Care One At Weymouth

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for two of three sampled residents (Resident #1 and #2), the Facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs.Findings include:

Review of the Facility Policy titled Baseline Care Plans, dated as last revised 3/2022, indicated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission.The Policy further indicated the baseline care plan includes instructions needed to provide effective, person-centered care of the residents that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the residents.1) Resident #1 was admitted to the Facility in 9/2025, diagnoses include respiratory failure, pneumonia, chronic obstructive pulmonary disease and is oxygen dependent.Review of Resident #1 Hospital Discharge summary, dated [DATE], indicated his/her immediate care needs were identified as followed;-Acute on chronic respiratory failure, dependent on four (4) liters (l) of oxygen;-Average Volume-Assured Pressure Support (AVAPS) use at night;-Pneumonia with antibiotic use;-Acute heart failure; and-Subcutaneous anticoagulation.Review of Resident #1's admission Resident Evaluation, dated 09/09/25, indicated he/she had an open area to his/her coccyx requiring a treatment.Review of Resident #1's Medical Record indicated that there was no documentation to support that Baseline Care Plans were developed and implemented to address these areas of concern within 48 hours of his/her admission.2) Resident #2 was admitted to the Facility in 11/2025, diagnoses include acute respiratory failure with hypoxia, dependent on supplemental oxygen related to chronic obstructive pulmonary disease, and congestive heart failure.Review of Resident #2 Hospital Discharge summary, dated [DATE], indicated his/her immediate care needs were identified as followed;- Chronic respiratory failure, dependent on two (2) l of oxygen;-Frequent falls; and-Constipation.Review of Resident #2's Medical Record indicated that there was no documentation to support that Baseline Care Plans were developed and implemented, or that the Comprehensive Care Plans addressed these areas of concern were in place within 48 hours of admission.

During an interview on 11/26/25 at 1:42 P.M., the Unit Manager said that she was not aware that Resident #1 did not have a completed baseline care plan and said that it was her responsibility to complete the baseline care plans.The Unit Manager said that as a team the management staff is to review a new admission chart the next day at morning meeting to ensure that the baseline care plans are completed.

During an interview on 11/26/25 at 2:18 P.M., the Assistant Director of Nurses (ADON) said that she was unaware that Resident #1 and Resident #2's baseline care plans had not been completed.The ADON said that each disciple should be initiating their individual baseline care plan and that the Unit Manager and Night Shift Supervisor should be checking for completion.

During an interview on 12/26/25 at 3:32 P.M., the Director of Nurses (DON) said that she was not aware of Residents #1 and #2 were missing their baseline care plans upon admission.The DON said that it is the Facility's expectation that the admitting nurse is to initiate the resident's baseline care plan and said, along with the other disciplines complete the Baseline care plan within 48 hours of admission.

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