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
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A resident with dementia, muscle weakness, and protein-calorie malnutrition had a care plan directing staff to offload his heels or use Prevalon boots while in bed. During observation, he was found in bed without the boots, and an LPN confirmed his heels were not offloaded even though they should have been.
Failure to care plan depression: A resident with MDD and ongoing depressive symptoms had psychology evaluations documenting depressed mood, loss of interest, sleep disturbance, fatigue, and appetite changes, and the MDS listed depression as an active dx. However, the care plan did not include depression as a focus area, and the MDS Coordinator and DON both stated it should have been care planned.
Incomplete care planning for ordered medications and diabetic footwear. The facility did not include ordered meds such as Eszopiclone, Lexapro, Mirtazapine, and Zolpidem in residents' comprehensive care plans, and one resident was not measured for diabetic shoes and insoles per MD order. The MDS Coordinator said the missing medication care plans were an oversight, while the DON and Administrator stated care plans are used to direct and guide resident care.
A facility failed to include person-centered comprehensive care plan focus areas for two residents receiving ordered meds. One resident with atrial fibrillation was receiving Eliquis, and another resident with insomnia was receiving Trazodone, but neither current care plan addressed the medication use. The MDS Nurse stated she was responsible for care plan development and said the omissions were due to oversight.
Failure to update a resident’s fall care plan with a Geri-chair intervention. A resident with dementia, osteoarthritis, diabetes, severe cognitive impairment, and a history of falls had a care plan listing multiple fall precautions, but after a witnessed fall and a physician order for a Geri-chair or tilt back WC, the care plan was not updated to include that intervention. Surveyors observed the resident in a Geri-chair, and the MDS Coordinator and DON acknowledged the care plan had not been updated.
Failure to care plan a resident’s impaired hearing. A resident with dementia and a history of hard of hearing was observed unable to hear normal conversation and stated he refused to use his hearing aid. The SSD and RN confirmed no care plan had been initiated for the hearing impairment or hearing aid refusal, and the DON stated the condition should have been care planned per facility policy and MDS triggers.
Failure to Offload Heels as Directed
Penalty
Summary
Resident #32, who was admitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition, had a care plan revised on 6/18/21 directing staff to offload his heels or use Prevalon boots when he was in bed, as he allowed. During observation on 7/9/26 at 11:22 AM, Resident #32 was found in bed without Prevalon boots in place. At 11:23 AM, an LPN stated the resident should have had his boots on, then lifted the blanket and observed the resident's legs resting on a pillow. When asked whether the resident's heels were offloaded, the LPN stated they were not and confirmed they should have been offloaded.
Failure to Care Plan Depression
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #22, who had diagnoses including Major Depressive Disorder and was documented by psychology evaluations as having recurrent, moderate depression. The resident’s evaluation notes described decreased interest in activities, persistent depressed mood, sleep disturbances, fatigue, and changes in appetite, with symptoms occurring on more than half of the days and causing moderate subjective distress. A later psychology note again documented persistent depressed mood, marked loss of interest, altered sleep patterns, and fatigue with moderate distress. The resident’s quarterly MDS dated 6/13/2026 documented an active diagnosis of depression in Section I, but the care plan did not include a focus area for depression. During interview, the MDS Coordinator stated the resident had been followed by Balance Wellbeing since 12/2025, the diagnosis was entered on 5/20/2026, and depression was not included in the care plan but should be. The DON also stated the resident should be care planned for depression. The facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident’s medical, nursing, and psychosocial needs and all services identified in the comprehensive assessment.
Incomplete Care Planning for Ordered Medications and Diabetic Footwear
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for 3 of 4 residents reviewed. Resident #12 had diagnoses including dementia, anxiety, malnutrition, and depression, and her physician orders included Eszopiclone for insomnia, Lexapro for depression, and Mirtazapine for protein-calorie malnutrition. Although these medications were active and administered, the comprehensive care plan dated 04/23/26 did not include care planning for Eszopiclone, Lexapro, or Mirtazapine. Resident #3 had diagnoses including PTSD, depression, and stroke, with a BIMS score of 08 indicating severely impaired cognition. Her physician order dated 06/01/26 included Zolpidem Tartrate 5 mg at bedtime for insomnia, and the MDS indicated she received a hypnotic medication during the look-back period. The comprehensive care plan did not indicate Zolpidem. During interview, the MDS Coordinator stated she reviewed the records and did not see care plans for Resident #12's medications or Resident #3's Zolpidem, and said it was an oversight. Resident #2 was also identified in the deficiency statement as not being measured for diabetic shoes and diabetic insoles per physician order. 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 revised as conditions change. The DON and Administrator stated that care plans were a team effort and used to direct and guide resident care, and that if care plans were not done properly, care could be missed.
Missing Care Plan Focus Areas for Anticoagulant and Antidepressant Medication Use
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident receiving anticoagulant medication. Resident #5 was admitted with atrial fibrillation and had a physician order for Eliquis 5 mg by mouth twice daily. The June 2026 MAR showed the resident received Eliquis as ordered, and the quarterly MDS assessment coded the resident as moderately cognitively impaired and receiving anticoagulant medication. However, the resident’s current comprehensive care plan, last reviewed on 6/19/26, did not include a care plan focus area for anticoagulant medication use. The facility also failed to develop a person-centered comprehensive care plan for a resident receiving antidepressant medication. Resident #8 was admitted with insomnia and had a physician order for Trazodone 50 mg by mouth at bedtime. The June 2026 MAR showed the resident received Trazodone as ordered, and the quarterly MDS assessment coded the resident as cognitively intact and receiving antidepressant medication. The resident’s current comprehensive care plan, last reviewed on 6/18/26, did not include a care plan focus area for antidepressant medication use. In both cases, the MDS Nurse stated she was responsible for developing the care plans and identified the missing care plan areas as an oversight.
Failure to Update Fall Care Plan With Geri-Chair Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included all of Resident #1’s fall interventions. Resident #1, a [AGE]-year-old female with dementia, osteoarthritis, and diabetes mellitus, had a quarterly MDS showing a BIMS score of three, indicating severe cognitive impairment, and was assessed as having falls with one fall without injury. Her comprehensive care plan identified her as being at risk for falls related to debility, advanced age, and behaviors, and included interventions such as a low bed with fall mat, tilt back wheelchair, staff education, correct positioning in chair, nonskid tape under the fall mat, use of a call light, monitoring for changes in condition, and a pommel cushion added to the chair. After Resident #1 experienced a witnessed fall from her wheelchair in the TV area, a physician order was entered for safety devices including a low bed, fall mat, and Geri-chair or tilt back wheelchair. At the time of survey observation, Resident #1 was seen in a Geri-chair in the TV area and stated she liked it and was comfortable in it. However, the care plan did not include the Geri-chair intervention. The MDS Coordinator stated she had seen Resident #1 in the Geri-chair but had not yet updated the care plan, and the DON stated whoever had the resident should have seen the order for the Geri-chair and updated the care plan.
Failure to Care Plan Hearing Impairment
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address Resident 33’s impaired hearing. Resident 33 was admitted with diagnoses including dementia, muscle weakness, and abnormal gait and mobility, and the H&P documented a history of hard of hearing. The MDS dated 6/5/2026 indicated the resident was moderately impaired in cognitive skills for daily decision making and had minimal difficulty hearing. During an observation and interview on 6/29/2026, Resident 33 was lying in bed and stated he could not hear the surveyor during a normal conversation, that he was hard of hearing, and that he refused to use his hearing aid. The SSD stated the resident had difficulty hearing, refused to use the hearing aid, and had no care plan initiated for impaired hearing. RN 2 later confirmed there was no care plan for the resident’s impaired hearing and that one should be in place to address the hearing impairment and refusal to use the hearing aid so staff could communicate effectively. The DON stated that a resident with impaired hearing should be care planned according to facility policy and that hearing impairment triggered on the MDS should be care planned, including refusal to use the hearing aid.
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