Patapsco Healthcare

Inspectors wroteBased on observations and interviews it was determined that the dietary staff failed to wear hairnets or beard nets while in the kitchen. This deficient practice was discovered during two observations of four staff during the complaint survey.

Inspectors wroteBased on record review and staff interview; it was determined that the facility failed to protect a resident (resident #13) from physical abuse from a facility staff member. This was evident for 1 of 15 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility staff failed to implement a person-centered care plan when a resident refused medications and when a resident refused personal care. This deficient practice was evidenced in 2 (#1 & #9) of 3 resident records reviewed for care plans during the complaint survey.

Inspectors wroteBased on medical record review and interview, the facility failed to update a resident's (resident #15) care plan after two altercations with other residents. This was evident in 1 of 15 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interviews it was determined that the facility staff failed to adhere to professional nursing standards by not documenting on the medication administration record (MAR) when narcotics were administered but removed from the narcotic inventory and write legibly on the narcotic inventory sheet. This deficient practice was evidenced in 1(#9) of 2 resident narcotic records reviewed during the complaint survey.

Inspectors wroteBased on medical record review and interviews it was determined that the facility staff failed to administer medications according to the scheduled times. This deficient practice was evidenced in 1 (#12) of 1 medication administration audit record reviewed during the complaint survey.

Inspectors wroteBased on medical record review and staff interview, the facility staff failed to provide supervision to prevent a mentally unstable resident (Resident #15) from physically abusing a vulnerable residents (Resident # 4 and Resident #14). This was evident for 1 out of 15 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and interviews it was determined that the pharmacy failed to provide accurate medication labels of the narcotic that was distributed to the facility. This deficient practice was evidenced in 1 (#12) of 2 resident medication regimens reviewed during the complaint survey.

Inspectors wroteBased on medical record review and interviews it was determined that the facility staff failed to ensure they used the five rights before administering a narcotic and administered the wrong medication. This deficient practice was evidenced in 1 (#12) of 3 medication administration records for 1 resident (Resident #12) reviewed during the complaint survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to ensure the freezer located in the kitchen was properly sealed to prevent air from getting into the freezer and ice build-up inside of the freezer. This efficient practice was discovered during the complaint survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure the care and services it delivers meet acceptable standards of quality, maintain documentation on how the facility obtains feedback, collects data, monitors adverse events, identifies areas for improvement, identifies improvement activities, implements corrective and preventative action, tracks performance, and conducts performance improvement projects. The was found to be evident by repeated citations from the previous annual survey and for QAPI review during the current annual survey.

Inspectors wroteBased on observation and interviews with staff, it was determined that the facility failed to provide the residents with respect and dignity by failing to 1.) knock/ask permission to enter prior to entering the residents' rooms, evident for 5 resident rooms (#222, #221, #223, #224, # 227) out of 15 resident rooms observed on the Liberty Hall Unit; 2.) ensure dependent residents were clothed and out of bed to chair, evident for 3 (Resident #23, Resident #124, and Resident #74); 3.) ensure residents clothing was timely laundered, evident for 5 (Resident #61, Resident #87, Resident #53, Resident #2, and Resident #125); and 4.) maintain privacy and appropriate covering during care and transfers, evident for 2 (Resident #13 and Resident #63) out of 57 residents reviewed during the survey.

Inspectors wroteBased on observations and interviews with residents and facility staff it was determined the facility failed to accommodate residents by allowing residents to smoke at the designated facility times. This was found to be evident for all residents who smoked including 2 Residents (# 4 and # 121) of 25 residents reviewed for smoking during the facility's survey.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the monitoring and oversight of food temperatures in accordance with professional standards for food service safety, failed to ensure sanitary practices were followed in accordance with professional standards for food service safety, failed to ensure food and food equipment was stored in accordance with professional standards for food service safety, failed to ensure thorough environmental cleaning and a sanitary environment of the kitchen, failed to ensure monitoring and oversight of kitchen equipment and environment, and failed to ensure kitchen wall paint was in good repair to prevent potential for contamination of food and food contact surfaces. This was evident during surveyor review of the kitchen task during the facility's recertification survey.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure: 1. & 2 .) medical record documentation from outside consult providers was present within the medical record. This was evident for: 1.) 1 out of 1 Resident (#55) reviewed for urinary catheter and 2.) 1 out of 1 Resident reviewed for Neglect (#134) and during the surveyor's review of Complaint #2694340 during the facility's recertification survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) meetings had the required committee members in attendance and conducted meeting at least quarterly. This was found to be evident for 1 out of 2 quarterly committee attendance sheets reviewed during the survey and due to no documentation made available for 3 out of 4 quarterly meetings in 2025.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure the facility environment was kept safe, clean, comfortable, and homelike. This was found to be evident of 4 (Resident # 4, # 41, 31 and # 121) of 40 residents observed and 2 out of 2 ceiling vents observed during the facility's survey.

Inspectors wroteBased on review of record review, interview, it was determined the facility failed to ensure facility Residents were free from abuse. This was evident for 1 out of 1 facility reported incident (#2728128) reviewed by the surveyor during the facility's recertification survey.

Inspectors wroteBased on record review and interview it was determined the facility failed to ensure an allegation of abuse was timely reported and failed to ensure all applicable agencies were notified. This was evident for 1 out of 1 facility reported incident (#2728128) reviewed during the facility's recertification survey.

Inspectors wroteBased on review of Facility Reported Incident #2728128, interview, and record review it was determined the facility failed to ensure a thorough investigation. This was evident for 1 out of 1 facility reported incident (#2728128) reviewed by the surveyor during the facility's recertification survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to provide the resident representative with written notification of transfers to the hospital and written notification of the facility's bed hold policy upon transfer to the hospital. This was found to be evident for 2 (Resident #11 and Resident #2) out of 3 residents reviewed for hospitalizations during the annual survey.

Inspectors wroteBased on record review, and interviews with residents and staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect the resident's status. This was evident for 3 (Resident #2, #99, and #125) out of 25 residents reviewed for smoking during the annual survey.

Inspectors wroteBased on record reviews and interviews with staff, it was determined that the facility failed to ensure comprehensive person-centered care plans were developed and implemented for residents which reflect resident's goals, measurable objectives, and interventions to meet the specific goal for the resident. This was evident for 1 resident (Resident #84) out of 5 residents reviewed for choices, 2 residents (Resident #55 and Resident #53) out 25 residents reviewed for smoking, and 1 resident (Resident #5) reviewed for communication-sensory during the annual survey.

Inspectors wroteBased on observations, record review, and interview with staff, it was determined that the facility failed to ensure the use of a functional communication system for a non-English speaking resident. This was evident for 1 resident (Resident #5) reviewed for communication-sensory during the annual survey.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure adequate one-to-one supervision for Resident #69 as ordered by the physician. This occurred for 1 of 1 resident reviewed for supervision during the annual survey.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a Resident's environment was free from accident hazards. This was evident during 1 out of 1 initial observation made of Resident #105 during the facility's recertification survey.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to ensure oxygen therapy was administered as ordered by the physician. This was evident for 1 resident (Resident #5) out of 3 residents reviewed for respiratory care during the annual survey.

Inspectors wroteBased on observations, record review, and interview with residents and staff, it was determined that the facility failed to ensure residents were properly assessed for the safe use of bedrails, obtain consent from the resident or resident representative prior to use of bedrails, and obtain a physician's order for the use of bedrails. This was evident for 4 (Resident #23, #74, #87, and #124) out of 7 residents reviewed for accidents during the annual survey.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure sufficient nursing staff to meet the needs of residents to provide one-to-one supervision for Resident #69 as ordered by the physician.

Inspectors wroteBased on observation and interview with staff, it was determined that the facility failed to assure that medications were secure in a locked medication cart under the direct observation of authorized staff in an area where residents could not access it. This was evident for 1 treatment cart observed on the 2nd floor Liberty Hall nursing unit.

Inspectors wroteBased on observation, record review, and interview with the resident and staff, it was determined that the facility failed to obtain routine dental care for the resident. This was evident for 1 resident (Resident #23) reviewed for dental services during the annual survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure food provided was palatable and at safe and appetizing temperature. This was evident for 1 food test tray provided by the facility during the surveyor's review of the kitchen task during the facility's recertification survey.

Inspectors wroteBased on observation and interview, the facility failed to ensure oxygen equipment was properly dated and labeled in accordance with infection control standards (Resident #136) failed to store clean linen appropriately in accordance with infection control and prevention guidelines to prevent cross contamination. This was evident during observations during the annual survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure the maintenance of the facility's dishwasher plumbing. This was evident upon the surveyor's initial tour and during subsequent observation of the facility's kitchen during review of the kitchen task during the facility's recertification survey.

Inspectors wroteBased on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a clean, sanitary, and homelike environment in good repair. This deficient practice was observed on 2 of 2 units reviewed (Promenade and Liberty Units) and in the laundry room during the annual recertification survey.

Inspectors wroteBased on medical record review and review of pertinent document and interviews it was determined the facility staff failed to notify the resident's representative when there was a significant change in the resident's treatment plan. This was evident for 1 (Resident #14) of 24 residents reviewed for a complaint during the complaint survey.

Inspectors wroteBased on review of facility investigative material and interview with residents and facility staff, it was determined that the facility failed to thoroughly investigate an injury sustained by a resident. This was evident for 1 (Resident #9) of 11 residents reviewed for a facility reported incident during the complaint survey.

Inspectors wroteBased on medical record review, review of pertinent documents and staff interviews, it was determined that the facility failed to ensure the discharge information was sufficiently documented in the medical record. This was evident for 1 (Resident #30) of 24 residents reviewed for a complaint during the complaint survey.

Inspectors wroteBased on facility staff roster and staff interview, it was determined that the facility failed to employ a qualified activities director from 10/2024 to 12/2024. This deficient practice was found during a complaint survey.

Inspectors wroteBased on facility staff roster and staff interview, it was determined that the facility has a bed capacity of 160 and did not employ a qualified social worker from 4/2025 - 5/2025 and then again from 7/2025 to the present on a full-time basis. This deficient practice was found during a complaint survey.

Inspectors wroteBased on record reviews, staff interviews, and review of other pertinent information, it was determined that the facility failed to keep and maintain a safe and effective system for securing and counting narcotic medications. This was evident for 2 out of 7 medication carts reviewed for medication storage. These actions resulted in the finding of an Immediate Jeopardy which was identified on 9/26/24 at 5:45 PM. An IJ summary tool was provided to the facility on 9/26/24. The facility submitted a draft of their plan to remove the immediacy on 9/26/24 at 8:36 PM, and it was not accepted. The facility submitted a second draft of their plan to remove the immediacy on 9/26/24 at 9:30 PM, and it was not accepted. The facility submitted a third plan on 9/27/24 at 12:15 AM and it was accepted by the state agency at 9/27/24 at 12:30 AM. [...]

Inspectors wroteBased on observation staff and resident interviews, it was determined that the facility failed to provide residents with an environment that promotes a dignified existence. This deficient practice was evidenced in 10 (Resident #2, #42, #48, #71, #76, #26, #85, #281, #34, #15 ) 21 resident's reviewed for dignity during the survey.

Inspectors wroteBased on observations, staff and residents' interview, it was determined the facility failed to provide safe clean homelike environment. This deficient practice was discovered on 5 units of 5 units observed during the survey.

Inspectors wroteBased on surveyor review of a facility reported incidents, review of medical records, and family and staff interviews, it was determined that the facility failed to report and submit facility related incident reports (FRI) to OHCQ related to injury of unknown origin, serious bodily injury, elopement, misappropriation of resident property and potential employee related abuse towards a resident within the required two-hour framework and failed to submit a follow up investigation report within 5 days. This was evident 9 (Resident #131, #133, #117, #78, #104, #89, #144, #145, #139) out of 38 facility reported incidents reviewed during the survey.

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of residents' admission to the facility and provide the resident and their representative with the baseline care plan. This was evident for 7 (#27, #104, #12, #48, #49, #54, #281) ) of 12 residents reviewed for baseline care plans during the annual survey.

Inspectors wroteBased on observations, record reviews and interviews it was determine the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for the residents' highest practicable being. This was evident for 4 of 82 residents (Resident #27, #104, #61) reviewed during the survey.

Inspectors wroteBased on record review and staff interview, the facility failed to provide supervision to prevent a resident-to-resident altercations and to ensure residents were free of accident hazard devices. This was evident for 3 (Resident #72, #140, #34 ) of 6 resident's reviewed for supervision.

Inspectors wroteBased on medical record review and interview with facility staff it was determined that the nurse practitioner failed to ensure physicians documented resident conditions and treatments accurately, write complete orders, address, sign & date pharmacy recommendations, and failed to ensure that physician progress notes were entered into the medical record. This deficient practice was evidenced in 4 (#56, #67, & #129, #139) of 8 resident records reviewed for physician care during the survey.

Inspectors wroteBased on a review of facility investigative material and interview with facility staff, it was determined that the facility failed to ensure that residents remained free of abuse. This was evident for 1 (Resident #151) out of 2 residents reviewed for abuse during the survey.

Inspectors wroteBased on medical record review and interview with facility staff and resident family members, it was determined that the facility failed to maintain accurate Controlled Drug Receipt/Record/Disposition and an environment that was free of misappropriation of property. This was evident during the review of 2 of 8 (Resident # 101, #104) residents reviewed during the survey.

Inspectors wroteBased on facility administrative and medical records review and interviews, it was determined that the facility staff failed to complete thorough investigations of an alleged resident to resident abuse incident, injuries of unknown origin and failed to maintain and provide investigation documentation of a facility reported incidents reported to the state agency. This deficient practice was evidenced in 4 of 38 facility reported incidents for residents (#67, #131, #72, #89) reviewed during the survey.

Inspectors wroteBased on review of Minimum Data Set (MDS) Assessment documentation and interview with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 1 (Resident #124) of 61 residents reviewed during the survey.

Inspectors wroteBased on a medical record review, interview with facility staff, and the resident RP (Responsible Party) it was revealed the facility staff failed to notify the physician in a timely manner of a resident (#135) change in condition. This occurred in 1 of 1 resident reviewed during the survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to complete a care plan for a resident who was receiving hospice care and a resident who was receiving oxygen therapy. This deficient practice was evident in 2 (#67 & #129) out of 7 medical records reviewed for care plan during the survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to have quarterly care plan meetings for a resident. This deficient practice was evident in 1(#42) of 3 records reviewed for care plan meetings during the survey.

Inspectors wroteBased on observations, medical record review and interviews it was determined that the facility staff failed to adhere to professional nursing standards as evidenced by not signing the narcotic form to verify the was completed during change of shift, failed to give resident report to the oncoming nurse, failed to report narcotics were taped in the blister packs, and administering oxygen therapy without a complete order. This was evident for 1 of 1 (Resident #67) reviewed for oxygen and 4 of 6 change-of-shift narcotic counts that were reviewed during the survey.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that facility staff fail to arrange medical transportation for a resident's follow up appointment. This deficient practice was evident for 1 (#281) of 1 resident reviewed for incontinence during the survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that the posted staffing schedule was updated and accurate. This was found to be evident when tours of the facility were conducted during the facility's survey.

Inspectors wroteBased on medical record review and interviews it was determined that the pharmacist failed to communicate timely the need to discontinue two unnecessary intranasal medications after the pharmacy review was completed in August and September 2024. This deficient practice was evidenced in 1 (#9) of 2 resident records reviewed for unnecessary medications during the survey.

Inspectors wroteBased on interviews, and medical record reviews it was determined that facility staff failed to follow physician orders and fail to schedule dental appointments. This deficient practice was evident for 1 (#120) of 1 residents reviewed for pain during the survey. The finds include: On 09/17/2024 at 09:53 AM, during an interview with Resident #120, the surveyor asked if they have any pain concerns. Resident #120 reported tooth pain in their left upper and lower molars due to cracked teeth. The surveyor asked Resident #120 if they had gone to the dentist to address the cracked teeth, Resident #120 replied No. When ask why, Resident #120 stated they did not know the reason. During an interview with the Director of Nursing (DON) #2 on 09/17/24 at 10:01 AM, the surveyor inquired about Resident#120's cracked teeth and any scheduled dental appointments. [...]

Inspectors wroteBased on observations of the facility's kitchen and food services, it was determined that the facility failed to store food items to maintain the integrity of the specific item and accurately maintain dishwasher temperature logs. This was evident during the initial tour of the kitchen.

Inspectors wroteBased on record review and interview it was determined that the facility staff did not update the facility assessment to reflect how the facility with address all the needs of the residents. This deficient practice was discovered during the survey.

Inspectors wroteBased on a review of the facility investigation, medical record, interviews with facility staff and other pertinent documentation it was determined that the facility nursing staff failed to document the administration of medication and failed to have updated and accurate records of the residents' belongings in the medical record. This was true for 3 of 4 residents (Resident #135, #42, #111) reviewed during the survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and guidelines linen management and for resident's residing in the facility. This was found to be evident for 1 (Resident # 15, #2) of 77 residents observed during observations made during the survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to keep the facility in good operating condition. This deficient practice discovered on the [NAME] Cove unit during the survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to provide care which promoted the highest practicable well-being for residents, failed to obtain finger sticks as ordered by the physician for Resident (7) and failed to initiate aspiration precautions for Resident (#7) per recommendations, and failed to follow a resident's care plan and apply a splint (Resident #7, #26 and #106). This was evident for 3 of 57 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner for Residents (#7) This was evident for 1 of 6 residents selected for unnecessary medication review during the annual survey process and 1 out of 57 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review, observation and interview, the facility failed to provide dental services for a resident(Resident #55). This was evident for 1 out of 57 residents selected for review during the annual survey process.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to 1) maintain confidential information-HIPPA located in a medication cart computer, and 2) follow the Maryland State regulation regarding the facility providing a copy of a resident's MOLST to the guardian within 48 hours. The HIPPA violation was observed one time and the MOLST violation was evident for (Residents #43, #69) of 57 residents selected for review during the annual survey.

Inspectors wroteBased upon record review and staff interview it was determined that facility staff failed to ensure that the resident's medical record was accurate and complete (Resident #37, #40, #55, #61, #69 and #87). This was evident for 6 of 57 residents selected for review during the annual survey process.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure that a resident's health related information was protected (#159). This was true for 1 out of the 57 residents that make up the survey sample.

Inspectors wroteBased on reviews of a medical record review and staff interview, it was determined the facility staff failed to notify a resident's physician and family member of a significant weight loss. This was evident for 2 (Residents #89 and #101) of 2 residents reviewed for notification of changes during an annual recertification survey.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to thoroughly investigate the allegation of abuse for Residents (#262 and #263). This was evident for 2 of 3 residents selected for review of facility reported incidents of alleged abuse and 2 of 57 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #82) of 57 residents reviewed during an annual recertification survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to initiate a care plan to address insomnia for Resident (#7). This was evident for 1 of 57 residents selected for review of care plans during the annual survey process.

Inspectors wroteBased on medical record review and interview, the facility failed to provide treatment/services to maintain vision (Resident #106). This is evident for 1 out of 57 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to initiate an AIMS test for a resident as recommended by the facility pharmacist and ordered by the resident's physician. This was evident for 1 (Resident #88) of 6 residents reviewed for unnecessary medications during an annual recertification survey.

Inspectors wroteBased on medical record review and interview it was determined the facility failed to keep a resident free from unnecessary psychotropic medications (Resident #57). This was evident for 1 of 57 residents selected for review during the annual survey process.

Inspectors wroteBased on record review, observation of medication pass and interview, it was determined the facility staff failed to obtain a medication error rate less than 5% for (Residents #84 and #259). This was evident for 2 out of 5 residents observed for medication pass and 4 errors out of 31 opportunities for error and a medication error rate of 5.71%.

Inspectors wroteBased on observation, it was determined the facility staff failed to properly store medications. This was observed once during an annual recertification survey.