Failure to Inform Resident of Elopement Risk and Wander-Guard Placement
Summary
The facility failed to inform a resident in advance about changes to their plan of care, specifically regarding the placement of a wander-guard device on their motorized wheelchair. This deficiency was identified during an abbreviated survey, where it was found that the resident was not notified of their elopement risk status or the implementation of the wander-guard device. The resident only became aware of the device when they attempted to exit the facility, triggering an alarm. The facility's policy requires residents to be informed and educated about their rights and any changes to their care plan, which was not adhered to in this case. The resident involved had a history of spinal cord injury, quadriplegia, anxiety, and pressure ulcers, with intact cognition as per a recent assessment. Despite this, a psychiatry progress note indicated that the resident did not have full capacity to make complex medical decisions. The facility's elopement and wandering policy was reviewed, which includes placing a wander-guard on residents deemed at risk. However, there was no documented evidence that the resident or their family was informed or educated about the elopement risk or the wander-guard device. Interviews with facility staff, including a registered nurse supervisor and the director of nursing, revealed that the resident was assessed as an elopement risk after leaving the facility unsupervised. The staff followed protocol by placing a wander-guard on the resident's wheelchair without their consent, citing erratic behavior and safety concerns. The director of nursing stated that the resident had instructed the facility not to inform their family about any matters related to them, further complicating the communication process.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with intact cognition and diagnoses including sepsis, DM, AFib, pneumonia, and bilateral heel DTIs was not included with his representatives in baseline, comprehensive, or discharge care plan development. The baseline, comprehensive, and discharge care plan signature pages were blank, there was no documentation the plans were reviewed with the resident or his representative, and a representative said she requested care plan and discharge meetings but was never notified.
Missed Quarterly Care Conferences: A resident with type 1 DM, diabetic autonomic neuropathy, and major limb amputations had a BIMS score of 15, but the IDT did not hold quarterly care conferences after the last documented meeting. SS staff confirmed the conferences should have occurred every 3 months and could not explain why they were missed, and MDS nurses stated the meetings were needed so residents would know the plan of care and whether needs were being met.
Failure to Document Required Care Conferences and Care Plan Communication: The facility did not complete or document required admission and quarterly care conferences for multiple residents, including residents with significant cognitive impairment and complex medical and psychiatric diagnoses. Records showed delayed or missing care conference documentation, and forms for one resident contained staff signatures but no notes showing what was discussed with the resident or guardian. Interviews with the guardian, SW, and DON confirmed that required care conference timing and communication expectations were not met.
Missing IDT care conferences for four residents. The facility did not document an initial or quarterly IDT care conference for one resident with moderately impaired cognition, did not document an initial conference for one resident with intact cognition who said staff never invited her to a care conference, and did not document quarterly conferences for two residents with impaired cognition/memory problems and SFM representatives. The SSD and ADMN confirmed the missing documentation and stated the social services department was responsible for scheduling, conducting, and documenting these IDT meetings.
Failure to Invite Resident to Care Plan Meetings: A resident with intact cognition, anxiety, depression, and max ADL assistance was not shown to have been invited to or included in care plan meetings. The EMR had no care conference documentation after one note, and staff interviews confirmed uncertainty about when the last meeting occurred and how invitations were handled, despite the care plan calling for resident participation.
A resident with a history of falls, gait impairment, and a right femur fracture was not included in quarterly care conferences, and his representative was not invited or informed about meetings. The resident and representative both reported ongoing pain after a fall, repeated x-rays that did not identify the fracture, and no staff discussion of a care plan despite the resident later going to the hospital, where the fracture was found and surgery was done. The DON confirmed the last care conference appeared to be months earlier and that quarterly conferences with guardian participation were expected.
Resident and Representatives Not Included in Care Plan Development
Penalty
Summary
The facility failed to ensure a resident and his representatives participated in the development and implementation of his person-centered care plan. The resident was admitted with diagnoses including sepsis with septic shock, diabetes, atrial fibrillation, and bacterial pneumonia. His admission MDS showed a BIMS score of 13, indicating intact cognition, and he was able to feed himself, used a wheelchair, and was frequently incontinent of urine. His record also showed physician orders for wound care and heel offloading related to bilateral heel deep tissue injuries, along with a pressure-reducing mattress and daily heel treatment. The resident’s baseline care plan listed a preference for care plan updates during normal care plan meetings, but the signature page for the resident, representatives, and staff was blank. The comprehensive care plan addressed full code status, visual impairment, bilateral heel DTI, infection risk, impaired skin integrity risk, physical mobility weakness, and diabetes, but its signature page was also blank and there was no documentation that it had been reviewed with the resident or his representative. The discharge plan was likewise unsigned by the resident or representatives. A representative stated she requested both a care plan meeting and a discharge care plan meeting a few days before discharge but was never notified of one. The DON stated the SW handled scheduling of care plan meetings, the SW said the resident discharged before she could schedule a comprehensive care plan meeting, and the DON stated nurses should complete and print the baseline and discharge care plans, review them with the resident and/or representative, and obtain signatures.
Missed Quarterly Care Conferences
Penalty
Summary
The facility failed to facilitate person-centered care planning meetings for one resident when the interdisciplinary team did not hold the resident’s quarterly care conferences. The resident was admitted with diagnoses including type 1 diabetes mellitus with diabetic autonomic neuropathy and acquired absence of both upper limbs below the elbows and both lower limbs above the knees. The resident’s quarterly MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. Review of the resident’s care conference records showed the last interdisciplinary care conference was held on 8/4/2025, and no additional care conferences were documented afterward. During interviews, Social Services staff confirmed the resident should have had care conferences every three months but could not find documentation explaining why they were not held. Social Services staff also confirmed there were no documented care conferences in 10/2025, 1/2026, or 4/2026, and MDS nurses stated quarterly care conferences should have been completed so residents would know the plan of care and whether their needs were being met.
Failure to Document Required Care Conferences and Care Plan Communication
Penalty
Summary
The facility failed to complete and document care conferences after admission for two residents and quarterly care conferences for two residents, and it also failed to document that care plan information was shared with the resident or resident representative. The report states that the planning of care should include assessment of the resident’s current condition, needed services, and updates communicated to the resident and/or representative, with a copy of the care plan available for review, but this was not done as documented for the residents reviewed. Resident #5 had diagnoses including hyponatremia, non-Alzheimer’s dementia, traumatic brain injury, anxiety, bipolar disorder, schizophrenia, and asthma. The resident’s MDS showed a BIMS score of 9 out of 15 with moderate cognitive impairment and delirium symptoms present. The record showed the resident had a court-appointed guardian as decision maker, and the first documented care conference occurred more than 3 months after admission. The guardian stated in interview that the facility had not held a care conference with him until November and that psychiatric medication changes were made without communication to him during the first month after admission. Resident #3’s MDS identified severe cognitive impairment with a BIMS score of 3, diagnoses of heart failure, diabetes mellitus, and non-Alzheimer’s dementia, and extensive dependence for multiple ADLs, along with delusions and behavioral symptoms directed toward others. The care conference notes showed no documentation for a 5-month period, and the notes did not include documentation of a facility self-report regarding a staff member who grabbed the resident’s arm. Resident #11’s MDS identified severe cognitive impairment with a BIMS score of 5, diagnoses of Di George’s Syndrome, diabetes mellitus, and schizophrenia, and need for assistance with several ADLs. The record showed only one care conference progress note, and two facility forms contained staff signatures but no documentation of what was discussed with the resident. The Social Worker and DON stated care conferences were held weekly and that the first care conference should have been completed within the first 30 days after admission, while the facility policy required care plan development within 7 days of the required MDS assessment and no more than 21 days after admission, with quarterly review and updates.
Missing IDT Care Conferences for Four Residents
Penalty
Summary
The facility failed to schedule, conduct, and document interdisciplinary team (IDT) care conferences with residents and/or their representatives for four sampled residents. The report states there was no documentation of an initial or quarterly IDT care conference for one resident admitted on 1/25/2026, whose face sheet identified a significant family member as the representative and whose MDS showed a BIMS score of 10/15, indicating moderately impaired cognition. During interviews, the MDSC and SSD confirmed that the social service department was responsible for scheduling, conducting, and documenting these conferences and that no documented evidence existed for the resident's initial or quarterly care conferences. For another resident admitted on 4/23/2026, who was self-responsible for daily decision making and had a BIMS score of 15/15, the record contained no documented evidence of an initial IDT care conference. The resident stated staff did not arrange or invite her to attend a care conference after admission, and that her significant family member requested a meeting with the facility team. The SSD confirmed there was no documented evidence of an initial IDT care conference after admission and stated the resident should have completed an initial care conference to discuss plan of care needs. The report also found no documented evidence of quarterly IDT care conferences for two additional residents. One resident, admitted on 7/17/2025, had a significant family member as representative and a BIMS score of 7/15, indicating severely impaired cognition. Another resident, admitted on 12/17/2024, also had a significant family member as representative and had short-term and long-term memory problems noted on the MDS. The SSD confirmed there were no quarterly IDT care conferences scheduled or conducted for either resident, and the administrator stated the SSD was responsible for scheduling, conducting, and documenting initial and quarterly IDT care conferences for all residents, with initial conferences within 72 hours after admission and quarterly thereafter.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to ensure Resident 38 was given the opportunity to participate in the development and implementation of her person-centered plan of care when staff did not invite her, or her responsible party, to care plan meetings. Resident 38’s EMR documented diagnoses of anxiety and depression, and her Annual MDS showed a BIMS score of 15, indicating intact cognition. The record also showed she required maximal assistance with ADLs, had no behaviors, and participated in restorative programs with some improvement noted in the look-back period. Resident 38’s care plan documented that staff would encourage her to make her own decisions and provide support as needed. However, the EMR contained only one care conference note, dated 09/10/25, and no evidence of a care plan conference after that date. During interviews, Resident 38 stated she was unsure when she last attended or was invited to a care plan meeting. SSD X reported that an email would be sent to the resident’s DPOA and that the resident was given an invitation by hand, while Administrative Nurse E stated the last care conference note she could locate was from 09/10/25 and that care plan meetings were expected every three months. The facility policy stated the resident, family, and/or legal representative are encouraged to participate in care plan development and revisions, and every effort will be made to schedule meetings at the best time for the resident and family.
Failure to Include Resident and Representative in Quarterly Care Planning
Penalty
Summary
The facility failed to ensure that quarterly care planning meetings were completed and that the resident and the resident’s representative were included in care planning so they could make informed decisions about healthcare and treatment options. The deficiency involved one resident who had been admitted to the facility with diagnoses including fracture of the right femur, history of falling, unsteadiness on feet, and abnormalities of gait and mobility. A Minimum Data Set assessment showed intact cognition and that the resident required substantial to maximal assistance with rolling and was dependent for transfers. The resident’s representative reported that after a fall in November 2025, the resident continued to complain of pain in his leg and hip, but the facility only provided pain medication and did not resolve the concern. The representative stated that the resident called 911 himself because he was fed up with the lack of action, and the resident later went to the hospital where a fracture was found and surgery was performed. The representative also stated she was not familiar with care conferences, had not been invited to any meetings, and had not been contacted by staff to discuss the resident’s ongoing pain or a plan of care. The resident similarly reported that he had ongoing pain after the fall, that x-rays were done at the facility and did not show anything wrong, and that he asked for more testing such as an MRI. He stated that no care conferences or meetings were held with staff and his guardian to discuss his care, and that he was not aware of any request for his guardian to attend a meeting. The acting DON reviewed the record and stated the last care conference form and note appeared to be from September, confirmed care conferences should occur quarterly or every three months, and stated the guardian would be invited to attend. The facility policy required resident and family or representative involvement in care planning and timely invitation to the care plan conference.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.