Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for multiple residents, and failure of staff to follow existing care plan interventions. For two residents with PEG tubes and one resident with a dialysis catheter, the facility did not fully develop care plans at admission to reflect their diagnoses and required Enhanced Barrier Precautions (EBP). One resident was admitted with a PEG tube in August 2025, but EBP related to the PEG tube was not added to the care plan until March 2026, and there was no EBP signage on the door during observation. Another resident admitted with end stage renal disease and a dialysis catheter had no care plan focus for the dialysis catheter or EBP, despite having an order for EBP and being admitted with the catheter; there was also no EBP signage observed on the door. For a resident with diverticulitis and colostomy status, the care plan did include EBP, and there were orders for EBP and colostomy care every shift; however, there was no EBP signage on the door, and the MDS nurse stated she had been told that residents with colostomies did not require EBP, even though EBP remained on the care plan and staff were expected to follow care plan interventions. Another resident with cerebral palsy, epilepsy, and gastrostomy status had a care plan directing staff to check PEG tube placement and gastric contents/residual volume prior to medication administration per facility protocol, but observation showed an LPN administering medications via the PEG tube without checking for placement before pushing the medication. Two residents with PTSD diagnoses did not have their mental health needs fully addressed in their care plans. One resident admitted in 2023 with PTSD and other mental health diagnoses had a quarterly MDS showing a mood severity score of 18, with difficulty sleeping, little interest in activities, and feeling depressed or hopeless nearly every day, and psychiatry notes documented PTSD and schizoaffective disorder related to past trauma and ongoing nightmares; however, the care plan contained no focus for PTSD. Another resident admitted in 2016 with PTSD and borderline personality disorder had an active PTSD diagnosis on the MDS, but the comprehensive care plan did not address PTSD, including triggers, symptoms, or trauma-informed interventions. The Social Services Director, MDS nurse, DON, and Administrator all acknowledged that the PTSD diagnosis and related care plan focus had been overlooked and that care plans were expected to be fully developed and implemented so staff would know how to properly care for residents.
Penalty
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A resident with paroxysmal atrial fibrillation, encephalopathy, severely impaired cognition, and documented moderate hearing difficulty with hearing aids did not have a care plan addressing hearing loss or hearing aid use. Review of the care plan showed no problem focus or interventions for hearing aid care or storage, despite MDS assessments indicating hearing needs. Staff confirmed there was no care plan for hearing loss, and the Administrator reported the resident’s hearing aids had been lost and later reordered. Facility policy required the IDT to periodically review and revise care plans based on resident needs, but this was not done for the resident’s hearing and hearing aid management.
Two cognitively intact residents with documented pressure ulcers on admission, including an unstageable ulcer that later progressed to stage II and a sacral pressure injury, did not have any corresponding pressure-ulcer care plans or interventions in their records. Review of progress notes and skin evaluations confirmed the presence of these wounds, while care plan review showed no entries addressing them. In an interview, the MDS coordinator and the DON acknowledged that the care plans did not include the residents’ pressure ulcers, despite facility policy requiring comprehensive care plans to be developed following resident assessments.
A resident with cognitive impairment and multiple comorbidities had recurrent redness and rash under the breasts, in the groin, and other skin folds documented repeatedly on shower sheets over an extended period, with notes that the condition had worsened and been present for months. A Wound NP later assessed the resident and diagnosed extensive fungal dermatitis with detailed measurements of affected areas. Despite this ongoing skin impairment and the facility policy requiring a comprehensive person-centered care plan with measurable objectives and timetables, no such care plan or documented interventions specific to the rash were found in the medical record, as confirmed by the MDS nurse.
A resident with multiple chronic conditions, including dementia and Parkinson’s disease, was initially assessed as low risk for wandering but later scored as moderate and then high risk on wander-risk evaluations. Despite these increasing risk scores, the sections of the wander-risk tools designated for care plan interventions were left blank, and no elopement-risk care plan was initiated. The resident began self-propelling in a wheelchair and ultimately exited through an emergency exit door, triggering an alarm and sustaining an unwitnessed fall outside before being promptly found and assessed by staff. Interviews showed that an LPN completing the assessments had never filled out the intervention section, the MDS/RN relied on IDT judgment and did not care plan solely for wandering behavior, and leadership acknowledged that a care plan should have been implemented earlier in accordance with facility policy requiring care plan revisions when resident conditions change.
A resident with COPD, anxiety disorder, and osteoporosis, who had intact cognition but was dependent on staff for all ADLs, used a power wheelchair with a seatbelt for mobility. However, the resident’s care plan did not address the use of the power wheelchair or seatbelt, and the medical record contained no assessment of the appropriateness of the seatbelt. The DON and DOR confirmed both the resident’s use of the device and the absence of any related assessment or care plan, resulting in a deficiency in comprehensive care planning for device use.
The facility failed to include non-invasive mechanical ventilator (BiPAP) use in the comprehensive care plans for two residents with chronic respiratory conditions and sleep apnea, despite active physician orders and MDS assessments documenting BiPAP use. Both residents had BiPAP orders for nightly use, and one also had orders for use as needed during daytime sleep, yet their care plans contained no BiPAP-related problems, goals, or interventions. The MDS nurse, responsible for nursing care plans, acknowledged the omissions, while the DON and Administrator stated they expected BiPAP to be addressed in the care plans, consistent with facility policy requiring comprehensive, measurable, person-centered care plans that include all services identified in the assessment.
Failure to Implement Person-Centered Care Plan for Hearing Loss and Hearing Aids
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing hearing loss and hearing aid use for a resident, as required by its care planning process. The resident was admitted with diagnoses including paroxysmal atrial fibrillation and encephalopathy, and an MDS 3.0 assessment initially documented minimal difficulty hearing with hearing aids, later showing severely impaired cognition, moderate hearing difficulty, and continued hearing aid use. Despite these documented needs, review of the resident’s care plan, last revised on 03/13/26, showed no problem focus related to being hard of hearing or wearing hearing aids and no interventions for hearing aid care or storage. Staff interviews confirmed the absence of a hearing loss/hearing aid care plan, and the Administrator reported that the resident’s hearing aids had been lost and subsequently reordered, with new aids arriving on 03/23/26. Policy review showed that the facility’s interdisciplinary team was required to periodically review and revise care plans based on resident goals, preferences, and needs, but this was not done for the resident’s hearing loss and hearing aid management. This deficiency was cited for failure to implement a comprehensive person-centered care plan for hearing aids and hearing loss for one resident reviewed for care plans, under Complaint Number 2802107.
Failure to Care Plan for Residents’ Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, person-centered care plans addressing pressure ulcers for two cognitively intact residents. Resident #106 was admitted with multiple medical diagnoses, including essential hypertension, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, and acute kidney failure. The most recent MDS 3.0 assessment showed the resident had an unstageable pressure ulcer upon admission. A progress note dated 02/18/26 documented that this resident had a stage II pressure ulcer, yet review of the resident’s care plan revealed no care plan or interventions addressing the stage II pressure ulcer. Resident #107 was admitted with diagnoses including rheumatoid arthritis, chronic obstructive pulmonary disease, and a cognitive communication deficit, and was also assessed as cognitively intact on the most recent MDS 3.0. A skin evaluation dated 02/05/26 documented a pressure injury to the sacrum that was present upon admission. However, review of this resident’s care plan showed no plan or interventions for a pressure ulcer. During an interview on 03/20/26, the MDS coordinator and the DON confirmed that the care plans did not address the residents’ pressure ulcers or contain related interventions. Facility policy titled “Care Planning,” dated 09/2013, requires that a comprehensive care plan for each resident be developed within seven days of completion of the resident assessment, but this was not done for these residents’ pressure ulcers.
Failure to Develop Comprehensive Care Plan for Ongoing Fungal Dermatitis
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan addressing an ongoing skin rash for a resident with multiple medical conditions, including cerebral infarction with left hemiplegia, mood disorder, HTN, and epilepsy. A quarterly MDS assessment documented moderate cognitive impairment and a need for staff assistance with ADLs, but indicated no skin issues. However, repeated shower sheet documentation over the course of two months noted redness under both breasts and in the groin area, with staff recording that the redness had worsened and that it had been present for months. Interventions documented on the shower sheets were limited to lotion, powder, and brief notations, without evidence of a formal, measurable care plan. Further review of the medical record showed that a Wound NP later evaluated the resident and diagnosed extensive fungal dermatitis involving the skin folds under both breasts, the periumbilical area, groin, and buttocks, with specific measurements recorded for several affected areas. Despite this documented, ongoing rash and subsequent wound evaluation, there was no evidence in the medical record that a comprehensive person-centered care plan with measurable objectives and timetables was developed to address the skin impairment. The MDS nurse confirmed the absence of such a care plan or documented interventions to treat or prevent worsening of the rash, and the facility’s care plan policy required a comprehensive person-centered care plan for each resident to meet physical, psychosocial, and functional needs.
Failure to Timely Care Plan for Resident Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and implement a comprehensive, measurable care plan addressing elopement risk for a resident identified as being at risk for wandering and elopement. The resident was admitted with multiple diagnoses including anxiety, chronic kidney disease, type 2 diabetes, cognitive communication deficit, Parkinson’s disease, and dementia without behavioral disturbance, and had a legal guardian. An initial wander-risk evaluation in late 2025 identified the resident as low risk for wandering, and an annual MDS assessment documented that the resident was cognitively intact, did not wander, and required partial to moderate assistance with ambulation using a wheelchair. A subsequent wander-risk evaluation in early 2026, completed by an LPN, showed the resident had progressed to a moderate risk for wandering, but the section of the form asking what interventions would be care planned was left blank. A discharge, return-anticipated MDS again documented that the resident did not wander and required partial to moderate assistance with ambulation. A later wander-risk evaluation in mid-February 2026, completed by an MDS/RN, identified the resident as high risk for wandering, and again the section for care plan interventions was left blank. On the same date, a progress note documented that the resident pushed on an exit door, activated the door alarm, and was found on his right side outside the emergency exit door with his wheelchair beside him after an unwitnessed fall; he was assessed and brought back to the nursing station for closer monitoring. A facility investigation confirmed that the resident had exited through an emergency exit door on a hall under construction and had been outside for less than five minutes, with alarms and egress doors functioning and staff responding immediately. Interviews with the LPN and MDS/RN revealed that nurses completed wander-risk assessments and the MDS/RN handled care planning, that the LPN had never completed the care plan intervention section of the wander-risk tool, and that the MDS/RN did not initiate an elopement risk care plan when the resident’s risk level increased from low to moderate because the IDT believed the resident was not an elopement risk. The Administrator and DON confirmed that a care plan should have been initiated when the resident began self-propelling around the facility and that this was not done until after the elopement event, despite facility policy stating that assessments are ongoing and care plans are revised as resident conditions change.
Failure to Care Plan and Assess Seatbelt Use with Power Wheelchair
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of a power wheelchair with a seatbelt for one resident. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and osteoporosis, and had intact cognition but was dependent on staff for all ADLs. Review of the resident’s care plan dated 12/12/25 showed no inclusion of the power wheelchair or seatbelt use, and the medical record lacked any assessment of the appropriateness of the seatbelt in the power wheelchair. During interviews, the DON and DOR confirmed that the resident used a power wheelchair with a seatbelt for mobility, that no assessment regarding seatbelt use had been conducted, and that the resident’s plan of care should have reflected the use of the seatbelt. These findings demonstrate that the facility did not develop and implement a complete, measurable care plan that addressed all of the resident’s needs related to the use of the power wheelchair and seatbelt, nor did it perform an assessment to determine the appropriateness of the device, resulting in a deficiency in comprehensive care planning for device use.
Failure to Include BiPAP Use in Comprehensive Care Plans for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans that addressed the use of non-invasive mechanical ventilators (BiPAP) for two residents with chronic respiratory conditions. One resident had diagnoses including COPD, chronic respiratory failure, and obstructive sleep apnea, with an active order for auto BiPAP every night at bedtime and as needed during daytime sleep. A quarterly MDS showed moderately impaired cognitive skills and documented use of a non-invasive mechanical ventilator in the 14-day look-back period. Despite this, the resident’s comprehensive care plan, in place since admission, did not address BiPAP use, even though surveyors observed a BiPAP machine in the resident’s room on multiple occasions. The MDS nurse, responsible for nursing care plans, confirmed during interview that there was no BiPAP care plan and stated the resident should have one so staff would know about the BiPAP. The second resident had chronic respiratory failure and obstructive sleep apnea, with an order to wear BiPAP at night for sleep apnea and an admission MDS indicating intact cognition and use of a non-invasive mechanical ventilator in the last 14 days of the assessment period. Review of this resident’s comprehensive care plan, initiated at admission, also showed no care plan or interventions related to BiPAP use. The MDS nurse acknowledged the absence of BiPAP-related interventions in this care plan. The DON and the Administrator both stated in interviews that they expected BiPAP use to be addressed on residents’ comprehensive care plans, and the facility’s Comprehensive Care Plans policy required development of person-centered care plans with measurable objectives and timeframes that include all services identified in the comprehensive assessment and meeting professional standards of quality.
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