Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a Baseline Care Plan for a resident who was admitted with diagnoses of myocardial infarction and major depression. The resident's electronic medical record did not contain a Baseline Care Plan, despite facility policy requiring an initial person-centered care plan to be completed within 48 hours of admission. The omission was confirmed through record review and an interview with administrative staff, who stated that a baseline care plan assessment is expected upon admission. The lack of a Baseline Care Plan was identified during a review of the resident's records and was not in accordance with the facility's stated procedures for ensuring continuity of care and communication among staff.