Failure to Develop Comprehensive Care Plan for Admitted Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with measurable objectives and timetables for one resident, identified as #91, as required by its March 2022 Care Plans, Comprehensive, Person-Centered policy. The policy stated that comprehensive care plans must be completed within seven days of the required MDS assessment and no more than 21 days after admission. Admission records showed the resident was admitted on 10/07/25 and discharged on 11/23/25, and an admission assessment dated 10/14/25 confirmed the admission date. Review of the electronic medical record revealed that no comprehensive care plan had been developed for this resident during their stay. On 02/11/26 at 12:24 p.m., the MDS coordinator was unable to locate a comprehensive care plan for this resident in the electronic medical record and acknowledged that the resident had been in the facility long enough that a care plan should have been developed, stating it should have been completed no later than 14 days after the admission MDS assessment. At 12:48 p.m. the same day, the DON also confirmed they could not locate a comprehensive care plan for the resident and stated that both their expectation and facility policy required the comprehensive care plan to be developed within 14 days of completion of the resident’s comprehensive assessment.
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