F0656

E

Failure to Develop Comprehensive Person-Centered Care Plans Based on Admission MDS Assessments

Seguin, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for multiple residents, as required by their own policy and federal regulations. For Resident #2, record review showed an extensive list of medical diagnoses, including chronic combined systolic and diastolic CHF, COPD, coronary artery disease with unstable angina, dysphagia following cerebral infarction, diabetes with autonomic polyneuropathy, hypertension, renal disease, anxiety disorder, visual impairment, and generalized muscle weakness. Her admission MDS documented impaired vision requiring corrective lenses, moderate cognitive impairment (BIMS 10), dependence or high assistance needs for mobility, toileting, showering, dressing, and personal hygiene, bowel and bladder incontinence, use of a wheelchair, and multiple active diagnoses and treatments such as a therapeutic diet, antidepressants, antiplatelets, and oxygen. The MDS triggered care areas including cognitive loss/dementia, visual function, communication, ADL function/rehab potential, urinary incontinence, falls, nutritional status, pressure ulcer, and psychotropic drug use. Despite this, her comprehensive care plan only contained an entry for full code status, and no other identified conditions or triggered care areas were addressed.

For Resident #3, the facility also failed to develop a comprehensive care plan beyond code status. This resident’s face sheet and admission MDS documented Type 2 diabetes, vitamin D deficiency, depression, insomnia, essential hypertension, low back pain, dementia, muscle wasting and atrophy, generalized muscle weakness, difficulty walking, unsteadiness on feet, lack of coordination, and a cognitive communication deficit. The MDS showed a BIMS score of 12 (moderate cognitive impairment), supervision or touch assistance for some functional tasks, independence with rolling, sit-to-stand, and transfers, and continence of bowel and bladder. Active diagnoses included hypertension, diabetes, non‑Alzheimer’s dementia, depression, insomnia, low back pain, muscle wasting, generalized weakness, lack of coordination, and unsteadiness on feet. The resident used a pressure-reducing device for bed, was receiving antidepressants, and was utilizing speech and physical therapy. The MDS triggered care areas for cognitive loss/dementia, ADL function/rehab potential, urinary incontinence/indwelling catheter, falls, nutritional status, and psychotropic drug use. However, the comprehensive care plan initiated only listed the resident as full code, with no development of care plan interventions for the triggered areas.

For Resident #4, the facility again did not develop a comprehensive care plan consistent with the admission MDS findings. This resident had numerous diagnoses, including cerebral infarction with resulting hemiplegia/hemiparesis of the left non-dominant side, vascular dementia with agitation and behavioral disturbance, osteoporosis, hyperlipidemia, alcohol dependence in remission, major depressive disorder, generalized anxiety disorder, insomnia, chronic pain, essential hypertension, atherosclerotic heart disease, atrial fibrillation, combined systolic and diastolic CHF, speech and language deficits following stroke, disorders of arteries and arterioles, constipation, gout, contracture of the left hand, chronic kidney disease, overactive bladder, benign prostatic hyperplasia, dysphagia, lack of coordination, cognitive communication deficit, and shoulder subluxation. The admission MDS documented minimal hearing loss in some environments, impaired vision with corrective lenses, severe cognitive impairment (BIMS 5) without behaviors, wheelchair use with inability to ambulate, maximal assistance needs for movement, transfers, dressing, showering, and toileting/hygiene, setup assistance for personal hygiene, oral care, and eating, frequent bowel and bladder incontinence, scheduled pain medication for pain affecting sleep and activities, shortness of breath when lying flat, current tobacco use, and risk for pressure ulcers. The resident was receiving multiple medication classes including antidepressant, anticoagulant, diuretic, opioid, antiplatelet, and anticonvulsant. The MDS triggered care areas for cognitive loss/dementia, visual function, communication, ADL function/rehab potential, urinary incontinence/indwelling catheter, falls, nutritional status, pressure ulcer, psychotropic drug use, and pain. The comprehensive care plan initiated for this resident contained only a care area for verbally inappropriate behaviors, with no other triggered care areas developed.

Interviews with facility leadership further described the circumstances leading to the deficiency. The Administrator stated that the facility did not currently have an on-site MDS Coordinator and that corporate staff were performing the work remotely. A corporate LVN reported she had been remotely assigned MDS coordination for about one week, following the departure of the facility’s full-time MDS Coordinator, and that she had not yet reviewed any care plans. The DON acknowledged awareness that some residents did not have comprehensive care plans and stated she had been working on them when possible while corporate staff began filling the role. She confirmed that the comprehensive care plans for the three cited residents had not been developed and was unsure why they were not completed in December when a prior MDS Coordinator was still in place, noting that the previous coordinator had been struggling despite being given sample care plans. The DON stated that a comprehensive care plan should be developed and implemented within 20 days of admission and that such plans are important so staff know how to care for each resident and to provide a general picture of the resident and their care needs. Facility policy dated March 2022 specified that the comprehensive, person-centered care plan is to be developed within seven days of completion of the required MDS assessment and no more than 21 days after admission.