Legacy At Jacksonville

The facility failed to ensure Resident #92 had a baseline care plan that included interventions to address his admission diagnoses and physician orders within 48 hours of admission.

This failure could place newly admitted residents at risk of receiving inadequate care and services.

Findings included: A record review of a face sheet dated 04/28/2026 indicated Resident #92 was an [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included pneumonia (infection of the lungs), chronic congestive heart failure (known as CHF, a chronic, progressive condition where the heart cannot pump blood efficiently causing fatigue, swelling, and shortness of breath), chronic kidney disease (kidney damage leading to causing the kidneys to work less efficiently), chronic obstructive pulmonary disease (known as COPD, a progressive, incurable lung disease that causes obstructed air flow , making it difficult to breathe), malignant neoplasm of the prostate (cancer of the prostate), osteoarthritis (a degenerative joint disease leading to pain, stiffness, and reduced mobility), and weakness. A review of the physician's orders dated 02/06/2026 indicated Resident #92 had allergies to aluminum hydroxide, calcium carbonate, cefdinir, magnesium carbonate, magnesium hydroxide, and Protonix. A record review of an admission MDS dated [DATE] indicated Resident #92 had a BIMS score of 00 which indicated he had difficulties with short-term memory, orientation, and attention and required extensive assistance with most of his activities of daily living. A review of the medical records indicated Resident #92 did not have a baseline care plan. A review of the progress notes dated 02/14/2026 indicated Resident #92 discharged from the facility on 02/14/2026.

During an interview with the DON on 04/28/2024 at 01:45 PM, she said a 48-hour care plan should have been completed when the charge nurse admitted Resident #92.

She said the completion of the Nursing admission Assessment was designed to identify any assessment findings of concern and trigger them for the baseline care plan.

The DON said Resident #92's Baseline care Plan was not completed because the Nursing admission Assessment was incomplete.

The DON said she was new to the facility and was not sure who was responsible for ensuring the Baseline Care Plans were completed.

She said the purpose of the Baseline Care Plan was to provide directions for caring for a resident and without it, a resident could be at risk for not receiving the care and services he or she requires. A record review of the facility's undated Baseline Care Plan policy indicated the following: Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission.The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. 1.

The baseline care plan will:a. Be developed within 48 hours of a resident's admission. b.

Include the minimum healthcare information necessary to properly care for a resident including, but not limited to:i.

Initial goals based on admission orders. ii.

Physician orders. iii.

Dietary orders.iv.

Therapy services. v. PASARR recommendation, if applicable .