§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 observations, review of facility policy, review of clinical records, and staff in our view, it was determined that the facility failed to develop and implement a person center and comprehensive care plan related to resident's nutritional needs and weight loss for one resident. (Resident R1)
Findings include:
Review of facility policy titled "Care Plans, Comprehensive Person Centered" dated March 2022, revealed that a comprehensive person center care plan includes measurable objectives and timetables to meet all resident's physical, psychosocial and functional needs. The care plan includes the resident's goals upon admission, reflects currently recognized standards of practice for problem areas and conditions. When possible, the care plan interventions address the underlying source of the problem areas. Assessments of the residents are ongoing, and care plans are reassessed as information about the resident and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the residents' condition.
Review of policy titled "Weight Assessment and Intervention" dated March 2022, revealed that resident weights are monitored for undesirable or unintended weight loss or gains. Undesirable weight change is evaluated, this evaluation includes recent target weight range, resident's calorie protein and other nutrient needs compared to the resident's current intake, the relationship between current medical condition or clinical situation and recent fluctuations in weight and whether and to what extent weight stabilizing or improvement can be anticipated. Care planning for weight loss or impaired nutrition is a multi-disciplinary effort and includes the physician nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. Individualized care plan shall address, to extent possible the identified cause of weight loss, goals and benchmarks for improvement, and time frames and perimeters for modern monitoring and reassessment. Interventions for undesirable weight loss are based on careful consideration of the following; resident choice preferences, common nutrition, functional factors that may inhibit independent eating, environmental factors that may inhibit appetite, chewing and swallowing abnormalities, medications that may interfere with appetite, the use of supplementation or feeding tubes and end of life directives.
Review of Review of resident R 1's admission minimum data set (MDS- a federal mandated assessment tool for all residents) dated December April 23, 2025, revealed that resident R1 was admitted into the facility April 16, 2025, 2024 with diagnosis' including Coronary artery disease( a heart disease that happens when coronary arteries cannot supply the heart with enough blood, oxygen and nutrients), hypertension(high blood pressure-a condition where the force of blood in the heart is consistently too high), diabetes(the body does not produce enough insulin or cannot properly use insulin, leading to high blood sugar levels), aphasia(inability to swallow ), malnutrition(Lack of proper nutrition ), and depression(persistent feeling of sadness and changes of how you think, sleep, eat , and act). Resident assessment with a cognitive BIMS (brief interview for mental status) score of 11, indicating the resident is moderate cognitive impairment. Review of resident's weight summary dated April 16th, 2025, resident was recorded as being 118.0 pounds admission, April 23rd, 2025, resident reported being 107.6, indicating a 10.4-pound weight loss. After two weeks the resident was weighted again and was documented as 102.8 pounds, indicating a 4.8-pound weight loss.
Review of resident R1's care plan revealed that Resident is at risk for malnutrition related to muscle fat wasting on NFPE (nutrition focused physical exam), need for modified food texture food, need for an ONS (oral nutrition supplements), altered nutrition related labs, increased metabolic needs and chronic medical diagnosis which was initiated April 22, 2025. The intervention for this focus was to provide a regular, thin liquid diet that noted "I prefer the following foods: pescatarian diet" A diet that is free of meat and chicken, primarily a plant-based diet with fish consumption.
Further review of resident R1's care plan revealed no focus or intervention and goals of resident 's documented weight loss.
Continued review of resident R1's care plan revealed there was no interventions of resident's "preference" of pescatarian diet and supplemental needs that accompany this diet.
Interview with dietitian, employee E5, conducted on May 14, 2025, at 10:53 AM confirmed that the resident has documented weight loss which has not been included in the resident care plan. Employee E5 stated that she has worked with the kitchen staff to develop a pescatarian diet for resident R1. There is no indication that the facility has any documented menu choices for pescatarian residents' preferences.
28 Pa Code 211.10(c) Resident care policies
28 Pa Code 211.12(d)(5) Nursing service
| | Plan of Correction - To be completed: 06/13/2025
"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."
Resident R1 Care Plan has been updated to address a documented weight loss and a "Pescatarian diet" preference. The facility will complete an audit of current residents' care plans to validate residents with a documented weight loss and or a diet preference has been addressed. Variances were addressed at the time of the audit and placed on the facility audit tool. The Licensed Nurses and Dietician will be educated on the importance of developing a comprehensive care plan for each resident as it relates to a resident's weight loss or a documented diet preference. NHA/Designee will complete random audits 2x per week for 3 weeks and then monthly for 3 months of resident care plans to validate residents with a documented weight loss and or diet preference has been addressed. The results of the audits will be submitted to the quality assurance performance improvement committee monthly for review and recommendations, including the need for further audits if indicated based on the audit findings.
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