Largo Nursing And Rehabiliation Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on administrative record review and interviews with facility staff it was determined the facility failed to ensure that allegations of abuse were immediately reported. This was found to be evident for 1 resident (# 1) of 44 residents reviewed during a complaint survey. Findings include,Complaint 2611778 was reviewed

on 10/29/25 at 10:00AM for multiple concerns including an allegation of abuse regarding Resident # 1.

According to the report, Resident # 1 reported that a male nurse who applied cream molested him/her.Further review of the facility's investigation and a corrective action form for Licensed Practical Nurse (LPN # 11) dated 9/9/25 revealed the following comments: Resident # 1 reported to the nurse (#11)

on 9/7/25 that a Geriatric Nurse Assistant touched him/her inappropriately on 9/5/25 while providing care and changing the resident brief pad. The resident stated that the night nurse was made aware of this on 9/5/25. The Nurse (#11) failed to report the alleged abuse to the supervisor timely.Further review of a statement by LPN (staff # 1) dated 9/8/25 indicated that while meeting with the resident regarding care concerns, Resident #1 stated that while receiving incontinent care on the night shift, a male GNA (#12) touched him/her inappropriately. Staff # 1 immediately notified the Social Worker, Administrator and the Director of Nursing (DON).An interview was conducted with the Nursing Home Administrator (NHA) on 10/30/25 at 8:45AM and she was asked to explain the expectations of staff reporting allegations of abuse.

The NHA stated that the facility became aware of resident abuse allegations after Staff # 1, reported Resident # 1's allegations of abuse to the administration team and the facility immediately investigated. The abuse allegations were unsubstantiated. The NHA stated that it is the facility's expectation that all staff report allegations of abuse immediately and that the night shift nurse (#12) and the staff (#11) failed to report the resident allegations of abuse to administration. She stated that education was provided for all staff on 9/9/25, 9/10/25 and 9/11/25.All concerns were discussed with the Administration team at the exit conference on 11/3/25.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Largo Nursing and Rehabiliation Center

600 Largo Road Glenarden, MD 20774

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, record reviews and interviews, it was determined that the facility failed to ensure the proper process of discharge for the resident. This was evident for 1 (#3) resident out of 1 resident investigated

during the facility's complaint survey.Findings include:On [DATE REDACTED] at 9:00 AM during review of complaint #297110, it revealed the following The assigned social worker (Social Services Coordinator #21) repeatedly failed to return calls or follow through on discharge planning. After months of dishonesty and lack of communication, I confronted [them] in frustration. Since then, [they] have refused to speak with me and directed me to the administrator, leaving my [family member name] without proper social work advocacy.On [DATE REDACTED] at 1:36 PM during initial call with complainant, this Surveyor was informed that the resident was ready to be discharged around [DATE REDACTED] but unable to get a Registered Nurse (RN) assessment needed to set-up home care; this was due to the Social Worker being out on leave. Upon the return of the Social Worker, the RN assessment was then completed, however the family was then notified the facility had difficulty getting insurance clearance for Home Care. Family stated that the resident was admitted with no open areas, a wound developed in Nov/[DATE REDACTED], it healed and then reopened in [DATE REDACTED]. The resident had a wound at the time of leaving the facility during an approved leave of absence (LOA) with family on [DATE REDACTED].

While out on LOA with family, the resident declined to return; the facility then discharged the resident on [DATE REDACTED] due to failure to return, and no Home Care was set-up either. The wound became worse and infected and the resident had to return to the hospital to be admitted for care.On [DATE REDACTED] at 11:16 AM during

interview and record review, Social Services Coordinator staff #21 confirmed they were on leave of absence (LOA) [DATE REDACTED]-[DATE REDACTED]. Staff #21 shared upon their return to the facility they noted the resident Medicaid benefits were expired and refiled around early February. Staff #21 was unable to produce any documentation relating to expired benefits timeframe and evidence of benefits renewal process. Staff #21 then stated the resident was transferred to the other facility Social Services Coordinator upon their return, but again no documentation of this transfer or delays in communication with the resident and family were provided. Staff #21 reviewed with the Surveyor the Telligen DC Care Connect system for this resident which was the communication system to discuss discharge readiness and Home Care needs with outside connected agencies. The entries noted the following: [DATE REDACTED]-Resident family unable to be reached; [DATE REDACTED]-Beneficiary was assessed; [DATE REDACTED]-LOC (level of care, which is needed to request home care) was submitted on [DATE REDACTED], but staff #21 was unclear on why resident was not discharged at this point. Lastly, on [DATE REDACTED]-Beneficiary assessed, indicating ready for discharge as well, but no discharge or home care readiness documentation was provided. Surveyor asked staff #21 if there was any additional documentation based on these findings given to the team to indicate resident was ready for discharge and Home Care approved but staff #21 stated ‘No'.

Event ID:

Facility ID:

If continuation sheet