Failure to Revise Care Plans and Include Required IDT Members in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to revise care plans with current information and to ensure required interdisciplinary team (IDT) members participated in care plan meetings. For one resident admitted in August 2019, care plan meeting notes from late December 2025 showed that neither the CNA responsible for the resident nor the provider attended or provided input. Another resident admitted in March 2025 had a care plan meeting in December 2025 attended by a family member, Unit Manager (UM), Social Services Director (SSD), recreation staff, dietician, and scheduler, but there was no indication that the responsible CNA or provider participated. A third resident admitted in April 2025 had a December 2025 care plan meeting attended by the UM, Social Services Assistant (SSA), recreation staff, dietician, and scheduler, again without the provider or CNA. The SSD confirmed that CNAs with responsibility for residents and providers were not invited to care plan meetings and did not attend the meetings for two of the residents. The facility also failed to update care plans with current resident conditions and interventions for two residents. One resident reported sometimes receiving only one shower a week and refusing showers when feeling cold or unwell; two CNAs confirmed that this resident had been refusing showers and that refusals were reported to the nurse and documented on a shower sheet. However, review of the resident’s care plan dated January 2026 showed no interventions or documentation of shower refusals, and the UM confirmed the resident was often non‑compliant with showering and that these refusals were not reflected in the care plan. Another resident admitted in January 2024 had overgrown, yellow, thick, and cracked toenails observed during survey, with the resident stating they had not been cut in a long time; the DON confirmed the toenails were overgrown. A progress note from October 2025 documented painful mycotic toenails and instructions for removal of affected nail tissue with follow‑up for routine foot care, yet the resident’s care plan dated January 2026 did not include interventions for toenail care, and the DON stated that resident care should be documented on the care plan.
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