§483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.
§483.20(b) Comprehensive Assessments
§483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.
§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
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Observations:
Based on review of facility policy, facility documents, clinical record review, and staff interview it was determined that the facility failed to revise a care plan to accurately reflect the current status for one of three residents (Resident R1).
Findings included:
Review of the facility "Assessment -Comprehensive Person-Centered Care Planning" last reviewed 1/2/25, indicated to assure documentation, development, and implementation of a comprehensive person-centered care plan for all residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Review of the clinical record indicated Resident R1 was admitted to the facility on 6/28/23.
Review Resident R1's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 10/13/25, indicated the diagnosis of traumatic spinal cord dysfunction, anemia (low iron in the blood) and neurogenic bladder.
Review of Resident R1's physician orders dated 12/10/25, indicated right anterior lower extremity trauma wound, leave open to air allow steri- strips to fall off.
Review of nursing progress note dated 11/26/25, at 12:03 p.m. indicated notified by nurse that resident sustained a laceration to right anterior medial shin when staff were putting on her pants the hook from urine bag caught her leg causing the laceration, it's v-shaped skin flap attached at wound bed edges well approximated fatty tissues visible with clear serosanguinous discharge draining/weeping surrounding skin shinny fragile edematous.
During an interview completed on 12/11/25, at 11:00 a.m. the Nursing Home Administrator (NHA) stated that Resident R1 has "lymphedema and frail skin".
During an interview completed on 12/11/25, at 1:45 p.m. upon asking Nurse Aid (NA) Employee E2 concerning Resident R1's leg appearance indicated they are sometimes swollen and leak, that she also has special pumps that she uses.
Review on 12/11/25, at 1:30 p.m. Resident R1's current care plan failed to include any interventions for lymphedema or preventative measures for impaired skin integrity.
During an interview completed on 12/11/25, at 2:45 p.m. Registered Nurse Employee E16 confirmed that Resident R1's current care plan did not include interventions for lymphedema or preventative measures for impaired skin integrity.
During an interview completed on 12/11/25, at 3:10 p.m. the Nursing home Administrator confirmed that the facility failed to revise a care plan to accurately reflect the current status for one of three residents (Resident R1).
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
28 Pa. Code 211.11(e) Resident Care Plan.
| | Plan of Correction - To be completed: 01/12/2026
1. On 12-01-2025 DON updated resident's R1 care plan.
2. Care plans were checked for identified residents with dx of lymphedema, fragile skin and foley catheters for accuracy and to ensure proper problems were addressed with corresponding interventions.
3. Staff educator/designee conducted education with licensed staff on care planning.
4. DON/Designee will audit care plans for all residents and any new admission with dx of lymphedema, fragile skin and foley catheters daily x 1 week, 2x week for 2 weeks and weekly x one month. Audit results will be reviewed by the QA Committee until consistent substantial compliance has been achieved.
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