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F0657
D

Failure to Update Care Plan for Resident with Communication Barrier

Stockbridge, Georgia Survey Completed on 07-17-2025

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 review and revise the comprehensive care plan for one resident with a known language barrier. The resident's primary language was Spanish, which impacted her ability to communicate with staff and participate fully in facility activities. Although the care plan initially addressed these communication challenges by including interventions such as providing an interpreter and using an interpreter line, no updates or reassessments were made to the care plan regarding communication needs after admission. The MDS Coordinator confirmed that communication barriers were only addressed during the initial assessment and not routinely revisited unless staff reported concerns, despite quarterly MDS assessments being completed. Record review showed that the resident remained cognitively intact but continued to experience difficulty conveying her needs to staff. Staff interviews and policy review indicated that the facility's process did not ensure ongoing evaluation or revision of the care plan to address the resident's evolving communication needs. As a result, the care plan did not reflect any changes or updates to interventions for communication, despite the resident's ongoing challenges.

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