Failure to Involve Residents/Representatives and Update Interdisciplinary Care Plans for Changing Clinical Needs
Summary
Surveyors identified a deficiency in the facility’s failure to develop, review, and revise comprehensive care plans with an interdisciplinary team that included residents and/or their representatives, and to update care plans when residents’ conditions changed. Multiple residents and family members reported that care plan conferences had not occurred since a change in facility ownership, despite prior practice of quarterly meetings. For example, one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and diabetes, had a baseline care plan and a signed POA document, but there were no care conference attendance sheets, and the family stated they had not been included in care plan meetings since the new company took over. Another cognitively intact resident and that resident’s son both reported they had never been invited to care conferences since admission, and the social services director acknowledged that many care conferences were not completed and that residents and families had not been part of quarterly assessments. The facility also failed to revise care plans to reflect significant changes in residents’ clinical status and treatment orders. One resident with intact cognition and a right femur fracture was being transferred with a whole body mechanical lift per therapy evaluation and documentation, but the care plan still listed stand-pivot transfers with one staff and a gait belt; staff reported they had not received updated transfer information and expected therapy to update the care plan. Another resident with moderate cognitive impairment and multiple diagnoses had a care plan with 19 focus areas whose interventions had largely not been updated since the prior year, despite the facility no longer offering restorative nursing services; there was no EMR documentation of care conferences or timely updates, and late entries were added to progress notes only after surveyor inquiry. A resident who experienced a fall, hospitalization, and diagnosis of Influenza A had a marked decline in transfer ability and required a full-body mechanical lift and transmission-based precautions, but the care plan was not updated to reflect the new transfer status or the need for PPE until after surveyor review. Additional failures involved skin integrity and catheter-related care planning. One resident admitted with a Stage 2 pressure ulcer and later placed on and then removed from an indwelling urinary catheter had care plan interventions that continued to reference catheter care and Enhanced Barrier Precautions for the catheter after the catheter was discontinued by physician order; the MDS showed the resident as incontinent without a catheter, but the care plan was not revised. Another resident at risk for pressure injuries developed in-house acquired moisture-associated skin damage on the buttocks and a deep tissue injury on the right heel, with multiple wound treatment orders and documentation of a scoop mattress and lack of repositioning aids; however, the care plan did not include MASD, the DTI, or related interventions such as pressure-reducing devices or nutrition/hydration measures. A different resident admitted without pressure injuries developed in-house Stage 2 pressure ulcers on the buttocks and a DTI on the right heel; the care plan contained no prevention focus, goals, or interventions until after the wounds occurred. Further, residents with existing or worsening pressure injuries did not have their care plans revised to reflect new or escalated needs. One cognitively intact resident with an in-house Stage 2 sacral pressure ulcer later required surgical debridement of a Stage 4 sacral ulcer with exposed bone and a wound vacuum; the care plan showed a generic focus on potential for pressure injury and an in-house Stage 2 sacral ulcer but no new interventions after the ulcer progressed and the resident returned from the hospital with a wound vac and more advanced wound status. Another cognitively intact resident at risk for pressure ulcers developed unstageable skin on 12/23, but there was no care plan update or added interventions for this finding. Interviews with the MDS coordinator, DON, RN staff, and social services indicated that the MDS coordinator was primarily responsible for building and updating care plans, floor nurses generally did not update care plans, and care conferences were not consistently scheduled or documented with IDT participation, residents, or families, resulting in multiple care plans that were outdated, incomplete, or not reflective of current clinical orders and conditions.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Update Care Plans for Comfort Care and Pressure Ulcers: The facility did not revise the care plan for a resident placed on comfort care after a clinic visit showed worsening fluid retention, cough, swelling, and decreased strength; the plan omitted the no-hospitalization order, discontinuation of labs, and guidance for comfort if the resident declined. The facility also failed to update another resident’s care plan after the MDS identified four Stage II pressure ulcers, leaving only general skin-risk interventions instead of wound-specific goals and treatment measures.
Care plans and related care guides were not updated for a resident with pain, a resident with recurrent falls, and a resident with severe cognitive impairment and transfer needs. One resident’s plan lacked individualized nonpharmacological pain interventions, another resident’s plan omitted a motion sensor that staff were using for fall prevention, and a third resident’s plan and Kardex incorrectly stated the resident was independent with transfers despite staff using a transfer belt and Hoyer lift with two-person assistance.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to revise care plans for two residents left key safety and behavior needs undocumented. One resident with dementia had scissors removed after cutting clothing and hair, but the care plan did not include supervised scissor use. Another resident with a wander guard repeatedly wanted to go outside and attempted to go out on his own, but the care plan did not identify elopement risk or specific interventions for staff. Interviews confirmed staff knew about both residents’ needs, yet the care plans did not reflect those changes.
Failure to update care plan after change in condition: A resident was hospitalized with acute urinary retention and constipation related to neurogenic bowel, but the care plan was not revised to reflect the new diagnosis or related interventions. The MDS Director and MDS Coordinator stated they were unaware of the hospital transfer and acknowledged the care plan should have been updated to support coordinated, individualized care.
The facility failed to revise care plans for two residents to reflect current care needs and behaviors. One resident with multiple cardiac and pulmonary conditions, including HF, AFib, and COPD, reported frequent self-connection to a bedside pacemaker monitoring device known to staff, yet the comprehensive care plan contained no interventions or instructions regarding this monitoring. Another resident with CHF, alcohol-induced dementia, MRSA carrier status, and psychotic disorder was repeatedly observed with large urine puddles on the bedroom floor, and an RN stated that this resident urinated on the floor regularly and therefore had a private room, but the active care plan only addressed scheduled toileting and episodes of voiding in a trash can, without documenting the ongoing behavior of urinating on the floor.
Failure to Update Care Plans for Comfort Care and Pressure Ulcers
Penalty
Summary
The facility failed to revise the care plan for a resident who was changed to comfort care only after a clinic visit identified worsening fluid retention, weight gain, generalized swelling, decreased strength, occasional shortness of breath, and a persistent cough. The physician ordered that the resident not be hospitalized, that metolazone be stopped, Lasix be increased to 80 mg twice daily, and that labs be discontinued per family request. The current care plan addressed diuretic therapy and a goal for the resident to be free of discomfort, but it did not include the comfort care status, the order not to hospitalize, the discontinuation of lab draws, or instructions for maintaining comfort if the resident’s condition worsened. Nursing notes showed the resident remained in her room in a recliner and was heard coughing continuously, with the cough worsening. Staff administered PRN morphine for chronic cough related to fluid overload, but it was ineffective and the resident reported severe pain and no relief from the cough and discomfort. Additional notes documented continued coughing, shortness of breath, and little relief after cough syrup and morphine were given. The DON acknowledged the care plan should have been revised to identify what staff were to do to provide comfort if the resident’s condition worsened. The facility also failed to revise the care plan for another resident who developed pressure ulcers. The resident’s comprehensive MDS identified four Stage II pressure ulcers, and the CAA directed staff to address the wounds on the care plan with daily treatment, weekly and as-needed monitoring, physician notification for decline or signs of infection, and goals to slow or minimize decline and provide symptom relief or palliative measures. However, the current care plan only identified the resident as at risk for skin integrity impairment and included general measures such as nutrition, moisture control, skin care, and barrier cream use; it did not identify the actual pressure ulcers or include interventions to promote healing or reduce infection or discomfort. The MDS nurse stated she missed revising the care plan to include the pressure ulcers, and the DON stated it was her expectation that a pressure ulcer be identified on the care plan with appropriate goals and interventions.
Care plans not updated for pain interventions, fall precautions, and transfer needs
Penalty
Summary
The facility failed to update care plans and related care guides to reflect current, individualized interventions for three residents. For one resident with quadriplegia related to a spinal injury and ongoing pain, the admission MDS showed intact cognition, scheduled pain medication, and no non-medication pain interventions. The resident stated he had a lot of pain and had been seen by a pain doctor, but the care plan only listed general pain management and comfort measures without identifying the resident’s preferences for nonpharmacological interventions or documenting whether any had been attempted, effective, ineffective, or preferred. The MAR/TAR and progress notes also lacked identification of nonpharmacological pain interventions. For another resident with moderately impaired cognition and a history of multiple falls, the quarterly MDS documented two or more falls with no injury and one fall with nonmajor injury. The care plan included several fall precautions such as frequent safety checks, a low bed, a floor mat, and non-slip footwear, but it did not include the motion sensor with automated auditory reminders that staff were using. Staff observed the resident with the motion sensor in place, and nursing staff stated the device had been used since after a fall in November 2025. The care plan did not identify when the motion sensor should be used or what adverse effects should be monitored. For a third resident with severe cognitive impairment, delusions, behavioral symptoms, and diagnoses including dementia with behavioral disturbances, anxiety, affective disorder, diabetes, and hearing loss, the care plan and Kardex stated the resident was independent with transfers. However, staff observed the resident being transferred with a transfer belt, requiring assistance from two nursing assistants, and later being moved to and from twin mattresses placed on the floor using a Hoyer lift with two staff. Staff confirmed the resident was not independent with transfers and that the care plan and Kardex had not been revised to reflect the resident’s current transfer ability or the use of the Hoyer lift and mattresses on the floor.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Revise Care Plans for Safety and Elopement Needs
Penalty
Summary
The facility failed to revise the care plan for 2 of 12 sampled residents, R15 and R18, after changes in condition and identified needs were documented. The report states the care plan was not updated within 7 days of the comprehensive assessment and was not prepared, reviewed, and revised by a team of health professionals as required. Review of the records and interviews showed that the existing care plans did not reflect the residents’ current assessed needs and behaviors. For R15, the 4/6/26 quarterly MDS showed severely impaired cognition, with independence in dressing, toileting, and ambulation using a walker, and diagnoses including Alzheimer’s disease, dementia, muscle weakness, hallucinations, anxiety disorder, and long-term pain medication use. On 5/4/26, R15 stated the facility had taken away her scissors and she could no longer use them for knitting, while a bag of yarn and string was observed near her recliner. A 4/15/26 progress note documented housekeeping staff reported R15 had been cutting her clothes and had cut her hair, and social services noted a plan for supervised scissor use. R15’s care plan addressed leisure preferences and one-to-one interactions, but it did not include supervised assistance with scissors for safety reasons. The IDON confirmed R15 had been cutting her clothing and hair, was not safe to use scissors unsupervised, and that the care plan should reflect that need. For R18, the 5/6/26 quarterly MDS showed a BIMS score of 13, indicating cognition intact, with independence in dressing, toileting, and ambulation using a walker, wandering noted during the assessment period, and use of oxygen and multiple medications including antipsychotic, antidepressant, hypnotic, anticonvulsant, pain, and antiplatelet drugs. On 5/4/26, R18 stated he had an alarm on, wanted to go outside, and believed it was illegal that he could not go out by himself; he also said staff told him he needed someone to go outside with him but there was never anyone available. His care plan noted cognition-related needs and a wander guard, but it did not identify elopement risk, a goal, or interventions for what staff should do if he attempted to leave or when he wanted to go outside. The elopement evaluation left the risk for wandering and/or elopement blank, and interviews confirmed staff knew he wanted to go outside, sometimes attempted to go out on his own, and that the care plan lacked detailed interventions.
Failure to Update Care Plan After Hospitalization
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #38 to reflect a significant change in condition after the resident was diagnosed in the hospital with acute urinary retention and constipation related to neurogenic bowel. A review of the resident’s hospital record showed this diagnosis on 04/21/2026 at 12:05 AM, but none of the resident’s care plans reflected the new condition or related needs. During an interview on 04/27/2026, Resident #38 stated that episodes of constipation had previously led to urinary retention requiring self-catheterization. On 04/30/2026, the MDS Director and MDS Coordinator stated that care plans were revised after hospitalizations and with changes in condition, but they were not aware the resident had been transferred to the hospital. They acknowledged that the care plan should have been updated to include the resident’s new diagnosis and appropriate interventions and monitoring, and the facility policy stated that care plans are revised as residents’ information and condition change.
Failure to Revise Care Plans to Reflect Monitoring Device Use and Recurrent In-Room Voiding
Penalty
Summary
The deficiency involves the facility’s failure to update and revise comprehensive care plans to reflect current care needs and practices for two residents. One resident with a history of heart failure, paroxysmal atrial fibrillation, cardiomyopathy, stroke, diabetes, and COPD reported during interview that he had a pacemaker and frequently connected himself to a bedside monitoring machine, demonstrating the connection process and stating that staff were aware this was done frequently. Review of his electronic health record and most recent comprehensive care plan showed no interventions or instructions related to the use of this monitoring machine. The unit manager later acknowledged that the care plan had not been revised to include these interventions or instructions. For the second resident, who had a history including CHF, anemia, alcohol dependence with alcohol-induced dementia, MRSA carrier status, and alcohol-induced psychotic disorder with delusions and other behavioral disturbances, surveyors repeatedly observed large puddles of urine on the bedroom floor, including under the bed and in the middle of the floor, accompanied by a strong urine odor. A nurse stated that the puddles were urine and that this resident urinated on the floor all the time, which was the reason he had a private room and could not have a roommate. Review of the resident’s active care plan showed a focus on self-care deficit for toileting with scheduled toileting assistance and a behavioral focus noting episodes of verbal aggression and voiding in the trash can, but it did not include that the resident urinated on the bedroom floor until it was later revised to add that he had daily episodes of urinating on the floor.
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