§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
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Observations:
Based on clinical record reviews and staff interviews, it was determined that the facility failed to review and revise care plans for two of 35 residents reviewed (Residents 12, 14).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated April 7, 2026, indicated that the resident had moderate cognitive impairment, required assistance from staff for her daily care needs and had diagnoses that included diaphragmatic hernia with obstruction (a defect in the diaphragm, which is the muscle separating the chest from the abdomen, that allows abdominal organs to push into the chest cavity and become trapped, twisted, or blocked, preventing the normal passage of food).
Physician's orders for Resident 12, dated April 3, 2026, included an order for the resident to receive a full liquid diet with thin consistency liquids.
A care plan for Resident 12, dated April 3, 2026, indicated that the Resident had anemia (low levels of healthy red blood cells), and a large hiatal hernia with food impaction (food is lodged, or trapped in a body cavity or passage). The resident was to be encouraged to eat food rich in iron such as green leafy vegetables, meat, eggs, poultry, nuts, grains, cereal and dried beans.
A care plan for Resident 12 dated April 7, 2026, indicated that the Resident had the potential for altered nutrient utilization because of a large hiatal hernia with mechanical impaction. Staff were to provide and serve a full liquid diet.
Interview with the Nursing Home Administrator on June 4, 2026, at 2:33 p.m. confirmed that Resident 12's care plan did not accurately reflect the resident's active care needs and should have been revised.
A Quarterly MDS assessment for Resident 14, dated May 2, 2026, indicated that the resident was cognitively impaired and required assistance from staff for daily care needs. The resident's care plan, dated May 5, 2026, indicated that the resident had behaviors.
A nursing note for Resident 14, dated May 3, 2026, indicated that the resident stated he wanted to harm himself.
Interview with Nurse Aide 1 on June 2, 2026, at 2:05 p.m. revealed that Resident 14 makes self-harm threats when he gets frustrated and has made similar statements in the past.
There was no documented evidence that Resident 14's care plan was updated to reflect his statements of self-harm or what interventions the staff should use when he makes these statements.
Interview with the Director of Nursing on June 4, 2026, and 2:28 p.m. confirmed that Resident 14's care plan should have been updated to reflect his statements of self-harm.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
| | Plan of Correction - To be completed: 07/14/2026
483.21(b)(2)(i)-(iii) REQUIREMENT
Care Plan Timing and Revision:
Christ the King Manor intents to ensure comprehensive care plans are reviewed and revised by our interdisciplinary team. Corrective action has been completed Resident 12 and Resident 14. Resident 12 now has a complete and accurate care plan addressing the nutritional needs for anemia and large hiatal hernia with food impaction with the physician ordered full liquid diet. Resident 14 now has a complete and accurate care plan addressing the statements of self-harm and include individualized interventions and staff guidance for when residents display behaviors.
All residents have the potential to be affected by the same deficient practice. Audit of all residents with significant changes in condition, behavioral concerns, dietary changes to make sure they appropriately reflect care plan. No other residents have this deficient practice.
Measures put into place to ensure deficient practice does not recur are as follows: Education to all licensed nurses, dietary staff and other interdisciplinary team regarding
- Requirements for development, review, and revision of comprehensive care plans
- Revising care plans when significant changes in condition occur
- Revising care plans when new physician orders, dietary changes, behavioral concerns, or other resident-specific needs are identified
- Review policy titled "Use of Care Plan."
Residents with Behaviors and new diet orders will be monitored to ensure deficient practice will not recur. Corrective actions will be monitored by the Director of Nursing and/or her designee. This will be completed daily for 14 days, bi-weekly for 2 weeks, and weekly for 2 weeks. Results of audits will be presented to the quality assurance committee.
Corrective actions will be monitored by submitting observations to Quality Assurance Committee for review, recommendations and compliance.
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