Failure to Update Care Plans With Current Orders and Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to revise and update care plans to reflect current physician orders and resident conditions for multiple residents. One resident had a physician’s order dated 12/31/25 for enteral feeding with 250 ml of Jevity 1.2 to be given when oral intake was less than 25% of meals, but the comprehensive care plan dated 04/22/25 did not include this enteral feeding order or related interventions. The DON confirmed that the resident’s enteral feeds and interventions were not documented in the care plan. Another resident, admitted on an unspecified date, was observed on 01/06/26 to have thick, layered toenails. This resident had a physician’s order dated 11/14/25 to check fingernails and toenails, trim and file as allowed every Tuesday and Friday, and document refusals. However, the care plan dated 12/28/25 did not include the nail care order or describe how staff manage care when the resident refuses nail care and becomes combative. A CNA reported that this resident does not allow staff to file or trim her nails and becomes combative, and the Unit Manager stated his expectation that the resident should be care planned for nail care and behaviors. A third resident had a physician’s order dated 12/29/25 for PRN oxygen therapy at 1–2 L/min via nasal cannula for low oxygen, but the care plan dated 09/08/25 did not include oxygen therapy or related interventions. The Administrator confirmed that the resident’s oxygen and interventions were not documented on the care plan and stated that oxygen should be documented there. Across these residents, surveyors identified that the facility did not ensure care plans were revised with the most current information, including new physician orders and behavioral responses to care, despite observations, record reviews, and staff interviews confirming the omissions.
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