F0657

E

Failure to Update Care Plans for Weight Loss, Cognitive Status, and Bed Rail Use

Washington, Missouri Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to review and revise comprehensive care plans when residents’ needs changed, as required by facility policy and federal regulations. The policy states that individualized care plans must be based on thorough assessments, including the MDS, and must be updated with significant changes in condition, at least quarterly, and when changes occur that impact care. Surveyors found that for multiple residents, care plans did not reflect significant weight loss, new or ongoing nutritional interventions, use of bed rails or assist bars, or cognitive diagnoses, despite these being documented elsewhere in the record and observed in practice.

For one resident with severe cognitive impairment, stroke, dementia with agitation, anxiety, depression, violent behavior, and stage III chronic kidney disease, the MDS and physician orders showed a soft and bite-sized diet, nutritional supplements (Boost Breeze and Super Cereal), and weekly weights due to weight loss from 155.4 lbs to 140.4 lbs. However, the care plan dated 12/03/25 was not updated to include the recent weight loss, the ordered supplements, or the increased frequency of weights. A CNA reported not knowing the resident had weight loss and stated that if aware, they would have tried to encourage more intake. The MDS Coordinator confirmed that weight loss and related interventions, including supplements and assistance level with eating, should be on the care plan.

Another resident with anoxic brain damage, diabetes, stroke, dementia, schizophrenia, gastroparesis, depression, and anxiety experienced a weight decrease from 179.2 lbs to 151.6 lbs over five months. Physician orders included a Level Six soft and bite-sized diet, yogurt twice daily, weekly weights, and a high-calorie supplement. Despite this, the care plan dated 12/15/25 did not document the significant weight loss, the use of nutritional supplements, or the change in weight-monitoring frequency. The CNA who assisted with feeding did not know about the weight loss, and the DON described needing to encourage this resident to eat, while the MDS Coordinator again stated that weight loss and interventions should be reflected in the care plan.

A resident assessed as cognitively intact was repeatedly observed in bed with a right grab bar/bed rail in the upright position on multiple days, yet the care plan dated 10/03/25 contained no direction for the use of bed rails. The MDS Coordinator stated that if a resident used bedrails, this should be listed on the care plan. Another resident with severe cognitive impairment, delusions, daily behavioral symptoms, and dependence on staff for eating had a documented weight drop from 129.8 lbs to 103.6 lbs over five months, with physician orders for a regular diet, house supplement, and weekly weights. The care plan dated 12/22/25 did not include the significant weight loss, the nutritional supplement, or the change in weight frequency. The CNA did not know the resident had weight loss and described variable assistance with eating, while the MDS Coordinator reiterated that weight loss and related interventions should be care planned.

A further resident with severe cognitive impairment and a diagnosis of Alzheimer’s disease had an admission MDS reflecting this condition, but the care plan dated 11/12/25 did not document the Alzheimer’s diagnosis or include any interventions related to cognitive impairment. The MDS Coordinator stated that the diagnosis should be on the care plan so staff know how to care for the resident. Another resident, cognitively impaired and requiring substantial/maximal assistance for bed mobility and transfers, was repeatedly observed with a left assist bar in the upright position on the bed, yet the care plan dated 10/23/25 did not document direction for use of the assist bar. A CNA stated that bed rails should be listed on care plans and that dementia or Alzheimer’s diagnoses should be included so staff know how to care for residents.

Interviews with leadership confirmed expectations that care plans be individualized and updated with changes. The MDS Coordinator reported having worked at the facility for only a couple of months, with no prior experience in MDS or care planning, and acknowledged that care plans should be updated with every change of condition, quarterly, and annually. The DON and Administrator both stated that the MDS nurse is responsible for updating care plans and that they expect care plans to direct resident care and include bed rails, weight loss and interventions, frequency of weight checks, nutritional supplements, cognitive status, and the amount of assistance needed. The Administrator also noted that the facility holds a morning meeting to discuss incidents or changes and expects care plans to be updated when needed based on those discussions.