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
Resources
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Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with hemiplegia after a cerebral infarction and chronic atrial fibrillation was receiving rivaroxaban 20 mg daily as an anticoagulant, as documented in active medication orders, the MDS, and the MAR over several months. However, the comprehensive care plan, from admission through a later update, did not include any problem, goal, or intervention related to anticoagulant use. The MDS Coordinator stated she reviews and updates care plans after MDS completion and acknowledged she had overlooked adding anticoagulant use to the care plan, while the Administrator reported an expectation that all high-risk medications, including anticoagulants, be reflected in resident care plans.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
Failure to care plan fall risk for a resident with severe vision impairment: A resident identified on MDS/CAA as being at risk for falls had no fall-risk interventions documented in the care plan. The resident required assistance with transfers, dressing, and hygiene, had severely impaired vision, and later sustained an unwitnessed fall from a wheelchair after falling asleep and not locking the brakes, resulting in facial bruising and a skin tear. The MDS nurse stated fall risk was not always added to the care plan if there was no prior fall history, while the DON stated any resident assessed at risk for falls was expected to have care plan guidance for staff.
A facility failed to maintain comprehensive care plans for three residents. One resident had documented activity preferences and needs, but no active activities care plan was in place. Another resident used a BiPAP with staff assistance, yet the care plan did not include the device. A third resident had a suprapubic catheter, but the care plan did not identify the catheter or who was responsible for catheter care and bag changes.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Care Plan for High-Risk Anticoagulant Therapy
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing anticoagulant medication use for a resident who had been prescribed rivaroxaban 20 mg daily with the evening meal for a history of cerebral infarction. The resident was admitted with hemiplegia following a cerebral infarction and chronic atrial fibrillation, and the active medication orders showed continuous administration of rivaroxaban from its start date through the survey review period. The quarterly MDS assessment documented that the resident was receiving an anticoagulant, and the Medication Administration Record confirmed daily administration of rivaroxaban over several months. Despite this ongoing anticoagulant therapy and the resident’s relevant diagnoses, the comprehensive care plan dated at admission and updated later did not include any focus area, goals, or interventions related to anticoagulant use. During an interview, the MDS Coordinator acknowledged that the care plan did not address the anticoagulant medication and stated that she must have overlooked it when updating the care plan after completing the MDS assessment. In a separate interview, the Administrator stated that her expectation was that all resident care plans reflect high-risk medications, including anticoagulants.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Failure to Care Plan Fall Risk for a Resident With Severe Vision Impairment
Penalty
Summary
The facility failed to develop a care plan for 1 of 13 residents, R15, who was identified as being at risk for falls upon admission. R15’s comprehensive MDS assessment accepted on 12/22/25 identified that the CAA for falls would be addressed on the care plan, with staff to monitor for fall risks related to medication, new surroundings, and adjustment due to vision and hearing deficits. The assessment also directed staff to ensure the call light was within reach, make sure R15 knew where it was located, and attach it so it would not slide away because of her vision impairment. R15’s quarterly MDS assessment accepted on 3/20/26 identified intact cognition, severely impaired vision, and the need for moderate assistance of one staff for transfers, dressing, and hygiene. Interview with R15’s family member identified that R15 recently had a fall after falling asleep while sitting in her wheelchair and falling face forward out of the chair, hitting her face on the nightstand and sustaining facial bruising. The nursing progress note dated 5/1/26 documented an unwitnessed fall in R15’s room after she forgot to lock her wheelchair brakes, fell asleep, leaned too far forward, and tipped out of the chair, resulting in a facial bump and bruise and a skin tear on her right ring finger. Review of R15’s current undated care plan showed no mention that she was at risk for falls and no information describing what staff were to do to minimize her fall risk. The MDS nurse stated that if a resident was identified as being at risk for falls upon admission but had no history of falls, that was not always added to the care plan regardless of the CAA findings. The DON stated it was her expectation that any resident assessed to be at risk for falls would have a care plan section alerting staff to those risks and how to provide care and minimize injury.
Incomplete Care Plans for Activity Needs, BiPAP Use, and Catheter Care
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and maintained for three residents reviewed for care planning. For one resident, a significant change MDS showed severe cognitive impairment and extensive to total assistance for all ADLs, along with preferences for books, newspapers, music, animals, news, groups of people, going outside, and religious services. An activity assessment also documented preferences for individual and group leisure, outings, worship services, nature, prayer, modern music, games, reading, group discussions, news, social activities, and connecting with team members, but the resident’s care plan did not include activity goals, participation, or interventions to address those needs. An activities lead confirmed the resident did not have an active activities care plan, and the administrator stated residents would be expected to have one. For another resident, the quarterly MDS identified intact cognition and use of a BiPAP machine was observed at the bedside with water next to it. The resident stated staff assisted with putting the mask on and off and turning the machine on and off at night. Nursing staff confirmed assistance was provided with the mask, machine, and water chamber, and that the water chamber should be filled weekly with mask and tubing changes documented on the MAR. However, the resident’s care plan addressed ADL deficits related to multiple sclerosis and impaired balance, but did not include any evidence that the resident required or used a BiPAP machine. The RN manager and DON both verified that BiPAP use should have been included on the care plan. For the third resident, the admission MDS identified intact cognition and an indwelling catheter. The resident stated he had a catheter prior to admission and that it had been changed to a suprapubic catheter because of infections, and he verified staff assisted with catheter care. The care plan addressed bladder incontinence with brief use, peri-care, scheduled checks, and monitoring for UTI signs, but did not identify the suprapubic catheter or specify who was responsible for catheter care and changing the catheter bag. The RN manager and DON both stated that catheter information should have been included on the care plan for coordination of care.
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