Failure to Develop Baseline Fall-Prevention Care Plan for High-Risk New Admission
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan addressing a resident’s high risk for falls within the required timeframe after admission. The resident was admitted with diagnoses including sepsis, weakness, cognitive deficit, insomnia, and a history of repeated falls. A BIMS score of 4 indicated severe cognitive impairment. A fall assessment completed shortly after admission identified the resident as high risk for falls with a score of 24, noting intermittent confusion, recent hospitalization, and wheelchair confinement with disorientation, although the mobility status documentation was not accurate. Despite these findings, no baseline care plan interventions were created to address fall risk, fall prevention, or the level of assistance needed for transfers and ambulation within the first days after admission. The record showed that the only care plan initiated shortly after admission was an ADL care plan indicating the resident required assistance with daily care needs related to general weakness/debility and direct feeding assistance, with other ADL interventions not added until after the fall. There was no documentation in the care plan or record indicating whether the resident was continent or incontinent or whether a toileting program was in place. The fall prevention care plan and additional ADL interventions, including the resident’s transfer needs, were not developed until after the resident experienced a fall and was discharged to the hospital. The DON confirmed that the resident had been assessed as high risk for falls upon admission and that therapy had determined the resident required at least one-person assistance for transfers and ambulation, but this information was not entered into the care plan or Kardex until after the incident. Staff interviews further demonstrated that direct care staff did not have clear guidance on the resident’s fall risk status or required assistance level. The RN manager stated that a baseline care plan had been developed within 24 hours of admission but did not include high fall risk, fall prevention interventions, or transfer/ambulation assistance needs, and acknowledged the importance of having transfer needs on the baseline care plan so staff know how to care for the resident. One CNA reported that the resident was able to get out of bed and walk but was unsteady and that she did not consider the resident a major fall risk because there were no fall-related signs or equipment in the room and no indication for frequent checks. Another CNA reported not knowing the resident’s continence status, that the resident could not communicate toileting needs, that the door remained closed all night, and that the last check occurred several hours before the fall. The DON stated that the care plan information should carry over to the Kardex for CNA use and acknowledged that the resident’s fall care plan and transfer status were missing until after the fall, which occurred four days after admission.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
