Failure to Update Care Plan After Sexually Inappropriate Resident Behaviors
Summary
The facility failed to update the care plan for a resident with a known history of sexually inappropriate behaviors following multiple incidents of inappropriate touching involving other residents. Despite documented incidents, including one where the resident placed their hand under another resident's shirt and rubbed their breast area in the dining room, the care plan did not include interventions to prevent recurrence of such behaviors. The resident had previously been sent to a behavioral health hospital after similar incidents, but no new interventions were added to the care plan upon their return or after subsequent events. The resident's medical record showed a history of cerebral infarction, hemiplegia, peripheral vascular disease, COPD, bipolar disorder, anxiety, sexual dysfunction, unspecified psychosis, and depression. The resident was moderately impaired cognitively and required substantial to maximal assistance with most activities of daily living. Progress notes documented repeated inappropriate behaviors, including touching and tickling other residents, and staff had to redirect the resident on multiple occasions. Staff interviews revealed a lack of awareness and documentation regarding the need for monitoring the resident for sexual behaviors. The LPN interviewed was unaware of any residents requiring such monitoring and did not view the resident's behaviors as concerning. The DON provided a monitoring form that was incomplete and lacked evidence of one-on-one monitoring. The care plan, even after being updated during the survey, still did not include specific interventions to prevent recurrence of sexually inappropriate behaviors.
Penalty
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A resident with osteomyelitis, type II DM, and dementia had an existing care plan identifying fall risk and a goal to remain free from fall-related injury. After the resident experienced a fall that led to hospital transfer, staff implemented new fall interventions such as bedside reorientation and visual cues to use the call light, but these interventions were not added to the written care plan until weeks later. The DON confirmed the care plan did not reflect the current fall interventions during this period, contrary to the facility’s care planning policy.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
The facility failed to conduct and complete quarterly interdisciplinary care conferences for multiple residents with complex medical conditions, including cardiovascular disease, COPD, dementia, and psychotic disorders. Although required MDS assessments and care plans addressing issues such as skin integrity, nutritional risk, and psychotropic medication monitoring were in place, the electronic records showed only sporadic care conferences, many of which were marked in error status or left incomplete with missing signatures and sections. Residents and families reported not participating in quarterly care conferences, and a corporate RN confirmed that the conferences were not held as required and that the facility’s policy calling for resident/family involvement and IDT participation in care planning was not followed.
The facility failed to update a cognitively intact resident’s care plan after two separate incidents in which the resident entered another resident’s room despite staff instruction. Following the first incident, staff verbally directed the resident not to enter the other resident’s room and demonstrated an alternate route to the back area for smoking and activities to avoid passing that room. A second incident occurred with the same two residents, and staff again reminded the resident to leave the room. Although the resident had dementia and existing care plan interventions addressing cognitive function and need for verbal cues, the care plan was not revised to include the new, specific interventions related to avoiding the other resident’s room and using the alternate route, as confirmed by the DON.
The facility failed to conduct and document required initial and quarterly care plan conferences with multiple residents and/or their representatives, despite facility policy requiring conferences within seven days of admission and quarterly thereafter. Several residents with complex conditions such as ALS, COPD, diabetes, severe malnutrition, vascular dementia, and chronic respiratory failure had intact cognition and completed MDS assessments, yet had either no care conferences or large gaps between conferences. Some residents reported never being invited to or aware of care plan meetings, and one resident with severe cognitive impairment had no documented initial conference with the responsible party. The Social Service Director and Social Work Director confirmed that conferences were not held or documented, sometimes citing behavioral issues, difficulty reaching family, or undocumented verbal discussions, without the required documentation of attempts, refusals, or explanations in the medical record.
Surveyors found that the facility failed to involve three residents and their representatives in ongoing care planning and care conferences. One resident with a history of cerebral infarction, chronic pain, aphasia, DM, HTN, and AFib reported not recalling any IDT care conference, and his guardian stated she had never been invited to one. Two cognitively intact residents with quadriplegia, toe amputations, atherosclerosis, DM, prior MI, colostomy, malnutrition, alcohol abuse, mood disorder, HTN, contractures, and neurogenic bladder reported having only an initial or no subsequent care conferences and not being shown or informed of their care plans. The SSD stated that admission, quarterly, annual, and as-needed care conferences are held and that residents and responsible parties are invited, but the Administrator confirmed there was no documented evidence of care conferences or IDT plans of care for these residents over an extended period.
Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s comprehensive care plan was revised in a timely manner to reflect current fall interventions after a fall event. The resident was admitted with diagnoses including acute osteomyelitis of the right ankle and foot, type II diabetes, and dementia. A care plan dated 03/10/26 identified the resident as being at risk for fall-related injury and falls due to history and fear of falling, with a goal to remain free from injury related to falls. A nursing note dated 03/25/26 documented that the resident went to the hospital, without additional information. In an interview, the resident reported having a fall that required hospital transfer, though he did not specify the date. Further review of the care plan showed that specific fall interventions, including reorienting the resident at bedside and providing a visual cue to use the call light for assistance, were created on 04/09/26 and were related to the fall that occurred on 03/25/26. In an interview, the DON confirmed that these interventions, which were implemented immediately after the fall, were not added to the written care plan until 04/09/26, leaving the care plan not up to date until that date. The facility’s “Care Planning” policy required that every resident have a person-centered care plan developed and implemented based on the comprehensive assessment, with measurable objectives and time frames to meet identified needs, but the resident’s care plan was not revised promptly after the fall as required.
Plan Of Correction
1. Resident #86 had their fall care plan updated on 4/9/26 by the Director of Nursing to reflect current fall interventions. 2. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC an audit of falls for the past 30 days will be completed by the Director of Nursing or designee to ensure fall care plans reflect current fall interventions. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Fall Management Policy to include updating the care plan with new interventions as appropriate. This education will be completed on or before 5/13/26. 4. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will audit new admissions, readmissions and residents who experience a fall weekly for four weeks, beginning 5/14/26 to ensure fall care plans reflect current fall interventions. Discrepancies noted during audits will be corrected with care plans updated to reflect current fall interventions. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Complete Quarterly Interdisciplinary Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were prepared, reviewed, and revised by an interdisciplinary team and that care conferences were scheduled and conducted quarterly, as required by facility policy. For one resident with cerebral atherosclerosis, stage IV kidney disease, and hypertension, records showed multiple timely MDS assessments and a care plan addressing risk for skin breakdown, but only one documented interdisciplinary care conference over an extended period. No additional care conferences were recorded in the electronic health record despite ongoing quarterly and annual assessments. Another resident with atrial fibrillation, COPD, chronic pain, and nutritional risk had an admission assessment and several quarterly MDS assessments completed, along with a care plan addressing nutritional risk and monitoring needs. However, the electronic record showed only one documented care conference, and both the resident and family confirmed they had not participated in quarterly care conferences. A third resident with Alzheimer’s disease, dementia, and psychotic disturbance had multiple quarterly and annual MDS assessments and a care plan for psychotropic medication monitoring, but only four care conferences were documented over a broad time frame, with all marked in error status. One of these assessments was incomplete, with only restorative nursing and nursing sections signed, and the resident’s family confirmed that quarterly care conferences had not occurred. A fourth resident with acute and chronic heart failure and vascular dementia with behaviors had multiple quarterly and annual MDS assessments completed and required staff assistance with ADLs. The electronic record showed only two care conferences, both noted as in error status or in progress, and one was incomplete with only restorative nursing and nursing sections signed. A corporate RN verified that the care conference assessments in the system were in error status, meaning the conferences were not complete and/or lacked required information and signatures, and confirmed that quarterly care conferences for all four residents had not been conducted as required. Review of the facility’s Resident Assessment policy showed that residents were to have the opportunity to discuss their goals of care and that care plans were to be developed by an interdisciplinary team with resident and/or family participation, but this policy was not implemented as written.
Failure to Revise Care Plan After Repeated Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan in response to repeated resident-to-resident incidents and newly implemented staff interventions. Resident #7 was admitted on 11/15/22 with diagnoses including COPD, major depressive disorder, chronic viral hepatitis, mild dementia, and type 2 diabetes. Resident #13, admitted on 01/30/24 with cerebral palsy, osteogenesis imperfecta, type 2 diabetes, major depressive disorder, need for assistance with personal care, convulsions, and aortic stenosis, was involved in two separate incidents with Resident #7 in Resident #13’s room. A nursing note dated 09/27/25 documented that Resident #7 was found in Resident #13’s room, after which staff verbally instructed Resident #7 not to enter Resident #13’s room and demonstrated an alternate route to the back of the facility for smoking and activities so he could avoid passing by Resident #13’s room. A self-reported incident dated 12/07/25 showed a second incident in which Resident #7 was again found in Resident #13’s room and was reminded by staff that he could not be there and needed to leave. Review of Resident #7’s care plan, with a review date of 12/23/25, showed an identified problem of alteration in cognitive function secondary to dementia, with interventions such as assisting with decision making, monitoring for changes in condition and cognition, and offering verbal reminders and cues. However, the care plan contained no revisions to reflect the two resident-to-resident incidents on 09/27/25 and 12/07/25, nor did it include the specific interventions directing Resident #7 not to enter Resident #13’s room or to use the alternate route to the back of the facility. A quarterly MDS 3.0 assessment for Resident #7 indicated he was cognitively intact, did not exhibit behavior symptoms or rejection of care, was independent with transfers, could self-propel in his wheelchair, and required setup to moderate assistance for ADLs. In an interview, the DON confirmed there were two incidents between the residents in Resident #13’s room, that Resident #7 had been educated about not entering that room and about using an alternative route, and that these interventions were not added to Resident #7’s care plan.
Failure to Conduct and Document Required Initial and Quarterly Care Plan Conferences
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document initial and quarterly care plan conferences with residents and/or their representatives as required by regulation and facility policy. The facility policy states that patient care conferences are to be held within seven days of admission, upon significant change, and quarterly thereafter, with the interdisciplinary team developing a comprehensive, person-centered care plan in conjunction with the resident and family or legal representative. For multiple residents, surveyors found missing or significantly delayed care conferences despite completed MDS assessments and intact cognition, and the Social Service Director confirmed that required conferences were not held. For one resident with diagnoses including moderate protein malnutrition, cystic fibrosis, ALS, anxiety, gastrostomy, chronic pain syndrome, major depression, and functional quadriplegia, records showed care conferences only on 02/10/25 and 10/15/25, with no evidence of quarterly conferences in between. Another resident with diabetes, morbid obesity, adult failure to thrive, COPD, chronic respiratory failure, asthma, schizoaffective disorder, anxiety, depression, personality disorder, and PTSD had intact cognition and required varying levels of ADL assistance, yet there was no documented evidence of any plan of care conferences. The Social Service Director verified that quarterly care conferences were not held for these residents. Additional residents were similarly affected. One resident with protein calorie malnutrition, COPD, peripheral vascular disease, and atherosclerosis with leg ulceration had care conferences documented only on 02/05/25 and 04/11/25, with no further quarterly meetings. Another resident with type 2 diabetes, a right below-knee amputation, moderate protein-calorie malnutrition, and chronic kidney disease had intact cognition, but there was no evidence of any care conferences; the resident reported never attending a care conference, and the Social Service Director stated conferences were not done due to the resident’s inappropriate sexual behaviors and inability to reach family, without documentation of attempts or explanations as required by policy. One resident admitted with acute on chronic diastolic heart failure, ulcer of anus and rectum, and type 2 diabetes had an admission care conference, during which the resident requested that the wife not be notified; however, no quarterly care conferences were completed afterward, despite an MDS showing intact cognition. The resident stated they were not aware of any care conferences being held. Another resident with malignant carcinoid tumor of the stomach, severe protein-calorie malnutrition, type 2 diabetes, and vascular dementia, with severe cognitive impairment and a son listed as emergency contact, had no evidence of an initial care conference with either the resident or responsible party. The Social Service Director confirmed there was no initial care conference and could not explain why. A further resident with acute and chronic respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, and morbid obesity with alveolar hypoventilation had intact cognition and required assistance with ADLs, with documentation that the resident rejected care on some days. The medical record contained no indication that a care conference had been conducted or attempted. The resident reported not being asked to participate in care plan meetings, expressed a desire to go home, and stated dislike of social work interactions, indicating no opportunity to engage in the care planning process. The Social Work Director confirmed there was no documentation of a care conference, acknowledged only a verbal discussion about a potential conference months earlier, and no subsequent attempts or documentation, contrary to the facility’s comprehensive person-centered care plan policy requiring conferences and documentation of refusals or impracticability.
Failure to Involve Residents and Representatives in Ongoing Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain complete, interdisciplinary care plans with resident and representative participation, as required. Record review showed that one resident admitted with multiple diagnoses including cerebral infarction, chronic pain, carotid stenosis, depression, anxiety, aphasia, diabetes, hypertension, atrial fibrillation, and hyperlipidemia had an MDS indicating moderately impaired cognition and moderate depression. This resident reported not remembering ever having a care conference with the IDT to discuss care concerns or his care plan. His guardian, assigned in August 2025, stated she had not been invited to or attended any care conference for him. The Administrator confirmed there was no documented evidence of care conferences or IDT plans of care for this resident since 2024. Two additional residents, both cognitively intact per their MDS assessments and with extensive medical histories including quadriplegia, toe amputations, atherosclerosis of the aorta, diabetes, prior myocardial infarction, colostomy, malnutrition, alcohol abuse, mood disorder, hypertension, contractures, and neurogenic bladder, also reported lack of ongoing care conference involvement. One resident stated he had only one care conference upon admission and had not been invited to or had any additional care conferences, and that he had never seen his care plan or been told what was in it. The other resident reported not being invited to or attending a care conference since transitioning from skilled care to LTC in late 2024 and stated she had not seen her care plan nor been informed of its contents. The SSD reported that care conferences are done on admission, quarterly, annually, and upon request, and that residents and responsible parties are invited, but also acknowledged that few attend. The Administrator verified there was no documented evidence of care conferences or IDT plans of care for these residents since 2024, affecting three of four residents reviewed for care planning and care conferences.
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