Failure to Follow Care Plans for Transfers and Two-Person Care
Summary
The facility failed to follow residents’ care plans for transfers and care provided in pairs. One resident with left-sided weakness following a stroke was documented to require a slide board for bed or chair transfers and, when toileting, one staff member plus an additional person to remove the wheelchair and place the commode. On 10/14/25, the resident’s family member reported that a CNA used inappropriate words in front of the resident and family and stood the resident up from his wheelchair without another staff member present. The facility’s investigation found that the CNA transferred the resident alone at the sink, and the CNA confirmed that this occurred. Record review showed the resident’s care plan had been revised to specify one-person slide board transfers from the recliner, wheelchair, or bed, and two staff members for toileting when the resident needed to stand. Interviews with therapy and nursing staff showed that transfer information was communicated through multiple sources, including the EMR, whiteboard, paper worksheets, and a binder, but staff described inconsistent locations and differing information. The therapy coordinator stated that one staff member should have stood with the resident while another moved the wheelchair and placed the commode behind him, and that it would have been unsafe for one staff member to do this alone because of the resident’s one-sided weakness and fall risk. A second resident with quadriplegia, anxiety, and depression had a care plan directing that cares be provided in pairs. A facility incident report stated that a CNA was in the resident’s room alone when a conversation occurred in which the CNA allegedly said she would pull his hair and punch him in the face if he called her a curse word again. The resident stated the staff member was in his room without another staff member present and that they were talking when the statement was made. The CNA’s written statement acknowledged being in the room by herself and stated, “I know I didn’t follow the care plan.” Interviews with nursing leadership confirmed that the resident’s care plan required two staff members present for cares and that staff were expected to follow the plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
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.