Failure to Update Care Plan After Change in Advanced Directives
Summary
The deficiency involves the facility’s failure to update a resident’s care plan to reflect a change in advanced directives. Record review showed that the resident was admitted with an advanced directive of Full Code status, and the care plan documented a focus on advanced directives with an established CPR (Full Code) order and corresponding initiation and creation dates. However, the resident’s code status was changed in October to Do Not Resuscitate (DNR), and this change was not reflected in the resident’s care plan. During interviews, the DON acknowledged that the resident’s care plan was not updated after the code status changed from Full Code to DNR. The MDS LPN stated that when a code status order changes, the care plan should be updated and that this is typically discussed in morning meetings before care plans are revised, but in this case the update did not occur. The Social Worker Director reported attending morning clinical meetings where advanced directives are reviewed and stated that if the care plan was not updated, it was likely missed during this process. Review of the facility’s “Advanced Directives Code Status” policy confirmed that when code status changes, Social Services and nursing must document the change and update the code status/advanced directives care plan, which did not happen for this resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for five residents. The affected residents had diagnoses including dementia, hip fracture, diabetes, HTN, depression, HF, muscle weakness, and unsteadiness on feet, and their records lacked evidence that the required summaries were given.
A resident admitted with a right femur fracture, muscle wasting and atrophy, HTN, and BPH did not have a baseline care plan completed within the required time frame. Record review showed the plan was overdue, and the DON acknowledged it had not yet been done and was 3 days late.
Failure to complete a baseline care plan within 48 hours of admission for a resident with DM2 and renal dialysis dependence. The EMR showed no baseline care plan had been initiated, and the resident said he did not remember meeting with staff since admission. The DON stated the IDT was responsible for care plans and confirmed the baseline care plan should have been completed but was missed as an oversight.
Baseline Care Plan Missing Secure Unit, Elopement Risk, and Behaviors: A resident with schizophrenia, depression, and severe cognitive impairment was admitted from a secure unit, but the baseline care plan did not include his secure-unit placement, elopement risk, or documented behaviors. Records showed prior wandering concerns, a later high elopement score, and multiple behavioral incidents including property destruction and aggressive actions toward staff.
A resident admitted and readmitted with multiple fractured ribs and diabetes did not have documentation that the baseline care plan was provided or discussed with the resident or representative. The record also lacked a resident or representative signature showing the care plan summary had been offered, despite the facility policy requiring the supervising nurse or MDS nurse/designee to provide the written summary and obtain verification.
Baseline Care Plans Not Developed Timely for Residents With Wounds: The facility failed to include wound-related needs in the baseline care plans for two residents. One resident had diabetic foot ulcers, a heel wound, and other skin issues with IV abx and wound care involvement, but the baseline plan did not identify the ulcers. Another resident had a left great toe arterial ulcer/eschar present on admission, yet the baseline plan did not document skin risk or the wound until later. The MDS Coordinator and DON stated the wound interventions and care plans should have been completed promptly and included individualized instructions.
Missing Baseline Care Plan Summaries for New Admissions
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for five of 30 residents reviewed. Facility policy stated that the resident and their representative are to receive a summary of the baseline care plan, including the resident’s initial goals, a summary of medications and dietary instructions, services and treatments to be provided, and updated information as needed. The affected residents were R10, R39, R42, R55, and R79. R10 was admitted with diagnoses including a closed right hip fracture with routine healing, dementia, and unsteadiness on feet. R39 was admitted with diabetes and hypertension. R42 was admitted with depression, diabetes, and hypertension. R55 was admitted with depression, hypertension, and muscle weakness. R79 was admitted with heart failure, muscle weakness, and unsteadiness on feet. Their clinical records lacked evidence that the written summary of the baseline care plan and order summary was provided to the resident and/or their representative. During interview, the Nursing Home Administrator confirmed there was no evidence that these summaries were provided.
Failure to Complete Baseline Care Plan on Time
Penalty
Summary
The facility failed to complete the baseline care plan within the required time frame for Resident #93, who was admitted with diagnoses including right femur fracture, muscle wasting and atrophy, essential hypertension, and benign prostatic hyperplasia without lower urinary tract symptoms. Record review showed that as of 07/01/26, the baseline care plan had not been completed and was due by 06/28/26. During an interview on 07/01/26 at 12:05 PM, the DON was asked to locate the resident’s baseline care plan and acknowledged that it had not yet been done and was 3 days overdue.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of Resident #3’s admission that included the instructions needed to provide effective and person-centered care. Resident #3 was a [AGE]-year-old male admitted on 06/25/26 with diagnoses of Type 2 Diabetes Mellitus without complications and dependence on renal dialysis. Record review on 06/30/26 showed no baseline care plan had been initiated in the electronic medical record under the assessment tabs. During an interview on 06/30/26, Resident #3 said he had only been at the facility a few days and did not remember having a meeting with staff since admission. Later that day, the DON stated the IDT was responsible for completing care plans and that baseline care plans were supposed to be completed within 48 hours of admission. She said a baseline care plan should have been completed for Resident #3 and identified the missed completion as an oversight. The facility policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, stated that a comprehensive, person-centered care plan is developed and implemented for each resident.
Baseline Care Plan Missing Secure Unit, Elopement Risk, and Behaviors
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #1 that included the instructions needed to provide effective and person-centered care within 48 hours of admission. Record review showed Resident #1 was a male with diagnoses including schizophrenia, depression, and cognitive communication deficit, and his MDS reflected severe cognitive impairment. The baseline care plan did not include that he was placed in a secure unit, that he was an elopement risk, or that he had behaviors documented on the record review. The record also showed that Resident #1 had been transferred from another LTC facility secure unit and had prior orders indicating he required a secured unit due to wandering. An elopement evaluation dated 05/15/26 reflected a score of 0.0, but later an elopement evaluation dated 06/12/26 reflected a score of 7.0, indicating high risk. Progress notes documented behavioral incidents including breaking a dining room window with a chair, slamming and breaking a plastic tray, waving a broken piece at staff, tearing blinds off the wall, throwing a cup that broke a window, and kicking a hole in the wall. Interviews with the NP, MD, MDS Nurse, Admin, Marketer, and DON confirmed the resident was transferred from a secure unit and that the baseline care plan did not include these immediate concerns.
Baseline Care Plan Not Provided or Documented
Penalty
Summary
The facility failed to provide Resident #73’s baseline care plan to the resident or his representative after his initial admission and readmission. Resident #73 was admitted with multiple diagnoses including multiple fractured ribs and diabetes. The facility’s Baseline Care Plan policy stated that a supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative and obtaining a signature to verify it was provided. The resident’s medical record did not document that the baseline care plan had been provided or discussed, and it did not contain a signature from the resident or representative showing that a copy had been offered. The Social Worker stated the record should have documented a signature indicating the baseline care plan had been discussed or offered, and the DON stated the record should have documented that a copy of the baseline care plan had been offered and had not.
Baseline Care Plans Not Developed Timely for Residents With Wounds
Penalty
Summary
The facility failed to develop and implement baseline care plans that included the instructions needed to provide effective, person-centered care for two residents with wound-related needs. For one resident, the baseline care plan dated 06/01/2026 stated that she required IV medications and was not at risk for skin concerns, even though she had multiple wound-related diagnoses and later documentation showed chronic right heel and plantar wounds, a right buttock wound, and a right posterior thigh laceration/DTI. Her record also reflected hospitalization for MRSA bacteremia, IV vancomycin treatment, and wound care specialty involvement, but the baseline care plan did not document her diabetic ulcers. For the same resident, skin assessments by the WCN documented a right plantar wound and right heel wound present on admission, and later care plan entries were not initiated until 06/22/2026. The care plan then addressed pressure ulcer risk, diabetic ulcers to the right foot, right heel, and right plantar area, and wound care to the right buttocks. The record review also showed orders for wound care to the right heel, right plantar area, and right buttocks, but the resident’s orders did not include any orders for assessing infection in the right foot. An MDS Coordinator stated that the resident’s diabetic ulcers were not documented in the baseline care plan and that the interventions should have been in the care plan so staff could provide individualized care. For the second resident, the baseline care plan dated 06/13/2026 documented total dependence for ADLs but did not identify skin risk or pain. A foot evaluation by the WCN documented eschar on the left big toe present on admission, and later progress notes described edema of the left foot, dry skin, insensate lower extremity, and an arterial ulcer with full thickness. The care plan for this resident was not initiated until 06/26/2026, when it identified a left great toe arterial ulcer and a left second toe arterial ulcer with weekly wound care monitoring. Physician orders included skin prep to the left big toe eschar, podiatry as needed, and later betadine to the left great toe and second toe. The DON stated that care plans should be completed immediately and that care plans should be done as soon as it is noticed.
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