Failure to Implement Comprehensive Care Plans for Smoking and PTSD
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, particularly concerning their smoking habits. Observations and record reviews revealed that six residents were not provided with adequate care plans addressing their smoking needs, which included necessary supervision and safety measures. For instance, one resident with moderate cognitive impairment was observed smoking without a required smoking apron, despite having a history of unsafe smoking practices. Another resident, who was not initially identified as a tobacco user, was found smoking unsupervised, highlighting discrepancies in smoking assessments and care plans. Additionally, the facility did not develop a care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident's care plan lacked focus areas or interventions addressing the PTSD diagnosis, despite the resident experiencing agitation and depression. This oversight indicates a failure to address the resident's mental health needs comprehensively, as required by the facility's policy on comprehensive care plans. The surveyors identified these deficiencies as creating potential risks for the safety and well-being of the residents. The facility's noncompliance with care planning requirements was determined to have the likelihood of causing serious harm or injury to residents, leading to the declaration of an Immediate Jeopardy situation. The facility's failure to monitor smoking practices adequately, maintain accurate smoking assessments, and ensure supervision during smoking activities contributed to this critical finding.
Removal Plan
- The facility failed to develop a comprehensive person-centered care plan for residents R25, R145, R111, R19, R71, R118, R266 and R365. The Regional Nurse Consultant and Director of Nursing reviewed and revised each of their smoking care plans to ensure that they are person centered and comprehensive.
- The Regional Director of Operations in-serviced the Director of Nursing, Assistant Director of Nursing, Minimum Data Set nurses and Regional Nurse Consultant on the smoking policy, ensuring that smoking care plans are followed and completed timely, and importance of accurate smoking assessments. The Administrator will be in-serviced by the Regional Director of Operations.
- Regional Director of Operations in-serviced the MDS nurses on reviewing for complete and accurate comprehensive person-centered smoking care plans for all residents who smoke.
- The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional operations, and/or Regional Nurse began in-servicing all staff on the smoking policy, all residents on Dementia Unit will be required to wear smoking aprons, smoking times, and on the smoking monitors will be present at all smoke breaks.
- Registered Nurses, Licensed Practical Nurses, Certified Nurse assistants, and Certified Medication Aides have been in-serviced on importance of following care plans. There is currently 94% in-serviced completion.
- The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional operations, and/or Regional Nurse began in-servicing all staff on the smoking monitors will be present at all smoke breaks.
- All new licensed staff will be in-serviced on these items above during the orientation process by the Assistant Director of Nursing and/or Director of Clinical Education.
- AD Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed for policy review and root cause analysis was determined staffing education was needed. Attendance to the meeting was Regional Director of Operations, Director of Nursing, Regional Nurse, President of Quality, business office manager, dietary manager, dietary assistant manager, medical supply clerk, transportation coordinator, Director of Rehab, Social Worker, and Unit Managers. The Medical Director was notified by phone.
- Corrective actions will be completed.
- Care Plan and Smoking Assessment Review: R25 - Unsafe smoker, Care plan revised, Smoking assessment was completed - requires supervision. R145 - is a safe smoker however was observed lighting cigarettes for other residents. R145 is a safe smoker - R111- is an unsafe smoker - requires supervision and an apron. R19 - is an unsafe smoker - needs supervision and an apron. R71- is an unsafe smoker. Resident solicits to residents, staff, and/or visitors when cigarettes are not available. Resident has a history of being non-compliant with smoking policy - requires supervision and an apron. R118 - is unsafe smoker - requires apron, cigarette holder, someone to light and extinguish and supervision. R266- Resident is a safe smoker - no supervision, R365- is a safe smoker; however, sometimes non-compliant with the smoking policy. History of lighting other resident's cigarettes - independent smoker.
- In-service education was conducted by Regional Director of Operations and Training and Development Coordinator, Licensed Practical Nurse Unit Manager. In-service included ensuring the residents have their smoking aprons, smoking times, and direct supervision over all smokers safe and unsafe.
- In-service education was conducted by Regional Director of Operations and LPN Unit Manager. In-service education was relating to the smoking policy, abiding by smoking times and ensuring all smokers are care planned. Once a person who wants to smoke is identified a smoking assessment is completed.
- Director of Nursing received in-service from her Regional Director of Operations. She was educated on the new smoking times, smoking policy and creating safe smoking habits for residents. Smoking assessments must be done quarterly and as needed (PRN) and all care plans must be updated to ensure they are in alignment with the assessment. Unsafe smokers will not have their equipment on them, instead they will be locked in a lock box.
- Assistant Director of Nursing received in-service education relating to all the smokers in the building. Smokers cannot smoke anytime they like and are not allowed to hold their own smoking material. In-service education consisted of smoker's policy, timely assessments and care plans. Each resident must be supervised every 2 hours, and a smoking list kept at each nursing section.
- Minimum Data Set nurse received in-service education from the Regional Director of Operations. Topics covered included updating care plans, the smoking policy and smoking assessments for all residents that smoke.
- LPN received in-service on smoking. Training pertained to the residents, fire extinguisher, aprons, and smoking hours. In addition to care plan for safe smokers and unsafe smokers. Unit Manager gave the staff the updated list of smokers with safe and unsafe identified residents. The smoker list is posted in the CNA book and the Nurse book behind the nurse's station.
- Scheduling Manager received smoking in-service training. Everyone on Magnolia Hall is considered unsafe. Apron should be on, they are not to have cigarettes or lighters on person. Smoking box is kept at the nursing station. Nursing keeps the list of the smokers, also list in the smoke box upstairs. Fire blankets are kept in the boxes in both locations up and down stairs. Smoking assessment must be done by the nurses, clinical manager or MDS personnel. Once the assessment is completed it is put in the care plan.
- CNA received smoking in-service. In-service training pertained to the safety of the residents, the nurses conducting the smoking assessments. Nurses are the monitors and the CNA are making sure they keep their smoking aprons on and providing supervision.
- In-service training for the removal plan determined all numbers are accurate.
- LPN received in-service on smoking. Training pertained to the residents, fire extinguisher, aprons, and smoking hours. In addition to care plan for safe smokers and unsafe smokers. Unit Manager gave the staff the updated list of smokers with safe and unsafe identified residents. The smoker list is posted in the CNA book and the Nurse book behind the nurse's station.
- CNA received in-service pertaining to smoking. In-service referred to the up-to-date policy, safe smokers, and unsafe smokers. Safe smokers do not have to have an apron on versus the unsafe smokers don't have to have an apron. Nurses are the ones who do the smoking assessment. The updated list is found at the nurse station. Unit upstairs smokes every two hours and downstairs on Magnolia start at 10:00 am - 6:00 pm.
- CNA received smoking in-service. In-service training pertained to the safety of the residents, the nurses conducting the smoking assessments. Nurses are the monitors and the CNA are making sure they keep their smoking aprons on and providing supervision.
- LPN received the in-service training for smoking. Training pertained to safe and unsafe smoker, the smoking aprons, light the cigarettes and monitor them. If the resident is deemed safe still monitor. Nurses can do the assessment for smoking. All Magnolia residents are monitored at all times during smoking times. Keep the cigarettes locked in the smoke box which is located in the Activities office. If any new staff, the staff can show them the list that is posted at the nurse's station.
- New onboarding employees will review the smoking policy as part of their orientation process. During this onboarding process the smoking components are: There is a new Smoking Schedule, and all staff should direct residents to the times. Smoking Assessment will be conducted as soon as the resident is identified as a smoker with care plan. All unsafe smokers should have a care plan, assessment, supervised residents will have on a smoking apron at all times. All residents on Magnolia are required to wear a smoking apron. Smoking Monitors should be present at all schedule smoking break times. Importance of following smoking care plans and accurately completing smoking assessment in a timely manner. Ensure smoking aprons are on correctly, residents are not allowed to light other resident cigarettes. Residents not on the smoking list are not allowed to smoke until the Charge Nurse, Administrator, or Director of Nursing have been notified and Smoking Assessment is completed.
- Record Review of the AD HOC QAPI Meeting confirmed the root cause was determined and that education to staff and residents on the smoking policy and expectations was needed, and a set smoking schedule established.
- Record Review revealed the removal plan binder with printed sheets in large bold print of the smoking schedule for the designated smoking area in courtyard and downstairs courtyard outside of Magnolia. Smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total of five (5) smoking breaks.
- Record review of the AD HOC QAPI Meeting Log revealed Medical Director was notified over the phone. Record review of the AD HOC QAPI Meeting Log for F835 confirmed all stated staff was present at the AD HOC QAPI Meeting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete care plans for oxygen therapy and dentures. Two residents had planned and provided services omitted from their comprehensive care plans. One resident with COPD had O2 therapy documented, but the care plan was delayed and did not include newly received dentures or current oral/dental status. Another resident with pneumonia and CHF had an active O2 order and was receiving oxygen, but oxygen was not included in the care plan.
Incomplete Care Plans for Hospice, Sensor Pad, and Oxygen Use: The facility failed to ensure care plans reflected key resident needs and behaviors for three residents. One resident’s plan did not include hospice services despite active hospice care and hospice aide visits. Another resident’s plan did not include use of a sensor pad even though he relied on it to call for help. A third resident’s plan did not reflect that he removed and reapplied his O2 cannula, although he stated he managed his O2 himself and an RN confirmed it.
A resident with multiple fall risk factors and several recent falls had a care plan that listed floor mats, but staff did not have the mats in place until later and could not locate corresponding orders in the EMR. The resident also received multiple high-risk meds, including a benzo, antidepressant, gabapentin, and opioid, yet the care plan did not address medication-related fall risk despite the resident’s falls and the meds’ known side effects.
A resident with PTSD had the diagnosis listed in the face sheet, physician visit, and quarterly MDS, but the care plan did not include PTSD or related interventions. The DON stated she did not see PTSD in the care plan and noted it was important to include the diagnosis so staff could document interventions such as avoiding triggers. Facility policy required person-centered trauma-informed care and individualized interventions, preferences, and triggers to be documented in the care plan.
The facility failed to include EBP instructions in the care plans of residents with a G-tube, a chronic wound, and an indwelling catheter. Observations showed PPE carts and signs directing staff to use gowns and gloves for direct care, but one care plan did not address EBP for G-tube or personal care, another lacked EBP guidance for wound care, and a third lacked EBP guidance for catheter care. The DON stated EBP should be care planned when required and staff were expected to follow the care plan and PPE guidance.
Care plans were inaccurate for multiple residents because current needs were omitted and resolved or discontinued issues remained listed. A resident with a pressure injury had no pressure injury care plan, another resident’s healed venous wound remained on the plan, one resident’s AC therapy and thrush were not updated, a resident on AC medication had no related focus area, and a resident with impaired vision had no vision-related care plan entries.
Incomplete care plans for oxygen therapy and dentures
Penalty
Summary
The facility failed to ensure that all planned and provided services were included in the comprehensive care plans for 2 of 19 sampled residents, Resident 34 and Resident 9. For Resident 34, the electronic health record showed a readmission with diagnoses including COPD, diabetes, and anxiety disorder, and the resident was able to make needs known. The quarterly MDS showed the resident received O2 therapy and had broken or loosely fitting full or partial dentures. During interview, Resident 34 stated they had dentures, but the bottom dentures did not fit right and had been taken a few weeks earlier to be fixed and had not been returned. Records also showed new dentures were received on 04/06/2026, but the focused care plans for ADL self-care performance deficit and oral/dental health problems did not include dentures. The focused care plan for COPD showed the resident was on O2 therapy, but it was not initiated until 06/15/2026, despite the resident having an order for continuous O2 at 2 L/minute via NC starting 05/27/2026. For Resident 9, the electronic health record showed admission with diagnoses of pneumonia, diabetes, and CHF, and the resident was able to make needs known. The record showed a provider order for O2 at 2 liters per minute with a start date of 11/19/2025, and the MDS showed the resident was receiving oxygen during the stay. However, the current plan of care reviewed on 06/17/2026 did not include oxygen. Staff stated the resident should have had a care plan in place for oxygen, and the DNS stated it was the expectation that residents with CHF who received oxygen had it included in their comprehensive care plan, but this did not happen for Resident 9.
Incomplete Care Plans for Hospice, Sensor Pad, and Oxygen Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that reflected identified resident needs for three residents. The report states that the care plan for Resident #7 did not reflect hospice services, the care plan for Resident #44 did not reflect use of a sensor pad, and the care plan for Resident #81 did not reflect that he took off and put on his oxygen cannula. The facility policy required a comprehensive care plan with measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #7 was a female with diagnoses including cerebral infarction and malignant neoplasm of the colon. Her MDS reflected severe cognitive impairment, moderate assistance with ADLs, and hospice care. Her care plan dated 02/17/2026 did not include hospice services, even though active orders reflected admission to hospice for CVA starting 02/04/2026. During observation, she was in bed with a hospice aide applying lotion to her legs, and she stated hospice came and gave her baths and showers. Resident #44 was a male with Parkinsonism, muscle spasms, and seizures. His MDS reflected moderate cognitive impairment, substantial assistance to total dependence for most ADLs, use of a manual wheelchair, and maximal assistance for locomotion and mobility. His care plan dated 05/01/2026 included an ADL self-care deficit and an intervention to encourage use of the call bell, but it did not reflect his sensor pad. During observation, his sensor pad was lying on his bed while he was seated in a tall wheelchair in his room, and he stated he would use the sensor pad to call for help if needed. Resident #81 had acute and chronic respiratory failure with hypoxia and was noted to have moderate cognitive impairment and need for minimal to moderate assistance with ADLs. His care plan addressed oxygen therapy and nebulizer use, but it did not reflect that he removed and reapplied his oxygen cannula. During observation, oxygen equipment was present near his bed, and he stated he used oxygen at night, put it on and took it off himself, and turned the concentrator on and off; an RN confirmed he could remove and replace his nasal cannula.
Incomplete Fall Prevention Care Planning
Penalty
Summary
The facility failed to develop, implement, and revise the comprehensive person-centered care plan for one resident with a history of falls. The resident was admitted with diagnoses including osteoarthritis, spinal stenosis, neurosarcoidosis, obstructive sleep apnea, macular degeneration, and restless leg syndrome. The resident’s care plan, initiated after a fall risk assessment, identified the resident as at risk for falls and fall-related injury due to generalized weakness, limited endurance, impaired balance, unsteady gait, history of falls, and decreased vision, and it included floor mats to the sides of the bed per orders. Record review showed the resident experienced three falls over a little more than one month, including one fall that resulted in shoulder pain and prompted diagnostic imaging. During interview, the resident stated that fall mats were not currently in place but would be liked. The ADON stated fall mats were identified in the care plan but could not locate fall mat orders in the EMR. A CNA stated staff were told by the DON or unit nurse when to place the mats and that staff first started using fall mats on the night of 6/10/26. The Administrator stated the facility was aware of the resident’s increased falls, had discussed the falls with the resident, and had recently ordered additional mats because the facility did not have enough. The resident’s record also showed use of multiple high-risk medications with fall-related side effects, including diazepam, escitalopram, gabapentin, and oxycodone. Review of the care plan showed no interventions addressing medication-related fall risk despite the resident’s falls and the presence of these medications. Facility policies stated that staff, with physician input, would implement a resident-centered fall prevention plan based on specific risk factors and modify care plans when goals and objectives were not achieved.
Missing PTSD Diagnosis and Interventions in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #4 that included his PTSD diagnosis and related interventions. Record review showed the resident was admitted and later re-admitted with PTSD, and his physician visit and quarterly MDS also listed PTSD as an active diagnosis. However, the care plan dated 4/22/206 did not include PTSD. During interview on 6/10/2026 at 4:48 PM, the DON stated she did not see PTSD in Resident #4’s care plans and said it was important to include the diagnosis so staff could show interventions such as avoiding certain triggers. The facility’s PTSD Management in Long-Term Care policy stated that residents with PTSD should receive person-centered trauma-informed care and that individualized interventions and resident preferences and triggers should be documented. The facility’s Care Plan policy stated care plans should include identified problems and needs, measurable goals and expected outcomes, and interventions and services to be provided.
Failure to Include EBP in Resident Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that included enhanced barrier precautions (EBP) for 3 of 5 residents reviewed who were identified to be on EBP. One resident had intact cognition, required moderate assistance with bathing, had a G-tube, and diagnoses included Parkinson’s disease, narcolepsy, anxiety, and dysphagia. That resident’s care plan addressed incontinence and G-tube care, but did not include instructions for EBP when staff provided G-tube care or personal care. The resident’s active medication orders directed that numerous medications be crushed and administered through the feeding tube, and a sign outside the room directed staff to wear a gown and gloves for direct care, including G-tube care. The DON stated G-tube care was one instance when EBP should be used and that EBP should be care planned when required. A second resident had severe cognitive impairment, obesity, an unstageable pressure ulcer, and moisture associated skin damage. The resident’s wound assessment identified a stable coccyx ulcer, but the care plan lacked any guidance for EBP use. During observation, an isolation cart outside the room had a contact precaution sign for the roommate and did not address whether the resident was on EBP; the cart contained gloves, masks, and eye/face protection, but no gowns. A nursing assistant stated gowns and gloves were not needed for care of that resident and entered the room without wearing either. A third resident had moderate cognition, an indwelling catheter, renal insufficiency, and urinary retention. The care plan included catheter change, daily catheter care, and infection monitoring, but did not include EBP instructions related to the catheter. Observation showed a cart outside the room with gowns and gloves and a sign identifying the resident as on EBP with instructions to wear gowns and gloves for direct care, including catheter care. The DON stated staff were expected to follow resident care plans and the facility policy regarding PPE for EBP.
Care plans missing current needs and unresolved conditions
Penalty
Summary
Care plans were not accurate for 5 of 22 sampled residents because needed care was not included and some resolved or discontinued conditions were not removed. The deficiency involved Residents 7, 5, 27, 4, and 98, and was identified through interview and record review. The report cited WAC 388-97-1020(1)(2)(a)(b). Resident 7 was admitted with stroke and right-sided weakness and had a pressure injury to the bottom. The resident stated their bottom was very sore and was observed lying flat on their back with heels on the mattress. The EHR showed no actual pressure injury care plan, even though a weekly skin assessment documented a stage two pressure ulcer to the bottom. Staff stated the resident should have had a pressure injury care plan but did not. Resident 5 had a focused skin integrity care plan that identified a chronic venous leg ulcer/wound on the right lower leg, but later EHR review showed no documentation of a current venous wound and the MDS showed zero venous ulcers/wounds. Resident 27 had a care plan that still listed anticoagulant therapy and thrush, but the EHR showed no current anticoagulant therapy or thrush infection, and staff stated both conditions should have been updated or resolved in the care plan. Resident 4 received an anticoagulant medication, but the plan of care had no focus area for anticoagulant use. Resident 98 had impaired vision noted on the MDS and stated they could not see well and needed to see the eye doctor, but the care plan had no problem, goal, or intervention related to visual deficit or glasses use.
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