Failure to Individualize and Implement Care Plan for Fall Prevention and Feeding Assistance
Summary
The deficiency involves the facility’s failure to develop, revise, and implement an individualized, person-centered care plan addressing supervision, fall prevention, and feeding assistance for a high fall-risk resident with intellectual developmental disability and severe cognitive deficits. The resident’s MDS documented that he was rarely or never understood and had severe cognitive impairment, and he had a known history of falls prior to admission. Despite this, the fall-risk care plan initiated on 12/22/25 contained only generic interventions such as educating/reminding the resident to call for assistance, keeping the call light within reach, and keeping the resident within supervised view “as much as possible,” without tailoring these interventions to the resident’s inability to understand or reliably use the call light or recognize danger. The DSD stated that this care plan was not individualized or specific to the resident’s cognitive and safety needs and that relying on the call light alone was insufficient given his decreased safety awareness and limited understanding. On the day of the fall, multiple staff interviews showed that the resident’s high fall-risk status and need for close supervision were not consistently communicated or incorporated into his care plan. CNA 1, who was assigned to the resident, reported that she was not informed the resident was a fall risk and therefore did not arrange for supervision when she left the area to use the restroom. She stated she had observed the resident independently wheeling himself in the hallway and had provided a meal tray, watching him eat independently, and that he remained seated in his wheelchair unsupervised in the hallway until approximately 8 p.m., when he was later found on the floor with a bleeding head wound. CNA 2, who worked on the same unit but was not assigned to the resident, also stated she was not informed the resident was a fall risk, observed him sitting alone in his wheelchair appearing confused, and did not recognize the need for close supervision. In contrast, CNA 3, a registry CNA, stated she had been informed by LNs at the start of the shift that the resident was a fall risk and had observed him attempting to stand from his wheelchair, but she reported that CNA 1 did not instruct her to monitor or supervise the resident before leaving for the restroom. Licensed nursing staff interviews further demonstrated that the resident’s supervision needs were not translated into an updated, individualized care plan or clear staff assignments. LN 1, the nursing supervisor on duty, stated he had verbally directed CNAs on the hallway to closely monitor the resident because he was a high fall-risk, had repeatedly attempted to get out of his wheelchair, and required close supervision at all times, including 1:1 supervision for safety. However, he acknowledged that there were no physician orders for 1:1 supervision and that the resident was not care-planned for 1:1 supervision, even though he believed this should have been done. LN 2 stated she was not aware the resident was identified as a fall risk prior to the incident, but given his IDD, confusion, and communication deficits, he should have been considered a safety and fall risk and the care plan should have been updated with interventions such as 1:1 supervision. The DON stated her expectation that staff complete a comprehensive safety assessment, personalize safety needs based on cognitive impairment and decreased safety awareness, and implement structured monitoring with clearly assigned staff responsibility, and acknowledged that failure to clearly communicate the fall risk and lack of supervision resulted in inadequate monitoring and hospitalization. The deficiency also includes failure to implement the resident’s nutritional care plan for feeding assistance. The resident’s nutritional care plan, initiated on 12/22/25, specified 1:1 feeding assistance, and a speech evaluation from the same date documented severe swallowing abilities, prior 1:1 feeder treatment, and aspiration risk. The facility’s feeding list included the resident’s name, and CNA 5 stated that although the resident could physically feed himself, he was on her feeder list due to difficulty swallowing and to prevent choking hazards. Despite these documented needs, CNA 1 reported that she provided the resident with a meal tray and watched him eat independently, indicating that 1:1 feeding assistance as outlined in the care plan was not followed. The DSD stated that staff were required to communicate resident-specific risks and care needs, including feeding assistance, through shift handoff reports and nurse-led huddles before providing care, and that failure to communicate these risks could result in preventable injuries such as choking. The DON stated that assigned staff were required to provide direct assistance during feeding due to choking risk and not leave the resident unattended, and that failure of staff to understand and follow the resident’s specific risks and care needs placed him at risk for injury, further health decline, and death.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with dementia, muscle weakness, and protein-calorie malnutrition had a care plan directing staff to offload his heels or use Prevalon boots while in bed. During observation, he was found in bed without the boots, and an LPN confirmed his heels were not offloaded even though they should have been.
Failure to care plan depression: A resident with MDD and ongoing depressive symptoms had psychology evaluations documenting depressed mood, loss of interest, sleep disturbance, fatigue, and appetite changes, and the MDS listed depression as an active dx. However, the care plan did not include depression as a focus area, and the MDS Coordinator and DON both stated it should have been care planned.
Incomplete care planning for ordered medications and diabetic footwear. The facility did not include ordered meds such as Eszopiclone, Lexapro, Mirtazapine, and Zolpidem in residents' comprehensive care plans, and one resident was not measured for diabetic shoes and insoles per MD order. The MDS Coordinator said the missing medication care plans were an oversight, while the DON and Administrator stated care plans are used to direct and guide resident care.
A facility failed to include person-centered comprehensive care plan focus areas for two residents receiving ordered meds. One resident with atrial fibrillation was receiving Eliquis, and another resident with insomnia was receiving Trazodone, but neither current care plan addressed the medication use. The MDS Nurse stated she was responsible for care plan development and said the omissions were due to oversight.
Failure to update a resident’s fall care plan with a Geri-chair intervention. A resident with dementia, osteoarthritis, diabetes, severe cognitive impairment, and a history of falls had a care plan listing multiple fall precautions, but after a witnessed fall and a physician order for a Geri-chair or tilt back WC, the care plan was not updated to include that intervention. Surveyors observed the resident in a Geri-chair, and the MDS Coordinator and DON acknowledged the care plan had not been updated.
Failure to care plan a resident’s impaired hearing. A resident with dementia and a history of hard of hearing was observed unable to hear normal conversation and stated he refused to use his hearing aid. The SSD and RN confirmed no care plan had been initiated for the hearing impairment or hearing aid refusal, and the DON stated the condition should have been care planned per facility policy and MDS triggers.
Failure to Offload Heels as Directed
Penalty
Summary
Resident #32, who was admitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition, had a care plan revised on 6/18/21 directing staff to offload his heels or use Prevalon boots when he was in bed, as he allowed. During observation on 7/9/26 at 11:22 AM, Resident #32 was found in bed without Prevalon boots in place. At 11:23 AM, an LPN stated the resident should have had his boots on, then lifted the blanket and observed the resident's legs resting on a pillow. When asked whether the resident's heels were offloaded, the LPN stated they were not and confirmed they should have been offloaded.
Failure to Care Plan Depression
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #22, who had diagnoses including Major Depressive Disorder and was documented by psychology evaluations as having recurrent, moderate depression. The resident’s evaluation notes described decreased interest in activities, persistent depressed mood, sleep disturbances, fatigue, and changes in appetite, with symptoms occurring on more than half of the days and causing moderate subjective distress. A later psychology note again documented persistent depressed mood, marked loss of interest, altered sleep patterns, and fatigue with moderate distress. The resident’s quarterly MDS dated 6/13/2026 documented an active diagnosis of depression in Section I, but the care plan did not include a focus area for depression. During interview, the MDS Coordinator stated the resident had been followed by Balance Wellbeing since 12/2025, the diagnosis was entered on 5/20/2026, and depression was not included in the care plan but should be. The DON also stated the resident should be care planned for depression. The facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident’s medical, nursing, and psychosocial needs and all services identified in the comprehensive assessment.
Incomplete Care Planning for Ordered Medications and Diabetic Footwear
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for 3 of 4 residents reviewed. Resident #12 had diagnoses including dementia, anxiety, malnutrition, and depression, and her physician orders included Eszopiclone for insomnia, Lexapro for depression, and Mirtazapine for protein-calorie malnutrition. Although these medications were active and administered, the comprehensive care plan dated 04/23/26 did not include care planning for Eszopiclone, Lexapro, or Mirtazapine. Resident #3 had diagnoses including PTSD, depression, and stroke, with a BIMS score of 08 indicating severely impaired cognition. Her physician order dated 06/01/26 included Zolpidem Tartrate 5 mg at bedtime for insomnia, and the MDS indicated she received a hypnotic medication during the look-back period. The comprehensive care plan did not indicate Zolpidem. During interview, the MDS Coordinator stated she reviewed the records and did not see care plans for Resident #12's medications or Resident #3's Zolpidem, and said it was an oversight. Resident #2 was also identified in the deficiency statement as not being measured for diabetic shoes and diabetic insoles per physician order. The facility's policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident and revised as conditions change. The DON and Administrator stated that care plans were a team effort and used to direct and guide resident care, and that if care plans were not done properly, care could be missed.
Missing Care Plan Focus Areas for Anticoagulant and Antidepressant Medication Use
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident receiving anticoagulant medication. Resident #5 was admitted with atrial fibrillation and had a physician order for Eliquis 5 mg by mouth twice daily. The June 2026 MAR showed the resident received Eliquis as ordered, and the quarterly MDS assessment coded the resident as moderately cognitively impaired and receiving anticoagulant medication. However, the resident’s current comprehensive care plan, last reviewed on 6/19/26, did not include a care plan focus area for anticoagulant medication use. The facility also failed to develop a person-centered comprehensive care plan for a resident receiving antidepressant medication. Resident #8 was admitted with insomnia and had a physician order for Trazodone 50 mg by mouth at bedtime. The June 2026 MAR showed the resident received Trazodone as ordered, and the quarterly MDS assessment coded the resident as cognitively intact and receiving antidepressant medication. The resident’s current comprehensive care plan, last reviewed on 6/18/26, did not include a care plan focus area for antidepressant medication use. In both cases, the MDS Nurse stated she was responsible for developing the care plans and identified the missing care plan areas as an oversight.
Failure to Update Fall Care Plan With Geri-Chair Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included all of Resident #1’s fall interventions. Resident #1, a [AGE]-year-old female with dementia, osteoarthritis, and diabetes mellitus, had a quarterly MDS showing a BIMS score of three, indicating severe cognitive impairment, and was assessed as having falls with one fall without injury. Her comprehensive care plan identified her as being at risk for falls related to debility, advanced age, and behaviors, and included interventions such as a low bed with fall mat, tilt back wheelchair, staff education, correct positioning in chair, nonskid tape under the fall mat, use of a call light, monitoring for changes in condition, and a pommel cushion added to the chair. After Resident #1 experienced a witnessed fall from her wheelchair in the TV area, a physician order was entered for safety devices including a low bed, fall mat, and Geri-chair or tilt back wheelchair. At the time of survey observation, Resident #1 was seen in a Geri-chair in the TV area and stated she liked it and was comfortable in it. However, the care plan did not include the Geri-chair intervention. The MDS Coordinator stated she had seen Resident #1 in the Geri-chair but had not yet updated the care plan, and the DON stated whoever had the resident should have seen the order for the Geri-chair and updated the care plan.
Failure to Care Plan Hearing Impairment
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address Resident 33’s impaired hearing. Resident 33 was admitted with diagnoses including dementia, muscle weakness, and abnormal gait and mobility, and the H&P documented a history of hard of hearing. The MDS dated 6/5/2026 indicated the resident was moderately impaired in cognitive skills for daily decision making and had minimal difficulty hearing. During an observation and interview on 6/29/2026, Resident 33 was lying in bed and stated he could not hear the surveyor during a normal conversation, that he was hard of hearing, and that he refused to use his hearing aid. The SSD stated the resident had difficulty hearing, refused to use the hearing aid, and had no care plan initiated for impaired hearing. RN 2 later confirmed there was no care plan for the resident’s impaired hearing and that one should be in place to address the hearing impairment and refusal to use the hearing aid so staff could communicate effectively. The DON stated that a resident with impaired hearing should be care planned according to facility policy and that hearing impairment triggered on the MDS should be care planned, including refusal to use the hearing aid.
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