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
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Care plan omissions were identified for two residents. One resident’s care plan did not include multiple documented diagnoses, including UTI, bleeding hemorrhoids, TBI, pneumonia, CKD, and diverticulitis, despite severe cognitive impairment. Another resident’s care plan did not include a physician order for biannual valproic acid level testing and monitoring for side effects, and the DON and MDS Coordinator stated these items should have been included.
Missed Quarterly Care Conference and Resident Participation: A resident who was cognitively intact and had HTN, arthritis, and schizophrenia did not have documented routine care conferences at the expected quarterly interval. The EMR showed care conferences were documented, but there was no evidence of one between two documented meetings, and the resident stated she had not been invited to any care meetings over the past year. The LSW and Admin both confirmed the lack of documentation and stated residents should be included when able.
A resident with cerebral palsy and depressive disorder had conflicting code status documentation in the medical record: the emergency care document showed full code, while the care plan listed DNR and no CPR. The DON stated the care plan was completed in error and should have been revised but had not been.
Missed Care Conference Participation: A resident with intact cognition was not given the opportunity to attend and participate in a care conference. Staff confirmed care conferences were expected after MDS assessments and significant changes, but the resident’s record showed no conference documented for several months, and the family member reported the last conference had been months earlier.
A resident with dementia, bipolar disorder, and HF was on hospice status, but the care plan did not identify the terminal illness as a focus area or include hospice/end-of-life interventions. The care plan only referenced hospice in limited areas such as ADL care, psychosocial support, activities, and anti-anxiety medication related to end of life. The DNS acknowledged the care plan was not revised to reflect the resident’s hospice status.
Care plans were not updated to reflect changed resident conditions, preferences, and interventions. One resident's plan still showed hospice and wound-based EBP after hospice ended and the wound healed, another still listed Influenza A after the illness had resolved, and a third did not include behavior interventions such as a door chime and bookshelf sticker or updated dining preferences. Two residents with family-requested cameras also had care plans that omitted the camera use, rationale, and related monitoring details.
Care Plan Omissions for Resident Diagnoses and Valproic Acid Monitoring
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for 2 of 32 residents reviewed. Resident #1 was admitted with diagnoses including frequent urinary tract infections, bleeding hemorrhoids, traumatic brain injury, pneumonia, chronic kidney disease, and diverticulitis, and the quarterly MDS showed a BIMS score of 7 indicating severe cognitive impairment. The resident’s care plan, revised 03/05/2026, did not include those diagnoses even though they were part of the resident’s documented medical history. Resident #8 was admitted with diagnoses including unspecified dementia, type 2 diabetes mellitus, and heart failure, and the quarterly MDS showed a BIMS score of 6 indicating severe cognitive impairment. The resident’s order summary included a physician order dated 01/23/2025 for valproic acid level testing every 6 months in October and April, but the care plan, revised 05/14/2026, did not include that order. During interviews, the DON and MDS Coordinator stated that both residents’ omitted diagnoses and the valproic acid monitoring order should have been included in the care plans, and the MDS Coordinator identified the omission as an oversight.
Missed Quarterly Care Conference and Resident Participation
Penalty
Summary
The facility failed to provide routine care conferences to allow resident participation for one resident who was reviewed for care conferences. The resident’s quarterly MDS assessment indicated admission to the facility, cognitive intactness, and diagnoses of high blood pressure, arthritis, and schizophrenia. The resident’s EMR showed care conferences were documented on 5/2/25, 10/7/25, 12/30/25, and 3/28/26, but there was no evidence of a care conference between 5/2/25 and 10/7/25. During interview, the resident stated she understood what care conferences were but had not been invited to any type of care meeting over the past year. The LSW stated care conferences should occur at admission, then every three months and/or with a significant change of condition, and that she was responsible for scheduling and documenting them in the EMR. The LSW could not provide documentation of a care conference between 5/2/25 and 10/7/25 and stated, "If it isn't documented it didn't happen." The Administrator confirmed care conferences were expected quarterly and should include residents if able or their representative, and also confirmed there was no documentation of a care conference for the resident during that interval. The facility policy stated residents and their designated responsible party are invited to attend the initial care planning conference and sequential conferences, including annual and significant change conferences.
Care Plan Not Updated to Match Current Code Status
Penalty
Summary
The facility failed to ensure a resident’s care plan was revised to reflect the resident’s current code status. The facility’s Care Plan policy stated that care plans would be reviewed quarterly, annually, and with a change of status to ensure they remained current. Resident #4 was admitted with multiple diagnoses including cerebral palsy and depressive disorder. The resident’s medical record contained a Plan for Emergency Care and Intensity of Treatment document showing full code status, while the resident’s care plan documented DNR status and no CPR. The DON stated that the care plan had been completed in error and should have been revised but had not been.
Missed Care Conference Participation
Penalty
Summary
The facility failed to provide R10 the opportunity to attend and participate in a care conference. R10’s quarterly MDS assessment dated 5/25/26 identified intact cognition and no hallucinations, delusions, rejection of care, or behaviors. During an interview on 6/1/26, R10 stated she had not had a care conference recently and said the last one was more than 3 months ago. Review of the record showed R10’s last documented Social Service Conference was on 1/16/26, and progress notes from 1/30/26 through 6/3/26 did not show any care conference held or scheduled. Staff interviews confirmed care conferences were expected to occur quarterly, after significant changes, and following MDS assessments, but R10’s quarterly and significant change MDS assessments were not followed by a documented conference. R10’s family member stated they typically attended care conferences, and the social services staff later verified that R10’s care conference had been missed and was only scheduled after the surveyor’s inquiry.
Care Plan Not Revised to Reflect Hospice Status
Penalty
Summary
The facility failed to revise a resident’s care plan to reflect hospice status and terminal illness for one sampled resident. The resident had diagnoses including dementia, bipolar disorder, and heart failure, and the 8/14/25 Significant Change MDS indicated hospice status. Review of the care plan showed hospice-related references for ADL care, psychosocial well-being, activities, and anti-anxiety medication related to end of life, but it did not identify the resident’s terminal illness as a focus area with interventions including hospice services or other end-of-life interventions. On 6/4/26, the DNS stated the expectation was for a terminal illness to be captured with interventions including hospice services on the care plan, and acknowledged the care plan was not revised to reflect the resident’s terminal illness and hospice status.
Care plans not revised for changed conditions, behaviors, and electronic monitoring
Penalty
Summary
The facility failed to revise comprehensive care plans to reflect significant changes in resident status, conditions, preferences, and interventions for three residents reviewed for care plan revision. One resident had a discharge return anticipated MDS showing moderate cognitive impairment, multiple diagnoses including cancer, septicemia, and non-Alzheimer's dementia, and hospice services. The resident's EHR showed hospice services were discontinued, but the care plan continued to identify the resident as receiving hospice care. The same resident's care plan also continued to state that Enhanced Barrier Precautions were required due to a wound, even though the wound had healed and the resident remained on EBP because of a urinary catheter. Another resident's comprehensive MDS identified moderate cognitive impairment, diabetes, CVA, and use of insulin, an anticoagulant, and an antidepressant. The resident's care plan still listed Influenza A as an active respiratory infection with an initiation date from the prior year, but the EHR did not identify ongoing signs, symptoms, treatment, or diagnosis of Influenza A. A third resident had severe cognitive impairment, dementia, PTSD, behavioral symptoms, and wandering behavior. The resident's care plan included dining preference interventions stating the resident preferred to sit alone during meals and liked to sit in the dining room by the television next to the window, but the EHR showed the resident had behavior management interventions in place, including a bookshelf sticker on the door and a door chime to alert staff when the room door opened, and these interventions were not included in the care plan. Observations showed the resident with wandering and behavioral concerns eating and sitting with other residents in the dining room rather than alone, and staff interviews confirmed the resident had become less agitated, spent more time outside the room, and that the door chime and bookshelf sticker had been implemented and were effective. Interviews also confirmed the hospice discharge, the healed wound, the ongoing catheter-related EBP need, and that Influenza A had not been present for quite some time. The DON stated care plans should be updated whenever there was a new diagnosis, condition, intervention, preference change, or other significant change in status, and that care plans served as the primary communication tool for staff. The facility also failed to update care plans for two residents with electronic monitoring in their rooms. One resident's care plan lacked the use of a camera, the rationale for it, and the fact that family had placed it for monitoring and interaction. Another resident's care plan also lacked the use of a video camera with audio capability, the rationale, and related interventions such as signage, staff awareness, and family interaction through audio. Records showed consent forms and progress notes documenting the cameras, staff notification, signage, and family involvement, but these details were not reflected in the care plans. Staff interviews confirmed that the camera use should have been outlined in the care plans and that nursing staff were responsible for updating them.
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