Failure to Develop Baseline Care Plan for ADLs Within 48 Hours of Admission
Penalty
Fine: $23,56582 days payment denial
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 develop and implement a baseline care plan within 48 hours of admission for a resident who was recently admitted with repeated falls, difficulty walking, muscle weakness, and a need for assistance with personal care. The admission Minimum Data Set indicated the resident required substantial to maximal assistance with activities of daily living (ADLs). However, review of the care plan initiated on 4/2/25 showed it lacked documented goals and interventions for ADLs. During interviews, a CNA confirmed the resident needed help with toileting and ambulation, and the DON acknowledged that the care plan did not address these needs.