Failure to Develop Comprehensive Person-Centered Care Plan for PASARR-Positive Resident
Penalty
Summary
Surveyors identified a failure to develop a comprehensive, person-centered care plan with measurable objectives and timeframes for one resident. Record review showed that this resident, a male with spastic quadriplegic cerebral palsy, spina bifida, recurrent depressive disorders, and protein-calorie malnutrition, had been admitted on 11/26/2025. His electronic health record contained no evidence of a comprehensive care plan, despite a completed comprehensive MDS that identified positive PASARR conditions and a BIMS score of 11, indicating moderate cognitive impairment. Interviews with staff and the resident confirmed that care was being provided based on verbal communication and the resident’s own directions rather than a documented comprehensive care plan. CNA A reported she was familiar with the resident’s care needs and preferences and that staff communicated across shifts through verbal reports. The resident stated he felt safe, had not been hurt, and that staff cared for him as he requested. He also stated he was receiving PASARR services and that staff were following his plan of care, although no comprehensive written care plan was found in the record. Facility leadership and the MDS nurse acknowledged that no comprehensive care plan had been completed for this resident beyond a baseline care plan dated 11/26/2025. The ADM and DON confirmed that the baseline care plan was being used in place of a comprehensive care plan and that the comprehensive plan had not been developed. The MDS nurse stated she was responsible for completing care plans after MDS assessments, but due to a change in ownership, a software transition, and staffing issues, she had not yet entered this resident’s care plan into the new system. The ADM, DON, ADON, and MDS nurse all indicated that the resident was receiving services, including PASARR-related services and discharge planning discussions, but these were not reflected in a comprehensive care plan as required by the facility’s Comprehensive Care Planning policy, which calls for measurable objectives, timeframes, PASARR-related services, resident goals for admission, desired outcomes, and discharge preferences.
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