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F0689
D

Failure to Prevent Accident Hazards and Inadequate Behavioral Monitoring

Baltimore, Maryland Survey Completed on 04-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's room was free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, one resident's bed was plugged into an outlet across the room using a power strip and an extension cord, both of which were resting on the floor. The resident reported that the outlet on their side of the room had not worked for approximately four months, necessitating the use of the extension cord and power strip for charging needs. The power strip, which had previously been secured to the wall, was found on the floor during the surveyor's observation. The situation persisted until the time of the survey, with the resident relying on this setup due to the inoperable outlet. Additionally, the facility did not adequately monitor and document the behaviors of a resident with known inappropriate sexual behaviors. The care plan for this resident included monitoring and documenting behavior episodes, but a review of the treatment administration record and progress notes revealed inconsistent or absent documentation of the resident's sexual behaviors, despite psychiatric evaluations noting ongoing incidents. The lack of detailed documentation and monitoring was confirmed during interviews with facility staff, who acknowledged that the expected behavioral documentation was not present in the resident's records.

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