§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
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Observations:
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for one of eight residents reviewed (Resident 7).
Findings include:
The facility's policy regarding care plans, dated July 22, 2025, indicated that the facility will develop a comprehensive person-centered care plan for each resident. The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. At a minimum, this will occur with each comprehensive and quarterly assessment in accordance with the Resident Assessment Instrument (RAI - a standardized, comprehensive process used in nursing facilities to assess residents' needs and develop individualized care plans) requirements.
A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 7, dated April 30, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included aftercare following surgery for a shoulder joint prosthesis (an artificial body part), and repeated falls. A care plan for the resident, dated July 15, 2025, revealed that the resident has a history of falls with a left should injury and left hip fracture, and is at risk for falls related to deconditioning, limited mobility, vertigo (a sensation of feeling off-balance, as if you or your surroundings are spinning or moving), orthostatic hypotension (a form of low blood pressure that occurs when a person stands up, leading to dizziness, lightheadedness, and potentially fainting), and weakness.
A Therapy note for Resident 7, dated April 28, 2025, revealed that the writer attended the falls meeting with interdisciplinary team (IDT - a group of professionals from various fields who collaborate to address a complex issue, often in healthcare, by sharing their unique expertise and working together to achieve a common goal). The resident fell while attempting to self-ambulate. She then fell again while sitting on the edge of her bed. New intervention is to add a bed alarm that the resident is unable to turn off.
A Therapy note for Resident 7, dated May 8, 2025, revealed that the writer attended the falls meeting with IDT. The resident fell in the shower room. New intervention is to place an alarm on her wheelchair.
A Therapy note for Resident 7, dated June 18, 2025, revealed that the writer attended the falls meeting with IDT. The resident fell attempting to self-transfer out of her bed. New intervention is to place a bed/chair alarm on the bed and wheelchair.
Observations of Resident 7 on July 23, 2025, at 4:35 p.m. revealed that the resident was lying in bed and there was a bed alarm hanging on the bedside stand drawer with a cord leading to the resident's bed.
However, as of July 23, 2025, there was no documented evidence that Resident 7's care plan was revised/updated to reflect those alarms had been added to the resident's bed and wheelchair.
Interview with the Director of Nursing on July 23, 2025, at 4:53 p.m. confirmed that the facility currently uses a bed and wheelchair alarm for Resident 7, and that there was no documented evidence that the resident's care plan was revised/updated to reflect the use of a bed and wheelchair alarm.
28 Pa. Code 211.12(d)(5) Nursing Services.
| | Plan of Correction - To be completed: 08/15/2025
The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegation of non-compliance cited during the annual re-licensure survey ended on July 23, 2025.
1. Actions taken for the situation identified:
The facility cannot retroactively address the incident. No Resident, including Resident 7, was adversely affected. Resident 7's Care plan has been updated to reflect current care needs.
2. How the facility will act to protect residents in similar situations:
The Interdisciplinary Team will review care plans of other residents for accuracy related to fall interventions.
3. System changes and measures to be taken:
The Interdisciplinary Team and licensed nursing staff, including agency staff, will receive education on updating resident care plans to reflect current fall interventions.
4. Monitoring mechanisms to assure compliance:
The Director of Nursing/designee will audit five (5) resident care plans for current fall interventions weekly for four (4) weeks then monthly for two (2) months for accuracy. Identified issues will be addressed when found. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
5. Date Corrective Action will be completed:
Substantial compliance is expected by August 15, 2025.
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