Failure to Implement Immediate, Individualized Fall Interventions After Resident Falls
Summary
The deficiency involves the facility’s failure to ensure immediate, individualized fall interventions were developed and implemented following falls for two residents identified as being at risk for accidents. For Resident C, who had diagnoses including peripheral vascular disease, lower extremity impairments, weakness, unsteadiness on feet, muscle wasting, and a cognitive communication deficit, the care plan identified fall risk factors and listed general interventions such as maintaining the call light and frequently used items within reach, using a fall mat, placing the bed against the wall, and keeping the wheelchair within reach. Despite this, Resident C experienced multiple falls over several months, including rolling or falling out of bed and being found on the floor or between the bed and wall, sometimes with injuries such as abrasions and facial lacerations. The immediate responses documented after these falls primarily consisted of assessing vital signs, assisting the resident back to bed, performing neurological checks, and cleansing and covering wounds, without documentation of new, individualized fall-prevention measures implemented at the time of each fall. Resident C’s falls included an incident where he reported dreaming and reaching out, leading to a fall from bed, another where he rolled out of bed and complained of shoulder pain, and a fall where he was found on his back between the wall and bed with an empty wine cooler bottle and stated he did not know what happened. Additional falls occurred when he attempted to get into his wheelchair and when he rolled out of bed and struck his face on the bedside table, resulting in lacerations around his left eye. Interviews with nursing staff indicated that actions such as obtaining vital signs and lifting the resident from the floor were not considered fall interventions, and that staff sometimes relied on a paper of suggested interventions or DON guidance when they could not identify an immediate intervention. This pattern showed that, despite repeated falls and existing fall-related care plan entries, there were no clearly documented, immediate, individualized interventions added in direct response to each new fall event. For Resident E, who had diagnoses including end stage renal disease, traumatic brain injury, cerebral infarction, unsteadiness on feet, weakness, and lack of coordination, the care plan for impaired safety and fall risk included interventions such as non-skid footwear, reminders to lock wheelchair brakes, brightly colored tape on wheelchair brakes, education on proper transfers, and maintaining a clutter-free environment. Resident E sustained a witnessed fall when he stood up unassisted and attempted to get into bed, resulting in him hitting his head, sustaining skin tears to his right elbow, and complaining of right thigh pain with grimacing and guarding on movement. The immediate actions taken were assessment for injuries, obtaining vital signs, initiating neurological checks, notifying the physician and family, and obtaining an x-ray order. An IDT note later referenced a therapy screen, and the DON stated that the therapy screening was the only intervention implemented for this fall. Staff interviews clarified that nursing assessments such as checking for injuries and vital signs were not considered immediate fall interventions, and that an immediate, resident-specific intervention was expected at the time of the fall, which did not occur for this resident.
Penalty
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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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