Resident #2, who has moderate cognitive impairment and a stage 3 pressure ulcer on his tailbone, had no care plan developed since his admission date. The 75-year-old man also suffers from multiple conditions including shortness of breath, constipation, paralysis on one side of his body, ear disorders, and dry eye syndrome.
When inspectors interviewed him on October 13, they found him sitting high up in a specialized hydraulic wheelchair. He didn't respond to their first attempts at conversation. Only after repeated encouragement did he speak, saying he had no issues with the facility.
His medical records showed a Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment. Despite this complex profile requiring individualized treatment goals, no care plan existed to guide his daily care.
A second resident also lacked any care plan documentation.
The facility's own policy, dated March 2022, requires comprehensive care plans with measurable objectives and timetables for each resident's medical, nursing, mental and psychological needs. These plans must be completed within seven days of a comprehensive assessment and no more than 21 days after admission.
When confronted about the missing care plans on October 14, the administrator and social worker claimed they weren't aware of the issues. Both said the MDS nurses were responsible for care plans, and the Director of Nursing should have overseen their completion.
The administrator blamed the oversight on staffing transitions. An interim Director of Nursing had recently left, and a new MDS nurse had been with the facility for only a couple of weeks before getting sick.
"They were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened," according to the inspection report.
The Assistant Director of Nursing also deflected responsibility during her interview at 2:00 PM that same day. As a Licensed Vocational Nurse, she said care plans were the responsibility of the MDS Nurse, who holds a Registered Nurse license.
The missing care plans represent more than paperwork violations. For Resident #2, the absence of a structured care approach could affect management of his stage 3 pressure ulcer, which involves full-thickness skin loss. His cognitive impairment score suggests he may struggle to communicate pain or other needs effectively.
Federal regulations require nursing homes to develop individualized care plans that address each resident's unique medical conditions and functional abilities. These documents serve as roadmaps for staff, outlining specific interventions, goals, and timelines for treatment.
The facility's policy acknowledges this requirement, stating that care planning teams must develop comprehensive approaches for each resident. The interdisciplinary team process is designed to ensure all aspects of a resident's wellbeing are addressed systematically.
Without care plans, staff lack clear direction on how frequently to reposition Resident #2 to prevent his pressure ulcer from worsening, what interventions to use for his constipation, or how to accommodate his communication needs given his cognitive impairment.
The inspection found that management's daily morning meetings discussed the need to address care planning issues, but no concrete action had been taken to ensure compliance. The administrator's admission that he "did not know what happened" suggests a breakdown in oversight systems.
Staff turnover and illness, while common challenges in nursing homes, don't exempt facilities from meeting federal care requirements. The inspection revealed that despite knowing about staffing transitions, administrators failed to implement backup systems to ensure continuity of care planning.
Rose Trail's violation affects "some" residents according to the inspection classification, suggesting the care plan failures extended beyond the two residents specifically documented. The facility received a citation for minimal harm or potential for actual harm.
For residents like #2, who depend on structured care approaches to manage multiple chronic conditions, the absence of individualized planning leaves them vulnerable to complications that proper oversight might prevent.
The inspection was conducted in response to a complaint, indicating that concerns about care quality had reached state regulators from an outside source. Federal inspectors completed their review on November 18, 2025, documenting the systematic failure to provide required care planning services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rose Trail Nursing and Rehabilitation Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
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