Care Plan Deficiencies in Resident Participation and Documentation
Summary
The facility failed to ensure the participation of residents in the care planning process and did not adequately review and revise care plans for several residents. Resident 4 was not invited to care plan meetings, as confirmed by both the resident and the Nursing Home Administrator (NHA). Despite having multiple care conferences, there was no documentation of Resident 4's attendance or invitation, which is against the facility's policy that supports resident participation in care planning. Resident 28's care plan did not include documentation of a skin rash or interventions for its treatment, despite the resident having a rash for about six months and receiving treatment for it. Additionally, Resident 28 expressed a preference for wearing a bra, which was not addressed in the care plan. The NHA acknowledged that the care plan was not updated upon the resident's re-admission after a hospital discharge, leading to missing personalized care information. Resident 37 also had a skin rash that was not documented in their care plan, despite having physician orders for treatment. Similarly, Resident 58's care plan lacked documentation of antipsychotic medication use and the target behaviors it was intended to manage. The Director of Nursing (DON) confirmed that these omissions were not in line with the facility's expectations for care plan documentation.
Plan Of Correction
R4 unable to retroactively correct care plan. R4 was recently offered to participate in the care planning process and declined on 2/19/25 invited by the Activities Director, documented on clinical record of resident's choice to decline. R4 acknowledged understanding of residents right to participate in the care planning process. R28 unable to retroactively correct clinical record of the presence of the rash, it is confirmed the rash was resolved. R28 care plan was reviewed and updated to reflect all care areas specific to the resident preferences, such as wearing a bra daily. Section V of the MDS care area assessment summary for R28 was also updated for assistance with eating, oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, transfers, and mobility, along with preference of importance to choose clothing. R28's care plan specifics for ADL self-care performance also reviewed for additional interventions and updated. R37 care plan for rash was updated on 2/6/25 for the treatment of the rash. R58 care plan was updated on 2/17/25 to reflect the antipsychotic medication was being utilized to manage residents identified targeted behaviors and on 2/5/25 it was indicated on the R58's care plan that it was updated to reflect antipsychotic use. R4, R28, R37 and R58 currently reside at the facility and no adverse effects related to practice. The facility has determined that all residents have the potential to be affected by this deficient practice. The DON, Shift Supervisors, Social Services, Activities Director and MDS Coordinator will audit all care plans to ensure the comprehensive care plans are being updated or new care plans completed for all residents including readmissions from hospital to reflect individual preferences and Resident-specific ADL information to include interventions by March 14, 2025. To prevent other residents from being affected the DON will re-educate the Social Services and Activities Director, Activities Director and Shift Nurse Supervisors by March 14, 2025 on the requirements and policy of the Comprehensive Care Plan and quarterly review assessments, as well as compliance with the Care Plan Revisions. Additional training to include residents right to be invited to Comprehensive Care plans and document that the invite was offered or refused, along with documentation that resident understands and acknowledges their rights to attend care plan meetings. The DON will also educate on directives of physician orders, documenting the identification of any medical concerns or progress along with interventions and treatment follow up for residents. The DON and NHA will also in-service the IDT Team on communication of any new information or updates in the daily standup and clinical meetings to include, change of condition or significant change to be updated in the resident's care plan. An audit will be conducted by the DON, Activities and/or Social Services Director to ensure comprehensive care plans and assessments are completed timely, updated/revised for all residents weekly x 4 then monthly for 2 months, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Care plan omissions were identified for two residents. One resident’s care plan did not include multiple documented diagnoses, including UTI, bleeding hemorrhoids, TBI, pneumonia, CKD, and diverticulitis, despite severe cognitive impairment. Another resident’s care plan did not include a physician order for biannual valproic acid level testing and monitoring for side effects, and the DON and MDS Coordinator stated these items should have been included.
Missed Quarterly Care Conference and Resident Participation: A resident who was cognitively intact and had HTN, arthritis, and schizophrenia did not have documented routine care conferences at the expected quarterly interval. The EMR showed care conferences were documented, but there was no evidence of one between two documented meetings, and the resident stated she had not been invited to any care meetings over the past year. The LSW and Admin both confirmed the lack of documentation and stated residents should be included when able.
A resident with cerebral palsy and depressive disorder had conflicting code status documentation in the medical record: the emergency care document showed full code, while the care plan listed DNR and no CPR. The DON stated the care plan was completed in error and should have been revised but had not been.
Missed Care Conference Participation: A resident with intact cognition was not given the opportunity to attend and participate in a care conference. Staff confirmed care conferences were expected after MDS assessments and significant changes, but the resident’s record showed no conference documented for several months, and the family member reported the last conference had been months earlier.
A resident with dementia, bipolar disorder, and HF was on hospice status, but the care plan did not identify the terminal illness as a focus area or include hospice/end-of-life interventions. The care plan only referenced hospice in limited areas such as ADL care, psychosocial support, activities, and anti-anxiety medication related to end of life. The DNS acknowledged the care plan was not revised to reflect the resident’s hospice status.
Care plans were not updated to reflect changed resident conditions, preferences, and interventions. One resident's plan still showed hospice and wound-based EBP after hospice ended and the wound healed, another still listed Influenza A after the illness had resolved, and a third did not include behavior interventions such as a door chime and bookshelf sticker or updated dining preferences. Two residents with family-requested cameras also had care plans that omitted the camera use, rationale, and related monitoring details.
Care Plan Omissions for Resident Diagnoses and Valproic Acid Monitoring
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for 2 of 32 residents reviewed. Resident #1 was admitted with diagnoses including frequent urinary tract infections, bleeding hemorrhoids, traumatic brain injury, pneumonia, chronic kidney disease, and diverticulitis, and the quarterly MDS showed a BIMS score of 7 indicating severe cognitive impairment. The resident’s care plan, revised 03/05/2026, did not include those diagnoses even though they were part of the resident’s documented medical history. Resident #8 was admitted with diagnoses including unspecified dementia, type 2 diabetes mellitus, and heart failure, and the quarterly MDS showed a BIMS score of 6 indicating severe cognitive impairment. The resident’s order summary included a physician order dated 01/23/2025 for valproic acid level testing every 6 months in October and April, but the care plan, revised 05/14/2026, did not include that order. During interviews, the DON and MDS Coordinator stated that both residents’ omitted diagnoses and the valproic acid monitoring order should have been included in the care plans, and the MDS Coordinator identified the omission as an oversight.
Missed Quarterly Care Conference and Resident Participation
Penalty
Summary
The facility failed to provide routine care conferences to allow resident participation for one resident who was reviewed for care conferences. The resident’s quarterly MDS assessment indicated admission to the facility, cognitive intactness, and diagnoses of high blood pressure, arthritis, and schizophrenia. The resident’s EMR showed care conferences were documented on 5/2/25, 10/7/25, 12/30/25, and 3/28/26, but there was no evidence of a care conference between 5/2/25 and 10/7/25. During interview, the resident stated she understood what care conferences were but had not been invited to any type of care meeting over the past year. The LSW stated care conferences should occur at admission, then every three months and/or with a significant change of condition, and that she was responsible for scheduling and documenting them in the EMR. The LSW could not provide documentation of a care conference between 5/2/25 and 10/7/25 and stated, "If it isn't documented it didn't happen." The Administrator confirmed care conferences were expected quarterly and should include residents if able or their representative, and also confirmed there was no documentation of a care conference for the resident during that interval. The facility policy stated residents and their designated responsible party are invited to attend the initial care planning conference and sequential conferences, including annual and significant change conferences.
Care Plan Not Updated to Match Current Code Status
Penalty
Summary
The facility failed to ensure a resident’s care plan was revised to reflect the resident’s current code status. The facility’s Care Plan policy stated that care plans would be reviewed quarterly, annually, and with a change of status to ensure they remained current. Resident #4 was admitted with multiple diagnoses including cerebral palsy and depressive disorder. The resident’s medical record contained a Plan for Emergency Care and Intensity of Treatment document showing full code status, while the resident’s care plan documented DNR status and no CPR. The DON stated that the care plan had been completed in error and should have been revised but had not been.
Missed Care Conference Participation
Penalty
Summary
The facility failed to provide R10 the opportunity to attend and participate in a care conference. R10’s quarterly MDS assessment dated 5/25/26 identified intact cognition and no hallucinations, delusions, rejection of care, or behaviors. During an interview on 6/1/26, R10 stated she had not had a care conference recently and said the last one was more than 3 months ago. Review of the record showed R10’s last documented Social Service Conference was on 1/16/26, and progress notes from 1/30/26 through 6/3/26 did not show any care conference held or scheduled. Staff interviews confirmed care conferences were expected to occur quarterly, after significant changes, and following MDS assessments, but R10’s quarterly and significant change MDS assessments were not followed by a documented conference. R10’s family member stated they typically attended care conferences, and the social services staff later verified that R10’s care conference had been missed and was only scheduled after the surveyor’s inquiry.
Care Plan Not Revised to Reflect Hospice Status
Penalty
Summary
The facility failed to revise a resident’s care plan to reflect hospice status and terminal illness for one sampled resident. The resident had diagnoses including dementia, bipolar disorder, and heart failure, and the 8/14/25 Significant Change MDS indicated hospice status. Review of the care plan showed hospice-related references for ADL care, psychosocial well-being, activities, and anti-anxiety medication related to end of life, but it did not identify the resident’s terminal illness as a focus area with interventions including hospice services or other end-of-life interventions. On 6/4/26, the DNS stated the expectation was for a terminal illness to be captured with interventions including hospice services on the care plan, and acknowledged the care plan was not revised to reflect the resident’s terminal illness and hospice status.
Care plans not revised for changed conditions, behaviors, and electronic monitoring
Penalty
Summary
The facility failed to revise comprehensive care plans to reflect significant changes in resident status, conditions, preferences, and interventions for three residents reviewed for care plan revision. One resident had a discharge return anticipated MDS showing moderate cognitive impairment, multiple diagnoses including cancer, septicemia, and non-Alzheimer's dementia, and hospice services. The resident's EHR showed hospice services were discontinued, but the care plan continued to identify the resident as receiving hospice care. The same resident's care plan also continued to state that Enhanced Barrier Precautions were required due to a wound, even though the wound had healed and the resident remained on EBP because of a urinary catheter. Another resident's comprehensive MDS identified moderate cognitive impairment, diabetes, CVA, and use of insulin, an anticoagulant, and an antidepressant. The resident's care plan still listed Influenza A as an active respiratory infection with an initiation date from the prior year, but the EHR did not identify ongoing signs, symptoms, treatment, or diagnosis of Influenza A. A third resident had severe cognitive impairment, dementia, PTSD, behavioral symptoms, and wandering behavior. The resident's care plan included dining preference interventions stating the resident preferred to sit alone during meals and liked to sit in the dining room by the television next to the window, but the EHR showed the resident had behavior management interventions in place, including a bookshelf sticker on the door and a door chime to alert staff when the room door opened, and these interventions were not included in the care plan. Observations showed the resident with wandering and behavioral concerns eating and sitting with other residents in the dining room rather than alone, and staff interviews confirmed the resident had become less agitated, spent more time outside the room, and that the door chime and bookshelf sticker had been implemented and were effective. Interviews also confirmed the hospice discharge, the healed wound, the ongoing catheter-related EBP need, and that Influenza A had not been present for quite some time. The DON stated care plans should be updated whenever there was a new diagnosis, condition, intervention, preference change, or other significant change in status, and that care plans served as the primary communication tool for staff. The facility also failed to update care plans for two residents with electronic monitoring in their rooms. One resident's care plan lacked the use of a camera, the rationale for it, and the fact that family had placed it for monitoring and interaction. Another resident's care plan also lacked the use of a video camera with audio capability, the rationale, and related interventions such as signage, staff awareness, and family interaction through audio. Records showed consent forms and progress notes documenting the cameras, staff notification, signage, and family involvement, but these details were not reflected in the care plans. Staff interviews confirmed that the camera use should have been outlined in the care plans and that nursing staff were responsible for updating them.
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