Failure to Implement Respiratory-Focused Baseline Care Plans and Provide Plan Summaries
Summary
The deficiency involves the facility’s failure to develop and implement effective, person-centered baseline care plans within 48 hours of admission for residents with significant respiratory needs, and failure to provide a required written summary of the baseline care plan to a resident’s representative. For one resident with severe cognitive impairment, acute respiratory failure, COVID-19, pneumonia, CHF exacerbation, and continuous oxygen orders, the baseline care plan created at readmission did not address respiratory needs or continuous oxygen therapy. The plan was largely blank except for behavior and diet comments, and did not include individualized interventions such as maintaining the head of bed elevation or reminders not to remove the nasal cannula, despite these needs being documented in transfer forms and physician orders. The same resident’s daughter reported that the resident required continuous oxygen, preferred to have the head of bed elevated to breathe better, and needed reminders not to remove her nasal cannula due to confusion. She stated that on several visits she found the resident without the nasal cannula and with the head of the bed flat, and that staff were not consistently communicating about the resident’s preferences and comfort needs. The daughter also confirmed she never received a copy of the initial plan of care and had not met with anyone at the facility regarding her concerns about her mother’s respiratory status, contrary to facility policy requiring that a written summary of the baseline care plan be provided to and signed by the resident or representative. For a second resident with a history of end stage renal disease on dialysis, cardiac arrest, CHF, acute and chronic respiratory failure, COPD, colostomy, and hypertension, hospital records documented chronic respiratory failure and oxygen dependency, and the resident returned with a primary diagnosis of acute respiratory failure. Physician orders included three respiratory inhalers, and nursing notes and vital signs documented oxygen use on multiple dates. However, both the admission and readmission baseline care plans did not address the resident’s respiratory status, respiratory medical conditions, or chronic oxygen use. The MDS Director and DON acknowledged that respiratory assessments, care plan focuses, and interventions such as oxygen use, monitoring, head of bed elevation, and observation for respiratory distress should have been included, and that the baseline care plan form, even before modification, allowed for documentation of such needs.
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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