F0655

D

Failure to Provide Written Baseline Care Plan Summary to Newly Admitted Resident

Sun City, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The facility failed to provide a written summary of the baseline care plan to a newly admitted resident, identified as Resident C. Resident C was admitted with diagnoses including congestive heart failure and angina pectoris, and a History and Physical documented that the resident had the capacity to understand and make decisions. During an unannounced survey, record review showed no evidence that a written summary of the baseline care plan had been provided to the resident or the resident’s representative, despite the facility’s policy requiring development of a baseline care plan within 48 hours of admission and provision of a written summary to the resident and representative.

Interviews with staff revealed inconsistent understanding and implementation of the baseline care plan process. The MDS nurse reported that baseline care plans are completed within 72 hours and that nurses are to give a copy to the resident or responsible party. An LVN stated she was not familiar with the baseline care plan because she was not involved in admissions. The RN Supervisor stated she was not aware that the baseline care plan was supposed to be completed within 48 to 72 hours or that residents or responsible parties were to receive a copy. The DON stated that the admission nurse initiates the baseline care plan and department heads complete it within 48 hours, and that a copy should be provided to the resident or representative, but acknowledged there was no proof that any care plan meeting occurred with Resident C or that a copy of the baseline care plan summary was provided.