§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 and/or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of five sampled residents. (Resident 1)
Findings include:
Clinical record review revealed that Resident 1 had diagnoses that included a history of falls, muscle weakness, and lack of coordination. Review of the Minimum Data Set assessment dated September 16, 2025, revealed that the resident used a motorized wheelchair. Review of a therapy discharge summary dated May 14, 2025, revealed that the resident required distant supervision when using his motorized wheelchair outdoors. Further review of the clinical record revealed that the resident left the nursing unit daily to visit with his wife in another level of care in the building and staff were aware. Review of the care plan revealed that the resident was non-compliant with requesting staff supervision to use his motorized wheelchair outside.
In an interview on October 27, 2025, at 10:57 a.m. the Director of Nursing confirmed that the resident was not compliant with requesting supervision with use of his motorized wheelchair outdoors
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There was a lack of documented evidence that the facility developed an individualized care plan to meet the resident's need for supervision and implemented interventions to address his continued non-compliance with notifying staff when he desired to leave the building.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 12/15/2025
A comprehensive review of R1 care plan was completed upon return from the hospital on 10/23/25 during the initial assessment period by the interdisciplinary team. Areas addressed included PT/OT/ST, fall risk interventions and an elopement evaluation. Updates were made to his plan of care, goals and interventions, creating an individualized care plan that addresses R1 needs.
Care conference review held on 11/5/25 to further personalize his comprehensive plan of care with the R1and POA/family with a goal to maintain R1 safety.
The sign-out process was reviewed with R1 and his POA/family during care conference on 11/5/25.
Director of Healthcare Services will audit all residents who leave the unit for physician order noting resident can safely leave unit independently by 11/7/25.
The care coordinator will send a therapy referral for evaluation of resident safety off unit for residents identified as not having physician order on record addressing ability to leave unit by 11/7/25.
Assistant Director of Healthcare Services, social worker and RNAC will review comprehensive care plans for same residents identified to assure individualize interventions are noted regarding travelling off the unit and any safety needs by 11/14/25.
Care Coordinator, or designee will add a "blue door" to each resident's mobility device to identify to all team members that the resident is able to leave the unit independently by 11/10/25
Care Coordinator, or designee will initiate the use of "blue doors" on resident wheelchairs or walkers to identify those that can leave independently
Director of Healthcare Services will re-educate sign out process with team members, residents via resident council, resident's first emergency contact and the receptionist team by 11/20/2025
The resident sign out sheets will be moved from the current table near the main nurses' station to a wall pocket in the same area, placed at wheelchair height with a bright sign to draw attention to it by 11/14/25.
Assistant Director of Healthcare Services, or designee will audit use of sign out book weekly X 12 weeks or until compliance is achieved starting week of 11/17/25. Results shared at QAPI beginning in December
Assistant Director of Healthcare Services, or designee will audit new therapy orders for safety on/off unit compared to comprehensive care plan for accuracy weekly X 12 weeks starting week of 11/17/25. Results shared at QAPI beginning in December
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