Failure to Individualize and Revise Fall Care Plans After Repeated Falls
Summary
The deficiency involves the facility’s failure to develop and revise individualized fall care plans that addressed resident-specific supervision needs after multiple falls for two cognitively impaired residents. For the first resident, who had dementia, an impulse disorder, anxiety, a history of falls, and a very low BIMS score indicating significant cognitive impairment, the MDS showed the resident required maximal assistance to stand and was totally dependent on staff for transfers. Progress notes documented numerous falls over an extended period, including witnessed and unwitnessed falls in the hallway, in front of the nurses’ station, and in the resident’s room, some resulting in lacerations and hospital transfers. Despite this pattern, the written fall care plans remained generic and did not address the resident’s need for close supervision. The initial fall care plan for this resident, initiated in early December, listed broad interventions such as assessing fall risk on admission and with changes in condition, assisting with ambulation and transfers per therapy recommendations, determining transfer ability, using floor mats, alerting the provider after a fall, performing neuro and bleeding evaluations per protocol, implementing fall precautions per facility protocol, and maintaining a clutter-free room. The Director of Staff Development (DSD) stated that this care plan contained nothing individualized for fall prevention and did not address the resident’s supervision needs, despite the resident’s inability to follow directions, lack of situational awareness, and inability to use the call light purposefully. A subsequent care plan created after a witnessed fall in mid-February focused on post-fall monitoring, including medication review, monitoring and reporting signs and symptoms such as pain and changes in mental status, and performing neuro checks for 72 hours, but again did not include preventive or supervision-related interventions. After another fall in late March that resulted in lacerations and a possible shoulder injury, the fall care plan was revised to include contacting hospice MD if authorized to send the resident to the hospital, monitoring and reporting signs and symptoms for 72 hours, performing neuro checks, and sending the resident to the ER for further evaluation. The DSD stated these interventions did not prevent further falls and that the care plans should have been revised with individualized interventions based on the resident’s needs, including his higher need for supervision that led to his placement in front of the nurses’ station. A unit manager (UM 2) confirmed that the interdisciplinary team was supposed to meet after each fall to investigate the cause and develop relevant interventions, but acknowledged that the resident’s care plans did not address his supervision needs and that no assessment had been done to determine those needs. For the second resident, who had Alzheimer’s disease, unspecified dementia, difficulty walking, muscle weakness, and a BIMS score indicating cognitive impairment, the MDS showed the resident required moderate assistance for transfers. Progress notes documented multiple falls over time, including assisted and unassisted falls in the bathroom, in the resident’s room, by the commode, in the hallway, in front of the nurses’ station, and in the dining room, with some falls resulting in head and facial bleeding, a compression fracture, and hospital transfers. A unit manager (UM 1) stated that this resident wanted to remain independent but was confused, frail, and required staff to monitor her every 15 minutes to ensure she was not trying to get up on her own. UM 1 also noted that the last fall risk evaluation before a January fall had been done many months earlier and that the resident should have been reassessed for fall risk with her quarterly MDS assessments. UM 1 reviewed the resident’s fall risk care plan, which had been created shortly after an early fall and revised later, and stated it was vague. The care plan included an intervention stating, “If resident is a fall risk, initiate fall precautions,” but UM 1 indicated the resident’s fall risk should have been clearly determined earlier with specific fall precautions. Another intervention, “Determine resident’s ability to transfer,” was also identified as something that should have been established long before. An intervention to “increase rounding frequency,” initiated after the January fall, lacked clarity about who was responsible and did not specify the intended 15-minute interval. Another intervention stated that when the resident was up in a wheelchair, she would be placed at the nursing station, yet the resident still experienced an unwitnessed fall in front of the nurses’ station and another fall in the dining room afterward. An IDT note following the January fall documented the team’s meeting and confirmation of a compression fracture but did not include any discussion of the root cause of the fall or recommendations to prevent further falls. The interim DON, who had recently started in the role, reported that falls for residents, including these two, had not been thoroughly investigated to determine their causes. She stated that IDT documentation she reviewed only described the falls without identifying root causes, and emphasized that without determining how the falls happened, relevant interventions could not be added to care plans to prevent further incidents. The medical records director confirmed that the facility did not have a policy for care plan development or revision. As a result of these actions and inactions, the facility failed to revise fall care plans with resident-specific interventions that addressed supervision needs for the two residents after falls occurred, creating the potential for further falls as stated in the report.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
IDT Did Not Review Quarterly Care Plan Revisions: A resident with anoxic brain damage, pulmonary HTN, and paraplegia had quarterly MDS assessments completed, but no IDT care conferences were documented for an extended period while the care plan was revised multiple times. Interviews showed the CQAN said the quarterly care planning process included an IDT meeting and that the IDT significantly influenced the care plan, while the MDS Coordinator said she completed quarterly reviews even when no IDT had been held.
Failure to Offer Quarterly Care Conferences: A resident with depression, anxiety, chronic pain, and DM was not consistently offered or documented for quarterly care conferences. The EMR showed one conference note where the resident declined participation, but no evidence of any later conferences being offered, provided, or refused. The resident said she did not always know the plan of care, and the family member said she had not been invited in over a year and did not know what was going on with the resident’s care.
A resident with chronic respiratory failure with hypoxia and diabetes had physician orders for continuous O2 and compression stockings, but was observed without either in place. The care plan did not document the oxygen or compression stocking interventions, and the DON stated refusals also were not documented.
A resident with major depressive disorder, stroke-related weakness/paralysis, and anxiety had a care plan that did not reflect her PASRR positive status for mental illness or include PASRR-related interventions, even though records showed she had been receiving MI specialized services and attending quarterly PASRR meetings. The annual MDS was coded as no ID/DD-related PASRR condition, and staff including the MDS coordinators, DON, and Administrator acknowledged the care plan was inaccurate and should have been reviewed and revised by the IDT.
Care plan not updated for new insulin use and blood sugar monitoring. A resident with DM and intact cognition began receiving insulin and required BG monitoring, but the care plan did not reflect the new insulin regimen or monitoring needs. The MAR showed insulin orders, and a progress note documented BG checks before lunch and dinner. Staff stated the resident was a new diabetic and the care plan had not been updated to match the new diagnosis.
A resident’s CCP was not updated after an oxygen order changed from 3 LPM to 4-5 LPM, and two other residents’ CCPs did not reflect self-administration of medications. One resident with schizophrenia had multiple meds ordered for bedside storage or unsupervised self-administration, but the CCP had no related focus or interventions. Another resident with dementia and diabetes was observed self-administering insulin even though the CCP only addressed staff administration.
IDT Did Not Review Quarterly Care Plan Revisions
Penalty
Summary
The facility failed to ensure Resident #40’s comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after quarterly assessments. Resident #40 was admitted with diagnoses including anoxic brain damage, pulmonary hypertension, and paraplegia. The record showed an IDT care conference was completed in January 2026, and the resident later had a Significant Change Assessment on 2/2/26 and Quarterly Assessments on 3/9/26 and 6/7/26, but no other IDT care conferences were documented until 8/13/26. The resident’s care plan was revised multiple times between January 2026 and 8/13/26, including revisions on 2/12/26, 2/17/26, 2/22/26, 2/23/26, 2/25/26, 3/25/26, 4/6/26, 4/15/26, 4/21/26, 5/4/26, 5/13/26, 6/9/26, 7/30/26, 8/7/26, and 8/10/26. During interviews, the CQAN stated the quarterly care planning process included an IDT meeting and that the IDT significantly influenced the information incorporated into the quarterly care plan, while the MDS Coordinator stated she completed quarterly care plan reviews regardless of whether an IDT had been held. The facility policy stated comprehensive, person-centered care plans are based on resident assessments and developed by an IDT.
Failure to Offer Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure quarterly care conferences were provided or offered for one resident who was cognitively intact and did not exhibit rejection of care behavior. The resident’s quarterly MDS indicated diagnoses of major depressive disorder, anxiety, chronic pain, and diabetes. A progress note from 5/21/25 documented that a conference occurred without the resident or a resident representative in attendance, and the resident stated she did not want to participate. The EMR did not contain evidence that any other care conference was offered, provided, or refused after that date. During interviews, the resident stated she did not always know what the plan was and could not remember attending or being offered a care conference in a long time. The social worker verified that no care conferences were documented in the EMR since May 2025 and stated care conferences should be completed quarterly. The social worker also stated the resident was due for conferences in March and June 2026 and that the family member would have been invited. The family member stated she had not been invited to or attended a care conference in over a year and did not know what was going on with the resident’s care. The DON stated quarterly care conferences were expected and that if the resident declined to participate, the EMR would have evidence of the refusal. Facility policy required residents and their representatives to be invited at least two weeks in advance, and if not invited, an explanation had to be included in the medical record.
Care Plan Not Updated for Oxygen and Compression Stocking Needs
Penalty
Summary
The facility failed to ensure a resident’s care plan was revised to reflect current needs and interventions. The facility’s policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident, and that care plans are revised as resident information and conditions change. Resident #55 was admitted with multiple diagnoses including chronic respiratory failure with hypoxia and diabetes, and had physician orders for compression stockings to the right leg and continuous oxygen at 1-2 L/min via nasal cannula as tolerated. On 8/4/26, Resident #55 was observed in her room with a portable liquid oxygen unit on the back of her wheelchair and an oxygen concentrator at bedside, but she was not wearing oxygen or compression stockings. CNA #2 stated the resident did not have oxygen on and should have. Review of the resident’s care plan showed it did not document the use of oxygen or compression stockings. The DON stated the care plan had not documented the use of oxygen or compression stockings and should have, and that refusals should have been documented but were not.
Care plan not updated for PASRR-positive resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one resident with PASRR positive status for mental illness. Resident #2 was admitted and readmitted with diagnoses including major depressive disorder, stroke with hemiplegia and hemiparesis, and anxiety disorder. Her annual MDS dated 03/13/2026 showed a BIMS score of 10, indicating moderate cognitive impairment, and the MDS Section A1500 was coded as no ID/DD-related PASRR condition. However, record review showed she had been PASRR positive for mental illness since a Level 1 screening dated 07/24/2025 and had a PASRR Comprehensive Service Plan dated 08/27/2025 showing she received MI specialized services. The resident’s care plan updated on 07/08/2026 addressed antipsychotic medication use for major depressive disorder with monitoring and reporting interventions, but no care plan identified her PASRR positive status or included interventions related to PASRR services. During interviews, the resident and family stated she had been PASRR positive since admission, attended quarterly PASRR meetings, and received MI specialized services. MDS Coordinator A, MDS Coordinator B, the DON, and the Administrator all stated the care plan should reflect PASRR positive status and be reviewed and revised by the IDT, and they acknowledged the annual MDS and comprehensive care plan were not accurate.
Care plan not updated for new insulin use and blood sugar monitoring
Penalty
Summary
The facility failed to update the care plan for R36 when the resident began using insulin and required blood sugar monitoring. R36 had a diagnosis of diabetes mellitus, and the Quarterly MDS documented a BIMS score of 15, indicating intact cognition, with no insulin use listed on the medication list at that time. The Annual MDS later documented that R36 received seven days of insulin, but the care plan dated 06/27/2026 did not include information that the resident had started insulin or needed blood glucose monitoring. The MAR dated 06/28/2026 showed insulin orders for 10 units subcutaneously at bedtime with blood glucose checks and 14 units subcutaneously in the morning, and a progress note dated 07/16/2026 documented that blood sugar was to be checked before lunch and dinner. Administrative Nurse E stated that R36 was a new diabetic and the care plan had not been updated, and Administrative Nurse D stated that care plans should be updated when a resident has a new diagnosis. The facility policy on care plan revisions upon status change stated that the process was intended to provide a consistent review and revision of the care plan for residents experiencing a status change.
CCPs Not Updated for Oxygen Orders and Self-Administration Needs
Penalty
Summary
The facility failed to keep the Comprehensive Care Plan (CCP) updated for a resident with malignant neoplasm of the left bronchus or lung, chronic obstructive pulmonary disease, and chronic respiratory failure. The resident’s CCP still listed oxygen at 3 liters per minute via nasal cannula with a start date of 10/23/2025, while the active physician’s order reviewed on 7/21/2026 directed continuous oxygen via nasal cannula at 4 to 5 liters, with a start date of 5/23/2026. The Clinical Nurse Manager confirmed on 8/3/2026 that the CCP had not been updated when the oxygen order changed and should have been. The facility also failed to include self-administration of medications in the CCPs for two residents. One resident with schizophrenia had active orders for several medications that could be kept at bedside or were marked for unsupervised self-administration, including cough drops, Vicks VapoRub, saline mist, and Abreva, and was observed with cough drops on the bedside table while stating the medication could be kept in the room. The CCP contained no focus, goal, or interventions related to self-administration, and the CNM confirmed this omission. Another resident with unspecified dementia and type 2 diabetes mellitus had an order for insulin lispro injections, no order for self-administration, and a CCP that addressed insulin-dependent diabetes only with medication administration by staff; however, the resident was observed being handed an alcohol wipe and syringe and then self-administering insulin.
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