Failure to Develop and Provide Resident-Specific Baseline Care Plans Within 48 Hours of Admission
Summary
The deficiency involves the facility’s failure to develop and provide person-centered baseline care plans within 48 hours of admission for multiple newly admitted residents, as required by facility policy. For each of five sampled residents, the baseline care plan section in the admission Observation note contained only generic statements such as receiving medications as ordered, skilled care, pain medications as ordered, skin care to prevent breakdown, dietary needs as ordered, and assistance with activities of daily living as necessary. These baseline care plans did not include resident-specific conditions or treatments that were documented elsewhere in the medical record. The facility’s own policy stated that an interim baseline care plan would be developed within 48 hours of admission to ensure resident needs were met until the comprehensive care plan was completed. For one resident admitted with a displaced fracture of the left femur, muscle wasting, type 2 diabetes, cerebral infarction, and protein calorie malnutrition, the admission notes documented an indwelling urinary catheter and two post-operative surgical wounds to the left hip. However, the baseline care plan did not identify the catheter or the surgical wounds, and the baseline care plan checklist was not completed until several days after it was due. The comprehensive care plan did not address the catheter until more than two weeks after admission and did not address skin integrity until nearly a month after admission. Another resident admitted with a non-traumatic acute subdural hemorrhage, nondisplaced fracture of the right humerus, dysphagia, diabetes with hyperglycemia, protein calorie malnutrition, and dementia had a neurosurgery recommendation for a soft collar at all times following a fall with head injury. The baseline care plan did not identify the fracture or the need for the soft collar, and the baseline care plan checklist was completed after its due date. The resident’s fall and humerus fracture were not included in care planning until several days after admission, and the resident reported not recalling any staff discussing their care or keeping them informed about their care needs. Another resident admitted with a displaced transverse fracture of the right patella, protein calorie malnutrition, PTSD, anxiety, major depressive disorder, and acquired absence of the right upper limb had a surgical incision to the right knee with sutures, slough tissue, and a wound vac, as well as an IV antibiotic order. The baseline care plan did not identify the surgical wound, wound vac, or IV antibiotic, and the checklist was completed late. The comprehensive care plan did not include the antibiotic or wound vac until more than a week after admission. A further resident with a brain neoplasm, protein calorie malnutrition, hemiplegia, and bipolar disorder had antipsychotic, hypnotic, and antidepressant medications ordered upon admission, but these were not specified in the baseline care plan, and the checklist was completed after its due date. The comprehensive care plan did not address these psychotropic medications until nearly two weeks after admission, and the resident stated they were not aware of their plan of care and that no one had reviewed specific aspects of their care or discharge plan with them. A fifth resident admitted with acute kidney failure, protein calorie malnutrition, sepsis, and spinal stenosis had wounds to the sacrum and both buttocks and was receiving antidepressant medication. The baseline care plan again contained only general statements and referenced skin issues with a direction to see orders/observations that were not attached to the document provided to the resident. The baseline care plan checklist was completed after its due date, and the comprehensive care plan did not include the antidepressant use or pressure wounds until several days after admission. Interviews with facility staff, including the SSD, DOR, LPN, MDS coordinator, and DON, confirmed that the baseline care plan was treated as a general, non–resident-specific document attached to the initial nursing observation, that completion often occurred beyond 48 hours (especially for Friday admissions), and that specific care needs were typically discussed later at a “Path” meeting held three to five days after admission. Staff also confirmed that the developed baseline care plan was not specific to resident care needs and was not provided to residents or representatives in a timely manner.
Penalty
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A resident admitted with CHF and moderate cognitive impairment did not receive a baseline care plan within 48 hours of admission to address CHF-related needs. The MDS nurse, responsible for initiating diagnosis-related care plans, confirmed that no CHF-specific baseline care plan existed, even though the resident required assistance with multiple ADLs. The DON acknowledged that baseline care plans are important on admission, and facility policy requires timely development of a baseline care plan including goals, physician and dietary orders, and interventions based on admission information, but these requirements were not followed for this resident’s CHF diagnosis.
Surveyors determined that the facility did not develop a complete baseline care plan for a newly admitted resident with dementia and postprocedural intestinal obstruction. The MDS showed the resident had severely impaired cognition and required staff assistance with ADLs, but the baseline care plan only noted an ADL self-care performance deficit related to comorbidities without specifying the resident’s basic ADL care needs. An LPN confirmed the plan lacked essential information needed to provide care, and policy review showed that baseline care plans were required to include details on ADL assistance needs.
A resident admitted with CKD stage 5 on dialysis, neuromuscular bladder dysfunction, and anxiety did not have a baseline care plan developed within 48 hours of admission, as confirmed by record review and staff interviews. The Interim DON acknowledged that the baseline care plan was only started several days after admission and stated that her expectation was for an RN to complete it within the first 48 hours. The Administrator similarly reported that nursing was expected to complete the baseline care plan upon admission and recognized that failure to do so could affect quality of care by leaving staff without needed care instructions. When surveyors requested the facility’s baseline care plan policy, no policy was provided before exit.
The facility failed to complete and individualize baseline care plans within 48 hours of admission for several newly admitted residents. Some residents had no baseline care plan in the EMR, while others had plans that were signed but undated or missing key information such as required assistance levels for ADLs, transfer methods, diet orders, use of assistive devices, and ordered rehab therapies. An LPN reported that nurses initiate baseline care plans at admission, and the MDS/RN acknowledged that staff may not know how to provide care if plans are not resident-specific. The regional nurse consultant confirmed that some residents lacked individualized baseline care plans and that the facility likely did not have signed baseline care plans or documentation that copies were provided, despite a policy requiring completion of a comprehensive baseline care plan within 48 hours including physician, dietary, therapy, and social service information.
Failure to complete a baseline care plan within 48 hours of admission for a resident with pneumonia, CHF, CKD, COPD, prostate cancer, osteoarthritis, and weakness. The resident had a BIMS score of 00, required extensive ADL assistance, and had multiple allergies listed in physician orders, but no baseline care plan was found in the record. The DON stated the 48-hour care plan should have been completed on admission and that it was not done because the Nursing admission assessment was incomplete.
A resident with diagnoses including heart failure and anxiety was admitted without a baseline care plan developed within 48 hours to address immediate and individualized care needs. An Interim Care Plan assessment for this resident was started but not completed, so no individualized interim care plan was in place. The DON reported that the admitting nurse typically completes this assessment to initiate the interim care plan, but this did not occur, despite facility policy requiring a baseline plan of care to be developed within 48 hours of admission.
Failure to Develop Baseline Care Plan for CHF on Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission to address a resident’s primary admitting diagnosis of congestive heart failure (CHF). The resident was admitted with CHF and had an MDS assessment showing moderately impaired cognitive skills for daily decision-making and functional needs including assistance with oral hygiene, eating, personal hygiene, and dependence for toileting hygiene and bathing. Review of the admission record and baseline care plans showed no documented baseline care plan specific to CHF, despite CHF being the primary admitting diagnosis. The MDS nurse, who stated that diagnosis-related care plans are initiated by the MDS department, confirmed that there was no baseline care plan for CHF and acknowledged that one should have been in place. The DON stated that baseline care plans are important to be initiated on admission to ensure nursing staff provide appropriate care based on admitting diagnoses and to allow staff to evaluate and revise interventions as needed. The facility’s own policy titled “Baseline Care Plan,” last reviewed on 4/24/2025, requires that a baseline care plan be developed within 48 hours of admission and include minimum healthcare information such as initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. The policy also specifies that the admitting or supervising nurse must gather information from the admission assessment, hospital transfer information, physician orders, and discussions with the resident or representative to establish initial goals and interventions addressing current needs and health and safety concerns. Despite these requirements, no baseline care plan addressing the resident’s CHF was developed within the required timeframe.
Failure to Include ADL Needs in Baseline Care Plan
Penalty
Summary
Surveyors found that the facility failed to implement an adequate baseline care plan addressing activities of daily living (ADL) needs for a newly admitted resident. The resident was admitted with diagnoses including postprocedural intestinal obstruction and dementia, and the MDS assessment documented severely impaired cognition and a need for staff assistance with ADLs. The baseline care plan, dated on the admission day, only noted that the resident had an ADL self-care performance deficit due to comorbidities and did not include further details about the resident’s basic ADL care needs. An interview with the MDS LPN confirmed that the baseline care plan lacked the basic information needed to care for the resident. Review of the facility’s Baseline Care Plan/48 Hour Care Plan policy showed that baseline care plans were required to include information regarding resident needs for assistance with ADLs, which was not done in this case. This deficiency was cited for one resident out of 13 reviewed for baseline care plans, with a facility census of 112 residents, and was investigated under Complaint Number 2963128.
Failure to Complete Timely Baseline Care Plan After Admission
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to develop a baseline care plan within 48 hours of admission for one resident. Record review showed that a male resident, identified as Resident #80, was admitted on 4/27/2026 with diagnoses including chronic kidney disease stage 5 requiring dialysis, dependence on renal dialysis, neuromuscular dysfunction of the bladder, and anxiety. Review of the electronic clinical record on 4/30/2026 revealed that no initial baseline care plan had been developed within the required 48-hour timeframe following his admission. During interviews, the Interim DON confirmed on 4/30/2026 that a baseline care plan had not been completed within 48 hours and stated she had only started the baseline care plan that day. She reported that her expectation was that baseline care plans be completed within the first 48 hours after admission by an RN and acknowledged that not completing the baseline care plan could result in staff not knowing how to care for the resident. In a separate interview, the Administrator stated her expectation that nursing complete the baseline care plan upon admission and acknowledged that failure to complete it timely could affect residents’ quality of care by staff not knowing how to care for them. When surveyors requested the facility’s baseline care plan policy from the DON on 4/30/2026, no policy was provided prior to exit.
Failure to Complete and Individualize Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete individualized baseline care plans within 48 hours of admission that contained the minimum healthcare information necessary to properly care for multiple residents, and to ensure these plans were reviewed with and offered to residents or their representatives. Record review showed that one resident admitted on 9/25/25 had a signed baseline care plan that lacked documentation of required assistance levels for transfers, bed mobility, bathing, dressing, toileting, eating, and did not include the physician-ordered diet. Another resident’s baseline care plan, last revised on 1/9/26, was signed but undated and similarly omitted the level of assistance needed for transfers, bed mobility, bathing, dressing, toileting, and eating. A third resident admitted on a specified date had no baseline care plan at all, and a fourth resident’s baseline care plan, uploaded on 12/19/25 and signed but undated, did not indicate how the resident transferred, walked, whether assistive devices were required, or the amount of assistance needed for dressing or toileting. Additional record reviews revealed that another resident admitted on a specified date had no baseline care plan in the EMR, and a further resident’s baseline care plan dated 4/5/26 did not specify how she transferred between surfaces, her diet, or the specific physician-ordered rehabilitation therapies. Interviews with the regional nurse consultant confirmed that two residents did not have individualized baseline care plans completed and that the facility likely did not have signed baseline care plans or documentation that copies were provided to residents or their representatives. An LPN stated that nurses initiate baseline care plans during admission and that all nurses and leadership can update them, and the MDS/RN acknowledged that staff may not know how to provide care if care plans are not resident-specific and completed, and confirmed that two residents’ baseline care plans, although reviewed with their representatives, were not personalized with specific care information. Policy review showed that the facility’s care plan policy required baseline care plans to be started on the first day of admission, completed within 48 hours, and to include minimum healthcare information such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, which was not consistently done.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #92. The resident was an [AGE] year-old male admitted with diagnoses including pneumonia, chronic congestive heart failure, chronic kidney disease, COPD, malignant neoplasm of the prostate, osteoarthritis, and weakness. His physician orders listed allergies to aluminum hydroxide, calcium carbonate, cefdinir, magnesium carbonate, magnesium hydroxide, and Protonix. An admission MDS showed a BIMS score of 00, indicating difficulty with short-term memory, orientation, and attention, and that he required extensive assistance with most activities of daily living. The medical record showed that Resident #92 did not have a baseline care plan. The resident was discharged from the facility on 02/14/2026. During interview, the DON stated that a 48-hour care plan should have been completed when the charge nurse admitted the resident, and that the Nursing admission Assessment was intended to identify concerns and trigger the baseline care plan. The DON said the baseline care plan was not completed because the Nursing admission Assessment was incomplete, and she was new to the facility and unsure who was responsible for ensuring baseline care plans were completed. The facility policy stated that the baseline care plan was to be developed within 48 hours of admission and include minimum healthcare information such as initial goals based on admission orders, physician orders, dietary orders, therapy services, and PASARR recommendations if applicable.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one of three newly admitted residents reviewed. Record review on 4/28/26 showed that Resident B, whose diagnoses included heart failure and anxiety, was admitted on an unspecified date and did not have a baseline care plan in place addressing individualized care needs. An Interim Care Plan assessment for this resident, dated 4/21/26, had been initiated but was not completed, and therefore no individualized interim care plan was in place. During an interview on 4/29/26, the DON stated that the admitting nurse usually completed the Interim Care Plan assessment, which would then initiate an individualized interim care plan. The facility’s policy, dated 2026, required that a baseline plan of care to meet each resident’s immediate health and safety needs be developed within 48 hours of admission. This deficiency was cited in relation to Intakes 29994502, 2738801, and 2989481. This deficiency was cited under 410 IAC 16.2-3.1-30(a).
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