Failure to Develop Comprehensive Care Plans for Anticoagulant Use, Dementia, and Pressure Ulcer Prevention
Summary
The deficiency involves the facility’s failure to develop comprehensive, individualized care plans addressing all identified needs for two residents. For one resident with vascular dementia and agitation, record review showed an active order for Eliquis 2.5 mg twice daily with instructions to monitor for adverse reactions, but the resident’s care plan did not address the use of this anticoagulant medication. During interview, the MDS RN confirmed that the anticoagulant should have been included in the care plan. The same resident had diagnoses including vascular dementia with agitation and was prescribed psychotropic medications, yet the care plan did not include dementia-related care. The MDS RN verified that dementia care should have been incorporated, despite the facility’s own dementia policy requiring individualized care plans that consider symptoms, disease progression, and co-existing conditions. The second resident had a history of sacral/buttocks pressure ulcers that had previously healed, with APRN documentation that preventive interventions such as scheduled repositioning, pressure-relieving devices, incontinence care, and protective dressings remained in place. A subsequent wound clinic note documented that the prior sacral ulcer site had broken down again, with fat layer exposed, and attributed contributing factors including moisture-associated skin damage and trauma from a shower chair. The resident reported that the wound may have reopened due to prolonged time in a wheelchair without repositioning assistance and stated that staff did not consistently assist with repositioning every two hours as recommended. Review of the care plan revealed no documented interventions for pressure ulcer prevention or management, despite a Braden Scale score of 11 indicating high risk. Nursing staff confirmed the resident was at high risk for pressure ulcer development and that the care plan did not include pressure ulcer prevention interventions, and the MDS RN reported that the pressure injury care plan had been discontinued after healing and was not reinitiated until after the wound reopened, leaving the resident without an active pressure injury prevention care plan during that period.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to develop comprehensive care plans for two residents. One resident, with dementia and anxiety, was prescribed antipsychotic medications without a care plan for psychoactive medication use. Another resident, also with dementia and anxiety, was incontinent of bowel and bladder but lacked a care plan for incontinence care. These deficiencies were confirmed through staff interviews, highlighting non-compliance with the facility's policy on timely care plan development.
The facility failed to complete comprehensive care plans for several residents, leading to deficiencies in addressing their specific medical needs. A resident with an indwelling catheter lacked a care plan for its management, while another with hemiplegia and a catheter had no care plan for bowel/bladder care. A resident on hospice with respiratory needs did not have a respiratory care plan, and another with cerebral infarction lacked a plan for activities of daily living. Additionally, a resident with a cutaneous abscess had no care plan for the actual skin impairment.
A facility failed to include oxygen use in a resident's care plan, despite the resident's severe cognitive impairment and need for oxygen due to COPD. The oversight was confirmed by the DON and had the potential to affect all residents in the facility.
The facility failed to develop individualized care plans for two residents, leading to deficiencies in their care. One resident's care plan lacked necessary details about nectar thickened liquids, despite physician orders and a nutritional risk assessment indicating the need for such interventions. Another resident's care plan inaccurately included an intervention to stop smoking, even though the resident was not a tobacco user. These errors were confirmed by facility staff.
The facility failed to include activities in the care plans for three residents, despite their interests and cognitive abilities. Interviews confirmed that the responsibility for updating activity care plans was not met. The facility's policy requires comprehensive care plans within seven days of assessment, involving the care planning team, including the activity director.
A facility failed to develop a discharge plan of care for a resident with complex medical needs, including cerebral infarction and diabetes mellitus type-1. Despite communication between the resident's power of attorney and the Social Service Designee (SSD) about necessary home care products and services, no active discharge planning or referrals were made. The SSD did not create a discharge plan due to concerns about forgetting updates, and the facility's policy for discharge planning was not adhered to.
Deficiency in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that resident-centered comprehensive care plans were in place for two residents. Resident #5, who was admitted with diagnoses including dementia and anxiety, was prescribed antipsychotic medications such as Geodon and later Seroquel. However, there was no comprehensive care plan addressing the use of psychoactive medications for this resident. This deficiency was confirmed during an interview with the Director of Nursing, who verified the absence of a care plan for psychoactive medications. Similarly, Resident #77, admitted with diagnoses of dementia and anxiety, was found to be incontinent of bowel and bladder. Despite this condition being present since admission, there was no comprehensive care plan for incontinence care. This was confirmed through interviews with a State Tested Nursing Assistant and a Registered Nurse, both of whom acknowledged the lack of a care plan for incontinence care. The facility's policy mandates the development of a comprehensive person-centered care plan within seven days after the completion of the comprehensive MDS assessment, which was not adhered to in these cases.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were completed for all care areas for several residents, leading to deficiencies in their care. Resident #130, who was admitted with an indwelling catheter due to obstructive uropathy, did not have a comprehensive care plan addressing the catheter. Despite receiving regular catheter care, there were no physician orders or documentation in the medical records regarding the catheter's care or continuation. Interviews with staff confirmed the lack of documentation and care planning for the catheter. Resident #22, admitted with hemiplegia, hemiparesis, and an indwelling catheter, also lacked a comprehensive care plan addressing bowel/bladder or catheter care. Observations confirmed the presence of the catheter, and interviews with staff verified the absence of a care plan for these areas. Similarly, Resident #41, who required respiratory support and was on hospice, did not have a respiratory care plan, despite being dependent on staff for activities of daily living and having a tracheostomy. Resident #57, with diagnoses including cerebral infarction and congestive heart failure, lacked a care plan for activities of daily living, despite being dependent on staff for mobility and transfers. Additionally, Resident #71, who had a cutaneous abscess on the buttock, did not have a care plan addressing the actual skin impairment, although there was a plan for the risk of skin impairment. Interviews with the Director of Nursing confirmed the absence of appropriate care plans for these residents, highlighting a systemic issue in the facility's care planning process.
Care Plan Deficiency for Oxygen Use
Penalty
Summary
The facility failed to ensure that the care plan for Resident #252 was comprehensive and included all necessary care needs. Resident #252, who was admitted with diagnoses of hypertension, kidney failure, muscle weakness, and chronic obstructive pulmonary disease (COPD), was severely cognitively impaired and required supervision for oral and personal hygiene, set up help for eating, and substantial assistance with toileting and showering. The resident was also on oxygen. However, a review of the care plan dated 08/28/24 revealed that it did not address the use of oxygen, which was confirmed by the Director of Nursing during an interview. This oversight affected one resident reviewed for comprehensive care plans and had the potential to affect all 102 residents in the facility. The facility's policy on comprehensive person-centered care plans, dated December 2016, stated that care plans should describe all services that assist residents in achieving their highest level of physical, mental, and psychosocial well-being.
Deficiencies in Individualized Care Plans for Two Residents
Penalty
Summary
The facility failed to develop individualized care plans for two residents, leading to deficiencies in their care. For one resident, who was moderately cognitively impaired and at nutritional risk, the care plan did not include necessary details about nectar thickened liquids or instructions regarding thin liquids, despite physician orders and a nutritional risk assessment indicating the need for such interventions. The resident had a diagnosis of pneumonitis due to inhalation of food and vomit, requiring specific dietary modifications to prevent aspiration. The omission was confirmed by the Regional Clinical Director during an interview. For another resident with diagnoses including adjustment disorder, dementia, major depressive disorder, type two diabetes mellitus, and hypertension, the care plan inaccurately included an intervention to stop smoking, even though the resident was not a tobacco user according to multiple assessments. This error persisted across several care plan reviews over nearly two years. The facility's Administrator confirmed the inaccuracy, acknowledging that the resident had never been a smoker.
Failure to Include Activities in Resident Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans that included activities for three residents, affecting their overall care. Resident #9, who was cognitively intact and required assistance with various activities of daily living, had interests in arts and crafts. However, the care plan for this resident did not include any activities. Similarly, Resident #13, who was also cognitively intact and required supervision and assistance with daily activities, had interests in word puzzles and watching television, but their care plan was also missing activities. Resident #45, with cognitive skills for independent decision-making and requiring set-up assistance for daily living activities, had interests in arts, crafts, bingo, cards, and board games, yet their care plan lacked any mention of activities. Interviews with the Activities Director and the RN MDS Coordinator confirmed that the responsibility for completing and updating residents' activity care plans was not fulfilled for these residents. The facility's care planning policy mandates that a comprehensive care plan be developed within seven days of completing the resident assessment (MDS) and should be based on the resident's comprehensive assessment. The policy also specifies that the care planning team, including the activity director/coordinator, is responsible for developing these individualized care plans. Despite these guidelines, the care plans for Residents #9, #13, and #45 were incomplete, lacking the necessary inclusion of activities.
Failure to Develop Discharge Plan of Care
Penalty
Summary
The facility failed to develop a discharge plan of care for a resident, which was identified during a review of medical records, policy, and interviews. The resident, who was admitted with diagnoses including cerebral infarction, diabetes mellitus type-1, tracheostomy, and anoxic brain injury, was discharged without a documented discharge plan. Despite the resident's power of attorney and the Social Service Designee (SSD) communicating about the need for home care products and services, no active discharge planning or referrals were made as per the Minimum Data Set (MDS) assessment. The SSD admitted to not developing a discharge plan of care due to concerns about forgetting to update it. Although the SSD had been working on discharge arrangements for about a month before the resident's discharge, there was no evidence of a formal discharge plan. The facility's policy required an effective discharge planning process involving the interdisciplinary team and the resident or their representative, which was not followed in this case.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
