Federal inspectors found that Resident #4, admitted in October, had no baseline care plan, no comprehensive care plan, and no MDS assessment completed by the time investigators arrived. The facility's own policy requires baseline care plans within 48 hours of admission.
The confusion ran deep through the nursing staff. When asked about baseline care plans on October 21, Licensed Vocational Nurse J said she thought the Assistant Director of Nursing did them. "She said she thought they must be done by an RN," inspectors wrote.
But the Assistant Director of Nursing, who had held her position for just three weeks, told inspectors the next day that she "did not know baseline care plans were supposed to be done on admission until yesterday." She had worked at the facility since July 2024.
The MDS Coordinator, responsible for resident assessments, had started her job on September 29 with no prior experience. She told inspectors that floor nurses should complete baseline care plans, but admitted she didn't know the facility's 48-hour deadline.
Even the admission checklist used by floor nurses omitted baseline care plans entirely. LVN J showed inspectors a checklist from a book at the nurses' station that guided admission procedures. Only after further questioning did she produce a second list from July or August that included baseline care plans. "She said she was not aware that they were to be completing them," the inspection report noted.
The Director of Nursing told inspectors on October 22 that the admission nurse would handle baseline care plans "going forward." But the Administrator said the MDS Coordinator would be responsible.
Nobody seemed to grasp the consequences until inspectors explained them. The MDS Coordinator acknowledged that without baseline care plans, "staff may not know how to take care of the residents." The Assistant Director of Nursing agreed that "staff would not know how to take care of the residents without the baseline care plan."
The Director of Nursing was more direct: "residents potentially would not be cared for properly without a baseline care plans."
The Administrator went furthest, telling inspectors that "care could be missed if baseline care plans were not completed and residents could be at risk of harm."
Resident #4's case illustrated the problem. His diagnoses included bipolar disorder, a mental health condition characterized by extreme mood swings between emotional highs and lows, and epilepsy, which causes seizures. Both conditions require specific monitoring and interventions that should have been outlined in a care plan within two days of his arrival.
Instead, he remained in the facility's electronic medical records system with empty tabs where his assessments and care plans should have appeared. The MDS tab showed no completed assessment. The care plan tab showed no comprehensive care plan. The assessments tab showed no baseline care plan.
The facility had written policies dating to December 2016 that clearly stated the requirements. The policy read: "A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission" and "To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission."
Despite having these policies for nearly nine years, the systematic breakdown revealed that supervisory staff didn't know the requirements, floor staff didn't know their responsibilities, and the admission process failed to ensure compliance.
The Assistant Director of Nursing and Director of Nursing promised inspectors they would begin checking new admissions to ensure baseline care plans were completed. But their statements revealed the depth of the facility's oversight failures.
For Resident #4 and potentially other new admissions, the absence of baseline care plans meant staff lacked essential guidance on medication management, monitoring requirements, safety precautions, and daily care needs specific to each resident's medical conditions.
The inspection occurred after a complaint, suggesting the care plan failures may have contributed to problems serious enough to prompt outside reporting. Federal inspectors classified the violation as having potential for actual harm to residents.
Kennedy Health & Rehab's breakdown in basic admission procedures left vulnerable residents like the man with bipolar disorder and epilepsy without the individualized care plans that federal regulations require to ensure their safety and well-being during the critical first days of their stay.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kennedy Health & Rehab from 2025-10-22 including all violations, facility responses, and corrective action plans.