Deficiencies in Care Plan Implementation and Communication
Summary
The facility failed to implement an individualized comprehensive care plan for a resident reviewed for safety precautions. The resident was admitted with diagnoses including fluid disturbances and speech issues. The Minimum Data Set (MDS) assessment indicated the resident was rarely or never understood. Despite the care plan specifying the use of padding on bed rails for safety, observations revealed the rails were unpadded during the day. A Certified Nursing Assistant (CNA) confirmed the absence of padding and was unaware of the reason. The Restorative Unit Manager stated the padding was only applied at night when the resident became agitated, contrary to the care plan's requirements. Another deficiency was identified for a resident reviewed for communication needs. This resident, who had intact cognition and primarily spoke Spanish, expressed a desire for an interpreter when communicating with healthcare staff. The MDS assessment noted her social isolation and dependence on staff for personal care. However, her care plan did not address her communication needs or preference for an interpreter. An interview with the resident revealed a recent incident where a nurse administered a discontinued medication and mishandled another medication, leading to distress. The resident preferred Spanish-speaking staff and had communicated this preference, but it was not reflected in her care plan. The facility's policy on comprehensive care plans emphasizes the development of person-centered plans that incorporate residents' personal and cultural preferences. Despite this, the care plans for both residents failed to address their specific needs as identified in their assessments. The MDS Coordinator acknowledged the oversight in the communication care plan and confirmed that the resident's preference for an interpreter was known but not documented in the care plan.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: For Resident #92, the pads were placed per the Resident's care plan. Resident #92 was reassessed to ensure all precautions were properly implemented. CNA Q was re-educated on the importance of following care plan interventions, especially for residents with. For Resident #56, the care plan was updated to reflect the resident's primary language of Spanish with the intervention of utilizing an interpreter as indicated. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents with a diagnosis of and Residents who do not speak English proficiently have the potential to be affected. A facility-wide audit of all residents with was conducted to ensure appropriate interventions were care planned and in place. MDS Coordinator conducted an audit of all residents with limited English proficiency to ensure their communication needs were appropriately care planned. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Nurse leadership team, including Director of Nursing, Assistant Director of Nursing, Unit Managers, and MDS Nurses received in-service training on by Regional Nurse on the requirement for comprehensive Resident Centered care plans with focus on Residents with and/or limited English proficiency. Starting on all Direct Care staff (RNs, LPNs, and C.N.A.S) will receive mandatory training on the importance of following individualized care plan interventions, ensuring safety interventions are in place for precautions per plan of care, and on communicating with Residents with limited English proficiency per plan of care to include use of Propio 1 Interpreter Line. All Direct Care staff will be in-service by. Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct weekly audits of 5 Residents with or Limited English Proficiency for four weeks, then 10 monthly for at least three months, to ensure care plans are accurately implemented and followed. Any discrepancies found will result in immediate correction and staff re-education. Audit results will be reviewed in the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings. (e) The compliance date is.
Penalty
The facility failed to maintain accurate, resident-centered comprehensive care plans aligned with current assessments and communication needs. One resident with a nephrostomy was incorrectly care planned for a colostomy, while another resident continued to be care planned as a smoker despite no longer smoking or leaving bed to smoke. A third resident, assessed as mostly independent and able to perform personal hygiene such as shaving, still had a care plan stating dependence for all ADLs. Additionally, a Spanish-speaking resident who did not understand English and required interpreter services had no communication focus in the care plan, even though staff and clinical documentation acknowledged the language barrier and use of translation methods.
A resident who was totally dependent for eating and drinking due to multiple medical conditions was not provided with adequate hydration support. Observations showed fluids were not offered or consumed, and staff and family confirmed the resident could not access fluids independently. Despite being identified as high risk for dehydration, there was no care plan or physician order to address this need, and the facility lacked a dehydration policy.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan was not updated to address a resolved skin condition and lacked preventive measures for new issues. Another resident had no care plan for medications prescribed for agitation, with no monitoring for side effects. The MDS Coordinator acknowledged these oversights.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. One resident had inadequate floor mat interventions, resulting in falls. Another resident also lacked proper floor mat placement, increasing fall risk. A third resident received oxygen at a lower rate than prescribed, causing low oxygen saturation. Staff communication and adherence to care plans were insufficient.
The facility failed to develop a discharge care plan for a resident with a displaced tri-malleolar fracture, despite the resident's choice to be discharged home. Additionally, two residents were observed with unsecured urinary drainage bags, increasing the risk of complications. The facility did not adhere to its policies requiring comprehensive care plans and proper management of medical equipment.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident had no care plan intervention for floor mats, another had an initially incomplete care plan for floor mat use, and a third lacked a care plan for a required C-collar. These omissions resulted in inadequate documentation and implementation of necessary interventions.
Failure to Maintain Accurate, Resident-Centered Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain accurate, resident-centered comprehensive care plans consistent with residents’ assessed needs and conditions. For one resident with hemiplegia, overactive bladder, and a nephrostomy catheter, the care plan incorrectly documented a focus on an artificial bowel opening (ostomy/colostomy) with related bowel-output interventions, even though the resident did not have a colostomy. The MDS LPN and the DON both confirmed that the resident had a nephrostomy, not a colostomy, indicating the care plan did not reflect the resident’s actual medical status. Another resident with pulmonary fibrosis, morbid obesity, malnutrition, feeding difficulties, malignant neoplasm of the glottis, dysphagia, and GERD had a care plan focus indicating the resident was a smoker/tobacco user, initiated and last revised several years earlier. Interviews with the resident, an LPN, and the DON confirmed that the resident no longer smoked, did not get out of bed or go outside to smoke, and had not had a recent smoking evaluation because the resident was no longer an active smoker. Despite this, the care plan still identified the resident as a smoker, showing it had not been updated to reflect the resident’s current status. A third resident with hemiplegia, seizures, dementia with behavioral disturbance, and restlessness/agitation had a care plan focus stating the resident had self-care deficits and required assistance with all ADLs, including dressing, grooming, and bathing. However, interviews with nursing staff and the resident indicated the resident was mostly independent, steady, moved independently, and shaved independently after obtaining a razor from CNAs. The MDS assessment completed the prior month documented the resident as independent for personal hygiene, but the care plan, last updated many months earlier, still showed a need for assistance with all ADLs. Additionally, a Spanish-speaking resident who did not understand English and required an interpreter had no communication focus in the care plan, despite documentation in a skin exam note that a translator app and the resident’s son were used for communication, and staff interviews confirming the resident primarily spoke Spanish. The MDS LPN and DON acknowledged that care plans were not up to date and that a communication focus needed to be added, demonstrating that the care plans did not incorporate identified communication needs or align with the facility’s policy requiring culturally competent care planning.
Failure to Implement Hydration Care Plan for Dependent Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was at high risk for dehydration. Multiple observations revealed that the resident, who was totally dependent for eating and drinking due to quadriplegia and other significant medical conditions, did not have fluids readily accessible or being offered by staff. The resident was observed on several occasions lying in bed or sitting in a wheelchair without hydration available, and a marked water cup showed no change in water level over time, indicating fluids were not being consumed or offered. Interviews with the resident's family member and staff confirmed that the resident required total assistance and could not independently access fluids. The family member expressed concern that staff were not offering fluids frequently enough, and the RN/Unit Manager acknowledged that the resident was unable to request or obtain fluids on their own. Despite the resident's high risk for dehydration, as documented in the quarterly risk assessment and MDS, there was no care plan focus or physician order in place to address this risk, such as encouraging or offering fluids every two hours. The review of the resident's medical record showed that while there were care plan interventions for assistance with ADLs and monitoring for urinary tract infections, there was no specific intervention or policy addressing the resident's hydration needs. The facility was unable to provide a dehydration policy when requested. These findings demonstrate that the facility did not meet the requirement to develop and implement a comprehensive care plan that addresses all identified needs, specifically the risk for dehydration in this resident.
Plan Of Correction
1) Resident #68's plan of care updated to reflect at risk for dehydration on 8/5/2025 with appropriate interventions. 2) An audit of current residents' quarterly hydration risk evaluation was conducted on 08/20/2025 by Director of Nursing, Nurse Management team, or designee to verify residents to be at risk for dehydration. Care plan reviews with intervention updated to include providing necessary assistance, encouragement and offering of fluids throughout shift, as clinically indicated. 3) An in-service education was conducted on 08/19/2025 by the Administrator, Director of Nursing, or designee with all licensed/registered nurses addressing the significance of hydration risk evaluation completed on admission, quarterly, and/or significant change, and the implementation of a plan of care for a resident at risk for dehydration. 4) The nursing management team, Registered Dietitian, and/or Dietary Manager will review each resident with risk factors for dehydration to ensure appropriate interventions are implemented and an updated plan of care is complete. The Director of Nursing (DON), or designee, will complete five (5) random weekly chart audits for six (6) consecutive weeks to review quarterly hydration risk evaluations and verify that appropriate interventions have been put in place to reduce the risk of dehydration. Audits will assure that care plans remain updated to reflect these interventions. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in their care. For one resident, the care plan was not updated to reflect the resolution of a skin condition, and there were no interventions in place to prevent the development of new skin issues. The resident had a history of immobility and skin conditions, but the care plan did not include necessary updates or preventive measures. The MDS Coordinator acknowledged the oversight and stated that care plans should be updated within a couple of days when new issues arise. For another resident, the facility did not have a care plan in place for medications prescribed for agitation and restlessness. The resident had multiple medication orders, but there were no interventions documented to monitor for behaviors or side effects. The MDS Coordinator confirmed that a care plan should have been in place for the medications, including monitoring for potential side effects. This lack of a comprehensive care plan for medication management was identified as a deficiency during the survey.
Plan Of Correction
Resident #37 care plan updated for maintenance and prevention and Resident #59 care plan developed and implemented for medications. 100% audit of residents with medications and for development and implementation of care plans as identified. 100% Inservice of all licensed nursing staff for care plan development and implementation for medications. DON or designee to audit residents on medications and for care plan development and implementation weekly for 30 days and monthly ongoing. DON or designee to report findings of care plan audits to QAPI committee meeting monthly.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident #25 was observed with only one floor mat in place, despite a physician's order for two mats to prevent falls. The care plan for this resident did not include interventions for floor mats, and staff were unaware of the correct protocol, resulting in the resident being found on the floor multiple times. Resident #52 was also affected by inadequate care planning, as they were observed with only one floor mat in place, contrary to the prescribed two mats. The staff failed to communicate effectively about the required interventions, and the resident was found on the floor on several occasions. The care plan for this resident did not adequately address the need for floor mats, contributing to the risk of falls. Resident #95 experienced a deficiency in care related to the administration of oxygen. The resident was observed receiving oxygen at a rate lower than the physician's order, which led to a dangerously low oxygen saturation level. The staff did not verify the oxygen delivery rate during rounds, resulting in a delay in adjusting the oxygen to the prescribed level. This oversight in care planning and execution posed a significant risk to the resident's health.
Plan Of Correction
Immediate Action: Resident sample #25 - care plan was reviewed and revised to include implementation of floor mats per physician orders by the MDS Nurse. Resident sample #52 - floor mat was placed as per physician orders and care plan. The Nurse and CNA were educated by the Nurse Manager on the expectation of following physician orders and/or implementing the identified appropriate care plan interventions for floor mats. Resident sample #95 - the flow rate was increased from 1.25 liters per minute to 2 liters per minute as per physician orders and care plan. Saturation was checked and reported to the Hospice team. The Nurse was educated by the Nurse Manager on the expectation of following physician orders and/or implementing the identified appropriate care plan interventions for use. Identification of Residents with potential to be affected: All residents in the facility have the potential to be affected. Interdisciplinary review and verification of care plan interventions and orders for floor mats and use. System Changes: The facility Prevention Policy and Medication Administration Policy were reviewed for accuracy. Nurses and CNAs were educated and trained on the Falling Star Program and use of floor mats and resident use as indicated in the physician orders and care plan by the Director of Nursing and Risk Manager. Licensed nursing staff are to verify and document in the Treatment Administration Record the use of floor mats and orders for use every shift. Licensed nursing staff were educated by the Director of Nursing and the Assistant Director of Nursing on medication.
Deficiencies in Discharge Planning and Urinary Drainage Bag Management
Penalty
Summary
The facility failed to develop and implement a discharge care plan for a resident who was discharged home with family. The resident had a clinical diagnosis of a displaced tri-malleolar fracture of the right lower extremity and required orthopedic aftercare. Despite the resident's choice to be discharged, the facility did not create a discharge care plan, which is a requirement under the comprehensive care plan statute. The MDS Coordinator acknowledged the absence of a discharge care plan for the resident. Additionally, the facility did not ensure the security of urinary drainage bags for two residents. One resident was observed carrying their drainage bag in their hand and placing it on the floor, while another resident had their drainage bag tubing caught on the wheelchair's wheels. These practices increased the risk of urological complications if the bags were unintentionally pulled, leading to potential dislodgement. Staff members, including an LPN and the DON, were aware of these issues but did not consistently address them. The facility's policies and procedures require the development of a comprehensive care plan within seven days of a resident's assessment, which includes measurable objectives and timetables to meet the resident's needs. However, the facility failed to adhere to these policies, resulting in deficiencies related to the lack of a discharge care plan and the improper management of urinary drainage bags.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident # 1 was discharged home. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the MDS Coordinator/Social Service Director/designee of current residents to ensure a discharge care plan is developed within 48 hours of admission/re-admission to be completed by. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: MDS Coordinator/Social Service Director re-educated by the Chief Clinical Reimbursement Officer on the components of this regulation and to ensure residents have a discharge care plan developed within 48 hours of admission/re-admission to be completed by. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: MDS Coordinator/Social Service Director /designee to conduct ongoing quality monitoring through morning clinical meeting to ensure a discharge care plan is developed within 48 hours of admission/re-admission 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident #291 was observed with a floor mat on one side of the bed, but there was no care plan intervention for the use of floor mats. The MDS Coordinator confirmed that the floor mats had not been care planned until the day of the survey. Additionally, there were no physician orders for the floor mats, although the facility's policy did not require such orders. The lack of a comprehensive care plan for Resident #291's floor mat intervention was a clear deficiency. Resident #74 was observed with a floor mat on the right side of the bed, but the care plan did not initially reflect this intervention. The MDS Coordinator later revised the care plan to include the floor mat intervention, which had been implemented over the weekend. Despite the revision, the initial absence of a care plan for the floor mat intervention constituted a deficiency. The facility's policy allowed for the use of floor mats without a physician's order, but the care plan should have been updated to reflect the intervention. Resident #43 required a C-collar as per physician's orders, but there was no care plan for its use. Interviews with staff revealed that the resident was supposed to wear the C-collar constantly, but it was not always in place, and the resident was not compliant with wearing it during sleep or in the dining room. The C-collar was found in the laundry, wet and not ready for use. The absence of a care plan for the C-collar and the lack of consistent application of the physician's orders were significant deficiencies in the resident's care.
Plan Of Correction
N072-Comprehensive Care Plans Identify patients that were at risk and what did: Ref Resident #43 Regarding Resident #43 the brace with appropriate interventions was added to Care Plan. How will you identify other residents that are at risk: 100 % audit was completed to identify residents with brace. Any residents with brace were reviewed to ensure appropriate Care Plan was completed. Measures put in place: Upon admissions residents are assessed for devices. Any Devices such as braces or other devices are reviewed upon admission and reviewed in our morning meeting. During morning meeting the MDS Coordinator will update and validate to the team when this is completed. Restorative Nursing will be maintaining a weekly checklist of all new devices and will be addressed on care plan. Also training was completed on for care plan team members regarding Floor mats, C-Collar Devices and Following Physician Orders. Nursing staff to communicate and document anytime a resident refuses treatment such as the C-Collar to update care plan. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on assistive devices (brace and floor mats). How will you monitor: The Director of Nursing, MDS Coordinators, Restorative Nurse and or Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing. Regarding Resident #74 the Care Plan was completed with appropriate interventions to address. How will you identify other residents that are at risk: 100% audit was completed to identify residents at risk for and Care Plan with appropriate interventions. Measures put in place: Upon admissions residents are assessed for risk. Any residents at risk for a Care Plan will be completed with appropriate interventions to address. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on precautions and floor mats. How will you monitor: Through the continuous quality improvement program (Gang tackling) we will monitor compliance. The Director of Nursing, MDS Coordinators, Restorative Nurse and our Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing. Ref Resident #291 Regarding Resident #291 the Care Plan was completed with appropriate interventions to address floor mats. How will you identify other residents that are at risk: 100% audit was completed to identify residents with floor mats and Care Plan in place with appropriate interventions. Measures put in place: Upon admissions residents are assessed for floor mats. Any residents found to need a floor mat a Care Plan will be completed with appropriate interventions to address. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on floor mats. (risk for) How will you monitor: Through the continuous quality improvement program (Gang tackling) we will monitor compliance. The Director of Nursing, MDS Coordinators, Restorative Nurse and our Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
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