Maryland Gardens Post Acute

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#1) was free from abuse. Findings include: -Regarding resident #1: Resident was admitted to the facility on December 28, 2022 with diagnosis that included intracerebral hemorrhage, unspecified, flaccid hemiplegia affecting left dominant side, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, unspecified mood [affective] disorder. A review of the quarterly MDS (minimum data set) dated December 23, 2024 revealed a BIMS (brief interview of mental status) score of 14, indicating resident's cognition is intact. Further review of the MDS revealed no indicators for mood or behaviors. A review of the resident's care plan, initiated on December 23, 2024 revealed a focus for impaired cognitive function/impaired thought processes related to impaired decision making, neurological symptoms. Interventions included to administer medications as ordered. Further review of the care plan revealed a focus for psychosocial behaviors related to physically and verbally sexual inappropriateness. Interventions included intervening as necessary to protect the rights and safety of others and to monitor behaviors episodes and attempt to determine underlying cause. A review of the progress notes revealed an alert charting entry dated January 19, 2025 that at approximately 04:30am Certified Nursing Assistant (CNA) called nurse to room to find patient with hematoma to left above eye about golf size. According to resident, roommate had beam rummaging through his closet and taking his clothes. When approached about leaving his clothing alone resident was allegedly hit with a water pitcher by the roommate who allegedly threw it at him. Nurses assisted with wound dressing to bleeding hematoma at the time. The progress note stated notifications to administration, Director of Nursing (DON), case worker, and family all completed. The note stated police were also called and resident was sent to emergency room. Review of the progress notes revealed an entry dated January 19, 2025 that stated resident #1 returned from the hospital with no new orders. The resident was observed to have knots around the left side of forehead that had two steri-strips. The progress note stated the report from emergency room nurse from the hospital stated the CT scan was negative. -Regarding resident #2: Resident #2 was admitted on January 10, 2025 with diagnosis that included other acute osteomyelitis, left ankle and foot, major depressive disorder, recurrent, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the Medicare 5-day MDS dated January 15, 2025 revealed a BIMS (brief interview of mental status) score of 7 indicating severe cognitive impairment. Further review of the MDS reveale

Based on observation, staff interviews, clinical record review and facility documentation and policy review, the facility failed to ensure accurate documentation for one resident's injuries (#1 ). Findings include: -Regarding resident #1: Resident was admitted to the facility on December 28, 2022 with diagnosis that included intracerebral hemorrhage, unspecified, flaccid hemiplegia affecting left dominant side, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, unspecified mood [affective] disorder. A review of the quarterly MDS (minimum data set) dated December 23, 2024 revealed a BIMS (brief interview of mental status) score of 14, indicating resident's cognition is intact. Further review of the MDS revealed no indicators for mood or behaviors. A review of the resident's care plan, initiated on December 23, 2024 revealed a focus for impaired cognitive function/impaired thought processes related to impaired decision making, neurological symptoms. Interventions included to administer medications as ordered. Further review of the care plan revealed a focus for psychosocial behaviors related to physically and verbally sexual inappropriateness. Interventions included intervening as necessary to protect the rights and safety of others and to monitor behaviors episodes and attempt to determine underlying cause. A review of the progress notes revealed an alert charting entry dated January 19, 2025 that at approximately 04:30am Certified Nursing Assistant (CNA) called nurse to room to find patient with hematoma to left above eye about golf size. According to resident, roommate had beam rummaging through his closet and taking his clothes. When approached about leaving his clothing alone resident was allegedly hit with a water pitcher by the roommate who allegedly threw it at him. Nurses assisted with wound dressing to bleeding hematoma at the time. The progress note stated notifications to administration, Director of Nursing (DON), case worker, and family all completed. The note stated police were also called and resident was sent to emergency room. Review of the progress notes revealed an entry dated January 19, 2025 that stated resident #1 returned from the hospital with no new orders. The resident was observed to have knots around the left side of forehead that had two steri-strips. The progress note stated the report from emergency room nurse from the hospital stated the CT scan was negative. -Regarding resident #2: Resident #2 was admitted on January 10, 2025 with diagnosis that included other acute osteomyelitis, left ankle and foot, major depressive disorder, recurrent, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the Medicare 5-day MDS dated January 15, 2025 revealed a BIMS (brief interview of mental status) score of 7 indicating severe cognitive impairment. Further review of

Based on clinical record review, interviews, observations, facility documentation, and policies, the facility failed to implement written policies and procedures that prohibit and prevent abuse for 2 of 3 sampled residents (#1 and #3). Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on July 18, 2019, with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A physician order dated January 4, 2025, revealed a "change in condition for: redness/ mild edema to left eye orbital", and that the provider was notified. A review of the resident's clinical record revealed no evidence of any progress notes on January 4, 2025, that described an incident involving Resident #1. There was no evidence of a physician order for one to one staff monitoring for Resident #1. A review of the facility's Incident Report Log revealed no evidence of any incident report for Resident #1 on January 4, 2025. A facility Reportable Incident Self-Report submitted to the state health department on January 4, 2025 at 10:06 AM, revealed that "at approximately 9:00 a.m.," on January 04, 2025, a nurse (Staff #14) notified the Administrator (Staff #55) and the Assistant Director of Nursing (ADON / Staff #31) that Resident #1 "had slight redness to his eye". The report revealed that the resident is difficult to understand due to aphasia, however said something like 'pow' and was "hitting/making hitting actions to his left eye". Further, the report revealed that "we cannot tell" if the redness in his left eye is from being struck by another resident or from Resident #1 hitting himself. The report revealed that an additional staff member has been placed to provide consistent observation between Resident #1 and his two roommates. There was no evidence of an update to the care plan for an incident occurring January 4, 2025. -Regarding Resident #3: Resident #3 was admitted to the facility on January 3, 2025, with diagnoses that included malignant neoplasm of brain, brief psychotic disorder, and acute kidney failure. A Health Status note dated January 4, 2025, at 2:56 PM, revealed that Resident #3 is on a change in condition for his new admission to the facility. Patient is alert and oriented x 4. Patient is able to make needs known verbally. There was no evidence in the note that the resident was on one to one staff monitoring. There was no evidence of progress notes dated January 4, 2025, documenting a resident to resident incident involving Resident #3. A Physician Progress Note dated January 4, 2025, signed by the Medical Director (Staff #18), revealed that Resident #3 "has already been in physical confrontation apparently", and that "Behavioral health will be consulted for his aggressive behavior and psychosis". A Health Status Note dated January 5, 2025, revealed that Resident #3 was on a change of condition for a "resident to resident altercati

Based on clinical record review, interviews, observations, facility documentation, and policies, the facility failed to ensure that residents were protected from further abuse during an ongoing investigation of an allegation of abuse for 2 of 3 sampled residents (#1 and #3). Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on July 18, 2019, with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A review of the resident's clinical record revealed no evidence of any progress notes on January 4, 2025, that described an incident involving Resident #1. There was no evidence of a physician order for one to one staff monitoring for Resident #1. A facility Reportable Incident Self-Report submitted to the state health department on January 4, 2025 at 10:06 AM, revealed that "at approximately 9:00 a.m.," on January 04, 2025, a nurse (Staff #14) notified the Administrator (Staff #55) and the Assistant Director of Nursing (ADON / Staff #31) that Resident #1 "had slight redness to his eye". The report revealed that the resident is difficult to understand due to aphasia, however said something like 'pow' and was "hitting/making hitting actions to his left eye". Further, the report revealed that "we cannot tell" if the redness in his left eye is from being struck by another resident or from Resident #1 hitting himself. The report revealed that an additional staff member has been placed to provide consistent observation between Resident #1 and his two roommates. A care plan, revised April 04, 2024, revealed that Resident #1 has a behavioral problem and can demonstrate physical aggression toward others, with resident-to-resident incidents listed on June 6 and June 18, 2023. Interventions included intervene as necessary to protect the rights and safety of others, and to document behavior and possible causes. There was no evidence of an update to the care plan for an incident occurring January 4, 2025. -Regarding Resident #3: Resident #3 was admitted to the facility on January 3, 2025, with diagnoses that included malignant neoplasm of brain, brief psychotic disorder, and acute kidney failure. A Health Status note dated January 4, 2025, at 2:56 PM, revealed that Resident #3 is on a change in condition for his new admission to the facility. Patient is alert and oriented x 4. Patient is able to make needs known verbally. There was no evidence in the note that the resident was on one to one staff monitoring. There was no evidence of progress notes dated January 4, 2025, documenting a resident to resident incident involving Resident #3. A Physician Progress Note dated January 4, 2025, signed by the Medical Director (Staff #18), revealed that Resident #3 "has already been in physical confrontation apparently", and that "Behavioral health will be consulted for his aggressive behavior and psychosis". There was no evidence of a p

Based on clinical record review, interviews, observations, facility documentation, and policies, the facility failed to ensure that an allegation of abuse was reported to mandatory reporting agencies within the required timeframe for 2 of 3 sampled residents (#1 and #3). Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on July 18, 2019, with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A review of the quarterly Minimum Data Set (MDS), dated October 23, 2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A facility Reportable Incident Self-Report submitted to the state health department on January 4, 2025 at 10:06 AM, revealed that "at approximately 9:00 a.m.," on January 04, 2025, a nurse (Staff #14) notified the Administrator (Staff #55) and the Assistant Director of Nursing (ADON / Staff #31) that Resident #1 "had slight redness to his eye". The report revealed that the resident is difficult to understand due to aphasia, however said something like 'pow' and was "hitting/making hitting actions to his left eye". Further, the report revealed that "we cannot tell" if the redness in his left eye is from being struck by another resident or from Resident #1 hitting himself. -Regarding Resident #3: Resident #3 was admitted to the facility on January 3, 2025, with diagnoses that included malignant neoplasm of brain, brief psychotic disorder, and acute kidney failure. A Health Status Note dated January 5, 2025, revealed that Resident #3 was on a change of condition for a "resident to resident altercation". Resident was agitated and noncompliant with medication and vital signs. Resident has a one to one staff for monitoring. Resident has no physical or verbal aggression toward peers / staff this shift thus far. An Employee Coaching Form signed January 6, 2025, for a licensed practical nurse (LPN / Staff #2) revealed that the nurse was being terminated. The nurse "failed to complete admission requirements for a new resident" and "failed to report potential resident to resident altercation within the timeframe specified". An interview was conducted on January 8, 2025, at 10:15 AM, with a certified nursing assistant (CNA / Staff #90) who was assigned to the residents at the time of the incident. She stated she was in a nearby room providing care to another resident with the door open. She stated that she was not sure of the time, but that it was around 5:00 AM on January 4, 2025, that she heard Resident #1 coming out of his room yelling "I hate you" along with the expletive "motherf*****". Staff #90 stated that she went to see what was wrong, and that Resident #1 was slouched over in his wheelchair in the doorway of his room facing his bed. She stated that she observed Resident #3 in Resident #1's room, sitting on his bed, and wearin

Based on clinical record review, interviews, observations, facility documentation, and policies, the facility failed to ensure that a resident was not abused by another resident for 2 of 3 sampled residents (#1 and #3). The deficient practice could result in continued psychosocial and/or physical harm to resident. Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on July 18, 2019, with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A care plan dated February 12, 2024, revealed that the resident has a communication problem due to expressive aphasia with an intervention in place that Resident #1 is able to communicate by answering yes/no questions, hand gestures, and utilizing a communication book. Additionally, an intervention was to validate Resident #1's message by repeating aloud. An additional care plan revised April 04, 2024, revealed that Resident #1 has a behavioral problem and can demonstrate physical aggression toward others, with resident-to-resident incidents listed on June 6 and June 18, 2023. Interventions included intervene as necessary to protect the rights and safety of others, and to document behavior and possible causes. There was no evidence of an update to the care plan for an incident occurring January 4, 2025. A review of the quarterly Minimum Data Set (MDS), dated October 23, 2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A physician order dated January 4, 2025, revealed a "change in condition for: redness/ mild edema to left eye orbital", and that the provider was notified. A review of the resident's clinical record revealed no evidence of any progress notes on January 4, 2025, that described an incident involving Resident #1. There was no evidence of a physician order for one to one staff monitoring for Resident #1. A review of the facility's Incident Report Log revealed no evidence of any incident report for Resident #1 on January 4, 2025. A facility Reportable Incident Self-Report submitted to the state health department on January 4, 2025 at 10:06 AM, revealed that "at approximately 9:00 a.m.," on January 04, 2025, a nurse (Staff #14) notified the Administrator (Staff #55) and the Assistant Director of Nursing (ADON / Staff #31) that Resident #1 "had slight redness to his eye". The report revealed that the resident is difficult to understand due to aphasia, however said something like 'pow' and was "hitting/making hitting actions to his left eye". Further, the report revealed that "we cannot tell" if the redness in his left eye is from being struck by another resident or from Resident #1 hitting himself. The report revealed that an additional staff member has been placed to provide consistent observation between Resident #1 and his two roommates. The SBAR Communication Form dated January 04, 20

Based on observations, clinical record reviews, interviews and policy review, the facility failed to ensure provide a designated room to accomodate resident dining while undergoing renovations. Findings include: An observation on December 4, 2024 at 11:21 a.m. the facility had one dining room for the 55 residents that were residing in the skilled and long term care units. The tables and chairs were not placed in the main dining room area for the residents to eat at; and, the tables were in front of the kitchen food serving area, with the dining room chairs stacked up together. There were two hospital-type beds in the dining room and there were black screens approximately 2 feet on the left and right sides of the bed and approximately a foot from the end of the bed. An uncovered white clothing racks were placed around the dining room walls. The dining room was used as a bedroom by two residents An interview was conducted on December 4, 2024 at 11:32 a.m. with one of the residents residing in the dining room. The resident stated that he had been living in the dining room for about one month; and that, there were five to six other residents (male) who had been staying in the dining room with him. An interview with the cook (staff #53) was conducted on December 4, 2024 at 12:28 p.m. The cook stated the facility was doing renovations of resident rooms; and, the residents affected (#34 and #46) were using the dining room as their bedrooms. The cook said that the other residents not affected by the renovation were either eating outside in the patio or in their rooms. The kitchen Manager (staff #31) joined the interview and stated that there were no residents eating in the dining room; and that, two residents had been using the dining room as their bedroom for about one month now. An interview was conducted on December 4, 2024 at 12:33 p.m. with a female resident who stated that she had been eating her meal outside in the patio at the picnic tables while the cafeteria was getting fixed. She stated that there were about six residents at a time staying in the dining room because there were 2 rooms being renovated at a time. He/she said that each of these room had 3 residents. Another interview was conducted on December 4, 2024 at 12:35 p.m. with another resident who stated that all meals were eaten outside of the dining room; and that, nobody can eat inside the dining room right now. In an interview conducted with another resident on December 4, 2024 at 12:37 p.m., the resident pointed to an area where a picnic table was and stated that it was the area "where the birds don't S**t on it" and that was where he eat his meals. The resident further stated that residents at the facility do not eat inside the dining room. An interview was conducted on December 4, 2024 at 12:53 p.m. with a Certified Nursing Assistant (CNA/staff #6) who stated that the residents usually eat outside in the patio or go in their rooms. The CNA said that some residents can eat in the d

Based on observations, clinical record reviews, interviews and policy review, the facility failed to ensure an accessible bathroom was readily available for resident use for two residents (#34 and #46); failed to ensure that the bathroom of two residents (#23 and #28) were not used by other residents; and, failed to ensure an accessible, working call light was available for use for two residents (#34 and #46). Findings include: -Resident #34 was admitted on August 8, 2024 with diagnoses of hypertension, cerebrovascular accident, depression and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated November 12, 2024 revealed a Brief Interview Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed that the resident may need extra help with specific activities, had experienced social isolation on rare occasions and was receiving an antidepressant. -Resident #46 was admitted on May 10, 2023 with diagnoses of major depressive disorder, unspecified hearing loss, and personal history of traumatic brain injury. The quarterly MDS assessment dated November 8, 204 revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment. -Resident #28 was admitted on December 18, 2023 with diagnoses of chronic systolic (congestive) heart failure, type 2 diabetes mellitus, and mild stage 2 chronic kidney disease. The quarterly MDS assessment dated September 13, 2024 revealed a BIMS score of 15, which indicated the resident had moderate cognitive impairment. The bedroom of resident #28 was located on the south side next to the dining room; and, this is one of the resident bathrooms that residents #34 and #46 use. -Resident #23 was admitted on January 10, 2024 with diagnoses of schizoaffective disorder, bipolar type, post-traumatic stress disorder, and difficulty walking. The quarterly MDS assessment dated October 8, 2024 revealed a BIMS score of 10, which indicated the resident had moderate cognitive impairment. The resident's bedroom was located on the north side next to the dining room; and, this is one of the resident bathrooms that residents #34 and #46 use. An observation was conducted on December 4, 2024 at 11:21 a.m. and revealed there were two residents were in the dining room. The tables and chairs were not placed in the main dining room area for the residents to eat at. The tables were in front of the kitchen food serving area, with the dining room chairs stacked up together. There were uncovered white clothing racks were placed around the dining room walls. There were two hospital-type beds in the dining room that were used by two residents (#34 and #46). The beds had black screens which were approximately 2 feet on the left and right sides of the bed and approximately a foot from the end of the bed. An uncovered white clothing racks were placed around the dining room walls. There were no bathrooms for residents to use inside the dining room area; and, no