§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 policies, clinical records, observations and staff interviews, it was determined that the facility failed to implement interventions in a resident's care plan to prevent a wandering resident from entering other's rooms for six of 19 residents reviewed (Residents 13, 14, 15, 16, 17, 18).
Findings include:
The facility's policy regarding care plans, dated June 10, 2026, revealed that the resident's care plan will address resident goals, actual and potential problems, needs, strengths and individual preferences of the resident.
A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated June 15, 2026, revealed that the resident was severely cognitively intact, ambulated without assistance, and had wandering behaviors. The resident's care plan, most recently updated 6/26/26, revealed that she wanders and that she would not significantly intrude on the privacy or activity of others.
Observations of Resident 19 on June 30, 2026, revealed that the resident was walking the halls of the Stouffer 1 floor and wandering aimlessly.
A quarterly MDS assessment for Resident 13, dated May 9, 2026, indicated that the resident was severely cognitively impaired, required assistance for daily care needs, and had diagnoses that included anxiety. The resident's care plan, dated November 17, 2025, revealed that she is to have a stop sign on her room door to maintain privacy and that staff will observe placement of stop sign during rounds.
Observations of Resident 13 in room 149 on June 30, 2026, at 1:00 p.m. revealed that she was laying in her bed in her room and the stop sign at her doorway was not engaged.
A quarterly MDS assessment for Resident 14, dated March 27, 2026, revealed that the resident was cognitively intact. The resident's care plan, dated June 10, 2025, revealed that she was to have a stop sign on her door to maintain privacy and that staff would observe the placement of the stop sign during rounds.
Observations of Resident 14 in room 150 on June 30, 2026, at 1:11 p.m. revealed that she was sitting at the side of her bed and that the stop sign was not engaged on her doorway.
A quarterly MDS assessment for Resident 15, dated May 29, 2026, revealed that the resident was cognitively intact and required assistance from staff for all her daily care needs. The resident's care plan, dated April 18, 2024, revealed that the resident is to have a stop sign at her doorway.
Observations of Resident 15 in room 152 on June 30, 2026, at 1:11 p.m. revealed that the resident was laying in her bed and her stop sign was not engaged on her doorway.
A quarterly MDS assessment for Resident 16, dated March 27, 2026, revealed that the resident was severely cognitively impaired and required assistance from staff for her daily care needs. The resident's care plan, dated June 10, 2025, revealed that she was to have a stop sign at her door to maintain privacy and that staff would observe placement of the stop sign during rounds.
Observations of Resident 16 in room 155 on June 30, 2026, at 1:11 p.m. revealed that she was lying in her bed and that the stop sign was not engaged on her door.
A quarterly MDS assessment for Resident 17, dated May 31, 2026, revealed that the resident was severely cognitively impaired and required assistance from staff for her daily care needs. The resident's care plan, dated October 15, 2025, revealed that the resident was to have a stop sign at her door to maintain privacy and that staff would observe placement of stop sign during rounds.
Observations of Resident 17 in room 157 on June 30, 2026, at 1:13 p.m. revealed that she was laying in her bed and the stop sign was not engaged on her door.
A quarterly MDS assessment for Resident 18, dated May 3, 2026, revealed that the resident was severely cognitively impaired and required assistance from staff for her daily care needs. The resident's care plan, dated August 27, 2025, revealed that the resident was to have a stop sign on her door to maintain privacy and that staff would observe placement of stop sign during rounds.
Observations of Resident 18 in room 159 on June 30, 2026, at 1:13 p.m. revealed that she was lying in her bed and the stop sign was not engaged on her door.
Interview with Nurse Aide 1 and Nurse Aide 2 on June 30, 2026, at 1:10 p.m. revealed that they were agency nurse aides and that they believed the resident's stop signs only had to be up at certain times of the day and that when they charted regarding the stop sign they were signing off that the stop sign was at the door, not that it was engaged at the resident's door.
Interview with Licensed Practical Nurse 3 on June 30, 2026, at 1:20 p.m. revealed that the residents stop signs should be engaged in order to prevent Resident 19, or other wandering residents, into their rooms. She walked around the halls and placed the stop signs across from the residents' rooms.
Interview with the Director of Nursing on June 30, 2026, at 3:10 p.m. revealed that he put the stop signs in their proper place earlier this day, but that staff or residents may have taken them down since that time. He stated that they should be in place in order to prevent a wandering resident from entering their rooms. He further stated it may not be the best intervention since other residents tend to tear them down.
28 Pa. Code 211.11(d) Resident care plans.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 07/17/2026
Facility cannot retroactively correct this as the required timeframe has passed.
Residents who are care planned for stop sign usage have the potential to be affected by this.
The stop signs have been removed as a facility intervention due to them being easily removed by residents and failure of the Velcro backing.
The Director of Nursing and/or designee will audit 5 random records on the S1 unit weekly x 2 then monthly x 1 to ensure staff do not use the stop signs as an interventions to deter wandering residents from entering other resident rooms. Findings will be reviewed at the monthly facility Quality Assurance and Performance Improvement meeting.
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