Resident #2 lay in a recliner in the activities room when inspectors arrived in October. The patient had been admitted with dementia, anxiety disorder, and protein-calorie malnutrition. Short and long-term memory deficits left them severely impaired for decision making and requiring maximum assistance for most daily activities.
The physician had ordered hospice evaluation, do not resuscitate, and do not intubate. But the resident's care plan still listed "Full Code" as the advance directive.
Under that outdated plan, staff would perform cardiopulmonary resuscitation if the patient's heart stopped. The interventions spelled out exactly what would happen: CPR would be performed as ordered, staff would follow facility protocol for code status identification, and they would keep the family informed of condition changes.
None of it matched the doctor's actual orders.
A nurse's progress note from the evening shift documented that Resident #2 had been "admitted into hospice with new orders." Hospice staff provided morning care. But the comprehensive care plan remained unchanged.
The certified nursing assistant confirmed the patient had recently changed to hospice care. The licensed practical nurse acknowledged that hospice code status changes required updating the care plan "so that staff can provide the appropriate care."
The first floor unit manager, an LPN responsible for updating care plans, explained the process. For hospice residents, a Physician Orders for Life Sustaining Treatment form gets completed with the resident and family, then signed by the doctor. When code status changes, "the resident's care plan must be updated immediately to ensure that the correct care is administered should an emergency occur."
She knew the requirement. She knew her responsibility.
Resident #2's care plan was not updated.
The Director of Nursing confirmed the policy during questioning. "When an order is received for hospice and a change in code status, the care plan is immediately updated." But this patient's care plan still didn't reflect the change documented on the physician's order summary report.
The contradiction created a dangerous gap. Emergency staff responding to a cardiac arrest would follow the care plan's Full Code directive, not the physician's DNR order. They would perform chest compressions and attempt intubation on a patient whose doctor had specifically ordered against such interventions.
The facility's own policy, revised in August, requires a comprehensive, person-centered care plan with measurable objectives and timetables for each resident's physical, psychosocial and functional needs. The plan must be developed and implemented for every resident.
For Resident #2, the plan existed but reflected none of the reality of hospice care.
The unit manager who failed to update the care plan was the same person responsible for ensuring accuracy when resident code status changes. She understood that immediate updates prevent medical errors during emergencies. She confirmed that Physician Orders for Life Sustaining Treatment forms guide end-of-life care decisions.
But understanding policy and following it proved different things.
The inspection found similar gaps could affect other residents. Staff knew the requirements. Supervisors confirmed the protocols. The Director of Nursing stated the correct procedure.
Implementation failed at the bedside.
Resident #2 remained in hospice care with outdated emergency instructions attached to their medical record. The care plan promised CPR for a patient whose physician had ordered comfort care only. Family members who had made difficult decisions about end-of-life treatment could face the trauma of unwanted resuscitation attempts.
State regulations require nursing homes to develop and implement comprehensive care plans that reflect each resident's current medical orders and treatment goals. The regulation exists because care plans guide split-second decisions during medical emergencies.
When those plans contain wrong information, staff make wrong choices.
The inspection documented minimal harm with potential for actual harm affecting few residents. But for Resident #2, lying in that activities room recliner, the outdated care plan represented a more fundamental failure.
Their physician had written orders for comfort care. Their family had chosen hospice. Their medical team had documented the transition to end-of-life treatment.
Their care plan still promised aggressive resuscitation that nobody wanted and the doctor had forbidden.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crest Haven Nursing and Rehabilitation Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
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