Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase
WILLOWBROOKE CT SKILLED CARE CTR AT BAYLEIGH CHASE in EASTON, MD — inspection on January 17, 2025.
Found 11 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R45 ' s Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of
Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment.
During an interview on 01/08/25 at 12:27 PM the DON stated that she had a discussion with the Administrator after they became aware of R45 ' s allegations on 01/07/25 and that nothing had happened because she was waiting to discuss it with the Regional Clinical Nurse.
During an interview on 01/08/25 at 12:42 PM the Administrator stated that he consulted with the DON and Medical Director. He said that they decided there was no validity to R45 ' s allegations based on the fact that s/he never had a dog here, and that GNA2 has not worked here for a long time.
The Administrator stated that he did not interview the resident or any staff before making this conclusion.
He stated that when he does conduct an investigation, he will interview the resident and any staff that have been identified. He stated that he did not investigate the allegation, and that GNA1 was not suspended.
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Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601
indicating no cognitive impairment.
and time of the incident was 04/28/23 between the 11 PM to 7 AM shift.
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Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601
During an interview on 01/07/25 at 11:25 AM, R45 said Geriatric Nursing Assistant (GNA)1 hates him/her just because s/he is him/her. 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 R45. R45 said s/he believed she killed his/her dog, and that GNA1 ignores her job duties. R45 said GNA1 called him/her an (expletive). S/he said s/he reported it to the DON who told R45 that it was unacceptable behavior. S/he said GNA1 was still currently employed. R45 said GNA1 did not care about the care she provided to him/her. 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 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 R45 alleged that GNA1 called him/her an (expletive).
The DON said this was never reported and that 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 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.
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 never had a dog here, and that GNA2 has not worked here for a long time. He said this was not reported to 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 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.
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Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601
Review of R52's Fall Risk Evaluations completed on 09/21/23, 12/22/23, 12/28/23, 03/28/24,
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 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.
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Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601
1/14/25. At 5:14 AM, nursing documented that the resident complained of pain in the upper part of the
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.
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Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601
every 12 months.
This was evident for all GNA's working in the facility since 2022 and has the
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.
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Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601
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.
- 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.
The DON confirmed these findings on 1/9/25 at 4:30 PM that LPN#3.
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 835.
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Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601
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.
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Willowbrooke CT Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane Easton, MD 21601
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.
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 R24 was admitted to the facility on [DATE] 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 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 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.
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Form Approved OMB
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
Review of 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] with diagnoses which included Major Depressive Disorder, Mild Cognitive Impairment, Hallucinations, Unspecified Dementia, and anxiety disorder.
Review of 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, R45 said Geriatric Nurse Assistant (GNA)1 hated him/her just because s/he is him/her. 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 R45. R45 said s/he believed she killed his/her dog, and that GNA1 ignores her job duties. R45 said GNA1 called him/her an (expletive). S/he said s/he reported it to the Director of Nursing (DON) who told R45 that it was unacceptable behavior. S/he said GNA1 was still currently employed. S/he said the last time she gave R45 a shower s/he was afraid that GNA1 did not wash his/her body well or dry him/her off properly. R45 said GNA1 did not care about the care she provided to him/her. 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.
215137
Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.