Failure to Revise Care Plans After Behavioral Incidents and Falls
Summary
The deficiency involves the facility’s failure to develop, revise, and implement comprehensive, measurable care plans that addressed residents’ behavioral symptoms and fall risks after significant events. For one resident with Alzheimer’s disease, dementia, PTSD, and moderate cognitive impairment, the record showed multiple resident‑to‑resident verbal altercations and an incident on 2/24/2026 in which he was pushed to the floor, hit his head, and sustained skin tears after yelling at another resident near an exit door alarm. Although the Risk Manager reported that care plan approaches were requested to be updated after incidents on 2/24/2026, 3/30/2026, and 4/2/2026, the behavioral care plan for this resident only addressed refusal of care and resistance to assistance, with no updates reflecting his pattern of yelling at other residents at the exit door. His falls care plan identified him as at risk for injury due to unsteady gait, dementia, pain, stroke history, psychotropic use, and antiplatelet therapy, but no new fall‑related approaches were documented after 3/6/2026 despite the fall with head impact. Another resident with early‑onset Alzheimer’s disease, dementia with psychotic and mood disturbance, severe cognitive impairment, and daily wandering had documented physical behavioral symptoms toward others and frequent wandering. Progress notes indicated excessive wandering, exit‑seeking behaviors that were not easily redirected, and involvement in five resident‑to‑resident altercations between 2/24/2026 and 4/2/2026, all related to his wandering. His care plan included a wandering/elopement problem and a behavioral problem describing constant pacing, wandering, impaired awareness of personal space, and risk for resident‑to‑resident conflict, with approaches such as frequent observation, redirection from other residents’ rooms and crowded areas, reassurance, and use of a sensory chew. However, there were no documented care plan updates specifically addressing the series of resident‑to‑resident altercations that occurred during the review period. A third resident with Alzheimer’s disease, dementia with mood disturbance, adjustment disorder, severe cognitive impairment, and no behaviors coded on the MDS had multiple documented resident‑to‑resident incidents. Progress notes described him standing over his roommate yelling about noise, an altercation with another resident on 3/16/2026, and an event on 3/25/2026 where he stuck his foot out in an attempt to trip another resident who was pacing in front of his view of the television. His behavioral care plan, initiated in 2024 and last edited on 2/18/2026, focused on increased confusion and agitation at the end of the day that may lead to verbal aggression, with general approaches such as discussing behaviors, assisting with coping methods, altering care approaches if he became combative, protecting others’ rights and safety, monitoring behaviors, and psychiatry referral. No care plan revisions were documented to specifically address his observed attempts to trip another resident or the repeated resident‑to‑resident altercations. A fourth resident with Alzheimer’s disease, dementia with agitation and other behavioral disturbance, PTSD‑related psychosis, severe cognitive impairment, and frequent physical and verbal behavioral symptoms toward others had multiple falls and a documented resident‑to‑resident altercation. Progress notes showed several unwitnessed or observed falls in common areas and on the floor, as well as an incident where he took another resident’s hat and attempted to push another resident out of a wheelchair, after which he was pushed by the other resident. His falls care plan identified him as at risk for falls due to expected physical decline, psychotropic use for PTSD, resistance and combativeness, and antiplatelet therapy, with approaches last updated in 2024 and 2025. No recent updates were made to his care plan to reflect the series of falls or the resident‑to‑resident interaction. The MDS RN and DON acknowledged that care plans for these residents had not been reviewed and revised with new approaches after the problem behaviors and incidents occurred, despite facility policy requiring care plan review and revision when significant changes, unmet outcomes, or new needs are identified. The facility’s written policy on care plan development, revised 11/28/2017, states that care plans will be reviewed and revised as needed, including when a significant change in condition is noted or when outcomes are not achieved, and that all team members must report changes in condition and unmet goals to the primary/charge nurse and MDS coordinator. Documentation is required to be consistent with the resident’s plan of care, and revisions may be made by any member of the interdisciplinary team on an as‑needed basis. In the cases of these four residents, surveyors found that despite documented behavioral incidents, resident‑to‑resident altercations, and repeated falls, the corresponding care plans were not updated with new, measurable approaches to address the identified behaviors and risks, resulting in a failure to ensure comprehensive care plans that met all of the residents’ needs.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with anoxic brain damage, persistent vegetative state, and type 2 DM was assessed on the MDS as having impaired ROM in all extremities and total dependence for all ADLs, but the comprehensive care plan did not include any interventions addressing the limited ROM. An MDS LPN confirmed that the ROM limitation was omitted from the care plan, despite facility policy stating that the care plan is the written treatment to provide optimal personalized care and services. This deficiency was identified for one of several residents with limited ROM in a larger facility census.
A resident admitted with stage 2 and stage 3 heel pressure ulcers had physician orders for detailed wound care to the right heel, offloading of the right foot in bed, and use of a heelless shoe while ambulating. The comprehensive care plan identified risk for pressure ulcers and documented only the left heel wound, with general skin and pressure-relief interventions such as hydration monitoring, daily skin checks, pressure redistribution surfaces, and weekly nurse skin assessments. The care plan did not include the right heel pressure ulcer or the ordered interventions for offloading and heelless shoe use, which the DON confirmed were absent, contrary to facility policy requiring comprehensive, person-centered care plans for all identified conditions.
A resident with metabolic encephalopathy, chronic diastolic HF, peripheral vascular disease, and ESRD, who had mild cognitive impairment and required extensive assistance with all ADLs, had a PICC line in place with an order to schedule removal. However, review of the record showed no additional PICC line orders and no care plan addressing the PICC line in the comprehensive care plan. In an interview, a regional nurse confirmed there was no care plan or documentation of care for the PICC line, resulting in a cited deficiency.
Surveyors found that three residents with multiple comorbidities, including CHF, CKD, COPD, Parkinson’s disease, DM, and cancer, had documented bladder incontinence and dependence on staff for toileting hygiene and transfers per their MDS assessments, yet their active care plans did not address urinary or bowel incontinence or required toileting assistance. One cognitively intact resident was frequently incontinent of bladder and needed substantial/max assist with toilet transfers, another with moderately impaired cognition was always incontinent of bladder and bowel and required substantial/max assist for toileting, and a third cognitively intact resident was frequently incontinent of bladder and dependent on staff for toileting hygiene. The DON acknowledged that basic ADL and toileting/incontinence care plans were missing for these residents and confirmed that two of them, who remained in the facility, had known incontinence without corresponding care plan updates.
A resident with a documented history of depression was prescribed Buspirone and Vistaril for anxiety, and the MDS reflected use of anti-anxiety medications, yet the Active Diagnoses section did not list an anxiety disorder. Review of the resident's care plans showed they addressed only depression and antidepressant use, and the psychotropic medication care plan referenced only antidepressants, omitting the anti-anxiety drugs. The MAR confirmed ongoing administration of both anti-anxiety medications, and the DON acknowledged that the resident's anxiety and related medications were not included in the active care plans.
Surveyors found that the facility failed to develop comprehensive care plans for two residents, one with severe, ongoing pain and another with a history of frequent medication refusal. One resident, with multiple renal and diabetic conditions and physician orders for pain medications, had documented severe pain interfering with sleep and was observed in obvious distress, yet the care plan contained no pain management focus or interventions. Another resident with end stage renal disease and type 1 DM had repeated documented refusals of several ordered medications, but the care plan did not address or reflect this ongoing pattern of refusal, as confirmed by an LPN and a unit manager.
Failure to Include Limited Range of Motion Needs in Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to address a resident’s impaired range of motion in the comprehensive care plan. The resident was admitted with diagnoses including anoxic brain damage, persistent vegetative state, and type 2 diabetes mellitus. An MDS assessment documented that the resident was in a persistent vegetative state with no discernible consciousness, was dependent on staff for all ADLs, and had impaired range of motion in all extremities. Despite this, review of the resident’s care plan showed no interventions related to the limited range of motion. During an interview, the MDS LPN confirmed that the resident’s limited range of motion was not included on the care plan and acknowledged that this information should be present so staff are aware of the limitations. Facility policy stated that the care plan is the written treatment provided to enable optimal personalized care and services, but the resident’s range of motion needs were not incorporated, resulting in the cited deficiency. This deficiency was identified for one resident reviewed for limited range of motion, in the context of eight residents in the facility who had limited range of motion and an overall census of 112 residents. It was investigated under Complaint Number 2963128.
Failure to Include All Pressure Ulcers and Interventions in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included all of a resident's skin issues and associated interventions. A resident admitted with diagnoses including a stage 2 pressure ulcer of the left heel and a stage 3 pressure ulcer of the right heel had physician orders in place for specific wound care to the right heel, including cleansing with normal saline, applying a betadine wet-to-dry sterile dressing, covering with an ABD pad, wrapping with kerlix, and applying betadine only to the wound area. Additional orders included applying antibiotic cream and a Band-Aid to the left heel daily, offloading the right foot at all times while in bed, and using a heelless shoe on the right foot while ambulating. Review of the resident’s care plan, dated the same day as admission, showed the resident was identified as being at risk for pressure ulcers and other skin problems related to decreased mobility and diabetes, and it documented a wound to the left heel. Interventions listed included monitoring hydration every shift, monitoring skin daily with routine care, using a pressure redistribution cushion in the wheelchair, a pressure redistribution mattress on the bed, and completing weekly skin assessments by a nurse. However, the care plan did not include the right heel pressure ulcer or the specific interventions for offloading the right foot and use of the heelless shoe. In an interview, the DON confirmed that there was no care plan addressing the right heel pressure ulcer or these related interventions, despite facility policy requiring comprehensive, person-centered care plans with measurable objectives and services for identified problem areas and conditions.
Failure to Care Plan PICC Line for Dependent Resident
Penalty
Summary
The facility failed to develop and implement a care plan for a resident’s peripherally inserted central catheter (PICC) line, despite documentation in the medical record that an order was written to schedule an appointment for PICC line removal. The resident was admitted with diagnoses including metabolic encephalopathy, chronic diastolic heart failure, peripheral vascular disease, and end stage renal disease, had mild cognitive impairment, and required extensive assistance with all activities of daily living per the admission MDS assessment. Review of the comprehensive care plan showed no documentation related to the PICC line, and no other PICC line orders were observed in the record aside from the order to schedule removal. During an interview, the Regional Nurse confirmed there was no care plan developed for the PICC line or documentation of care, resulting in a cited deficiency affecting this resident and investigated under multiple complaint numbers.
Failure to Care Plan for Incontinence and Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing bladder and bowel incontinence and toileting assistance for three residents. For one resident with CHF, chronic kidney disease stage three, hypertension, and edema, the quarterly MDS showed she was cognitively intact, frequently incontinent of bladder, always continent of bowel, dependent on staff for toileting hygiene, and required substantial/maximal assistance with toilet transfers. Despite these documented needs, her care plans, initiated in late October and last revised in early April, did not include any care plan to address urinary incontinence or assistance with ADLs related to toileting. Another resident with Parkinson’s disease, adult-onset DM, COPD, and hypertension had an admission MDS indicating unclear speech but usual ability to make himself understood, minimal hearing difficulty, moderately impaired cognition, a need for substantial/maximal assistance with toileting hygiene and toilet transfers, and was always incontinent of both bladder and bowel. His active care plans, initiated in late February and last revised in early March, contained no care plan or interventions to address his incontinence or toileting needs. A third resident, with COPD, acute on chronic respiratory failure, lung cancer, heart failure, oxygen dependence, chronic kidney disease stage three, muscle weakness, syncope, and a history of fall, was cognitively intact and dependent on staff for toileting hygiene, required substantial/maximal assistance with toileting transfers, and was frequently incontinent of bladder per her quarterly MDS. Her care plans, initiated in March and in effect through her discharge in April, also lacked any care plan addressing urinary incontinence or toileting assistance. In an interview, the DON confirmed that these residents did not have basic care plans in place for ADL and toileting/incontinence needs and acknowledged that the two residents still in the facility were known to have incontinence without corresponding updates to their care plans.
Failure to Care Plan for Anxiety Disorder and Anti-Anxiety Medications
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's anxiety disorder and related anti-anxiety medications, as required by §483.21(b). The resident was admitted with a diagnosis of depression and later received new physician orders for Buspirone 5 mg twice daily and Vistaril 25 mg three times daily, both prescribed for anxiety. The quarterly MDS assessment documented that the resident received anti-anxiety medication during the assessment period, but the Active Diagnoses section did not list an anxiety disorder diagnosis despite the ongoing use of two medications for that condition. Review of the resident's active care plans showed no care plan specifically addressing anxiety or the use of anti-anxiety medications. Existing care plans addressed potential mood fluctuations and depression, focusing only on antidepressant use, and a separate care plan for risk of adverse reactions to psychotropic medications referenced only antidepressant therapy for depression. The MAR confirmed that the resident was receiving Buspirone and Vistaril as ordered for anxiety. In an interview, the DON confirmed that the resident's active care plans did not address her anxiety or the use of anti-anxiety medications and acknowledged that a care plan for anxiety should have been in place.
Plan Of Correction
1. Resident #100 had their order for Buspar and Vistaril orders clarified on 4/22/26 by the Unit Manager to clarify the indication for use of the ordered medications and validated care plan for accuracy. The Buspar order was clarified by the physician to be used for diagnosis of Depression and the Vistaril order was clarified by the physician to be used for a diagnosis of itching. The care plan was updated to include the use of the antianxiety/anxiolytic medications for diagnoses of Depression and Itching on 5/7/26 by Social Service Designee. The resident does not have an active diagnosis of Anxiety as clarified by the physician. 2. Like Residents are identified as residents who utilize medication for anxiety. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Medication Review Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure residents who utilize medication for anxiety have an active diagnosis and care plan in place to address anxiety. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Care Planning and Physicians Orders Policies to ensure orders include an accurate and appropriate diagnosis and a care plan is initiated or revised to indicate use of antianxiety/anxiolytic medications. This education will be completed on or before 5/13/26. 4. Utilizing the Medication Review Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will F 0656 complete an audit 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure residents who utilize medication for anxiety have an active diagnosis and care plan in place to address anxiety. Discrepancies noted from audits will be corrected to include clarification of orders and revision of care plans. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Develop Comprehensive Care Plans for Pain and Medication Refusal
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive care plans addressing pain management and medication refusal for two residents. One resident was admitted with diagnoses including acute pyelonephritis, bladder and kidney calculi, chronic kidney disease, and diabetes mellitus, had intact cognition, and required staff assistance with ADLs. Physician orders included Lyrica twice daily for chronic pain syndrome and Robaxin four times daily for pain, but the care plan dated shortly after admission did not include any focus or interventions for pain management. A pain assessment documented that this resident experienced severe pain frequently over the previous five days that interfered with sleep. Observation showed the resident in bed, constantly moving with a pained expression, and the resident reported urinary frequency, flank pain from a kidney stone, and rated the pain as 10 out of 10. The DON confirmed that the resident’s care plan did not address the need for pain management. The second resident was admitted with end stage renal disease and type 1 diabetes mellitus. The care plan developed after admission did not include a focus on the resident’s frequent refusal of medications, despite active physician orders for Lyrica, Renvela, calcium carbonate, trazodone, and Prostat. Multiple progress notes over several days documented repeated refusals of Renvela, calcium carbonate, trazodone, and Prostat at various times, indicating an ongoing pattern of medication refusal. An LPN confirmed that this resident had a history of frequently refusing medications throughout the stay, and the Unit Manager verified that the care plan did not reflect this frequent refusal. These findings show that the facility did not develop and implement complete, measurable care plans that addressed identified needs related to pain management and medication refusal for the affected residents.
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