§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 observation, facility policy review, clinical records review, and interviews with staff and residents, it was determined that the facility failed to follow the care plan for one of the three residents reviewed (Resident 1).
Findings:
A review of the facility's policy titled "Care/Service Plans", last revised in May 2021, it revealed "The interim care plan will reflect resident's goals and include interventions that address his or her current needs in a language and format that resident and /or representative, if applicable, understand". The policy also indicated "The care plan will include healthcare information necessary to care for a resident including Services and treatments to be administered by the community or personnel acting on behalf of the community".
A review of Resident 1's admission assessment revealed the resident was admitted to the facility on February 11, 2026, with a diagnosis of Inclusion Body Myositis (IBM- a degenerative, inflammatory disease that causes slow, progressive muscle weakness and wasting), urinary retention, weakness, and UTI (Urinary Tract Infection).
A review of Resident 1's ADL (activities of daily living) care plan developed on February 11, 2026, revealed that the resident was "Total Dependence" with walking. Interventions include electric wheelchairs.
A review of Resident 1's admission Minimum Data Set (MDS- a standardized assessment tool that measures health status in long-term care residents) dated February 11, 2026, revealed the resident was cognitively intact. The same MDS revealed the resident's walking was coded as "88," indicating "Not attempted due to medical condition or safety concerns"
A review of the nursing progress notes documented by licensed nurse Employee E3, dated February 13, 2026, at 4:08 p.m., revealed "At 11 am [resident's name] was transferring with private caregiver from bed to motorized scooter and [they] called for assistance, while ambulating with this writer and caregiver utilizing walker, legs got weak and [they] was lowered to the floor".
A review of the facility's documents "Incident Report" dated February 13, 2026, at 11:00 a.m., revealed "Resident's private duty aide put on call light to get assistance with walking resident to motorized wheelchair, nurse answered bell and assisted with ambulation with walker short distance and resident's leg got weak and [they]was lowered to the floor". The same report revealed "Steps taken to prevent recurrence (action): Place chair closer so resident can stand and pivot (It involves using one leg as a central axis while other footsteps in arc) or only need to take one or two steps to transfer to motorized wheelchair".
An interview was conducted with Employee E3 on June 24, 2026, at 1:00 p.m. Employee E3 confirmed witnessing Resident 1's fall on February 13, 2026. When asked by the surveyor how far the resident's chair (motorized) was from the bed during the incident, Employee E3 responded "not far", "few steps". When asked if they could show the placement of the resident's chair in the room during the incident, Employee E3 responded "I can't remember".
An interview with the Physical Therapist (PT), Employee E4, was conducted on June 24, 2026, at 1:10 p.m. Employee E4 reported evaluating the resident on February 11 and 12, 2026. Employee reported that during evaluation/treatment, Resident 1 was able to transfer and ambulate nine feet with them. However, due to the resident's medical condition (IBM), safety steps/processes needed to be taken and followed for ambulation. Employee E4 reported training staff to transfer the resident but not ambulate. Employee E4 reported, "We did not clear any other caregiver to ambulate [the resident]".
The above was conveyed with the Director of Nursing and Nursing Home Administrator on June 24, 2026, at 3:00 p.m.
The facility failed to follow Resident 1's ambulation care plan, which resulted in a fall with no injury.
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 08/20/2026
The statement on this plan of correction (POC) are not an admission to and do not constitute an agreement with the alleged deficiencies. The POC is prepared and/or executed solely because it is required by Federal and State Law.
Immediate Corrective Action
Resident 1 was assessed immediately after the incident; no injury was noted. The care plan for Resident 1 was reviewed and updated to clearly specify how staff will assist resident with transfer.
Identification of Other Residents at Risk
A review of all current residents' care plans will be conducted by the Clinical Manager or designee to ensure that residents' individualized care plan reflects the appropriate ambulation and transfer status. Any discrepancies will be promptly corrected.
Staff Education and Training
All current nursing and care associates will be re-educated by the Staff Development Coordinator or designee following the residents' individualized ambulation and transfer status care plan. All new current nurses and care associates during new employee orientation are educated on individualized care plan and following the ambulation and transfer status.
Monitoring and Quality Assurance
The Clinical Manager or designee will audit 10% of current resident care plans weekly x 4 and monthly x 2 to validate residents care plan accurately reflect appropriate ambulation and transfer status. Any discrepancies will be promptly addressed. Audit findings will be reviewed for three months during Monthly Quality Assurance Committee meeting for review, additional audits and education may be determined based on findings
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