§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
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Observations:
Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs for one of 14 sampled residents. (Resident 4)
Findings include:
Clinical record review revealed that Resident 4 had diagnoses that included delirium and dementia. Review of the Minimum Data Set assessment dated October 9, 2025, revealed the Care Area Assessment (CAA) noted for Resident 4 to have a care plan developed for cognitive loss/dementia. Review of the clinical record revealed that there was no care plan developed for cognitive loss/dementia. On August 14, 2026, a nurse noted that Resident 4 was observed verbally threatening another resident in the dining room. Review of the facility documentation dated August 14, 2026, revealed interventions that included Resident 4 would maintain a safe distance from the other resident, would not be in close proximity of the other resident, and would not be seated at the same table for activities or meals as the other resident. Review of Resident 4's care plan revealed he was at risk to demonstrate verbally abusive behaviors. The care plan did not include the interventions to maintain safe a distance from the other resident, would not be in close proximity of the other resident, and would not be seated at the same table for activities or meals as the other resident.
In an interview on August 27, 2026, at 11:48 a.m., the Director of Nursing confirmed the interventions were not documented in Resident 4's care plan.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 09/21/2026
1. Resident 4s care plan was updated to reflect cognitive loss/dementia diagnosis. Resident 4s care plan was updated to ensure all interventions were in place related to resident 4s verbal outbursts.
2. A facility wide audit will be completed by the Minimum Data Set (MDS) Nurse and reviewed by Regional MDS Nurse to ensure that all residents with a triggered cognitive loss/dementia Care Area Assessment (CAA) are care planned appropriately and applicable interventions are in place. A 30-day look back will be completed by DON or designee to ensure all Incident Report interventions are added to the resident's care plan.
3. Staff with responsibility to complete the MDS and care plans will be re-educated on the MDS CAA process per the Resident Assessment Instrument (RAI) and ensure care plans are in place and updated timely per F0656. The Interdisciplinary team (IDT) will be responsible for completing and updating care plans in a timely manner.
4. The Regional MDS nurse or designee will audit 5 residents weekly x 4 weeks then monthly x2 months to ensure that all residents with a triggered Care Area Assessment (CAA) are care planned appropriately and applicable interventions are in place, and all incident report interventions are updated timely. The results will be submitted to QAPI Committee for review and analysis of ongoing monitoring.
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