Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop a baseline care plan within 48 hours of admission for one resident. Record review showed that the resident was admitted on 06/20/25 and had a BIMS score of 13, indicating the resident was cognitively intact for daily decision making. Review of the clinical record did not show that a baseline care plan had been completed for this resident. During interviews, MDS coordinator #1 stated that they or the ADON were responsible for completing baseline care plans and, after reviewing both the electronic clinical record and the paper chart, could not locate a baseline care plan for the resident. The ADON confirmed that they were responsible for completing baseline care plans and acknowledged that a baseline care plan had not been completed within 48 hours of admission for this resident because the ADON had been off work on those days. The DON identified that 39 residents resided in the facility at the time of the survey, and the deficiency was identified for 1 of 14 sampled residents whose care plans were reviewed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.