Failure to Follow Two‑Person Bed‑Bath Care Plan Resulting in Repeat Injury
Summary
The deficiency involves the facility’s failure to implement and maintain accident‑prevention interventions and to follow an updated care plan for a resident with a prior fall and major injury. The resident had a history of a right closed hip fracture and displaced hip after falling from bed, and the facility’s practice and posted signage indicated that she required two‑person assistance and bed baths only. A sticker outside the resident’s room showed a two‑person assist requirement, and a sign above the bed stated “2 person bed baths only,” which the family confirmed was in place after the hip fracture. Despite this, the resident later reported being taken to the shower room, where staff pulled on her arm, after which she complained of shoulder pain. Record review showed that the resident’s care plan, revised after the hip fracture, documented that she was dependent on staff of two persons for bathing/showering three times per week as tolerated, with a cloth bed pad to be placed under her when bathing. This language was repeated in subsequent care plan entries, including after the humerus fracture. Bath documentation revealed inconsistent adherence to the care plan interventions: in the months following the hip fracture, the resident received a mix of bed baths and showers, with multiple entries marked as not available or refusals. Documentation showed that a shower was provided shortly before the resident reported to her daughter that she had been taken to the shower and that her arm had been pulled. Interviews further demonstrated a lack of alignment between the care plan, family preferences, and staff actions. The resident’s daughters reported that an X‑ray confirmed a left humerus fracture and that the resident described being brought to the shower and having her arm pulled. They also stated that the resident had complained of shoulder pain for two days before the X‑ray and that an LPN had been made aware. The MDS Coordinator stated she was unsure why the care plan had been updated to include baths/showers after the reported shoulder fracture and saw no clinical reason to prevent shower use, despite the family’s preference for bed baths. The Administrator and DON acknowledged that the family preferred bed baths and could not explain why the care plan was edited to allow showers after the second incident. The NP, who determined the fracture to be pathological based on osteopenia and lack of visible swelling or bruising, was not aware of the family’s bed‑bath‑only request, was unsure whether the resident had been taken to the shower, and confirmed that the injury could have been caused by pulling the resident’s arm.
Penalty
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The facility did not develop or implement individualized care plans for several residents with significant clinical needs and medication regimens. One resident with dementia, severe depression with psychosis, cognitive impairment, and antipsychotic use had no care plans addressing either the antipsychotic therapy or cognitive impairment. Another cognitively impaired resident receiving a diuretic for edema had no diuretic care plan. A third cognitively impaired resident with hemiparesis, an indwelling catheter, a feeding tube, and a Stage 3 pressure ulcer was receiving long-term prophylactic antibiotic therapy for UTIs without a corresponding care plan. These omissions were confirmed by facility leadership, including the ADON, an LPN assessment coordinator, and the NHA.
A resident with a documented history of depression was prescribed Buspirone and Vistaril for anxiety, and the MDS reflected use of anti-anxiety medications, yet the Active Diagnoses section did not list an anxiety disorder. Review of the resident's care plans showed they addressed only depression and antidepressant use, and the psychotropic medication care plan referenced only antidepressants, omitting the anti-anxiety drugs. The MAR confirmed ongoing administration of both anti-anxiety medications, and the DON acknowledged that the resident's anxiety and related medications were not included in the active care plans.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident with paraplegia and moderate cognitive impairment, dependent on staff for transfers and using a manual wheelchair, was observed alone in a courtyard sitting in direct sunlight without a drink, contrary to his care plan interventions. The resident reported being routinely left outside unattended, without a way to call staff, and not being offered sunscreen when outside. The care plan called for encouraging fluids, supplying and assisting with sunscreen, and offering assistance in and out of doors, but an RN acknowledged there was no monitoring system or set check times while the resident was outside and that there was no physician order for sunscreen available to offer.
Failure to Develop Care Plans for Key Diagnoses and High-Risk Medications
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans addressing specific clinical conditions and medication regimens for multiple residents. For one resident with a significant change MDS, the assessment documented cognitive impairment, dependence on staff for daily care, use of antipsychotic medication, and diagnoses of dementia, depression with severe psychosis, and obsessive-compulsive disorder. Physician orders directed administration of risperidone 0.25 mg twice daily for severe depression with psychotic features, yet there was no documented care plan addressing the resident’s antipsychotic use or her dementia and cognitive impairment. The Assistant Director of Nursing confirmed the absence of these care plans. Another resident’s quarterly MDS showed cognitive impairment, need for assistance with daily care, and diagnoses including dementia and hypertension, with physician orders for furosemide 40 mg for edema; however, there was no documented diuretic care plan, which the LPN Assessment Coordinator confirmed was missing. A third resident’s quarterly MDS documented cognitive impairment, limited range of motion on one side, dependence on staff for daily care, an indwelling urinary catheter, a feeding tube, a Stage 3 pressure ulcer present on admission, and diagnoses including cerebrovascular accident with right-sided hemiparesis/hemiplegia. Physician orders included long-term prophylactic nitrofurantoin 50 mg via feeding tube three times weekly for UTI prevention, but there was no documented care plan addressing this long-term antibiotic therapy. The Nursing Home Administrator confirmed the lack of a care plan for the resident’s prophylactic antibiotic use.
Plan Of Correction
Individualized care plans will be reviewed, developed, and implemented as needed for Residents 1, 2, and 43 to accurately reflect care and services provided. The Clinical and Clinical Reimbursement Consultants re-educated the Minimum Data Set (MDS) Coordinator, Interdisciplinary Team, and Administrative Nurses (Director of Nursing, Assistant Director of Nursing, Staff Development/Infection Control Nurse Coordinator, and Nursing Supervisor) regarding developing and implementing a comprehensive person-centered care plan on May 14 and May 15, 2026. Director of Nursing and/or designee will educate all Licensed Nursing staff regarding development of care plans. An initial audit review will be completed by the Director of Nursing and/or designee to assure the development and implementation of a comprehensive person-centered care plan to reflect current in-house residents with anticoagulants, cognitive impairments, diuretic(s), and prophylactic antibiotics. The Director of Nursing and/or designee will complete random audits for a comprehensive person-centered care plan reflecting current in-house residents with anticoagulants, cognitive impairments, diuretic(s), and prophylactic antibiotics weekly for 4 weeks and then monthly for 2 weeks. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Care Plan for Anxiety Disorder and Anti-Anxiety Medications
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's anxiety disorder and related anti-anxiety medications, as required by §483.21(b). The resident was admitted with a diagnosis of depression and later received new physician orders for Buspirone 5 mg twice daily and Vistaril 25 mg three times daily, both prescribed for anxiety. The quarterly MDS assessment documented that the resident received anti-anxiety medication during the assessment period, but the Active Diagnoses section did not list an anxiety disorder diagnosis despite the ongoing use of two medications for that condition. Review of the resident's active care plans showed no care plan specifically addressing anxiety or the use of anti-anxiety medications. Existing care plans addressed potential mood fluctuations and depression, focusing only on antidepressant use, and a separate care plan for risk of adverse reactions to psychotropic medications referenced only antidepressant therapy for depression. The MAR confirmed that the resident was receiving Buspirone and Vistaril as ordered for anxiety. In an interview, the DON confirmed that the resident's active care plans did not address her anxiety or the use of anti-anxiety medications and acknowledged that a care plan for anxiety should have been in place.
Plan Of Correction
1. Resident #100 had their order for Buspar and Vistaril orders clarified on 4/22/26 by the Unit Manager to clarify the indication for use of the ordered medications and validated care plan for accuracy. The Buspar order was clarified by the physician to be used for diagnosis of Depression and the Vistaril order was clarified by the physician to be used for a diagnosis of itching. The care plan was updated to include the use of the antianxiety/anxiolytic medications for diagnoses of Depression and Itching on 5/7/26 by Social Service Designee. The resident does not have an active diagnosis of Anxiety as clarified by the physician. 2. Like Residents are identified as residents who utilize medication for anxiety. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Medication Review Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure residents who utilize medication for anxiety have an active diagnosis and care plan in place to address anxiety. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Care Planning and Physicians Orders Policies to ensure orders include an accurate and appropriate diagnosis and a care plan is initiated or revised to indicate use of antianxiety/anxiolytic medications. This education will be completed on or before 5/13/26. 4. Utilizing the Medication Review Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will F 0656 complete an audit 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure residents who utilize medication for anxiety have an active diagnosis and care plan in place to address anxiety. Discrepancies noted from audits will be corrected to include clarification of orders and revision of care plans. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Implement Care Plan for Resident Outside in Courtyard
Penalty
Summary
The deficiency involves the facility’s failure to implement an existing care plan for a resident who liked to go outside in an unsecured courtyard area. During an observation, the resident was seen alone in his wheelchair in direct sunlight without a drink. In an interview shortly afterward, the resident reported that staff always left him outside unattended, that he had no way to notify staff when he was ready to return indoors, that he had not been offered sunscreen, and that he was ready to go back inside. The resident’s diagnoses included paraplegia, and his most recent Quarterly MDS showed he was moderately cognitively impaired, dependent on staff for transfers, and used a manual wheelchair for mobility. The resident’s care plan, in place since 2018, documented that he liked to go outside in an unsecured area, was not considered an elopement risk, had a BIMS score of 13, and had been educated to notify staff when outside and to remain on the sidewalk. Care plan interventions included encouraging the resident to have a drink of choice when outside, supplying sunscreen and assisting with its application when appropriate, and offering assistance in and out of doors. An RN stated there was no monitoring system or set time intervals for checking on the resident while he was outside unattended, and that staff often only told him a time limit for being outside. The RN also noted the resident was not wearing sunscreen because he often refused it previously, and the physician’s orders did not include an order for sunscreen to be available to offer. The facility’s Comprehensive Care Plan policy required periodic review and revision of care plan problems, goals, and interventions following each OBRA MDS assessment.
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