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F0657
E

Failure to Complete and Document Quarterly Care Conferences

Youngstown, Ohio Survey Completed on 09-17-2025

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 ensure that care conferences were completed quarterly for four residents, as required by policy and regulatory standards. Record reviews, interviews, and policy review revealed that care conferences for these residents were either not held or not documented within the required quarterly timeframe. For example, one resident with hemiplegia, aphasia, and dependency for all ADLs had their last documented care conference several months prior to the review, with no evidence provided for more recent conferences. Another resident with ataxic cerebral palsy and schizophrenia had a significant gap between care conferences, despite routine care plan updates. Similar deficiencies were found for two other residents with complex medical and cognitive needs, where care conferences were either not conducted or not documented as required. The facility's policy stated that care plans should be reviewed quarterly and/or with significant changes in care, with attendees signing and dating meeting documents. However, documentation for care conferences was missing or incomplete for the affected residents, despite ongoing care plan revisions. Interviews with the Social Service Designee confirmed the lack of evidence for timely care conferences. This deficiency was identified during a complaint investigation and affected half of the residents reviewed for care conferences.

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