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F0656
D

Failure to Develop and Implement Person-Centered Care Plans Addressing Communication and Religious Needs

Madison, Wisconsin Survey Completed on 05-05-2025

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 develop and implement comprehensive, person-centered care plans that addressed the individual needs, preferences, and cultural requirements of three residents. For one resident with Alzheimer's disease and polyosteoarthritis, the care plan included the use of interpreter services to communicate in her preferred language, Nepalese. However, interviews with staff revealed that they were unaware of the resident's language, had not used interpreter services, and instead relied on gestures or attempts to use translation apps, which were unsuccessful. The care plan's instructions for using interpreter services were not followed, resulting in ineffective communication with the resident. Two other residents, both practicing Muslims, did not have their religious preferences or needs reflected in their care plans. One resident expressed distress about being unable to pray as required by her faith due to cleanliness requirements and the lack of a clean space. The other resident reported being denied access to the chapel for prayer and felt that staff did not consider individual religious needs. Despite both residents voicing these concerns, their care plans did not include any focus, goals, or interventions related to their religious practices or preferences. Facility policy requires that care plans be person-centered, culturally competent, and include measurable objectives and timeframes to meet each resident's medical, mental, and psychosocial needs. The policy also specifies that the care plan should identify the resident's language and communication tools if the resident is non-English speaking, and should incorporate cultural and religious preferences. The failure to include and implement these elements in the care plans for the three residents led to the cited deficiencies.

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