F0656

E

Failure to Develop and Implement Comprehensive Care Plans and Nutrition Orders for Two Residents

Jefferson, Texas Survey Completed on 02-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans addressing all identified needs for two residents, as required by facility policy and the MDS assessments. For one resident with cerebrovascular disease, hemiplegia/hemiparesis following cerebral infarction, adult failure to thrive, polyneuropathy, hypertension, atherosclerotic heart disease, and nutritional deficiency, the admission MDS showed moderate cognitive impairment (BIMS 12), functional limitations in range of motion, wheelchair use, partial to substantial assistance with most ADLs, frequent urinary incontinence and occasional bowel incontinence, frequent pain requiring scheduled pain medication, a history of falls, risk for pressure ulcers, and use of antidepressant, diuretic, opioid, antiplatelet, and anticonvulsant medications. Despite this, the resident’s care plan, with an admission date of 1/18/26, contained only two problem areas: risk for impaired skin integrity/wound and an actual fall, and did not include problem areas or interventions for allergies, discharge plans, code status, cognitive status, incontinence status, activities, pain management, diet, ADL assistance, fall risk, pressure ulcer risk, bleeding risk, preferences, disease processes, or the listed medications.

Observation and interview with this resident showed he was sitting in a wheelchair and reported he could not use his right arm or leg and had previously been very independent and active before his stroke. He stated he was continent of urine but needed assistance to use a urinal because he could not manage his clothing and hold the urinal with one hand, and he expressed reluctance to ask for help while also not wanting to soil himself. He also stated he was angry about his current health situation, that his whole life had changed, and that he did not feel the facility realized that. The MDS Coordinator acknowledged that the comprehensive care plan was her responsibility along with another MDS Coordinator, that it should include areas such as code status, diet, allergies, assistance needed, skin, bowel and bladder, medications, fall and pressure ulcer risk, and health conditions, and that the comprehensive care plan for this resident was not completed within the required 21 days from admission.

For the second resident, who had diagnoses including cerebral infarction, dysphagia, cerebrovascular disease, chronic kidney disease, right eye blindness, vascular dementia, malignant neoplasm of the brain, cognitive symptoms following cerebral infarction, repeated falls, depression, and hypertension, the quarterly MDS indicated severe cognitive impairment (BIMS 7), wheelchair use, dependence on staff for all ADLs including eating, and continuous bowel and bladder incontinence. However, the resident’s ADL care plan, with an admission date of 12/27/25, still described an ADL self-care performance deficit related to confusion and impaired balance and stated that the resident was able to feed himself with meal and tray set-up, last revised on 8/20/25, and was not updated to reflect dependence on staff for eating. Additionally, there was a physician order, present on the order summary and MAR, for the resident to receive a health shake if less than 50% of a meal was consumed, with encouragement of intake and notification of the nurse, but there was no documentation that the resident ever received a health shake during the review period, despite multiple documented meals where intake was 0–25%, 26–50%, or refused. Nursing notes did not indicate that health shakes were offered or refused. Facility staff, including LVNs, the MDS Coordinator, the DON, the physician, and the administrator, stated that the comprehensive care plan is intended to direct resident care, should be complete and accurate, and that physician orders, including the health shake order, should have been followed.