F0656

D

Failure to Develop Comprehensive ADL Care Plans for Two Residents

San Antonio, Texas Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents. For one resident, a female with sequelae of cerebral infarction, vascular dementia without behavioral disturbance, and a documented need for assistance with personal care, the quarterly MDS showed she required maximal assistance with bathing and was totally dependent on staff for personal hygiene and toileting. Despite these assessed needs, her ADL self-care performance deficit care plan, initiated in 2023 and last revised in late 2025, listed shower/baths as "N/A" (not applicable), and therefore did not reflect her actual bathing and showering requirements as identified in the MDS and clinical record.

For another resident, a male with paraplegia, type 2 diabetes mellitus, and a need for assistance with personal care, the 5-day Medicare MDS documented that he was cognitively intact with a BIMS score of 15 and required maximal assistance with showering/bathing and transfers, total dependence for toileting, dressing, and wheelchair use, moderate assistance for certain bed mobility tasks, and supervision for rolling. His ADL self-care performance deficit care plan, however, did not identify these specific ADL needs and only stated that he should be encouraged to participate to the fullest extent possible with each interaction. Interviews with the new, inexperienced MDS Coordinator and the DON confirmed that the MDS Coordinator was responsible for care plans, was focused mainly on skilled residents, was still in training for LTC care plans, and that the care plans for both residents were missing required information and did not match the MDS assessments or actual care needs, contrary to the facility’s written policy on comprehensive person-centered care planning.