Failure to Involve Residents/Representatives and Update Interdisciplinary Care Plans for Changing Clinical Needs
Summary
Surveyors identified a deficiency in the facility’s failure to develop, review, and revise comprehensive care plans with an interdisciplinary team that included residents and/or their representatives, and to update care plans when residents’ conditions changed. Multiple residents and family members reported that care plan conferences had not occurred since a change in facility ownership, despite prior practice of quarterly meetings. For example, one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and diabetes, had a baseline care plan and a signed POA document, but there were no care conference attendance sheets, and the family stated they had not been included in care plan meetings since the new company took over. Another cognitively intact resident and that resident’s son both reported they had never been invited to care conferences since admission, and the social services director acknowledged that many care conferences were not completed and that residents and families had not been part of quarterly assessments. The facility also failed to revise care plans to reflect significant changes in residents’ clinical status and treatment orders. One resident with intact cognition and a right femur fracture was being transferred with a whole body mechanical lift per therapy evaluation and documentation, but the care plan still listed stand-pivot transfers with one staff and a gait belt; staff reported they had not received updated transfer information and expected therapy to update the care plan. Another resident with moderate cognitive impairment and multiple diagnoses had a care plan with 19 focus areas whose interventions had largely not been updated since the prior year, despite the facility no longer offering restorative nursing services; there was no EMR documentation of care conferences or timely updates, and late entries were added to progress notes only after surveyor inquiry. A resident who experienced a fall, hospitalization, and diagnosis of Influenza A had a marked decline in transfer ability and required a full-body mechanical lift and transmission-based precautions, but the care plan was not updated to reflect the new transfer status or the need for PPE until after surveyor review. Additional failures involved skin integrity and catheter-related care planning. One resident admitted with a Stage 2 pressure ulcer and later placed on and then removed from an indwelling urinary catheter had care plan interventions that continued to reference catheter care and Enhanced Barrier Precautions for the catheter after the catheter was discontinued by physician order; the MDS showed the resident as incontinent without a catheter, but the care plan was not revised. Another resident at risk for pressure injuries developed in-house acquired moisture-associated skin damage on the buttocks and a deep tissue injury on the right heel, with multiple wound treatment orders and documentation of a scoop mattress and lack of repositioning aids; however, the care plan did not include MASD, the DTI, or related interventions such as pressure-reducing devices or nutrition/hydration measures. A different resident admitted without pressure injuries developed in-house Stage 2 pressure ulcers on the buttocks and a DTI on the right heel; the care plan contained no prevention focus, goals, or interventions until after the wounds occurred. Further, residents with existing or worsening pressure injuries did not have their care plans revised to reflect new or escalated needs. One cognitively intact resident with an in-house Stage 2 sacral pressure ulcer later required surgical debridement of a Stage 4 sacral ulcer with exposed bone and a wound vacuum; the care plan showed a generic focus on potential for pressure injury and an in-house Stage 2 sacral ulcer but no new interventions after the ulcer progressed and the resident returned from the hospital with a wound vac and more advanced wound status. Another cognitively intact resident at risk for pressure ulcers developed unstageable skin on 12/23, but there was no care plan update or added interventions for this finding. Interviews with the MDS coordinator, DON, RN staff, and social services indicated that the MDS coordinator was primarily responsible for building and updating care plans, floor nurses generally did not update care plans, and care conferences were not consistently scheduled or documented with IDT participation, residents, or families, resulting in multiple care plans that were outdated, incomplete, or not reflective of current clinical orders and conditions.
Penalty
Resources
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Care plans were not individualized for two residents who frequently left the facility or failed to sign out. One resident had multiple LOAs and several instances of leaving without notifying staff, while the other resident had dementia-related diagnoses, low elopement risk, and episodes of not returning as expected or being found off the unit after stepping out to smoke. Staff interviews confirmed residents were expected to notify nursing, sign out, and provide return times, but the records did not include clear care plan interventions or staff direction for these situations.
A resident with CKD, muscle weakness, and difficulty walking had a care plan for impaired mobility and fall risk that directed staff to keep the call light within reach. Surveyors observed the resident seated in a chair with the call light clipped to the wall on the opposite side of the bed and out of reach; the resident said it was always there. The CNO stated the resident spent most of the day in the chair and preferred the call light clipped to the wall, and this preference was not care planned.
Care Plan Not Revised for New Fluid Restriction: A resident with CHF and intact cognition was placed on a new 1500 cc/24 hr fluid restriction, but the care plan only addressed diet and liquids and did not include the restriction or related non-compliance. An LVN said staff were aware of the order, while the ADON stated the new restriction should have been added to the care plan and revised after changes in care.
Failure to revise fall risk care plan after resident fall. A resident with repeated falls, dementia, weakness, and impaired cognition had an actual fall after sliding off the bed due to poor safety awareness. The COC, progress notes, and IDT fall conference documented the event and recommended frequent visual checks and help maintaining position in bed, but the fall risk care plan was not revised to reflect the new interventions.
Failure to timely reassess fall interventions: A resident with mild cognition and a history of repeated falls had 23 falls, most unwitnessed, after admission. The care plan identified high fall risk and included basic safety interventions, but the first 10 falls had no post-fall assessment, the first assessment was delayed, and an IDT discussion about unsafe bedside urinal use was not followed by a documented care plan update before the resident continued to fall while using the urinal and toilet.
A resident with epilepsy and dementia had repeated inappropriate sexualized behaviors toward residents, staff, and visitors, including grabbing buttocks and making sexually inappropriate comments. The care plan noted an initial 1:1 intervention after one incident and later documented a visitor-related allegation, but it was not revised to add further interventions after the behaviors continued. The DON stated the resident should have been monitored for inappropriate behavior and the care plan updated after the earlier incident.
Care plans lacked LOA and sign-out interventions
Penalty
Summary
The facility failed to develop and revise comprehensive, person-centered care plans to address resident-specific interventions for leaves of absence (LOAs) and for situations when residents left the facility without notifying staff or signing out. The deficiency involved 2 residents, R10 and R37, whose records and staff interviews showed repeated LOAs and instances of leaving without signing out, but whose care plans did not reflect specific interventions or staff direction for those events. R10’s record showed a complex medical history including diabetes, a diabetic foot ulcer, wound infection, alcohol use disorder, and chronic suicidal ideation. Although an elopement risk assessment identified R10 as low risk, progress notes from 6/1/26 through 7/12/26 documented 11 LOAs, including 3 occasions when R10 did not sign out. Staff interviews stated R10 was expected to notify nursing before leaving, provide an approximate return time, and sign out, but the medical record did not reflect interventions for when R10 left the facility or failed to sign out. The DON acknowledged that for a resident who frequently left the facility, those expectations should have been reflected in the care plan so staff would know what actions were required. R37’s record showed mild cognitive impairment, dementia-related diagnoses, and an elopement risk score placing R37 at low risk. Nursing notes documented that R37 did not return from an LOA on one occasion and, on another occasion, was found not to be in the building after stepping out to smoke. Staff interviews stated R37 often forgot to sign out and was re-educated when he returned, but the medical record lacked care plan updates for safety plans in the community or interventions when R37 did not sign out. The RN and DON both stated the care plan should have been updated to address R37’s failure to sign out and to direct staff on what should occur when he left without notifying staff or indicating when he would return.
Care Plan Not Revised to Match Resident Preference and Current Setup
Penalty
Summary
The facility failed to ensure a resident’s comprehensive care plan was revised to reflect current needs and interventions. The facility policy titled, "Comprehensive Care Plans and Conferences," stated that each resident must have a timely, person-centered, comprehensive care plan that is developed, maintained, reviewed, and revised by an interdisciplinary team and updated as needed based on changes in condition or response to interventions. Resident #3 was admitted with diagnoses including chronic kidney disease, muscle weakness, and difficulty walking. The resident’s care plan, initiated 5/7/26, identified impaired mobility with risk for falls related to use of an assistive device for ambulation and included the intervention to keep the call light and bedside table items within reach. However, on 7/7/26 the resident was observed seated in a chair next to the bed with the call light clipped to the wall on the opposite side of the bed and out of reach. The resident stated the call light was always there. A RCNA later confirmed the call button was out of reach and stated it should be clipped to the bed next to the chair. The CNO stated the resident spent most of the day in the chair and had the call light clipped to the wall on the opposite side of the bed because he did not like it clipped on the bed, and confirmed the resident’s preference to have it out of reach was not care planned.
Care Plan Not Revised for New Fluid Restriction
Penalty
Summary
The facility failed to ensure Resident #6’s comprehensive care plan was reviewed and revised after a new physician order for a fluid restriction. Resident #6 was admitted with diagnoses including chronic combined systolic and diastolic congestive heart failure, and the quarterly MDS reflected a BIMS score of 15, indicating intact cognition. The physician’s order dated 7/01/2026 directed a 1500 cc fluid restriction per 24 hours, with 300 cc total nursing and 1200 cc total dietary, divided across meals and shifts. Record review of the care plan printed 7/09/2026 showed care planning for diet and liquids, including NAS diet, thin liquids, and regular texture, but no additional care planning related to the fluid restriction. During interview, an LVN stated Resident #6 had recently been placed on a fluid restriction and was typically non-compliant, and she was unsure whether the restriction was in the care plan. The ADON stated the new fluid restriction should have been added to the care plan, along with the resident’s non-compliance, and said care plans are revised after changes are noted to residents’ care. The facility policy on comprehensive assessments and the care delivery process stated that monitoring results and adjusting interventions includes periodically reviewing progress and adjusting treatments.
Failure to Revise Fall Risk Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise Resident 41’s care plan for risk for falls after the resident had an actual fall on 6/7/2026. Resident 41 was admitted with diagnoses including repeated falls, dementia, muscle weakness, and difficulty walking. The resident’s MDS dated 5/13/2026 indicated severe impairment in cognitive skills for daily decision making and the need for substantial to maximal assistance with several activities of daily living, including oral hygiene, toileting hygiene, dressing, footwear, and personal hygiene, and dependence for showering/bathing. A Change in Condition evaluation dated 6/7/2026 documented that Resident 41 had a fall and was crying intermittently. Progress notes from 6/7/2026 at 6:20 AM stated the resident was on the floor and had been witnessed by a CNA at 6:10 AM. An IDT fall incident care conference dated 6/8/2026 stated the resident fell in the room after sliding off the bed due to poor safety awareness and noted the resident was confused, with recommendations including frequent visual checks and assistance in maintaining position in bed. Review of the care plan showed the risk-for-falls plan, initiated 3/12/2025 and revised 2/24/2026, was not revised after the fall and did not indicate interventions such as frequent visual checks were added after 6/8/2026.
Failure to Timely Reassess Fall Interventions
Penalty
Summary
The facility failed to appropriately assess and reevaluate interventions in a timely manner for a resident who had 23 falls during the review period. The resident was admitted on 1/20/2026 and had a care plan dated 1/21/26 identifying increased fall risk related to a history of falls, impaired decision making, failure to recognize physical limitations, impaired safety awareness, and attempts to self-transfer. The resident’s quarterly MDS showed mild cognition, no mood or behavior concerns, and substantial to max assistance needed for toileting, bathing, dressing, and personal hygiene, with dependence on others for putting on and off footwear. During interview, the resident stated staff had told him he had fallen about 17 times since admission and said he tried to do things for himself instead of calling staff, including when he dropped his glasses; he also said the reason for his nursing home placement was a fall at home. The record showed 23 falls from admission through 6/13/26, with 21 unwitnessed falls. The first 10 falls did not have a post-fall assessment, and the first post-fall assessment was not completed until 2/28/26. That assessment added interventions such as keeping the resident in the common area when up in the wheelchair, placing slide strips, locking the bed, moving the bed against the wall, frequent reminders, and hourly checks, along with education about waiting for staff. An IDT met on 4/28/26 after a fall involving use of the bedside urinal and noted several falls occurred while the resident was using the urinal; the team stated the resident would need to demonstrate safe urinal use without standing and would ask therapy for ideas, with the care plan to be updated. Therapy documented a co-treatment on 4/30/26 for urinal use and ambulation, noting the resident stood for 3 minutes to use the urinal. The record did not show further update, and the resident continued to fall while using the urinal on 5/8/26 and while using the toilet on 6/13/26. During interview, the administrator and VPS-A and B stated they would expect interventions discussed at IDT to be followed and reviewed.
Failure to revise care plan after repeated inappropriate sexualized behavior
Penalty
Summary
The facility failed to reassess and revise A resident’s person-centered care plan after repeated incidents of inappropriate sexualized behavior toward residents, staff, and visitors. The resident was admitted with diagnoses including epilepsy and dementia, and a February 4, 2026 History and Physical stated the resident was unable to answer questions. The record showed multiple incidents of sexually inappropriate behavior, including an allegation on February 25, 2026 that the resident grabbed another resident’s buttocks, a March 29, 2026 incident in which the resident attempted to grab a CNA’s bilateral buttocks in the hallway, and a May 21, 2026 incident in which a male visitor stated the resident touched his buttocks. The care plan documented a focus after the February 25 incident with a 1:1 intervention for 72 hours and a goal that the resident would not have inappropriate behavior, and it later documented the May 21 incident involving the visitor. However, the record did not show that the care plan was revised to include additional interventions after the repeated behaviors continued. On May 29, 2026, a CNA reported the resident approached her from behind and said, "I was going to smack your cheeks," and a visitor reported the resident grabbed his buttocks while passing by. The DON stated that after the March 29 incident, the resident should have been monitored for inappropriate behavior and the care plan should have been updated to address the behaviors.
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