§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 clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs for one of four sampled residents. (Resident 1)
Findings include:
Clinical record review revealed that Resident 1 had diagnoses that included traumatic brain injury and depression. Review of the Minimum Data Set assessment dated June 12, 2026, revealed Resident 1 had no cognitive impairment. Review of facility documentation dated August 19, 2026, revealed Resident 1 alleged staff pushed him out of bed and that he had a history of false allegations and manipulative behavior.
In an interview on August 26, 2026, at 3:35 p.m., the Administrator stated that Resident 1 often gets agitated depending on his care giver's ethnicity.
There was no documented evidence that the facility developed a care plan or interventions related to Resident 1's false allegations, manipulative behavior, or aggression triggers related to ethnicity.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 09/22/2026
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.
Resident #1's care plan was updated to reflect his history of false allegations and manipulative behavior/aggression related to caregiver ethnicity.
The Director of Nursing\designee will complete an initial audit of current resident care plans who have documented behavioral symptoms including agitation, aggression, allegations concerning staff, or other identified behavioral triggers.
Education will be provided to the facility licensed staff and the interdisciplinary team regarding the facility policy "Person-Centered Care Plan."
The Director of Nursing/designee will complete five random audits of resident's care plans weekly for four weeks and then monthly for two months to verify that behavioral symptoms and triggers are documented appropriately. Results of the audits will be reviewed with the Quality Assurance and Performance Improvement Committee.
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