of Health Care Quality (OHCQ) and the next 2 pages consisted of statements from 2 staff. There was no face sheet related to the resident involved in the investigation and no assessment related to the resident at the time of

the incident including vital signs and pain assessments.

Review of the second intake for Resident #902 that had the same type of occurrence, revealed the same concerns lacking in the investigation packet.

The DON was interviewed again on 1/7/25 at approximately 2:20 PM in the presence of the Nursing Home Administrator (NHA). The concern related to the lack of information in the investigation packets was reviewed at that time. The DON stated that she keeps the 'fall' investigations separate. She was then asked to provide

the survey teams with everything that she has related to the investigations so the survey can proceed and have it available for review in the morning.

On 1/8/25 at around 7:30 AM the DON met this surveyor in the conference room. She provided this surveyor with what the facility calls a 'fall huddle investigation worksheet,' and confirmed that now the investigations were complete.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0835 Regarding the investigation for Resident #903, although this occurrence involved a fall, didn't have a fall huddle worksheet completed, just one statement from a witness and now included the resident's physician Level of Harm - Minimal harm or order set. potential for actual harm Surveyor review of the medical record for Resident #903 revealed that there were 5 other incidents from Residents Affected - Some 12/2022 to the present that were not investigated and reported to the OHCQ and therefore, no interventions were reviewed or put in place for the prevention of further injuries.

A second review of the combined facility investigations and fall huddle investigation worksheet for the occurrence with Resident #902 revealed that the fall huddle documents what occurred, however, there is no assessment of the resident included or documentation of the acquired injuries of the resident from the occurrence. There was still no witness statements or other interviews related to the occurrences of that day from other staff or residents, and no updates completed on the care plan to show interventions to prevent

this incident from occurring again.

Resident #904 who was also reviewed for falls and injuries of unknown origin was also found to have had a fall with a fracture that was not reported to the OHCQ and another fall with a fracture that was not thoroughly investigated and therefore no interventions were reviewed or put in place for the prevention of further injuries.

On 1/8/25, after initiating the review of the facility investigations, the DON and NHA were interviewed again.

They were presented with the investigation packets that the DON had previously presented to the survey team and the concern that they were still lacking key elements of an investigation including assessments and interviews. They were also presented with the other identified falls and injuries found for Resident #903 and #904. The DON did not feel that injuries where they knew the resident fell , even though it was not observed, and a fracture was acquired, needed to be reported. Additionally, injuries such as bruising did not require reporting, however, they were still not internally investigating per the lack of provided documentation. They were asked at that time who was the abuse coordinator and responsible for the final review of the investigations prior to submission. The DON and NHA looked at each other, then the DON stated, I guess me because I am the DON.

Interview with the DON on 1/10/25 at 9:24 AM regarding the concerns related to the facility investigations revealed that they do not do root cause analysis' (RCA) for the incidents, aside from the fall huddle investigations, they discuss it but 'as far as documentation that's all they have.' She was asked if they review

the residents and put interventions in place. She stated that they review the falls and the entire 'team' which includes nursing and physical therapy review the fall huddle and sign the fall huddle form and decide on corrective actions.

On 1/10/25 at approximately 11:00 AM the NHA was notified of concerns related to the investigations and that during the surveyor's review, that there was one staff member that was identified as working with the residents that were identified with bruising and injuries of unknown origin and identified in a recent abuse allegation during this survey that was not suspended upon notification to the DON of that alleged abuse. The concern that the facility was not doing thorough investigations into injuries of unknown origin that they were aware of and looking at RCAs was reviewed at that time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0835 On 1/10/25 at approximately 11:00 AM the NHA was notified of concerns related to the investigations and that during the surveyor's review, that there was one staff member that was identified as working with the Level of Harm - Minimal harm or residents that were identified with bruising and injuries of unknown origin that the facility failed to identify. potential for actual harm This individual was also identified in an abuse allegation during this survey. The concern that the facility was not doing thorough investigations into injuries of unknown origin that they were aware of and looking at RCAs Residents Affected - Some was reviewed at that time.

2. a. During the survey an abuse allegation against a GNA was made. Upon notification to the DON the employee was not suspended at the time the allegation was made. On 1/13/25 the DON was asked what the process was when someone makes an abuse allegation. She stated to make the resident safe. She was asked why the decision was made not to send the alleged perpetrator home. The DON stated that she told

the GNA not to take care of [resident]. However, she acknowledged that the GNA was allowed to continue with the rest of her assignment on the same unit, and passing by the victim's room. This incident combined with a substantiated abuse occurrence from 2022 caused the OHCQ to determine there was an Immediate Jeopardy related to abuse and the health and safety of the residents on 1/13/25.

31982

Facility reported incident #MD00185366 was reviewed on 1/8/25 at 10:15 AM. The facility report indicated:

on 1/11/22 a family member reported Resident #901 alleged that the previous morning s/he called an employee a bitch and the employee smacked him/her on the mouth and told him/her not to call her names.

5 written statements were obtained from staff.

GNA10 indicated in her statement that while providing care on the evening of 10/28/22, Resident #901 reported to her that someone slapped him/her on the face twice during the day in the T.V. room, that she meant to report it but forgot.

Staff schedules revealed 26 nursing staff worked on Resident #901's unit between 10/28/22 and 10/30/22.

No statements were obtained from the other 21 nursing staff as well as any other facility staff including but not limited to dietary, activities, rehab, and housekeeping, who may have interacted with or observed Resident #901 between 10/28/22 and 10/30/22.

During an interview on 1/9/25 at 10:31 AM the DON confirmed that the police were not notified of Resident #901's abuse allegation and that GNA#10 failed to immediately report the allegation of abuse on 10/28/22. When asked if she expanded the investigation once she received GNA10's staff statement. She confirmed

she was aware of GNA#10's statement. However, she wasn't sure why she didn't get more staff statements.

3. Facility reported incident #MD00182604 was reviewed on 1/9/25 11:30 AM. The report and written witness statement revealed that on 4/25/22 at approximately 11:30 PM, LPN (Licensed Practical Nurse) #3 witnessed a GNA physically abused Resident #905.

LPN#3 did not report the incident until 4/26/22 at approximately 6:03 PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0835 The DON confirmed these findings on 1/9/25 at 4:30 PM that LPN#3.

Level of Harm - Minimal harm or The surveyor requested the facility's verification of the required abuse training for LPN#3. The DON indicated potential for actual harm - she was an agency staff. We don't have her abuse training. Then stated, the agency provides us with their license, background checks, the things that are required in Maryland, but we don't get their abuse training. Residents Affected - Some Cross reference F 835.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 31982

Residents Affected - Few Based on review of the medical record and interview with staff it was determined the facility staff failed to maintain complete and accurate medical records. This was evident for 1 (#901) of 9 residents reviewed for Abuse.

The findings include:

Facility reported incident #MD00185366 was reviewed on 1/8/25 at 10:15 AM. The facility reported that on 10/31/22, Resident #901 told his/her daughter that the previous morning he/she called an employee a bitch and the employee smacked him/her on the mouth and told him/her not to call her names.

The Director of Nursing (DON) reported the incident to the state agency an began an investigation.

In an interview on 1/8/25 at approximately 10:30 AM the Director of Nursing (DON) was asked identified that

a resident's change in condition should be documented in a narrative note in the progress note section of the Electronic Medical Record (EMR).

Review of Resident #901's medical record at that time revealed 17 Nursing Progress Notes written between 10/27/22 - 11/5/22. 1 note was a routine skin evaluation note dated 11/3/22 10:55 which stated, Skin warm and dry, skin color WNL (within normal limits) and turgor is normal. Neither this nor any of the other notes included documentation reflecting Resident #901's allegation of abuse, an assessment of the resident specific to the allegation of abuse including but not limited to evidence of injury, the resident's mental status, notification of the physician, and measures that were put into place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Level of Harm - Minimal harm or potential for actual harm 31982

Residents Affected - Some Based on record review and staff interview it was determined the facility failed to ensure that all nursing staff received training on abuse which included procedures for reporting incidents of abuse, neglect, exploitation, and misappropriation of resident property. This was evident for 1 (#905) of 9 residents reviewed for Abuse.

The findings include:

Facility reported incident #MD00182604 was reviewed on 1/9/25 11:30 AM. The report and written witness statement revealed that on 4/25/22 at approximately 11:30 PM, LPN (Licensed Practical Nurse) #3 witnessed Geriatric Nursing Assistant (GNA) #7 physically abused Resident #905.

The facility's initial report to the state agency revealed that LPN#3 did not report the incident until 4/26/22 at approximately 6:03 PM when she informed the Director of Nursing (DON).

During an interview on 1/9/25 at 4:30 PM the DON confirmed that LPN#3 failed to immediately report the incident and that GNA#7 continued to provide care for residents from 11PM 4/25/22 - 7 AM 4/26/22, and again on 4/26/22 from approximately 3 PM until 6:03 PM. She indicated that LPN#3 was an agency staff member who worked in the facility.

The surveyor requested the facility's verification of the required abuse training for LPN#3. The DON indicated - she was an agency staff. We don't have her abuse training. Then stated, the agency provides us with their license, background checks, the things that are required in Maryland, but we don't get their abuse training.

Cross reference F 600 and F 609.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 215137

F-F835

31982

4. Facility reported incident #MD00185366 was reviewed on 1/8/25 at 10:15 AM. The facility reported that Resident #901 told his/her daughter on 11/1/22 that the previous morning he/she called an employee a bitch and the employee smacked him/her on the mouth and told him/her not to call her names. The Director of Nursing (DON) reported the incident to the state agency and began an investigation.

There was no evidence that the allegation of abuse was reported to local law enforcement.

The investigative documentation included 5 statements written by staff who worked with resident #901 on or around the date of the alleged event. An undated statement by GNA (Geriatric Nursing Assistant) #10 indicated on Friday October 28th - Resident #901 mentioned that s/he was slapped twice on the face during

the day by someone in the TV room, but GNA #10 forgot to report it.

These and other findings were discussed with the DON during an interview on 1/9/25 at 10:31 AM. She confirmed that the police were not notified of the abuse allegation and that she was aware of that GNA#10 failed to report Resident #901's allegation of abuse made on 10/28/22.

5. Facility reported incident #MD00182604 was reviewed on 1/9/25 11:30 AM. The report indicated that GNA#7 was observed pulling Resident #905 by his/her collar, pull his/her hair, grab him/her by the neck and punch him/her in the abdomen at approximately 11:30 PM on 4/25/22. Per written statements, the incident was witnessed by LPN (Licensed Practical Nurse) #3, an agency nurse. GNA#6 was also present and per her statement witnessed some of the incident. The facility's investigation documentation revealed the incident was reported to the DON by LPN#3 at 6:03 PM on 4/26/22, 18 1/2 hours later, not immediately. GNA#6 indicated in her written statement that she did not report the incident because she thought LPN#3 reported it.

In an interview on 1/9/25 at 4:30 PM The DON confirmed that neither LPN#3 nor GNA#6 immediately reported the incident and that she was not aware until 6:03 PM the following day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0609 During an interview on 1/14/25 at 3:21 PM GNA#6 repeatedly indicated she was unable to recall details of

the incident. She was unable to recall why she thought LPN#3 was going to report the incident. She did Level of Harm - Minimal harm or recall that LPN#3 made a phone call but was unsure of who she called, and stated it could have been about potential for actual harm anything.

Residents Affected - Few Cross reference F 600 and F 835.

40902

Review of the facility's policy titled Abuse, Neglect, Involuntary seclusion, Exploitation, and Misappropriation of Property revised 07/23 revealed, anyone who witnesses and or suspects an incident of resident abuse (verbal, sexual, mental, or physical), neglect, mistreatment, exploitation' involuntary seclusion, and misappropriation of property or a crime must immediately report the incident to their department supervisor.

The department supervisor must immediately notify the executive director's administrator or designee, who in turn will notify the regional director of nursing, who in turn will notify the corporate director of resident health services and human resources, if necessary. Notify the appropriate state agency, adult protective services where state law provides for jurisdiction, and local law enforcement for a crime or allegation of a crime, immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or suspicion or actual commission of a crime, or not later than 24 hours if the events that cause the allegation do not involve abuse, a crime, and/or do not result in serious bodily injury, in accordance with state law through established procedures. Criminal acts include, but are not limited to, assault, sexual assault, and theft of resident property, including medications.

6. Review of Resident R45's Face Sheet located in resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE REDACTED] with diagnoses which included Major Depressive Disorder, Mild Cognitive Impairment, Hallucinations, Unspecified Dementia, and anxiety disorder.

Review of Resident R45's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. Further review revealed no behaviors were indicated.

During an interview on 01/07/25 at 11:25 AM, Resident R45 said Geriatric Nurse Assistant (GNA)1 hated him/her just because s/he is him/her. Resident R45 said GNA1 mouths off to him/her and when s/he reports something about GNA1 to administration GNA1 gets even with him/her by reporting something false about Resident R45. Resident R45 said s/he believed she killed his/her dog, and that GNA1 ignores her job duties. Resident R45 said GNA1 called him/her an (expletive). S/he said s/he reported it to the Director of Nursing (DON) who told Resident R45 that it was unacceptable behavior. S/he said GNA1 was still currently employed. S/he said the last time she gave Resident R45 a shower s/he was afraid that GNA1 did not wash his/her body well or dry him/her off properly. Resident R45 said GNA1 did not care about the care she provided to him/her. Resident R45 said GNA1 and GNA2 would gang up on him/her and talk about him/her in the hall because s/he could hear them. S/he said they said they were not going to do the right thing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0609 During an interview on 01/08/25 at 12:27 PM the DON stated she had a discussion with the Administrator

after they became aware of the allegations by Resident R45 but that was as far as it's gone. She stated they have not Level of Harm - Minimal harm or reported it to the state and that she was waiting to discuss it with Regional Clinical Nurse. The DON further potential for actual harm stated she did not know why she did not report the allegation that LPN1 reported to her about GNA1 and Resident R211, but she stated she should have reported both timely. Residents Affected - Few

During an interview on 01/08/25 at 12:42 PM the Administrator consulted with the DON, and he spoke to the Medical Director. He said that they decided there was no validity to the allegation based on the fact that she never had a dog here, and that GNA2 has not worked here for a long time. He confirmed this was not reported to the state and that he did not interview the resident or any staff before making this conclusion.

7. Review of Resident R211's ''Admission Record,'' located in the ''Profile'' tab of the EMR, revealed Resident R211 admitted to

the facility on [DATE REDACTED] with diagnoses including bipolar disorder, adjustment disorder, and dysphagia.

Review of Resident R211's quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 03/01/23 revealed s/he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment.

Review of the Self-Report Form provided by the facility, dated 05/01/23 at 2:00 PM revealed the date and time of the incident was 04/28/23 between the 11 PM to 7 AM shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30428 potential for actual harm Based on medical record review and interview with facility staff, it was determined that the facility staff failed Residents Affected - Few to thoroughly investigate allegations of abuse and injuries of unknown origin, and failed to protect residents from further abuse. This was evident for 7 (#902, #903, #904, #901, #905, Resident R45, and Resident R45) of 12 residents reviewed for abuse with additional occurrences found during the individual review of the resident's medical records that were not previously identified by the facility.

The findings include:

1. Review of the medical record for Resident #902 revealed initial admitting diagnosis including breast cancer, dysphagia (difficulty swallowing) and dementia.

A review on 1/7/25 at 2:00 PM an initial concern related to an unwitnessed fall, occurring on 7/12/23.

According to the facility investigation report, the resident was found on his/her back and bleeding from their left forehead. There was a black and blue bump already formed when the resident was found. Resident #902 complained of left shoulder and elbow pain and had difficulty moving their arm without grimacing. An x-ray was ordered.

Resident #902 was transferred to the hospital on 7/13/23 for treatment related to a nondisplaced olecranon (elbow fracture).

Further review of the facility reported incident on 1/10/25 at 7:23 AM failed to reveal any interviews with more than just the GNA that was assigned to care for Resident #902 on 7/12/23. Additionally, there was no new interventions or plan in place to prevent Resident #902 from falling again.

2. Review of the facility reported incident on 1/10/25 at 7:47 AM for Resident #903 noted admission diagnosis including unspecified dementia and abnormalities of gait.

According to the facility reported paperwork provided to the survey team, Resident #903 had an unwitnessed fall with injury occurring on 5/10/24 documented between 9:45 PM and 10:15 PM.

Resident #903 was sent to the hospital post fall with complaints of hip and lag pain. A CT (computed tomography scan, is a noninvasive medical imaging procedure that uses X-rays to create detailed pictures of

the inside of the body) was completed and diagnosed Resident #903 with a left intra trochanteric fracture-hip fracture.

According to the facility investigation packet, only the nurse and GNA caring for the resident were interviewed regarding his/her status prior to the fall. There was an identified concern with the bed alarm, however, no further documentation of interventions or audits to ensure that what was found faulty and possibly contributing to the resident's fall was corrected.

These concerns were reviewed with the facility DON and NHA throughout the survey and again on 1/13/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 26 215137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215137 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601

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 0610 3. a. Review of the medical record for Resident #904 on 1/8/25 at 7:53 AM revealed multiple comorbidities including dementia nd Parkinson disease. Review of the facility reported incident for Resident #904 revealed Level of Harm - Minimal harm or that Resident was found on the floor on 5/30/23 with a hematoma on their forehead and scant blood noted potential for actual harm on their mouth and nose. An order was acquired from the physician to send him/her to the ER for evaluation.

Residents Affected - Few At the hospital it was determined that the resident had a left orbital floor fracture, and a mild fracture of the left anterior maxillary wall. Additionally, a left subdural hematoma (a collection of blood between the brain and the skull that can be life-threatening).

The facility investigation report failed to include any interviews with staff or residents from the day of the incident. The report documented that the resident was unable to state what occurred and it was assumed that the resident fell out of his/her chair and hit their face causing the fractures.

b. During the review of the assumed fall on 5/30/23 for Resident #904, another unwitnessed fall was identified with an initially identified fracture on 3/15/23. This was not investigated with corresponding interviews of staff and residents with subsequent relevant interventions.

These concerns were reviewed with the facility Regional Clinical Nurse on 1/9/25 at approximately 3:30 PM and again with the facility DON and NHA on 1/13/25.

Cross reference with