Failure to Complete and Share Baseline Care Plans Within Required Timeframe
Penalty
Summary
The facility failed to complete and lock baseline care plans within 48 hours of admission for two residents and failed to provide and document provision of baseline care plan summaries to several other residents or their representatives. Policy revised 9/3/25 required initiation of a baseline care plan for each resident within 48 hours of admission, and that the facility review and provide the resident and/or representative with a summary of the baseline care plan and provider orders in an understandable language, with evidence of this in the medical record. Resident #4, admitted with chronic respiratory failure with hypoxia and dementia, had a baseline care plan that was not signed and locked until four days after admission, and the CNO confirmed it should have been completed and locked within 48 hours. Resident #70, initially admitted and later readmitted with diabetes and a need for assistance with personal care, had no baseline care plan documented in the medical record, which the CNO also confirmed. The facility also did not document that baseline care plans were provided and discussed with five residents or their representatives. Resident #7, with bipolar disorder and anxiety and assessed as cognitively intact on a quarterly MDS, had a 48-hour care plan form that did not document that she or her representative received a copy of the baseline care plan. Resident #9, with COPD and chronic kidney disease and documented as cognitively intact on a comprehensive MDS, had no documentation in the medical record that a baseline care plan was provided and discussed with her or her representative. Residents #11, #21, and #28, each with multiple diagnoses including COPD, obstructive sleep apnea, interstitial lung disease, heart failure, and COPD, similarly had no documentation that their baseline care plans were provided and discussed with them or their representatives. The CNO stated there was no documentation that these residents or their representatives had received copies of their baseline care plans.
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.