Failure to Update Care Plan After Hospice Discharge
Summary
The facility failed to revise and implement a person-centered comprehensive care plan for Resident 45 after the resident was discharged from hospice services. Despite the discharge occurring on November 16, 2024, the care plan was not updated to reflect this significant change in condition. Interviews with the License Vocational Nurse (LVN) and the Minimum Data Set Nurse (MDSN) revealed that the care plan should have been updated immediately to ensure proper communication and care for Resident 45. The LVN acknowledged receiving a verbal order from the hospice agency to discharge the resident and documented the conversation, but the care plan was not revised accordingly. Resident 45, who was admitted with diagnoses including hemiplegia, hypertension, anxiety, severe protein-caloric malnutrition, muscle weakness, and pain, was no longer receiving hospice services as of November 16, 2024. The Assistant Director of Nursing (ADON) confirmed that the care plan should have been updated by the licensed nurses to reflect the resident's current needs and condition. The facility's policy requires care plans to be reviewed and revised by the interdisciplinary team after each assessment and when changes in the resident's condition occur, which was not adhered to in this case.
Penalty
Resources
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A resident with Alzheimer’s disease, seizure disorder, and a knee contracture, who was severely cognitively impaired and dependent in all ADLs, had documented rehab recommendations for a semi‑reclining, slightly reclined high‑back wheelchair with specific trunk and leg positioning that were never added to the active care plan. The resident was later found on the floor in front of the same high‑back chair with a forehead hematoma and abrasion after being seated upright post‑meal, and a nurse reported not recalling a footrest in use. During survey observation, the resident was non‑responsive in bed while a reclined high‑back chair with footrest and board was present in the room, and the DON confirmed that the care plan did not include the rehab wheelchair positioning recommendations, showing the care plan was not revised after assessment findings.
Two residents’ care plans were not revised to match their current treatment orders. One cognitively impaired resident with paralysis and edema had a care plan stating they were receiving diuretic therapy, but the MAR showed no diuretics were being administered. Another cognitively impaired resident with hemiparesis, an indwelling catheter, a feeding tube, and a Stage 3 pressure ulcer had a care plan indicating ongoing IV medications for an ESBL urinary infection, while the clinical record contained no evidence of IV therapy. The DON and NHA acknowledged that the care plans should have been updated when these treatments were discontinued.
A resident with osteomyelitis, type II DM, and dementia had an existing care plan identifying fall risk and a goal to remain free from fall-related injury. After the resident experienced a fall that led to hospital transfer, staff implemented new fall interventions such as bedside reorientation and visual cues to use the call light, but these interventions were not added to the written care plan until weeks later. The DON confirmed the care plan did not reflect the current fall interventions during this period, contrary to the facility’s care planning policy.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
Surveyors found that the facility did not revise care plans to include new physician orders for two residents. One resident with a right leg fracture and edema had an order for a Tubi grip for edema management, but this intervention was not added to the care plan or TAR, and the resident was repeatedly observed without the Tubi grip in place despite reporting ongoing swelling. Another resident with COPD, depression, and cardiomegaly had a new order for continuous O2 at 3 LPM via NC, but the care plan still listed only older O2 orders at different settings and was not updated to reflect the current prescription.
Failure to Update Care Plan With Rehab Wheelchair Positioning Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to include rehabilitation recommendations for appropriate wheelchair positioning. The resident had Alzheimer’s disease, seizure disorder, and a knee contracture, with severely impaired cognition and dependence in all ADLs per a quarterly MDS. A rehab screening documented a recommendation for a semi‑reclining wheelchair, slightly reclined high‑back with trunk positioned in midline, and feet resting on leg rest calf pads due to reduced knee extension ROM. However, these specific wheelchair positioning recommendations were not incorporated into the resident’s active care plan. Prior to the survey, the resident experienced an incident in which they were found lying prone on the floor in front of their wheelchair in a common living room area, with a hematoma and abrasion to the right frontal forehead area, after having been in the same high‑back chair later observed in their room. The nurse reported the chair had been in an upright position at the time of the fall and did not recall a footrest being present. During survey observation, the resident was seen in bed, non‑responsive to repositioning or medication administration, with the high‑back chair reclined at 45 degrees and a footrest and board present in the room. The DON confirmed that the rehab recommendations for wheelchair positioning were not reflected in the resident’s care plan, demonstrating that the care plan had not been reviewed and revised to include these needs.
Plan Of Correction
1. On 4/30/26 the care plan for R9 was updated to reflect the appropriate wheel chair positioning with use of high back wheel chair. No negative outcome resulted from deficient practice. 2. All residents who utilize a high back wheel chair have the potential to be affected. DON/ designee completed audit of all residents who use a high back wheel chair to ensure that the recommended use and positioning was reflected on the care plans. Where needed, care plans were updated. 3. To prevent the potential for reoccurrence, the NHA/designee re-educated the IDT team on timely completion of all interdisciplinary plans of care and revisions as indicated by the resident's needs, wishes, or change in condition. 4. To monitor and maintain ongoing compliance, the DON/designee will audit residents with high back wheel chairs x4 weeks, then monthly x2 to ensure their care plans reflect the use and appropriate positioning of the device. The results of the audit will be forwarded to the facility QAPI committee monthly for further review and recommendations as needed.
Failure to Update Care Plans to Reflect Discontinued Treatments
Penalty
Summary
The deficiency involves the facility’s failure to revise comprehensive care plans to reflect current treatment orders for two residents. For one resident with cognitive impairment, paralysis following a cerebral infarction, and dependence on staff for daily care, a quarterly MDS assessment documented ongoing needs and a care plan dated March 18, 2026, stated that the resident was receiving diuretic therapy for edema and that staff were to administer the diuretic as ordered. However, review of the April 2026 MAR showed that the resident was not receiving any diuretic medication during the survey period, indicating that the care plan was not updated when the diuretic was discontinued. For another cognitively impaired resident with hemiparesis/hemiplegia, limited range of motion, an indwelling urinary catheter, a feeding tube, and a Stage 3 pressure ulcer present on admission, the quarterly MDS assessment documented multiple complex care needs. A care plan dated March 24, 2026, indicated that this resident was receiving IV medications for an ESBL urinary infection. Review of the clinical record revealed no documentation that the resident was actually receiving IV medications at that time. The NHA confirmed that the care plan should have been revised to show that IV medications were no longer being administered.
Plan Of Correction
F 0657 Comprehensive care plans will be revised for Residents 18 and 43 to reflect current status of diuretic and intravenous medications. The Clinical and Clinical Reimbursement Consultants re-educated the Minimum Data Set (MDS) Coordinator, Interdisciplinary Team and Administrative Nurses (Director of Nursing, Assistant Director of Nursing, Staff Development/Infection Control Nurse Coordinator, and Nursing Supervisor) regarding care plan timing and revision to the comprehensive care plan, to reflect specific care, on May 14 and May 15, 2026. Director of Nursing and/or designee will educate all Licensed Nursing staff regarding updating and maintaining comprehensive care plans. An initial audit review will be completed for current in-house residents to assure revisions to the comprehensive care plans for diuretic and intravenous medication(s) were accurately reflected. The Director of Nursing and/or designee will complete random audits for revisions to the comprehensive person-centered care plan reflecting use of diuretic and intravenous medication(s) weekly for 4 weeks and then monthly for 2 weeks. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s comprehensive care plan was revised in a timely manner to reflect current fall interventions after a fall event. The resident was admitted with diagnoses including acute osteomyelitis of the right ankle and foot, type II diabetes, and dementia. A care plan dated 03/10/26 identified the resident as being at risk for fall-related injury and falls due to history and fear of falling, with a goal to remain free from injury related to falls. A nursing note dated 03/25/26 documented that the resident went to the hospital, without additional information. In an interview, the resident reported having a fall that required hospital transfer, though he did not specify the date. Further review of the care plan showed that specific fall interventions, including reorienting the resident at bedside and providing a visual cue to use the call light for assistance, were created on 04/09/26 and were related to the fall that occurred on 03/25/26. In an interview, the DON confirmed that these interventions, which were implemented immediately after the fall, were not added to the written care plan until 04/09/26, leaving the care plan not up to date until that date. The facility’s “Care Planning” policy required that every resident have a person-centered care plan developed and implemented based on the comprehensive assessment, with measurable objectives and time frames to meet identified needs, but the resident’s care plan was not revised promptly after the fall as required.
Plan Of Correction
1. Resident #86 had their fall care plan updated on 4/9/26 by the Director of Nursing to reflect current fall interventions. 2. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC an audit of falls for the past 30 days will be completed by the Director of Nursing or designee to ensure fall care plans reflect current fall interventions. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Fall Management Policy to include updating the care plan with new interventions as appropriate. This education will be completed on or before 5/13/26. 4. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will audit new admissions, readmissions and residents who experience a fall weekly for four weeks, beginning 5/14/26 to ensure fall care plans reflect current fall interventions. Discrepancies noted during audits will be corrected with care plans updated to reflect current fall interventions. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Update Care Plans for New Edema and Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to revise resident care plans to reflect current physician orders and resident needs, as required by its Resident Care Plan Revisions policy. The policy, revised on 9/3/25, states that updates to the care plan will occur as needed based on the resident’s response to interventions or changes in condition. For one resident with a history including a right tibia fracture and anxiety, a physician order dated 3/6/26 directed edema management of the right lower leg with application of a Tubi grip in the morning and removal in the evening. On multiple observations on 3/30/26 and 4/2/26, the resident was seen sitting in her room without the ordered Tubi grip in place, and during an interview the resident reported that her right lower leg had been swollen for a while. Review of the resident’s care plan and Treatment Administration Record (TAR) on 4/2/26 showed no documentation of the Tubi grip order. A second resident, with diagnoses including COPD, depression, and cardiomegaly, had a physician order dated 3/9/26 for oxygen at 3 LPM continuously via nasal cannula using an oxygen concentrator and/or tank. Review of this resident’s care plan on 4/1/26 showed only prior oxygen interventions: oxygen via nasal prongs at 0–4 L PRN to maintain saturation at 90% or greater, initiated 2/10/25, and oxygen at 2 L/min continuously via nasal cannula, initiated 6/24/25. The more recent continuous 3 LPM oxygen order was not reflected in the care plan. In both cases, the CNO acknowledged that the residents’ care plans (and, for the first resident, the TAR) should have been updated to include the current physician orders but had not been revised.
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