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F0657
E

Failure to Timely Update and Document Resident Care Plans and Conferences

Windham, Connecticut Survey Completed on 04-22-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that resident care plans (RCPs) were developed, reviewed, and revised within the required timeframe following comprehensive assessments for all residents reviewed. Documentation was lacking for quarterly Resident Care Conferences (RCCs), and care plans were not consistently updated within 7 days of the Minimum Data Set (MDS) assessments. For multiple residents with complex medical conditions such as Parkinson's disease, dementia, heart disease, epilepsy, hemiplegia, chronic obstructive pulmonary disease, multiple sclerosis, and depression, the care plans did not reflect changes in their required assistance with activities of daily living (ADLs) as identified in their MDS assessments. For one resident with Parkinson's disease and dementia, the care plan was not updated to reflect increased assistance needs, and there was no documentation of a care conference following a recent MDS assessment. Interviews with staff revealed that care plan meetings were not being held on a quarterly basis, and the responsible staff could not provide reasons for these omissions. Another resident with epilepsy and hemiplegia had changes in ADL needs documented in the MDS, but the care plan was not revised accordingly, nor was there evidence of timely care conferences. Additional residents with cardiac and respiratory conditions, as well as those with multiple sclerosis and chronic pain, also experienced lapses in care plan updates and documentation of care conferences. In several cases, care plan meetings were either not held within the required timeframe or not documented at all, and staff interviews confirmed that the facility did not meet the expected schedule for care plan reviews and revisions. Facility policy required care plans to be developed within 7 days of a completed MDS, but this standard was not met for the residents reviewed.

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