F0655

D

Failure to Complete and Provide Baseline Care Plans on Admission

Towson, Maryland Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete and document baseline care plans (BLCPs), including current medication lists, within 48 hours of admission and to provide a summary of these BLCPs to the residents and/or their representatives. Surveyors reviewed the medical records of two residents and found that, although both had been admitted to the facility, there was no BLCP in their records and no evidence that a BLCP summary or current medication list had been given to them or their representatives. The regulatory expectation described in the report is that a BLCP must be completed within 48 hours of admission and must include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services, and that a summary of the BLCP and current medication list must be provided to the resident and/or representative and documented in the medical record.

During an interview, the DON explained that residents are supposed to receive a BLCP when they are admitted and that a copy is typically given within 48–72 hours. She stated that the BLCP is not printed separately but is added to the comprehensive care plan, and staff are supposed to write a progress note indicating that the resident or representative received it. When the surveyor requested copies of the BLCPs and documentation that they were provided for the two residents in question, the DON acknowledged that there was no evidence in the medical records for these residents and confirmed she did not see any BLCP summaries in the records. The DON also stated that, according to facility policy, staff are supposed to write a note documenting that the BLCP was given, but this had not been done for these two residents.