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F0657
D

Failure to Review and Update Care Plan After MDS Assessments

Washington, District Of Columbia Survey Completed on 05-05-2025

Penalty

Fine: $95,118
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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

Facility staff failed to review and implement the comprehensive person-centered care plan for one resident with multiple medical diagnoses, including dysphagia following cerebral infarction, hemiplegia, and oropharyngeal disease. Medical record review showed that after the completion of Minimum Data Set (MDS) assessments on three separate occasions—quarterly and annual assessments—there was no evidence that the care plans were reviewed or updated as required. During an interview, the Director of Social Work confirmed that the Inter-Disciplinary Team (IDT) did not review the resident's care plans following these MDS assessments.

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