F0655

D

Failure to Provide Written Baseline Care Plan Summary to Resident

Reseda, California Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The facility failed to provide a written summary of a baseline care plan to a resident and/or the resident’s representative following admission. A resident was admitted with diagnoses including cerebral infarction (stroke), diabetes mellitus, and hypertension. The resident’s MDS assessment showed intact cognition, independence with eating and oral hygiene, and a need for moderate assistance with toileting, showering, and dressing. An Interdisciplinary Care Conference (ICC) note dated shortly after admission documented that the checkbox indicating a copy of the care plan was provided to the resident or representative was left blank. During an interview and concurrent record review, the Case Manager was unable to recall whether a written baseline care plan summary had been provided and could not locate any documentation confirming that it had been given to the resident or family.

In a subsequent interview and record review, the DON confirmed that the facility’s practice was to develop a baseline care plan within 48 hours of admission and to provide a written summary of that plan to the resident and/or family. The DON reviewed the ICC notes and clinical record for the resident and was unable to find any indication that a written baseline care plan summary had been provided. Review of the facility’s baseline care plan policy, last revised for 1/2026–1/2027, showed that it required development and implementation of a baseline care plan within 48 hours of admission but did not specify the requirement to provide a written summary to the resident or family, even though the DON stated that copies of the baseline care plan summary should be provided. The absence of documentation and the unmarked ICC checkbox demonstrated that the resident and/or representative did not receive the required written baseline care plan summary.