Failure to Accurately Revise and Update Resident Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to revise and accurately maintain comprehensive care plans for two residents following their assessments. For one resident, review of the care plan dated 02/17/26 showed that focus areas related to enhanced barrier precautions and vision interventions contained another resident’s name instead of the correct resident’s name. During an interview, the DON confirmed that other residents’ names were used in this resident’s care plan. For another resident, record review showed admission with multiple diagnoses, including bipolar disorder, Alzheimer’s disease, age-related nuclear cataracts in both eyes, generalized anxiety disorder, and insomnia. During observation, this resident was seen ambulating in the room with a fall mat on the floor by the bed. However, review of the care plan dated 12/02/25 revealed no indication that a fall mat was in use for this resident. In an interview, the DON stated that any time a resident uses a fall mat it must be included in the care plan and confirmed that this resident’s care plan did not include the fall mat.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.