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F0657
D

Failure to Update Care Plans After Changes in Incontinence Products

Billings, Montana Survey Completed on 12-31-2025

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 update the comprehensive care plans for two residents following changes in their incontinence care interventions. Both residents reported dissatisfaction with the new reusable liners provided, stating that these products were less effective and resulted in more frequent accidents. One resident indicated that they were no longer participating in care planning discussions, despite having previously done so. Staff confirmed that care plans should reflect all incontinence products tried and any changes made, but the documentation did not include the recent switch to reusable liners or the residents' feedback regarding their effectiveness. Record reviews showed that the care plans for both residents had not been revised to include updated interventions, education provided about the risks and benefits of the new incontinence products, or the facility's decision to change the products. The care plans only referenced previous interventions and did not document the residents' current experiences or the facility's recent changes in incontinence management. This lack of timely and accurate care plan updates failed to address the residents' needs and preferences as expressed during interviews.

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