Lily Springs Rehabilitation And Healthcare Center

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

for resident care plans, particularly on the weekends. She said it was important to care plan when a resident refused medications and to care plan anything that was out of the ordinary. She said a care plan was a road map to the residents' life. She said a possible negative affect of not care planning medication refusals was it could affect their care. She said if a resident was not taking medications, and the refusal was not care planned, it would not be communication to the staff. She said no one would know that the resident was not taking the medication except the person the resident made the refusal to. She said she was responsible for the care plans.Interview on 08/22/25 at 6:15 pm with LVN A reflected she had tried to give Resident #1 her Nystatin powder and Resident #1 had refused. LVN A said a care plan was the plan of how to take care of each resident should be based on the individual needs of each resident. She said if a resident declines to take medication the resident's refusal of the medication should be reported to the DON and ADON and the refusal of the medication should be care planned. She said the nurses contributed to

the care plans, but the DON ultimately completed care plans. She said when Resident #1 had refused her Nystatin powder, she reported it to the MD, but she can't remember if she told the DON or ADON. She said possible negative effect of not care planning for medication refusals was that the condition for which the medication was prescribed could get worse. She said she did not know the facility system for care planning, and she did not have any additional information to add regarding not care planning for medication refusals.Attempted interview on 08/22/25 at 5:22 pm with the DON but she had left the facility because she was ill. Surveyor called and left her a voice mail and sent her a text message with no response.Interview on 08/22/25 at 6:03 pm with the Administrator reflected a care plan was a document that gave instructions on how to care for the residents, including resident preferences. She said if a resident was refusing to take a medication that should be care planned. She said a possible negative affect of not care planning for medication refusals would be that it would be more difficult for the team and doctors to figure out how to care for that resident. She said the MDS Coordinator and the ADON are responsible for care plans, but it ultimately falls under the responsibility of the DON. She said if the nurses are attempting to give medications to residents who are refusing medications the nurses needed to inform the DON. When the DON knew about the medication refusal, it should be care planned. She confirmed that she had looked at Resident #1's care plan and, as much as they talked about Resident #1 not taking her medications, Resident #1's refusal of her Nystatin Power should have been care planned. She said her facility's system for care planning was when the nursing staff identified any preferences, significant changes, or anything else that could change the current plan of care they reported it in the 24-hour report or as needed to the DON or ADON. This report was communicated to the IDT team (a collaborative group of professionals from different fields who work together to provide comprehensive, coordinated care for a resident) and the physician and any changes were made to the care plan and orders as indicated to reflect the resident's current status and needs. Review of Facility Care Plans, Comprehensive Person-Centered dated January 2023 reflected policy statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan will include measurable objective and time frames, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being, describe serviced that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.

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