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F0656
D

Failure to Develop and Implement Person-Centered Care Plan for Toileting Assistance

Spring Lake, Michigan Survey Completed on 06-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a person-centered care plan that accurately reflected the needs of a resident with a history of lumbar spine fusion, UTI, and fractures. The resident was documented in the Minimum Data Set as always continent of bowel and bladder and requiring substantial to maximal assistance for toilet transfers. However, the care plan included interventions for an indwelling catheter, which the resident did not have, and focused on infection risk related to a catheter. The care plan also indicated the resident required one staff member for toilet use. During observation and interview, the resident reported experiencing long wait times for call light responses when needing toileting assistance, sometimes waiting up to an hour and soiling herself as a result. She also reported that some staff at night instructed her to use her brief if she could not wait, which made her feel bad, even though staff were kind and cleaned her up. These findings indicate the care plan was not individualized to the resident's actual needs and was not effectively implemented to address her toileting assistance requirements.

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