F0657

E

Failure to Hold Quarterly Care Conferences and Timely Revise Care Plans

Caldwell, Idaho Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct required quarterly care conferences and to timely revise care plans based on residents’ changing needs. Facility policy dated 9/3/25 required that care plans be created, reviewed, and revised by an interdisciplinary team (IDT) with resident and/or representative involvement, and that updates occur as needed based on residents’ response to interventions and changes in condition. Record review showed that multiple residents with complex medical and psychiatric diagnoses had only an initial or single quarterly care conference documented, with no evidence of subsequent quarterly conferences in the electronic health record. The Administrator and Clinical Resource Nurse confirmed that if a care conference was not documented in the electronic health record, it was not completed.

For one resident with dementia, depression, anxiety, muscle weakness, and difficulty walking, a quarterly care conference was documented in July 2025, but there was no documentation of additional quarterly conferences around October 2025 or January 2026. Another resident with schizoaffective disorder, insomnia, anxiety, depression, and dementia had a care conference in August 2025, with no further quarterly conferences documented for November 2025 or March 2026. A resident with paranoid schizophrenia, depression, anxiety, and difficulty walking had a care conference in June 2025, but there were no records of required quarterly conferences for September and December 2025, nor documentation that a March 2026 conference was scheduled. Additional residents with schizoaffective disorder, depression, anxiety, dementia, bipolar disorder, heart failure, dysphagia, and sleep apnea similarly lacked documentation of required quarterly care conferences after an initial or single documented meeting.

The facility also failed to revise care plans in a timely manner for two residents when their care needs changed. One resident with paranoid schizophrenia, depression, anxiety, and difficulty walking had a fall care plan dated August 2023 that included various fall-prevention interventions and directed quarterly re-evaluation and revision with changes in condition or after a fall. A fall investigation on December 1, 2025 documented that the resident fell while unattended in the dining room, and the IDT directed that the resident be supervised at all times while in the dining room; however, this new supervision intervention was not added to the care plan until January 27, 2026. Another resident with major depressive disorder, anxiety disorder, and alcohol dependence had a care plan revised in April 2022 indicating independence with toileting and one-person assistance for occasional nighttime incontinence, but a later quarterly MDS documented that the resident was dependent on staff for all toileting needs. The DON confirmed the resident was dependent in toileting and that the care plan should have been revised to reflect the current care needs.