Failure to Implement Comprehensive Care Plans for Smoking and PTSD
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, particularly concerning their smoking habits. Observations and record reviews revealed that six residents were not provided with adequate care plans addressing their smoking needs, which included necessary supervision and safety measures. For instance, one resident with moderate cognitive impairment was observed smoking without a required smoking apron, despite having a history of unsafe smoking practices. Another resident, who was not initially identified as a tobacco user, was found smoking unsupervised, highlighting discrepancies in smoking assessments and care plans. Additionally, the facility did not develop a care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident's care plan lacked focus areas or interventions addressing the PTSD diagnosis, despite the resident experiencing agitation and depression. This oversight indicates a failure to address the resident's mental health needs comprehensively, as required by the facility's policy on comprehensive care plans. The surveyors identified these deficiencies as creating potential risks for the safety and well-being of the residents. The facility's noncompliance with care planning requirements was determined to have the likelihood of causing serious harm or injury to residents, leading to the declaration of an Immediate Jeopardy situation. The facility's failure to monitor smoking practices adequately, maintain accurate smoking assessments, and ensure supervision during smoking activities contributed to this critical finding.
Removal Plan
- The facility failed to develop a comprehensive person-centered care plan for residents R25, R145, R111, R19, R71, R118, R266 and R365. The Regional Nurse Consultant and Director of Nursing reviewed and revised each of their smoking care plans to ensure that they are person centered and comprehensive.
- The Regional Director of Operations in-serviced the Director of Nursing, Assistant Director of Nursing, Minimum Data Set nurses and Regional Nurse Consultant on the smoking policy, ensuring that smoking care plans are followed and completed timely, and importance of accurate smoking assessments. The Administrator will be in-serviced by the Regional Director of Operations.
- Regional Director of Operations in-serviced the MDS nurses on reviewing for complete and accurate comprehensive person-centered smoking care plans for all residents who smoke.
- The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional operations, and/or Regional Nurse began in-servicing all staff on the smoking policy, all residents on Dementia Unit will be required to wear smoking aprons, smoking times, and on the smoking monitors will be present at all smoke breaks.
- Registered Nurses, Licensed Practical Nurses, Certified Nurse assistants, and Certified Medication Aides have been in-serviced on importance of following care plans. There is currently 94% in-serviced completion.
- The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional operations, and/or Regional Nurse began in-servicing all staff on the smoking monitors will be present at all smoke breaks.
- All new licensed staff will be in-serviced on these items above during the orientation process by the Assistant Director of Nursing and/or Director of Clinical Education.
- AD Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed for policy review and root cause analysis was determined staffing education was needed. Attendance to the meeting was Regional Director of Operations, Director of Nursing, Regional Nurse, President of Quality, business office manager, dietary manager, dietary assistant manager, medical supply clerk, transportation coordinator, Director of Rehab, Social Worker, and Unit Managers. The Medical Director was notified by phone.
- Corrective actions will be completed.
- Care Plan and Smoking Assessment Review: R25 - Unsafe smoker, Care plan revised, Smoking assessment was completed - requires supervision. R145 - is a safe smoker however was observed lighting cigarettes for other residents. R145 is a safe smoker - R111- is an unsafe smoker - requires supervision and an apron. R19 - is an unsafe smoker - needs supervision and an apron. R71- is an unsafe smoker. Resident solicits to residents, staff, and/or visitors when cigarettes are not available. Resident has a history of being non-compliant with smoking policy - requires supervision and an apron. R118 - is unsafe smoker - requires apron, cigarette holder, someone to light and extinguish and supervision. R266- Resident is a safe smoker - no supervision, R365- is a safe smoker; however, sometimes non-compliant with the smoking policy. History of lighting other resident's cigarettes - independent smoker.
- In-service education was conducted by Regional Director of Operations and Training and Development Coordinator, Licensed Practical Nurse Unit Manager. In-service included ensuring the residents have their smoking aprons, smoking times, and direct supervision over all smokers safe and unsafe.
- In-service education was conducted by Regional Director of Operations and LPN Unit Manager. In-service education was relating to the smoking policy, abiding by smoking times and ensuring all smokers are care planned. Once a person who wants to smoke is identified a smoking assessment is completed.
- Director of Nursing received in-service from her Regional Director of Operations. She was educated on the new smoking times, smoking policy and creating safe smoking habits for residents. Smoking assessments must be done quarterly and as needed (PRN) and all care plans must be updated to ensure they are in alignment with the assessment. Unsafe smokers will not have their equipment on them, instead they will be locked in a lock box.
- Assistant Director of Nursing received in-service education relating to all the smokers in the building. Smokers cannot smoke anytime they like and are not allowed to hold their own smoking material. In-service education consisted of smoker's policy, timely assessments and care plans. Each resident must be supervised every 2 hours, and a smoking list kept at each nursing section.
- Minimum Data Set nurse received in-service education from the Regional Director of Operations. Topics covered included updating care plans, the smoking policy and smoking assessments for all residents that smoke.
- LPN received in-service on smoking. Training pertained to the residents, fire extinguisher, aprons, and smoking hours. In addition to care plan for safe smokers and unsafe smokers. Unit Manager gave the staff the updated list of smokers with safe and unsafe identified residents. The smoker list is posted in the CNA book and the Nurse book behind the nurse's station.
- Scheduling Manager received smoking in-service training. Everyone on Magnolia Hall is considered unsafe. Apron should be on, they are not to have cigarettes or lighters on person. Smoking box is kept at the nursing station. Nursing keeps the list of the smokers, also list in the smoke box upstairs. Fire blankets are kept in the boxes in both locations up and down stairs. Smoking assessment must be done by the nurses, clinical manager or MDS personnel. Once the assessment is completed it is put in the care plan.
- CNA received smoking in-service. In-service training pertained to the safety of the residents, the nurses conducting the smoking assessments. Nurses are the monitors and the CNA are making sure they keep their smoking aprons on and providing supervision.
- In-service training for the removal plan determined all numbers are accurate.
- LPN received in-service on smoking. Training pertained to the residents, fire extinguisher, aprons, and smoking hours. In addition to care plan for safe smokers and unsafe smokers. Unit Manager gave the staff the updated list of smokers with safe and unsafe identified residents. The smoker list is posted in the CNA book and the Nurse book behind the nurse's station.
- CNA received in-service pertaining to smoking. In-service referred to the up-to-date policy, safe smokers, and unsafe smokers. Safe smokers do not have to have an apron on versus the unsafe smokers don't have to have an apron. Nurses are the ones who do the smoking assessment. The updated list is found at the nurse station. Unit upstairs smokes every two hours and downstairs on Magnolia start at 10:00 am - 6:00 pm.
- CNA received smoking in-service. In-service training pertained to the safety of the residents, the nurses conducting the smoking assessments. Nurses are the monitors and the CNA are making sure they keep their smoking aprons on and providing supervision.
- LPN received the in-service training for smoking. Training pertained to safe and unsafe smoker, the smoking aprons, light the cigarettes and monitor them. If the resident is deemed safe still monitor. Nurses can do the assessment for smoking. All Magnolia residents are monitored at all times during smoking times. Keep the cigarettes locked in the smoke box which is located in the Activities office. If any new staff, the staff can show them the list that is posted at the nurse's station.
- New onboarding employees will review the smoking policy as part of their orientation process. During this onboarding process the smoking components are: There is a new Smoking Schedule, and all staff should direct residents to the times. Smoking Assessment will be conducted as soon as the resident is identified as a smoker with care plan. All unsafe smokers should have a care plan, assessment, supervised residents will have on a smoking apron at all times. All residents on Magnolia are required to wear a smoking apron. Smoking Monitors should be present at all schedule smoking break times. Importance of following smoking care plans and accurately completing smoking assessment in a timely manner. Ensure smoking aprons are on correctly, residents are not allowed to light other resident cigarettes. Residents not on the smoking list are not allowed to smoke until the Charge Nurse, Administrator, or Director of Nursing have been notified and Smoking Assessment is completed.
- Record Review of the AD HOC QAPI Meeting confirmed the root cause was determined and that education to staff and residents on the smoking policy and expectations was needed, and a set smoking schedule established.
- Record Review revealed the removal plan binder with printed sheets in large bold print of the smoking schedule for the designated smoking area in courtyard and downstairs courtyard outside of Magnolia. Smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total of five (5) smoking breaks.
- Record review of the AD HOC QAPI Meeting Log revealed Medical Director was notified over the phone. Record review of the AD HOC QAPI Meeting Log for F835 confirmed all stated staff was present at the AD HOC QAPI Meeting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with hemiplegia after a cerebral infarction and chronic atrial fibrillation was receiving rivaroxaban 20 mg daily as an anticoagulant, as documented in active medication orders, the MDS, and the MAR over several months. However, the comprehensive care plan, from admission through a later update, did not include any problem, goal, or intervention related to anticoagulant use. The MDS Coordinator stated she reviews and updates care plans after MDS completion and acknowledged she had overlooked adding anticoagulant use to the care plan, while the Administrator reported an expectation that all high-risk medications, including anticoagulants, be reflected in resident care plans.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
Failure to care plan fall risk for a resident with severe vision impairment: A resident identified on MDS/CAA as being at risk for falls had no fall-risk interventions documented in the care plan. The resident required assistance with transfers, dressing, and hygiene, had severely impaired vision, and later sustained an unwitnessed fall from a wheelchair after falling asleep and not locking the brakes, resulting in facial bruising and a skin tear. The MDS nurse stated fall risk was not always added to the care plan if there was no prior fall history, while the DON stated any resident assessed at risk for falls was expected to have care plan guidance for staff.
A facility failed to maintain comprehensive care plans for three residents. One resident had documented activity preferences and needs, but no active activities care plan was in place. Another resident used a BiPAP with staff assistance, yet the care plan did not include the device. A third resident had a suprapubic catheter, but the care plan did not identify the catheter or who was responsible for catheter care and bag changes.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Care Plan for High-Risk Anticoagulant Therapy
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing anticoagulant medication use for a resident who had been prescribed rivaroxaban 20 mg daily with the evening meal for a history of cerebral infarction. The resident was admitted with hemiplegia following a cerebral infarction and chronic atrial fibrillation, and the active medication orders showed continuous administration of rivaroxaban from its start date through the survey review period. The quarterly MDS assessment documented that the resident was receiving an anticoagulant, and the Medication Administration Record confirmed daily administration of rivaroxaban over several months. Despite this ongoing anticoagulant therapy and the resident’s relevant diagnoses, the comprehensive care plan dated at admission and updated later did not include any focus area, goals, or interventions related to anticoagulant use. During an interview, the MDS Coordinator acknowledged that the care plan did not address the anticoagulant medication and stated that she must have overlooked it when updating the care plan after completing the MDS assessment. In a separate interview, the Administrator stated that her expectation was that all resident care plans reflect high-risk medications, including anticoagulants.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Failure to Care Plan Fall Risk for a Resident With Severe Vision Impairment
Penalty
Summary
The facility failed to develop a care plan for 1 of 13 residents, R15, who was identified as being at risk for falls upon admission. R15’s comprehensive MDS assessment accepted on 12/22/25 identified that the CAA for falls would be addressed on the care plan, with staff to monitor for fall risks related to medication, new surroundings, and adjustment due to vision and hearing deficits. The assessment also directed staff to ensure the call light was within reach, make sure R15 knew where it was located, and attach it so it would not slide away because of her vision impairment. R15’s quarterly MDS assessment accepted on 3/20/26 identified intact cognition, severely impaired vision, and the need for moderate assistance of one staff for transfers, dressing, and hygiene. Interview with R15’s family member identified that R15 recently had a fall after falling asleep while sitting in her wheelchair and falling face forward out of the chair, hitting her face on the nightstand and sustaining facial bruising. The nursing progress note dated 5/1/26 documented an unwitnessed fall in R15’s room after she forgot to lock her wheelchair brakes, fell asleep, leaned too far forward, and tipped out of the chair, resulting in a facial bump and bruise and a skin tear on her right ring finger. Review of R15’s current undated care plan showed no mention that she was at risk for falls and no information describing what staff were to do to minimize her fall risk. The MDS nurse stated that if a resident was identified as being at risk for falls upon admission but had no history of falls, that was not always added to the care plan regardless of the CAA findings. The DON stated it was her expectation that any resident assessed to be at risk for falls would have a care plan section alerting staff to those risks and how to provide care and minimize injury.
Incomplete Care Plans for Activity Needs, BiPAP Use, and Catheter Care
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and maintained for three residents reviewed for care planning. For one resident, a significant change MDS showed severe cognitive impairment and extensive to total assistance for all ADLs, along with preferences for books, newspapers, music, animals, news, groups of people, going outside, and religious services. An activity assessment also documented preferences for individual and group leisure, outings, worship services, nature, prayer, modern music, games, reading, group discussions, news, social activities, and connecting with team members, but the resident’s care plan did not include activity goals, participation, or interventions to address those needs. An activities lead confirmed the resident did not have an active activities care plan, and the administrator stated residents would be expected to have one. For another resident, the quarterly MDS identified intact cognition and use of a BiPAP machine was observed at the bedside with water next to it. The resident stated staff assisted with putting the mask on and off and turning the machine on and off at night. Nursing staff confirmed assistance was provided with the mask, machine, and water chamber, and that the water chamber should be filled weekly with mask and tubing changes documented on the MAR. However, the resident’s care plan addressed ADL deficits related to multiple sclerosis and impaired balance, but did not include any evidence that the resident required or used a BiPAP machine. The RN manager and DON both verified that BiPAP use should have been included on the care plan. For the third resident, the admission MDS identified intact cognition and an indwelling catheter. The resident stated he had a catheter prior to admission and that it had been changed to a suprapubic catheter because of infections, and he verified staff assisted with catheter care. The care plan addressed bladder incontinence with brief use, peri-care, scheduled checks, and monitoring for UTI signs, but did not identify the suprapubic catheter or specify who was responsible for catheter care and changing the catheter bag. The RN manager and DON both stated that catheter information should have been included on the care plan for coordination of care.
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