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F0657
D

Failure to Timely Revise Care Plans and Conduct Care Conferences

Kenosha, Wisconsin Survey Completed on 07-24-2025

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 revise care plans and conduct timely care conferences for two residents, as required by policy and regulatory standards. For one resident with diagnoses including pneumonia, acute respiratory failure, hypertension, dysphasia, depression, and anxiety, the comprehensive care plan was not completed within the required timeframe after admission. The initial care plan did not include focus areas for hearing deficit or depression, despite documented evidence of moderate depression and a known hearing impairment. The care plan was not updated to address these issues until more than a month after admission, and only after the surveyor brought the omissions to the facility's attention. Interviews with staff revealed a lack of clarity regarding responsibility for updating care plans and acknowledged that the required focus areas were not included initially. Another resident with multiple chronic conditions, including COPD, asthma, morbid obesity, diabetes, congestive heart failure, bipolar disorder, anxiety, depression, panic disorder, and PTSD, did not have a care conference scheduled following a quarterly MDS assessment. The resident was unaware of care conferences and expressed interest in participating. Documentation showed that the last care conference occurred several months prior, and no subsequent conference was scheduled in accordance with the facility's policy and the MDS assessment schedule. Staff interviews confirmed that the care conference had not been held as required and that scheduling was delayed. The facility's policy mandates that comprehensive care plans be developed within seven days of completing the comprehensive MDS assessment and that care conferences be held quarterly or in accordance with the MDS schedule. In both cases, the facility did not adhere to these requirements, resulting in incomplete or delayed care planning and lack of resident involvement in care conferences.

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