§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 review of facility policy, and review of clinical record, it was determined that facility did not ensure to develop and implement a care plan related to incontinence care and bed side rails for one of seven residents reviewed. (Resident R2)
Findings include:
Review of facility policy 'Comprehensive Person Centered Care Plans,' indicates that a person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
Further review of policy indicated that the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.
Review of Resident R2's clinical record revealed a medical history of anemia (low red blood count), history of falling, chronic kidney disease, type two diabetes mellitus (failure of the body to produce insulin), high blood pressure, dementia (progressive degenerative disease of the brain).
Further review of Resident R2's clinical record revealed a nursing note, dated April 4, 2026, at 9:10 pm, indicating resident was incontinent of bowel and bladder.
Further review of Resident R2's clinical record revealed bed rail evaluation completed on September 10, 2025, at 3:47 pm, indicating approved bed side rails to promote independence.
Review of Resident R3's care plan revealed no evidence of goals or interventions related to incontinence care or use of bed side rails.
28 Pa Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 03/26/2026
- Resident R2 no longer residing at the facility to update care plan.
- An audit was completed by DON/Designee for current residents on ensuring care plans for bed rails and Incontinent care goals and interventions are in place for applicable residents upon assessment.
- Education is completed by DON/ Designee with licensed nurses on the necessity of care plan for bed rails and Incontinent care goals and interventions per assessment.
- The DON/Designee will audit random care plans weekly x 4 weeks then monthly x 2 months to assure that bed rails and Incontinent care interventions and goals are care- planned as applicable for all residents. Findings of the audits will be reported to QAPI.
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