Failure to Develop Comprehensive Care Plans for Pain and Medication Refusal
Summary
The deficiency involves the facility’s failure to develop comprehensive care plans addressing pain management and medication refusal for two residents. One resident was admitted with diagnoses including acute pyelonephritis, bladder and kidney calculi, chronic kidney disease, and diabetes mellitus, had intact cognition, and required staff assistance with ADLs. Physician orders included Lyrica twice daily for chronic pain syndrome and Robaxin four times daily for pain, but the care plan dated shortly after admission did not include any focus or interventions for pain management. A pain assessment documented that this resident experienced severe pain frequently over the previous five days that interfered with sleep. Observation showed the resident in bed, constantly moving with a pained expression, and the resident reported urinary frequency, flank pain from a kidney stone, and rated the pain as 10 out of 10. The DON confirmed that the resident’s care plan did not address the need for pain management. The second resident was admitted with end stage renal disease and type 1 diabetes mellitus. The care plan developed after admission did not include a focus on the resident’s frequent refusal of medications, despite active physician orders for Lyrica, Renvela, calcium carbonate, trazodone, and Prostat. Multiple progress notes over several days documented repeated refusals of Renvela, calcium carbonate, trazodone, and Prostat at various times, indicating an ongoing pattern of medication refusal. An LPN confirmed that this resident had a history of frequently refusing medications throughout the stay, and the Unit Manager verified that the care plan did not reflect this frequent refusal. These findings show that the facility did not develop and implement complete, measurable care plans that addressed identified needs related to pain management and medication refusal for the affected residents.
Penalty
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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.
Surveyors found that the facility did not develop or implement required care plans for two residents with identified needs related to hypotension and pain. One resident with chronic kidney disease and heart failure had ongoing MD orders for midodrine to treat low BP, but no hypotension care plan was in place, which the DON acknowledged should have existed. Another resident with peripheral autonomic neuropathy and peripheral vascular disease was cognitively intact, had pain that interfered with daily activities, received PRN tramadol 1–3 times per day and scheduled gabapentin, yet had no pain care plan; the MDS nurse stated she had forgotten to initiate it.
A resident with multiple conditions, including a tibia fracture, CVA, unsteadiness, need for assistance with personal care, and generalized muscle weakness, had a physician order for 5 oz of wine daily PRN. Facility policy required the IDT to develop a comprehensive person-centered care plan with measurable objectives and timeframes, including all needs identified in the assessment and necessary healthcare information. Review of the resident's care plan showed that the ordered wine use was not included, and the DON confirmed that this intervention was not care planned despite the existing order.
Surveyors found that the facility failed to develop and maintain comprehensive care plans for two residents, one receiving an anticoagulant and psychotropic meds for vascular dementia with agitation, and another with a history of sacral pressure ulcers and a high Braden risk score. The first resident’s care plan did not address anticoagulant use or dementia-related care despite active orders and facility policy requiring individualized dementia care planning. The second resident’s care plan lacked any pressure ulcer prevention or management interventions, even though prior sacral ulcers had healed with documented preventive measures in place and the ulcer later reopened; staff confirmed the resident’s high risk and the absence of an active pressure injury prevention care plan during that time.
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 Develop and Implement Care Plans for Hypotension and Pain
Penalty
Summary
The facility failed to develop and implement complete care plans addressing all identified needs for two residents, specifically related to hypotension and pain management. For one resident with diagnoses including stage 3 chronic kidney disease and heart failure, a physician’s order dated 11/16/25 directed administration of midodrine 10 mg three times daily for hypotension, to be held if systolic blood pressure exceeded 120, and this order was later changed on 3/23/26 to midodrine 10 mg every eight hours as needed for systolic blood pressure less than 120. Despite these ongoing medical orders for treatment of hypotension, there was no corresponding care plan addressing hypotension in the resident’s record. During interview, the DON acknowledged that there should have been a care plan for hypotension. Another resident, admitted with diagnoses including peripheral autonomic neuropathy and peripheral vascular disease, was documented on the admission MDS as cognitively intact and experiencing pain that occasionally interfered with day-to-day activities, with receipt of pain interventions. Physician’s orders included tramadol 50 mg every six hours as needed for pain, which the MAR showed was administered 1–3 times daily, and gabapentin 300 mg three times daily for neuropathy. Despite the documented pain, frequent use of PRN tramadol, and scheduled gabapentin, there was no pain care plan in the resident’s record. In interview, the MDS nurse stated there should have been a pain care plan and that she must have forgotten to initiate it.
Failure to Include Physician-Ordered Wine Use in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan that included all of a resident's needs, specifically omitting an ordered intervention related to wine use. Facility policy required the IDT to create a comprehensive care plan with measurable objectives and timeframes based on the comprehensive assessment, and to implement a baseline care plan within 48 hours of admission. Resident #6, admitted and later readmitted with multiple diagnoses including left tibia fracture, stroke, unsteadiness on feet, need for assistance with personal care, and generalized muscle weakness, had a physician's order dated 4/9/26 for 5 oz of wine daily as needed every 24 hours. Review of the resident's comprehensive person-centered care plan showed that this wine order was not included, and during an interview on 4/30/26 at 4:30 PM, the DON confirmed that the resident's wine use was not care planned and acknowledged that it should have been. This omission demonstrated that the facility did not fully follow its own Comprehensive Person-Centered Care Planning policy for this resident, as the care plan did not reflect all physician-ordered services identified in the resident's assessment.
Failure to Develop Comprehensive Care Plans for Anticoagulant Use, Dementia, and Pressure Ulcer Prevention
Penalty
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.
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