Failure to Complete Comprehensive Care Plan After Admission Assessment
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident, as required by its policy and the RAI process. The facility’s Care Plan Process policy dated 09/2019 stated that a care plan appropriate to each resident’s needs and wishes would be developed based on assessment and reassessment within required timeframes. For a resident who entered the facility on 06/19/25, an MDS admission assessment dated 06/25/25 identified needs in ADL functioning, urinary incontinence, nutritional status, and pressure ulcers that were selected to be care planned, and the MDS coordinator signed the assessment as completed on 06/25/25. Record review of the resident’s EMR showed only a baseline care plan dated 06/20/25 and no comprehensive care plan in the care plan section. During an interview on 09/24/25 at 11:15 a.m., the DON confirmed that there was no comprehensive care plan for this resident in the EMR and acknowledged that a comprehensive care plan should have been created by that time, consistent with the facility’s policy to complete baseline and comprehensive care plans in a timely manner.
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