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:
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
A resident with paraplegia and moderate cognitive impairment, dependent on staff for transfers and using a manual wheelchair, was observed alone in a courtyard sitting in direct sunlight without a drink, contrary to his care plan interventions. The resident reported being routinely left outside unattended, without a way to call staff, and not being offered sunscreen when outside. The care plan called for encouraging fluids, supplying and assisting with sunscreen, and offering assistance in and out of doors, but an RN acknowledged there was no monitoring system or set check times while the resident was outside and that there was no physician order for sunscreen available to offer.
A resident with dementia, anxiety, repeated falls, and dependence on staff for ADLs did not have dentures and glasses addressed in the comprehensive care plan, despite documentation of very impaired cognition, communication difficulties, poor intake with chewing problems, and inconsistent eye contact. Existing nutrition and ADL care plans directed staff to assist with eating, dressing, personal care, and grooming but omitted any mention of dentures, glasses, or the resident’s preferences and responses to using them. Observations found the resident seated in a Broda chair without dentures or glasses, while staff reported these items were in the room and that the resident’s willingness to use them varied, and nursing leadership acknowledged the care plan should have reflected their use and refusals.
A resident with leukemia, dementia, anxiety, and depression was observed in bed using a transfer pole and a 1/4 bed rail, but these assistive devices were not documented in the resident’s comprehensive care plan. Record review confirmed the absence of any care plan addressing the transfer pole or 1/4 bed rail, and the CRN acknowledged that a care plan for these devices should have been in place.
A resident with multiple diagnoses, including chronic PTSD and joint replacement surgery aftercare, did not have their PTSD addressed in the comprehensive person-centered care plan, despite facility policy requiring that all individual conditions and needs be reflected with measurable goals and interventions. Review of the care plan showed no focus, interventions, or tasks related to PTSD, and the CNO acknowledged that the PTSD diagnosis should have been included in the care plan but was not.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Implement Care Plan for Resident Outside in Courtyard
Penalty
Summary
The deficiency involves the facility’s failure to implement an existing care plan for a resident who liked to go outside in an unsecured courtyard area. During an observation, the resident was seen alone in his wheelchair in direct sunlight without a drink. In an interview shortly afterward, the resident reported that staff always left him outside unattended, that he had no way to notify staff when he was ready to return indoors, that he had not been offered sunscreen, and that he was ready to go back inside. The resident’s diagnoses included paraplegia, and his most recent Quarterly MDS showed he was moderately cognitively impaired, dependent on staff for transfers, and used a manual wheelchair for mobility. The resident’s care plan, in place since 2018, documented that he liked to go outside in an unsecured area, was not considered an elopement risk, had a BIMS score of 13, and had been educated to notify staff when outside and to remain on the sidewalk. Care plan interventions included encouraging the resident to have a drink of choice when outside, supplying sunscreen and assisting with its application when appropriate, and offering assistance in and out of doors. An RN stated there was no monitoring system or set time intervals for checking on the resident while he was outside unattended, and that staff often only told him a time limit for being outside. The RN also noted the resident was not wearing sunscreen because he often refused it previously, and the physician’s orders did not include an order for sunscreen to be available to offer. The facility’s Comprehensive Care Plan policy required periodic review and revision of care plan problems, goals, and interventions following each OBRA MDS assessment.
Failure to Include Dentures and Glasses in Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, individualized care plan addressing a resident’s dentures and glasses. The resident had dementia with severely impaired cognition, anxiety disorder, repeated falls, and required staff assistance with oral care, toileting, bathing, dressing, footwear, and personal hygiene. The MDS and CAAs documented that the resident was very cognitively impaired, needed staff to anticipate his needs, and had communication difficulties, including missing or not understanding what was said. Existing care plans for nutrition and ADLs directed staff to provide verbal cues and assistance with eating, dressing, personal care, and grooming, but did not identify that the resident used dentures or glasses, nor did they include his preferences or responses to using these items. Facility records showed that the resident’s bottom dentures had previously broken after he placed them in his overall pocket and they fell out when staff removed his overalls. A dietitian note documented that the resident had dentures and reported difficulty chewing tougher meats, and a social services note documented that he did not always exhibit good eye contact during conversation. During observation, the resident was seated in a Broda chair near the television without his dentures or glasses and appeared restless and fidgeting. Social services staff confirmed that the dentures and glasses were in the resident’s room and that whether he wore them depended on his mood. Administrative nursing staff acknowledged that the care plan should have reflected that the resident had dentures and glasses and that he sometimes refused to wear them, but this information was not included in the care plan despite the facility’s use of the RAI process to develop individualized care plans.
Care Plan Omission for Resident Assistive Bed Devices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a resident’s comprehensive, person-centered care plan accurately reflected the use of assistive devices. One resident, admitted with multiple diagnoses including leukemia, dementia, anxiety, and depression, was observed in bed with a transfer pole on the left side of the bed and a 1/4 bed rail on the right side. Review of the resident’s care plan showed no documentation of the transfer pole or the 1/4 bed rail. In a subsequent interview, the CRN confirmed that there was no care plan implemented related to the 1/4 bed rail and transfer pole and acknowledged that there should have been. This lack of documentation and care planning for the assistive devices constituted the cited failure and had the potential to result in unmet care needs and increased risk to resident safety, as noted in the survey findings.
Failure to Care Plan for Resident’s PTSD Diagnosis
Penalty
Summary
Surveyors found that the facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident’s diagnosed Post-Traumatic Stress Disorder (PTSD). The facility’s policy on Comprehensive Care Plan and Conferences, dated 9/3/25, required that care plans reflect residents’ individual conditions, risks, needs, behaviors, cultural values, and preferences, and include measurable goals, appropriate interventions, and realistic timeframes. Resident #13 was initially admitted and later readmitted with multiple diagnoses, including chronic PTSD and joint replacement surgery aftercare, and the medical record dated 3/3/26 documented a diagnosis of chronic PTSD. However, on 3/31/26 at 2:09 PM, review of the resident’s care plan showed no focus, interventions, or tasks addressing the PTSD diagnosis. On 4/1/26 at 12:47 PM, the CNO confirmed that the resident’s PTSD diagnosis should have been care planned and had not been, demonstrating noncompliance with the facility’s care planning policy.
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