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:
Failure to Include Bipolar Disorder and Anxiety in Care Plan: A resident with bipolar disorder, anxiety, depression, and dementia had psychiatry notes documenting ongoing symptoms and medication management, but the care plan did not include focus areas for bipolar disorder or anxiety. The MDS coordinator confirmed these diagnoses were not included in the care plan.
Missing behavior and side effect monitoring for psychotropic medications: A resident with dementia, psychotic disorder, anxiety, and depression, another resident with traumatic brain injury and schizoaffective disorder, and a third resident receiving multiple psychotropics had no documented behavior monitoring or side effect assessments to support ongoing use of the medications. Staff confirmed missing monitoring orders and records, and the DON could not provide documentation showing routine monitoring of behaviors, symptoms, or AIMS follow-up after dose increases.
Failure to care plan an external catheter urinary wicking system: A resident with anxiety, chronic pain, scoliosis, and end stage HF was admitted cognitively intact but dependent for toileting and personal hygiene and always incontinent. His care plan addressed incontinence care, but it did not include the external catheter system, who would reapply it, or when the collection canister would be emptied. The resident said he needed help with setup and reapplication, urine containers were observed on the floor with one full of dark yellow urine, and the DON stated the system should have been addressed on the care plan.
Incomplete and Outdated Person-Centered Care Plans: A resident’s care plan did not include full code status even though the chart and orders documented full code, and another resident’s care plan was not revised after recent behaviors led to a psych assessment documenting instability and directing redirection. The records showed significant medical and cognitive diagnoses, but the care plans did not fully reflect the residents’ current needs and status.
The facility failed to develop and implement complete care plans for two residents. One resident on dialysis had a care plan for ordered diet and meal intake monitoring, but multiple meal percentages were not documented after dialysis meals. Another resident with a suprapubic catheter was observed with an exposed, uncapped attachment nozzle, and the care plan did not include the resident’s self-care of the catheter. Staff and the DON confirmed the resident ate after dialysis and that the catheter tip should be covered when switched.
Care Plan Lacked Dialysis-Specific Information: A resident with acute kidney failure and renal failure was receiving hemodialysis 3 days per week, but the care plan did not include a dialysis-specific focus, goal, or interventions. RN and DON both confirmed the plan lacked basic details such as the nephrologist, dialysis location, access site care and monitoring, and the dialysis schedule.
Failure to Include Bipolar Disorder and Anxiety in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #11, who was reviewed for unnecessary medications. Review of the resident’s psychiatry note dated 04/29/26 documented diagnoses of bipolar disorder and other anxiety disorder, with the note stating that the resident had chronic episodes of depression and manic-like symptoms causing distress and functional impairment, and that mood stabilizer medication needed to be continued long term. A later psychiatry note dated 07/29/26 documented a past psychiatric history of bipolar disorder, depression, anxiety, and dementia, and stated that trazodone and Prozac were managing depression, donepezil was helping dementia, lamotrigine was assisting with bipolar disorder, and clonazepam was assisting with anxiety. Review of Resident #11’s care plan showed that it did not include a focus area for bipolar disorder or anxiety disorder. During interview on 08/12/26 at 1:25 PM, the Corporate MDS Coordinator stated that anxiety disorder and bipolar disorder were not included in the resident’s care plan and would be added. The facility’s policy on care plans stated that the comprehensive, person-centered care plan will describe the services to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.
Missing behavior and side effect monitoring for psychotropic medications
Penalty
Summary
The facility failed to ensure adequate monitoring for behaviors and side effects was documented for 3 of 6 residents reviewed. Resident #1 was admitted with diagnoses including dementia, seizure disorder, psychotic disorder, anxiety disorder, and depression, and had physician orders for multiple psychotropic medications, including olanzapine, haloperidol, and Ativan. No orders were found directing staff to monitor the resident for behaviors or side effects related to these medications. During review, staff confirmed that no such monitoring orders were present in the MAR or TAR, and the DON stated that behavioral and side effect monitoring orders had not been restarted after the resident returned from the hospital. Resident #11 was admitted with diagnoses including traumatic brain injury, schizoaffective disorder-bipolar type, major depressive disorder, and paraplegia, and had orders for Haldol, olanzapine, and divalproex sodium. The record did not contain an order for behavior monitoring or assessment of antipsychotic side effects, and there was no behavior monitoring flow record in the EMR. Although an AIMS assessment had been completed on 3/29/26 showing no abnormal movements, Haldol and divalproex doses were increased in May 2026 without a follow-up AIMS assessment for the dose changes or the scheduled quarterly assessment in June 2026. Resident #4 had orders for paroxetine, trazodone, divalproex, and risperidone, but the clinical record, including nursing documentation and behavior monitoring records, contained no documented behaviors, symptoms, frequency, severity, or other clinical indicators showing the continued need for the psychotropic medications. The DON was unable to provide documentation showing the resident's behaviors or symptoms were routinely monitored to evaluate effectiveness and continued clinical need, despite facility policy requiring behavior and side effect monitoring every shift using the electronic Behavior Monitoring Flow Record.
Failure to Care Plan External Catheter Urinary Wicking System
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was admitted with anxiety disorder, chronic pain syndrome, scoliosis, and end stage heart failure. The resident’s admission MDS, dated 06/08/2026, indicated a BIMS score of 13, that he was cognitively intact with little to no impairment, dependent on staff for toileting and personal hygiene, and always incontinent. The comprehensive care plan printed 08/10/2026 addressed bladder incontinence with interventions for incontinent care every 2 hours and moisture barrier application after each episode, but it did not include the resident’s external catheter urinary wicking system. The record did not identify who was responsible for reapplying the external catheter system, emptying the collection canister, or the frequency for those tasks. During interview and observation on 8/10/26, the resident stated he used the external catheter urinary wicking system, paid for the supplies himself, and needed assistance with setup and reapplication as needed. Two urine collection containers were observed on the floor next to the bed, and one was full of dark yellow urine. On 08/11/2026, the DON stated the hospice nurse applied the system weekly on Mondays, there were no orders or documentation for it being changed, and the system should have been addressed on the care plan to ensure care and services were provided on admission. During a later observation, the resident said the bag had been off since yesterday, then said it had just come off, and the DON and Regional Nurse applied the external catheter urinary wicking system after completing care.
Incomplete and Outdated Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, including measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs. For one resident, the record showed admission with diagnoses including complete traumatic amputation of the right foot, diabetes II, and cognitive communications deficit, and the admission record and physician orders documented full code status. The resident’s MDS reflected a BIMS score of 13/15 and wheelchair use, but the care plan did not include the resident’s full code status. For another resident, the record showed diagnoses including pelvic fracture, major depressive disorder, Alzheimer’s disease, dementia, anxiety disorder, and psychotic disorder, with a quarterly MDS documenting a BIMS score of 00 and no behavioral symptoms. The care plan included a potential for physical aggression related to dementia/confusion and a note about antidepressant use related to depression, but nursing staff did not review and revise the comprehensive person-centered care plan after recent behaviors prompted a psychiatric assessment that documented the resident as unstable and directed use of redirection. The DON stated care plans should be updated with changes as they happen, new orders, and quarterly updates.
Incomplete care planning and documentation for dialysis nutrition and catheter self-care
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #6 related to dialysis and meal intake documentation. Resident #6’s care plan, initiated on 5/21/2026, included interventions to provide and serve diet as ordered and to monitor intake and record it every meal. However, the Task ADL Eating and Meal Percentage record did not document meal intake percentages for 7/16/2026, 7/17/2026, 7/18/2026, 7/23/2026, 7/25/2026, 7/30/2026, 8/1/2026, 8/3/2026, 8/4/2026, and 8/6/2026. The physician order dated 5/20/2026 specified a renal diet, regular texture, regular/thin liquids, and a 1000 ml fluid restriction. Staff stated that after dialysis the resident returned to the facility for lunch and that meal intake should be recorded in PointClickCare, and the DON stated the resident normally received a chef salad or new tray after dialysis and that staff should record what was given and what was eaten. The facility also failed to include Resident #18’s self-care of a suprapubic catheter in the care plan initiated on 06/07/2026. During observation on 08/09/2026, the resident’s Foley bag was hanging from the bedside frame and the attachment nozzle was exposed and lying on the bed. Staff stated the resident switches to the leg bag himself and that the tip should be covered. The resident stated he wears the larger bag at night and puts the leg bag on in the morning himself, and the ADON/Infection Control Nurse stated that when a new leg bag is opened it comes with a blue cap and it needs to be covered when he switches it and leaves it on the bed. The MDS for 06/07/2026 documented an indwelling catheter Foley, and the physician order read suprapubic catheter care every shift.
Care Plan Lacked Dialysis-Specific Information
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and maintained for a resident with kidney failure who was receiving hemodialysis. R1's admission MDS dated [DATE] indicated she was cognitively intact, required minimal to moderate assistance with activities of daily living, and had diagnoses of acute kidney failure and renal failure. R1's EMAR showed an order for dialysis every Tuesday, Thursday, and Saturday, but her care plan did not include a focus, goal, or intervention specific to dialysis. During interview, RN-A confirmed R1 received dialysis 3 days per week and stated the care plan did not contain information about R1's nephrologist, where she received dialysis treatments, or how to monitor or care for the dialysis site. RN-A stated she would expect basic information related to dialysis. The DON also confirmed the care plan lacked a focus, goal, and intervention for R1's dialysis treatment and stated she expected care plans for residents receiving dialysis to include information such as access site care and monitoring, nutritional guidelines or restrictions, and the dialysis schedule.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.