Failure to Develop Comprehensive Care Plans for Residents
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents, R21 and R17, as required. R21, who had intact cognition and required limited assistance with mobility and personal care, did not have a comprehensive care plan documented in the electronic health record. Interviews with staff revealed that there was a lack of clear direction for R21's care, and the Minimum Data Set Coordinator (MDSC) confirmed that R21 was not on the list for care plan review, indicating a lack of an audit system to ensure care plans were completed. R17, who was moderately cognitively impaired and required extensive assistance with activities of daily living, had a care plan that was not updated with recommendations from occupational therapy and dietary. Observations showed that R17 was not receiving the prescribed dietary supplements and was not following occupational therapy guidelines, such as avoiding crossing legs. The registered dietician and dietary manager confirmed these discrepancies, and the MDSC acknowledged the care plan did not include the necessary updates. The Director of Nursing confirmed the findings and stated that care plans should be completed and updated as required.
Penalty
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A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A resident with dementia, dysphagia, DM, CHF, CKD, COPD, GERD, and a history of protein-calorie malnutrition was care planned for total assist with meals due to risk for weight loss and malnutrition, but staff documentation and interviews showed that CNAs frequently provided only set up, supervision, or independent-level assistance instead of feeding the resident. CNA charting over two months reflected mostly set up or independent meal assistance, with variable intake percentages, while staff reported relying on a unit "feed list" (with names in bold for residents to be fed) rather than the written care plan to determine the level of meal assistance. CNAs acknowledged they were unsure what the care plan specified about feeding and described a gradual shift from supervision to total feeding as the resident declined, demonstrating a failure to consistently follow the comprehensive person-centered care plan for meal assistance.
Staff failed to implement a care-planned pain management regimen for a post-surgical resident and did not develop a care plan for a fluid restriction for another resident. One resident with a laminectomy and a surgical wound had physician orders and a care plan for Hydrocodone-Acetaminophen every 4 hours, yet multiple scheduled doses were not administered while staff documented pharmacy communication issues, despite an available in-house stock system for narcotics. Another resident with ICH, DM, and TIA, cognitively intact and requiring maximal assist for ADLs, had a physician order for a 1420 cc/day fluid restriction, but the care plan, MAR/TAR, and meal slips contained no fluid restriction monitoring, and the resident was unaware of any restriction, even though an LPN stated such an order should be on the care plan.
Facility staff failed to consistently implement a comprehensive care plan for a resident with dysphagia and severe cognitive impairment, including not obtaining weekly weights as care-planned and not reliably providing the ordered puree diet. Record review showed only two documented weights over about a month despite a weekly weight intervention. Observation of a lunch meal revealed chicken that was a mixture of mechanically altered and pureed textures, which the SLP deemed unsafe for this resident. A family member reported the resident had been given an inappropriate milkshake with solid mix-ins and had received incorrect meal trays on multiple occasions, demonstrating inconsistent adherence to the resident’s diet and nutritional care plan.
A resident with uropathy and an indwelling Foley catheter had a comprehensive care plan that included an intervention to maintain a catheter privacy bag. During hallway observation, the urine collection bag was seen hanging on the bed’s hallway side without a privacy bag in place. In an interview, an LPN unit manager confirmed that the comprehensive care plan serves as instructions for care and acknowledged that the catheter privacy bag intervention was not being followed. Facility administrative and clinical leadership were later informed of these findings.
A resident with hypotension related to ESRD had a comprehensive care plan directing staff to administer Midodrine as ordered and to monitor vital signs as ordered and as clinically indicated, but staff did not implement the care-planned intervention to give Midodrine per the physician’s orders. An LPN acknowledged that the care plan is meant to guide staff in meeting residents’ individual needs, and facility policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Follow Care Plan for Total Meal Assistance
Penalty
Summary
Facility staff failed to follow a comprehensive person-centered care plan for a resident who was care planned to receive total assistance with meals. The resident had multiple diagnoses including dementia, dysphagia, COPD, diabetes, protein-calorie malnutrition, congestive heart disease, chronic kidney disease, and GERD. The comprehensive care plan, initiated in late 2022 and revised in late 2025, identified the resident as being at risk for weight loss or malnutrition related to chronic disease and cognitive impairment, and included interventions such as encouragement to eat, recording meal intake, supplements as ordered, weights as ordered, and total assist for meals (revised 12/7/25). Despite this, the annual MDS assessment dated 11/19/25 documented the resident as requiring only set up or clean up assistance with meals and being able to feed self during the lookback period, and also noted a significant unplanned weight gain. Review of CNA documentation for December 2025 showed that the resident was consistently documented as needing only set up assistance (code 05) or being independent (code 06) for meals on all days except one evening meal, when the resident was documented as dependent. Across 93 meals in December, the resident’s intake was recorded mostly in the higher percentage ranges, with some meals at lower intake and two refusals. In January 2026, prior to the resident’s transfer to the hospital on 1/9/26, documentation reflected variable levels of assistance: independent for some shifts, set up or clean up assist for others, supervision for two shifts, and dependent for six shifts, with one refusal. Meal intake percentages in January ranged from 76–100% for most meals to 0–25% for several meals. Interviews with CNAs and the Unit Manager revealed that direct care staff relied on a unit “feed list” rather than the resident’s care plan to determine whether to feed the resident or provide only set up/supervision. CNA #1 and CNA #2 described the resident as initially independent or requiring supervision with meals, with staff setting up trays and checking back, and only later providing full feeding assistance as the resident’s condition declined. CNA #2 and CNA #3 both stated they did not know what the care plan said about feeding and followed the list instead. The Unit Manager confirmed the existence of a list indicating which residents should be fed (names in bold) versus set up and supervised, and believed the resident’s name was in bold at some point, but could not recall the timeframe. These interviews and documentation demonstrated that staff actions did not consistently align with the care-planned intervention of total assist for meals.
Failure to Implement Pain Management Orders and Omit Fluid Restriction from Care Plan
Penalty
Summary
Facility staff failed to implement a comprehensive care plan for pain management for one resident following admission from the emergency room. The resident had a surgical wound related to a laminectomy and was assessed on the admission MDS as having a surgical wound, receiving scheduled pain medication, and experiencing occasional pain. The care plan identified actual impaired skin to the lower back related to laminectomy and pain related to the surgical wound, with an intervention to treat pain per orders prior to treatment or turning. The ER discharge summary and physician orders specified Hydrocodone-Acetaminophen 5-325 mg by mouth every 4 hours for 5 days, with the facility order entered on 3/29/2024. However, the eMAR showed that multiple scheduled doses from the evening of 3/29/2024 through the afternoon of 3/30/2024 were not administered. Progress notes documented that pharmacy reported not receiving the faxed or e-scribed prescription, and nursing staff made repeated calls to the pharmacy and on-call provider, with instructions at one point to hold the medication until the provider could send a prescription. Later documentation indicated the facility was still waiting for pharmacy delivery while the physician was aware. Despite this, the DON confirmed that the facility maintained an in-house stock of Hydrocodone-Acetaminophen 5-325 mg tablets and that all nurses had access to this stock via a code from the pharmacy, with a witness required for narcotics. Multiple nurses, including an RN, a unit manager LPN, and another LPN, stated that urgent medications could be pulled from in-house stock or obtained stat from the pharmacy, and that this in-house system had been in place for several years. The facility’s own comprehensive care plan policy required implementation of all services identified in the assessment to meet residents’ needs and professional standards of quality. Facility staff also failed to develop a comprehensive care plan addressing fluid restriction monitoring for another resident. This resident was admitted with diagnoses including intracranial hemorrhage, diabetes mellitus, and transient ischemic attack, and was cognitively intact per a BIMS score of 13. The resident required maximal assistance for bed mobility, transfers, and hygiene, and had a physician’s order for a fluid restriction of 1420 cc per day. The comprehensive care plan in place focused on ADL self-care performance deficits related to impaired mobility and included an intervention to praise all efforts at self-care, but did not address the ordered fluid restriction. Review of the MAR/TAR for January and February and the resident’s meal slips showed no evidence of fluid restriction monitoring, and the resident reported not being aware of being on a fluid restriction. An LPN stated that fluid restriction monitoring would involve watching intake and acknowledged that such a restriction should be included on the care plan.
Failure to Implement Care-Planned Puree Diet and Weekly Weights
Penalty
Summary
Facility staff failed to consistently implement a person-centered comprehensive care plan for one resident with dysphagia, vascular dementia, stridor, and cerebral infarction. The resident’s admission MDS showed a BIMS score of 2/15, indicating severely impaired cognitive skills for daily decision making, and Section K documented a mechanically altered diet. The resident’s care plan identified risk for weight loss or malnutrition related to chronic disease, cognitive impairment, need for assistance with eating, and dysphagia requiring a puree diet, with an intervention for weekly weights initiated on 12/22/25. However, clinical record review revealed only two documented weights over approximately a one-month period, despite the weekly weight intervention, with weights recorded on 12/31/25 and 01/30/26. The facility also failed to consistently provide the correct diet texture as ordered and care planned. A provider order dated 12/19/25 specified a regular diet with dysphagia advanced texture and thin liquids, which was changed on 12/22/25 to a puree diet per hospital recommendations. On observation during a lunch meal, a CNA questioned the consistency of the resident’s chicken; the dietician stated the chicken needed more liquid, and the SLP determined the chicken was a mixture of mechanically altered and pureed and stated it would not be safe for this resident to eat. In a family interview, a family member reported concerns that the resident had not been receiving the correct diet, including being given a milkshake containing Oreo cookies and Reese’s Pieces on Super Bowl Sunday and receiving the wrong meal trays on three occasions. Facility administrative staff later terminated a CNA for providing the wrong texture milkshake. These findings demonstrated that the resident’s care-planned puree diet and weekly weights were not consistently implemented.
Failure to Follow Care Plan for Catheter Privacy Bag
Penalty
Summary
Facility staff failed to follow the comprehensive care plan for a resident with an indwelling Foley catheter by not maintaining a catheter privacy bag as care-planned. The resident had diagnoses including uropathy and an order for a 16 French Foley catheter with a 10 cc balloon due to obstructive and reflux uropathy. On the most recent MDS quarterly assessment, the resident was coded as having an indwelling catheter and scored 15/15 on the BIMS, indicating cognitive intactness for daily decision-making. The comprehensive care plan, initiated on 05/05/2025 and revised on 09/08/2025, identified a catheter focus and included an intervention to maintain a catheter privacy bag. During an observation from the facility hallway on 02/03/2026 at approximately 2:40 p.m., the resident’s catheter collection bag, containing urine, was seen hanging on the hallway side of the bed without a privacy bag in place. In a subsequent interview on 02/04/2026, the unit manager LPN stated that the purpose of a comprehensive care plan is to provide instructions for a resident’s care and, after reviewing the resident’s care plan, acknowledged that the intervention to maintain a catheter privacy bag was not being followed. Administrative staff, including the administrator, DON, regional director of clinical services, and assistant DON, were informed of these findings on 02/05/2026, and no additional information was provided before survey exit.
Failure to Implement Care Plan for Midodrine Administration
Penalty
Summary
Facility staff failed to implement the comprehensive, person-centered care plan for one of six sampled residents, Resident #5, related to the administration of the medication Midodrine for hypotension associated with end stage renal disease (ESRD). The comprehensive care plan dated 11/3/2025 identified a focus of hypotension related to ESRD and included interventions to give medications as ordered and to monitor vital signs as ordered and as clinically indicated. Surveyors determined that staff did not follow the care-planned intervention to administer Midodrine per the physician’s orders. In an interview, LPN #4 stated that the care plan is intended to guide staff on how to care for residents and their individual needs. The facility’s written policy on comprehensive, person-centered care plans states that a comprehensive care plan with measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs is to be developed and implemented for each resident. Administrative staff, including the administrator, director of nursing, and regional director of operations, were informed of these findings during the survey, and no additional information was provided by the facility prior to survey exit.
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