Non‑measurable, non–person‑centered care plans for multiple residents
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for all six residents reviewed. The facility’s own policy, dated 03/2022, required comprehensive person-centered care plans that include measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs. However, record review showed that the care plans contained generic, non–person-centered objectives that could not be evaluated, quantified, or verified. The MDS Coordinator, Social Worker, and Administrator each acknowledged during interviews that the objectives in the care plans were not person-centered or measurable, and that the MDS Coordinator and IDT were responsible for ensuring that care plan objectives met these standards. For one resident with hypothyroidism, dementia, psychosis, migraines, metabolic encephalopathy, HTN, and asthma, the admission MDS showed intact cognition, yet the care plan objectives were broad and non-measurable across multiple identified problem areas. These included decreased functional abilities related to impaired cognition and mobility, resistance to care related to adjustment to the facility, impaired decision-making and rejection of necessary care related to dementia and encephalopathy, a wish to remain in the facility, risk for cardiac complications related to HLD, ASHD, and HTN, risk of adverse drug effects from psychotropic use and polypharmacy, risk for weight changes related to depression and new admission, risk for psychosocial decline related to new SNF placement, frequent pain related to migraines and impaired mobility, decreased visual acuity, and risk for respiratory distress related to asthma. Objectives such as "maintain current level of function," "cooperate with care," "maintain stable weight," and "remain free from complications" lacked specific, measurable criteria or timeframes. For another resident with COPD, polyneuropathy, recurrent UTI, AFib, nicotine dependence, MDD, quadriplegia, HTN, and generalized anxiety, the quarterly MDS showed intact cognition, but the care plan again used non-measurable objectives. These covered high fall risk related to quadriplegia and impaired mobility, GERD requiring management, increased infection risk related to chronic UTI and neuromuscular bladder, AFib and HTN requiring monitoring, total assistance needs for mobility and ADLs, long-term care needs due to complex conditions, COPD and respiratory failure with PRN oxygen, bladder/BPH with chronic UTIs, depression, anxiety, mood disorder, insomnia, ADL self-care deficits, verbal aggression and poor coping, a history of false accusations, and multiple medication-related risks (antidepressants, anticoagulants, anti-anxiety meds, diuretics, anticonvulsants, oxygen therapy, and SOB related to COPD). Objectives such as remaining free from falls, infection, or adverse drug reactions, maintaining stable cardiovascular status, and demonstrating effective coping skills were not individualized or measurable. A third resident with post-traumatic seizures, schizoaffective disorder, generalized anxiety, and schizophrenia had an admission MDS indicating inability to complete the BIMS interview, yet the care plan still lacked measurable, person-centered objectives. Problem areas included ADL self-care deficits related to mobility impairment, behavior problems and self-harm (yelling, refusing care, hitting self on objects, cursing, hitting hand on walls/doors/windows, attempting to pull a fire extinguisher), impaired thought processes related to schizophrenia, psychosis, and IDD, HTN, a prior fall with no injury related to poor communication/comprehension, antidepressant use for insomnia, anticonvulsant use for schizophrenia and psychosis, potential nutritional problems related to cognitive impairment, and potential psychosocial well-being problems related to recent admission. Objectives such as maintaining current ADL function, having fewer episodes of yelling or self-harm, being able to communicate basic needs daily, remaining free of HTN complications, and complying with diet were not defined in measurable terms. For a fourth resident with combined systolic and diastolic heart failure, MDD, acute respiratory failure, dementia, generalized anxiety, and GERD, the quarterly MDS showed moderate cognitive impairment, and the care plan had not been updated since a review several months earlier. The care plan listed difficulty making self-understood related to dementia, no plans to discharge, history of major depression and anxiety, risk for nutritional decline related to depression, DM, dysphagia, diuretic use, and GERD, impaired abilities related to weakness and impaired cognition, bowel and bladder incontinence related to impaired mobility and cognition, risk for pain related to diabetic neuropathy and chronic pain, potential adverse reactions to sulfa and tramadol, use of Lexapro for depression, and dietary needs. Objectives such as maintaining ability to make needs known, having care needs met daily and PRN, being free from signs of increased depression or anxiety, maintaining stable weight, maintaining or improving functional abilities, being clean and dry, functioning with minimal interference from pain, having no allergic reactions, being free from antidepressant side effects, and complying with diet were not written in measurable, person-centered terms. For a fifth resident with lung cancer, HTN, secondary malignant neoplasm of lymph nodes, and chronic systolic heart failure, the admission MDS showed intact cognition, but the care plan again used generic, non-measurable objectives. Identified issues included the need for staff supervision when using tobacco, HTN, wound management and a documented pressure ulcer, decreased functional abilities related to terminal lung and lymph cancer, CHF, anemia, risk for weight changes and aspiration related to terminal condition and dysphagia, chronic pain related to cancer, terminal prognosis, and risk for bowel and bladder incontinence related to terminal condition. Objectives such as following the tobacco policy without injury, maintaining blood pressure within normal limits, showing wound improvement, managing the pressure ulcer, maintaining current function, having clear lung sounds and normal heart rate/rhythm, remaining free of anemia complications, maintaining stable weight and being free from aspiration signs, avoiding discomfort from analgesia side effects, maintaining comfort, and remaining continent were not measurable or individualized. For a sixth resident admitted with a displaced fracture of the right femur lesser trochanter, the admission MDS did not include a completed cognitive section, and no BIMS score was determined. The care plan for this resident included wound management, but the objective "wound will show signs of improvement" was not defined in measurable terms. Across all six residents, the facility’s care plans did not include specific, quantifiable goals or clear timeframes, despite the facility’s policy requiring comprehensive, person-centered care plans with measurable objectives and timetables.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete care plans for oxygen therapy and dentures. Two residents had planned and provided services omitted from their comprehensive care plans. One resident with COPD had O2 therapy documented, but the care plan was delayed and did not include newly received dentures or current oral/dental status. Another resident with pneumonia and CHF had an active O2 order and was receiving oxygen, but oxygen was not included in the care plan.
Incomplete Care Plans for Hospice, Sensor Pad, and Oxygen Use: The facility failed to ensure care plans reflected key resident needs and behaviors for three residents. One resident’s plan did not include hospice services despite active hospice care and hospice aide visits. Another resident’s plan did not include use of a sensor pad even though he relied on it to call for help. A third resident’s plan did not reflect that he removed and reapplied his O2 cannula, although he stated he managed his O2 himself and an RN confirmed it.
A resident with multiple fall risk factors and several recent falls had a care plan that listed floor mats, but staff did not have the mats in place until later and could not locate corresponding orders in the EMR. The resident also received multiple high-risk meds, including a benzo, antidepressant, gabapentin, and opioid, yet the care plan did not address medication-related fall risk despite the resident’s falls and the meds’ known side effects.
A resident with PTSD had the diagnosis listed in the face sheet, physician visit, and quarterly MDS, but the care plan did not include PTSD or related interventions. The DON stated she did not see PTSD in the care plan and noted it was important to include the diagnosis so staff could document interventions such as avoiding triggers. Facility policy required person-centered trauma-informed care and individualized interventions, preferences, and triggers to be documented in the care plan.
The facility failed to include EBP instructions in the care plans of residents with a G-tube, a chronic wound, and an indwelling catheter. Observations showed PPE carts and signs directing staff to use gowns and gloves for direct care, but one care plan did not address EBP for G-tube or personal care, another lacked EBP guidance for wound care, and a third lacked EBP guidance for catheter care. The DON stated EBP should be care planned when required and staff were expected to follow the care plan and PPE guidance.
Care plans were inaccurate for multiple residents because current needs were omitted and resolved or discontinued issues remained listed. A resident with a pressure injury had no pressure injury care plan, another resident’s healed venous wound remained on the plan, one resident’s AC therapy and thrush were not updated, a resident on AC medication had no related focus area, and a resident with impaired vision had no vision-related care plan entries.
Incomplete care plans for oxygen therapy and dentures
Penalty
Summary
The facility failed to ensure that all planned and provided services were included in the comprehensive care plans for 2 of 19 sampled residents, Resident 34 and Resident 9. For Resident 34, the electronic health record showed a readmission with diagnoses including COPD, diabetes, and anxiety disorder, and the resident was able to make needs known. The quarterly MDS showed the resident received O2 therapy and had broken or loosely fitting full or partial dentures. During interview, Resident 34 stated they had dentures, but the bottom dentures did not fit right and had been taken a few weeks earlier to be fixed and had not been returned. Records also showed new dentures were received on 04/06/2026, but the focused care plans for ADL self-care performance deficit and oral/dental health problems did not include dentures. The focused care plan for COPD showed the resident was on O2 therapy, but it was not initiated until 06/15/2026, despite the resident having an order for continuous O2 at 2 L/minute via NC starting 05/27/2026. For Resident 9, the electronic health record showed admission with diagnoses of pneumonia, diabetes, and CHF, and the resident was able to make needs known. The record showed a provider order for O2 at 2 liters per minute with a start date of 11/19/2025, and the MDS showed the resident was receiving oxygen during the stay. However, the current plan of care reviewed on 06/17/2026 did not include oxygen. Staff stated the resident should have had a care plan in place for oxygen, and the DNS stated it was the expectation that residents with CHF who received oxygen had it included in their comprehensive care plan, but this did not happen for Resident 9.
Incomplete Care Plans for Hospice, Sensor Pad, and Oxygen Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that reflected identified resident needs for three residents. The report states that the care plan for Resident #7 did not reflect hospice services, the care plan for Resident #44 did not reflect use of a sensor pad, and the care plan for Resident #81 did not reflect that he took off and put on his oxygen cannula. The facility policy required a comprehensive care plan with measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #7 was a female with diagnoses including cerebral infarction and malignant neoplasm of the colon. Her MDS reflected severe cognitive impairment, moderate assistance with ADLs, and hospice care. Her care plan dated 02/17/2026 did not include hospice services, even though active orders reflected admission to hospice for CVA starting 02/04/2026. During observation, she was in bed with a hospice aide applying lotion to her legs, and she stated hospice came and gave her baths and showers. Resident #44 was a male with Parkinsonism, muscle spasms, and seizures. His MDS reflected moderate cognitive impairment, substantial assistance to total dependence for most ADLs, use of a manual wheelchair, and maximal assistance for locomotion and mobility. His care plan dated 05/01/2026 included an ADL self-care deficit and an intervention to encourage use of the call bell, but it did not reflect his sensor pad. During observation, his sensor pad was lying on his bed while he was seated in a tall wheelchair in his room, and he stated he would use the sensor pad to call for help if needed. Resident #81 had acute and chronic respiratory failure with hypoxia and was noted to have moderate cognitive impairment and need for minimal to moderate assistance with ADLs. His care plan addressed oxygen therapy and nebulizer use, but it did not reflect that he removed and reapplied his oxygen cannula. During observation, oxygen equipment was present near his bed, and he stated he used oxygen at night, put it on and took it off himself, and turned the concentrator on and off; an RN confirmed he could remove and replace his nasal cannula.
Incomplete Fall Prevention Care Planning
Penalty
Summary
The facility failed to develop, implement, and revise the comprehensive person-centered care plan for one resident with a history of falls. The resident was admitted with diagnoses including osteoarthritis, spinal stenosis, neurosarcoidosis, obstructive sleep apnea, macular degeneration, and restless leg syndrome. The resident’s care plan, initiated after a fall risk assessment, identified the resident as at risk for falls and fall-related injury due to generalized weakness, limited endurance, impaired balance, unsteady gait, history of falls, and decreased vision, and it included floor mats to the sides of the bed per orders. Record review showed the resident experienced three falls over a little more than one month, including one fall that resulted in shoulder pain and prompted diagnostic imaging. During interview, the resident stated that fall mats were not currently in place but would be liked. The ADON stated fall mats were identified in the care plan but could not locate fall mat orders in the EMR. A CNA stated staff were told by the DON or unit nurse when to place the mats and that staff first started using fall mats on the night of 6/10/26. The Administrator stated the facility was aware of the resident’s increased falls, had discussed the falls with the resident, and had recently ordered additional mats because the facility did not have enough. The resident’s record also showed use of multiple high-risk medications with fall-related side effects, including diazepam, escitalopram, gabapentin, and oxycodone. Review of the care plan showed no interventions addressing medication-related fall risk despite the resident’s falls and the presence of these medications. Facility policies stated that staff, with physician input, would implement a resident-centered fall prevention plan based on specific risk factors and modify care plans when goals and objectives were not achieved.
Missing PTSD Diagnosis and Interventions in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #4 that included his PTSD diagnosis and related interventions. Record review showed the resident was admitted and later re-admitted with PTSD, and his physician visit and quarterly MDS also listed PTSD as an active diagnosis. However, the care plan dated 4/22/206 did not include PTSD. During interview on 6/10/2026 at 4:48 PM, the DON stated she did not see PTSD in Resident #4’s care plans and said it was important to include the diagnosis so staff could show interventions such as avoiding certain triggers. The facility’s PTSD Management in Long-Term Care policy stated that residents with PTSD should receive person-centered trauma-informed care and that individualized interventions and resident preferences and triggers should be documented. The facility’s Care Plan policy stated care plans should include identified problems and needs, measurable goals and expected outcomes, and interventions and services to be provided.
Failure to Include EBP in Resident Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that included enhanced barrier precautions (EBP) for 3 of 5 residents reviewed who were identified to be on EBP. One resident had intact cognition, required moderate assistance with bathing, had a G-tube, and diagnoses included Parkinson’s disease, narcolepsy, anxiety, and dysphagia. That resident’s care plan addressed incontinence and G-tube care, but did not include instructions for EBP when staff provided G-tube care or personal care. The resident’s active medication orders directed that numerous medications be crushed and administered through the feeding tube, and a sign outside the room directed staff to wear a gown and gloves for direct care, including G-tube care. The DON stated G-tube care was one instance when EBP should be used and that EBP should be care planned when required. A second resident had severe cognitive impairment, obesity, an unstageable pressure ulcer, and moisture associated skin damage. The resident’s wound assessment identified a stable coccyx ulcer, but the care plan lacked any guidance for EBP use. During observation, an isolation cart outside the room had a contact precaution sign for the roommate and did not address whether the resident was on EBP; the cart contained gloves, masks, and eye/face protection, but no gowns. A nursing assistant stated gowns and gloves were not needed for care of that resident and entered the room without wearing either. A third resident had moderate cognition, an indwelling catheter, renal insufficiency, and urinary retention. The care plan included catheter change, daily catheter care, and infection monitoring, but did not include EBP instructions related to the catheter. Observation showed a cart outside the room with gowns and gloves and a sign identifying the resident as on EBP with instructions to wear gowns and gloves for direct care, including catheter care. The DON stated staff were expected to follow resident care plans and the facility policy regarding PPE for EBP.
Care plans missing current needs and unresolved conditions
Penalty
Summary
Care plans were not accurate for 5 of 22 sampled residents because needed care was not included and some resolved or discontinued conditions were not removed. The deficiency involved Residents 7, 5, 27, 4, and 98, and was identified through interview and record review. The report cited WAC 388-97-1020(1)(2)(a)(b). Resident 7 was admitted with stroke and right-sided weakness and had a pressure injury to the bottom. The resident stated their bottom was very sore and was observed lying flat on their back with heels on the mattress. The EHR showed no actual pressure injury care plan, even though a weekly skin assessment documented a stage two pressure ulcer to the bottom. Staff stated the resident should have had a pressure injury care plan but did not. Resident 5 had a focused skin integrity care plan that identified a chronic venous leg ulcer/wound on the right lower leg, but later EHR review showed no documentation of a current venous wound and the MDS showed zero venous ulcers/wounds. Resident 27 had a care plan that still listed anticoagulant therapy and thrush, but the EHR showed no current anticoagulant therapy or thrush infection, and staff stated both conditions should have been updated or resolved in the care plan. Resident 4 received an anticoagulant medication, but the plan of care had no focus area for anticoagulant use. Resident 98 had impaired vision noted on the MDS and stated they could not see well and needed to see the eye doctor, but the care plan had no problem, goal, or intervention related to visual deficit or glasses use.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.