F0838

D

Incomplete Facility Assessment of Current Resident Population and Service Needs

Baltimore, Maryland Survey Completed on 02-24-2026

Penalty

Fine: $55,890

Summary

Facility staff failed to complete a comprehensive facility-wide assessment that included all information required to determine necessary resources to care for residents competently during routine operations and emergencies. During an extended survey, reviewers found that the existing facility assessment primarily described services the facility offers, rather than functioning as an assessment of the current resident population. The assessment indicated that the facility offers tracheostomy and gastrostomy services, but did not document that any current residents actually required these services.

At survey entrance, a resident matrix identified a resident with a tracheostomy, and subsequent record review showed that this same resident also had a gastrostomy tube for nutritional support. Despite this, the facility assessment did not reflect that any current residents needed tracheostomy or gastrostomy support. The assessment also referenced "supportive care" for behavioral/mental health providers but did not specify who provided this care or their qualifications (e.g., NP, physician, social worker), nor did it describe what support was provided or the type of clientele served. Multiple tours revealed residents in bed requiring staff assistance with ADLs and others independently mobilizing in wheelchairs or walking, yet the assessment did not include an actual evaluation of the current resident population for the assessed year. These concerns were discussed with the NHA during the survey.