§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 facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that a comprehensive, person-centered care plan was implemented, which resulted in a fall from bed and actual harm as evidenced by a fracture of the left hip and forehead laceration for one of three residents reviewed (Resident 1).
Findings Include:
Review of facility policy, titled "MDS Assessment Completion and Care Planning," last revised October 2024, read in part, "Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. ... Policy Explanation and Compliance Guidelines: 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially when changes are made."
Review of Resident 1's clinical record revealed diagnoses that included dementia (a decline in mental ability that interferes with daily life) and osteoporosis (bone disease causing bones to become weak, porous, and brittle).
Review of Resident 1's fall care plan revealed the interventions for, "tab alarm at all times in bed and chair, bilateral floor mattresses/alarming floor mats, low bed, can roll onto mattress beside bed at times" which was last revised on August 15, 2025.
Review of Resident 1's Kardex (quick reference tool utilized to identify a resident's care needs/preferences and assistance needed) revealed section titled, "Safety," which stated, "tab alarm at all times in bed and chair, bilateral floor mattresses/alarming floor mats, low bed, can roll onto mattress beside bed at times."
Review of facility incident report dated December 15, 2025, revealed Resident 1 sustained an unwitnessed fall from bed at 4:15 PM. Review of the incident description revealed, "resident rolled out of bed to floor. Bed was not in low position and mats were not on floor. Resident sustained a 4-5 cm laceration to left forehead ..."
Review of Resident 1's interdisciplinary progress notes revealed that an assessment conducted by the Registered Nurse revealed Resident 1 sustained a 4.5-5 cm laceration to left forehead, bleeding noted from the laceration. The physician was notified and an order to send Resident 1 to the emergency room for evaluation and treatment was obtained.
Review of Resident 1's hospital summary dated December 15, 2025, at 5:41 PM, revealed that the Resident was initially treated in the emergency department and was subsequently admitted to the hospital for an orthopedic consult and monitoring.
Review of the emergency room physician's notes revealed Resident 1's 2 cm facial laceration was repaired with staples. X-ray results revealed Resident 1 suffered a mildly displaced fracture of the proximal left femoral metaphysis (hip fracture). Resident 1 was deemed not appropriate for surgical intervention due to multiple health factors.
Review of a witness statement by Employee 1 (Certified Nurse Assistant assigned to Resident 1 at the time of the fall), dated December 15, 2025, revealed Employee 1 stated, in part, " ...I did put her to bed. I did place floor alarms on both sides. I also put the bed as low as it would go. I put her in bed at about 2 PM."
Review of a second witness statement by Employee 1, dated December 16, 2025, revealed Employee 1 stated, "On 12/15/25 at 2pm I put the resident to bed. I kept her body alarm that was on her chair on the lift pad as she was transferred so that it remained on her. Both floor alarms were down, I did fail to put the second fall mat down on the side her closet is on. Once in bed, I lowered her bed down as low as it would go. I left around 3:30 to get my food and saw her in bed. I returned maybe 5-10 minutes later and continued to my set assigned for 2nd shift."
Review of witness statements from Employee 4 (CNA), Employee 5 (Licensed Practical Nurse [LPN]), and Employee 6 (Registered Nurse [RN]) revealed that when they responded to Resident 1's room after the fall, Resident 1's bed was observed in an elevated position, the fall mattresses were propped against the wall, and fall mat alarms were in place but not connected.
During an interview with the Nursing Home Administrator (NHA) on December 29, 2025 at approximately 1:00 PM, he revealed that Employee 1 was an agency CNA and had completed orientation to the facility and training on November 25, 2025.Following the facility's investigation, it was determined that Employee 1 failed to follow Resident 1's plan of care, which resulted in Resident 1 falling from her bed and sustaining a left hip fracture and facial laceration. The facility notified Employee 1's agency and placed Employee 1 on the do not return list. The NHA revealed that he expected staff to follow residents' plans of care and that an all staff in-service was completed to review the importance of following care plans.
Following the fall, the facility initiated additional education for nursing staff. Review of education documentation dated December 17 - 23, 2025, revealed that nurse aides and licensed staff were educated on the importance of alarms functioning, mat placement, and following care plans.
During an interview with Employee 2 (Assistant Director of Nursing [ADON]) on December 29, 2025 at approximately 1:05 PM, Employee 2 confirmed she had received training on the importance of alarms functioning, mat placement, and following care plans.
During an interview with Employee 3 (RN) on December 29, 2025 at approximately 1:15 PM, Employee 3 confirmed she had received training on the importance of alarms functioning, mat placement, and following care plans.
The facility initiated weekly care plan compliance audits on December 15, 2025. Audits continue and results are reviewed at the weekly Quality Assurance and Performance Improvement Committee meetings.
Review of facility documentation revealed that on December 23, 2025, the facility had completed audits and education for staff to ensure compliance with following the care plan.
During the abbreviated survey, audits and staff education were reviewed. Staff interviews, resident interviews, resident record review, and observations revealed no concerns with following resident care plans.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(1) Management
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 01/12/2026
Past noncompliance: no plan of correction required.
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