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F0725
F

Failure to Maintain Adequate Nursing Staff and Timely Call Bell Response

Baltimore, Maryland Survey Completed on 10-17-2025

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 provide adequate nursing staff coverage and did not ensure timely response to resident call bells across all four nursing units. Observations revealed that a Geriatric Nursing Assistant (GNA) was required to cover multiple floors due to short staffing, and staffing sheets confirmed that the number of GNAs on duty was frequently below the facility's stated standard. Additionally, there were multiple days when the facility did not have the required 24-hour Registered Nurse (RN) coverage, with entire shifts lacking an RN. The Director of Nursing (DON) confirmed these staffing levels and acknowledged the shortfalls. Residents reported excessive wait times for staff to respond to call bells, with documented response times frequently exceeding the DON's stated expectation of 15 minutes, and in some cases, residents waited over 30 minutes. Review of call bell response logs and interviews with residents and staff corroborated these delays. On several occasions, surveyors observed units with no nursing staff present for extended periods, further confirming inadequate staffing and delayed response to resident needs.

See complete original report
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