Missed Quarterly Care Plan Meeting Following MDS Assessment
Penalty
Summary
Facility staff failed to conduct a required quarterly care plan meeting for Resident #13 following completion of a quarterly MDS assessment. The facility’s process is that once an in-depth assessment (MDS) is completed, the interdisciplinary team meets to develop and review care plans, which are to be reviewed and revised at each assessment time and at least quarterly. Care plans are intended to provide direction for individualized care, organized by the resident’s specific needs, and to communicate and organize actions to ensure needs are attended to. For Resident #13, who was admitted in 2022, the medical record review on 3/9/26 showed the last quarterly care plan meeting occurred on 10/29/25. Further review revealed that a quarterly MDS assessment for Resident #13 was completed on 12/21/25, but there was no documentation of a subsequent quarterly care plan meeting after the 10/29/25 meeting and the 12/21/25 MDS assessment. Social Services, who maintains care plan meeting documentation in her office, was unable to provide any record of a care plan meeting during that period. In interview, Social Services stated that a care plan meeting for Resident #13 had been scheduled for 12/23/25 but had to be rescheduled, and she did not realize it had not been rescheduled. On 3/10/26, the Surveyor informed the DON that Resident #13 did not have a quarterly care plan meeting following the 12/21/25 MDS assessment.
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