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F0655
B

Failure to Provide Written Baseline Care Plan Summaries to Newly Admitted Residents

Warsaw, New York Survey Completed on 02-09-2026

Penalty

Fine: $21,645
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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 newly admitted residents or their representatives with a written summary of the Baseline Care Plan within 48 hours of admission, as required by facility policy and 10 NYCRR 415.11. For eight of ten sampled residents, there was no documented evidence that a written summary of their initial care needs, including admission orders, dietary instructions, therapy, and social services, was given to them or their representatives. The facility’s policy dated 12/19/2022 required that a baseline care plan be developed within 48 hours of admission and that a paper copy summary be provided, or that a refusal of the copy be documented. However, records for multiple residents showed completed baseline care plans without any documentation that a written summary was provided or that it was declined. One resident with severe cognitive impairment and diagnoses including femur fracture, dementia, and anxiety had a baseline care plan dated shortly after admission, but there was no documentation that a written summary was provided to the resident’s representative, despite a social worker note indicating a meeting to review the plan of care. Another resident with severe cognitive impairment and diagnoses including dementia, CHF, and COPD had a baseline care plan and a documented meeting with the social worker and family to discuss the plan of care, but again no documentation that a written summary was provided. A third resident with moderately impaired cognition and diagnoses including atrial fibrillation, schizoaffective disorder, and dysphagia similarly had no documentation that a written summary of the baseline care plan was provided, despite a documented meeting with the resident and family. In an interview, the social worker stated that they verbally reviewed the baseline care plan and offered a copy, but did not document when a copy was offered or declined, and the DON stated they were not aware that copies were not being provided as required.

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