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 21 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 21 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 21 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 21 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 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51678 potential for actual harm Based on observation, interview, record review, and policy review, the facility failed to ensure one of six Residents Affected - Few observed residents (Resident (R)27) physician's orders had been followed for the removal of two lidocaine patches out of a total sample of 27 residents. This had the potential for the resident to have adverse reactions of patches being left on too long.

Findings include:

Review of R 27's Electronic Medical Record (EMR) under the Census tab revealed the resident was admitted to the facility on [DATE REDACTED].

Review of Resident R27's diagnoses located in the EMR under the Diagnosis tab revealed diagnoses of fracture of left femur and neuropathy (nerve pain).

Review of Resident R27's admissionMinimum Data Set (MDS) located under the MDS tab with as assessment reference date of 11/04/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated s/he was cognitively intact.

Review of Resident R27's Care Plan located in the EMR under the Care Plan tab dated 10/29/24 revealed a focus area for pain related to his/her left hip fracture after surgical repair. Interventions included administering him/her analgesia per physician orders.

Review of Resident R27's Physician's Orders located in the EMR under the Orders tab dated 11/02/24 revealed an order for two Lidocaine External Patches 1.8 %. Apply one to the left hip topically in the morning for pain on left hip. Remove patch at night. Apply one to left leg in the morning and remove patch at bedtime.

Review of Resident R27's January 2025 Medication Administration Record (MAR) located in the EMR under the Orders tab revealed on 01/08/25 RN6 had documented the patches had been removed at bedtime.

During an observation on 01/09/25 at 8:53 AM of Registered Nurse (RN) 4 during medication administration revealed two lidocaine patches were still on Resident R27; one on her left hip and one on her left leg. RN4 removed those patches and applied two new lidocaine patches to Resident R27's left hip and leg. There was no date or initials

on the lidocaine indicating when they were applied and/or initials of who applied them.

During an interview on 01/09/25 at 10:50 AM with RN4, she confirmed the lidocaine patches were to have been removed the previous night on 01/08/25. She confirmed Resident R27's January 2025 MAR documented the lidocaine patches had been removed by RN6.

During an interview and review of Resident R27's January 2025 MAR on 01/09/25 at 4:00 PM with the Director of Nursing (DON) confirmed RN6 had documented the removal of two lidocaine patches for Resident R27. The DON agreed RN6 should not have documented the removal of the patches until after she had removed them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 21 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 0658 Review of the facility policy revised October 2019 Medication Administration and Management revealed, Following medication administration - All authorized community staff should adhere to the following Level of Harm - Minimal harm or guidelines: Document medication administration/treatment on the electronic record. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 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 17 of 21 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 18 of 21 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 19 of 21 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 40902

Residents Affected - Many Based on observation, record review, interview, and policy review, the facility failed to ensure staff were taking meal temperatures to ensure they were served at safe temperatures before each meal was served.

This had the potential to affect all residents of the facility who consumed food from the kitchen, with the exception of one resident who was nothing by mouth (NPO).

Findings include:

Review of the food temperature logs provided by the Dietary Manager (DM) revealed for the time period from 01/01/25 until 01/09/25 revealed temperatures were not documented for all three meals or all the hot food items prepared for each meal.

During an interview on 01/10/25 at 1:50 PM the DM reviewed the temperature logs and stated she was having a difficult time understanding which meals or meal items were being temped based on the documentation. She said she started in this position four months ago and had not been reviewing the temperature logs until this week. She said she just became aware that staff were not temping all the food items prepared for each meal or for every meal. She said she expected staff to temp all foods items prepared and to ensure it was at the correct safe serving temperature before it leaves the kitchen and is served to residents.

During an interview on 01/10/25 at 2:33 PM the Director of Nursing (DON) said she expected that food was served at the correct temperature and that staff were ensuring things were done in a timely manner. And she would expect staff to ensure that food was prepared at the appropriate temperature before it left the kitchen and was served to residents.

Review of the facilities policy titled Food Temperatures revised 01/13 revealed, to strive to ensure proper serving temperatures, food temperatures will be obtained and recorded prior to meal service and any inappropriate temperatures will be corrected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 43050

Residents Affected - Many Based on interview and review of facility documentation, the Quality Assurance (QA) committee failed to complete a thorough Performance Improvement Project (PIP) that was a continuous improvement of processes, measured outcomes, develop, and implemented action plans, measured success, and contained

a root cause analysis. This failure had the potential to affect all 55 residents in the facility by not identifying problems that impact their quality of life, quality of care, and resident safety.

Findings include:

Review of a document provided by the facility titled Quality Assurance, Performance Improvement (QAPI) and Compliance Program, dated 10/2022, indicated .The purpose of Quality Assurance, Performance Improvement (QAPI) and Corporate Compliance is to take a proactive, systematic, interdisciplinary, comprehensive, and data-driven approach to strive to continually improve the quality of life, care and services for our residents, caregivers, and other partners legally, morally, and ethically .Establish performance thresholds and goals, identify deviation in performance and evaluate progress .

During an interview on 01/10/25 at 10:01 AM with the Director of Nursing (DON) revealed, Each department has a form that can be filled out and sent to the Administrator about areas of concern or for improvement. Also, all residents can report a concern through Resident Council or to any nurse or employee. The Infection Preventionist (IP) identified an issue of increasing pressure ulcers, and we did a PIP. When the DON was asked who was on the committee for the PIP, how did they track outcome, develop, and implement action plans, have a root cause analysis, and measure the success of actions? The DON stated, I collected the information from the IP and filled out the form and that was our PIP.

During an interview on 01/10/25 at 1:58 PM, the Administrator revealed, My expectations for QAPI is that we need narratives, we are doing the work but are not documenting the work. We do not have the proof to show you. We need to focus on detail.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 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 21 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 21 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 21 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 21 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