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F0655
E

Failure to Complete and Distribute Baseline Care Plans Within 48 Hours of Admission

Novato, California Survey Completed on 05-14-2025

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 complete baseline care plans (BCPs) within 48 hours of admission for five sampled residents. Record reviews showed that the BCPs for these residents were not finalized within the required timeframe, and the signature sections for both the residents and their representatives were left blank. Additionally, there was no documentation indicating that copies of the BCPs had been provided to the residents or their representatives as required by facility policy. During an interview and concurrent record review, the Infection Preventionist confirmed that the BCPs for the five residents were not completed within 48 hours of admission and that no evidence existed showing that copies had been distributed to the appropriate parties. The facility's policy, revised in November 2018, specifies that a baseline care plan must be completed within 48 hours of admission and a summary provided to the resident and/or their representative.

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