F0657

D

Missed Care Plan Reviews and Failure to Implement 1:1 Supervision Intervention

Denton, Maryland Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The facility failed to hold required quarterly care plan meetings for one resident and failed to implement a care plan intervention for another resident. For Resident #75, interview on 03/10/2026 revealed the resident denied having regular care plan meetings. Medical record review on 03/11/2026 showed documented care plan meetings on 12/04/2024, 09/17/2025, and 01/16/2026, with no additional meetings documented between 12/04/2024 and 09/17/2025. The Regional Social Worker confirmed on 03/11/2026 that no care plan meetings were held for this resident between 12/04/2024 and 09/17/2025 and acknowledged that meetings due in March and June 2025 were missed.

For Resident #1, the facility did not implement a care plan intervention for inappropriate sexual behavior. Progress notes reviewed on 03/11/2026 documented multiple occasions of inappropriate sexual behavior. The resident’s care plan, reviewed the same day, included an intervention for 1:1 supervision related to this behavior. However, observation on 03/11/2026 at 10:33 AM found the resident on the unit without 1:1 supervision. In an interview on 03/10/2026, an RN stated the resident continued to display inappropriate behaviors with other residents daily and that 1:1 supervision had not been in place for “maybe 2 months.” On 03/13/2026, the DON acknowledged that the resident displayed inappropriate sexual behavior and did not currently have 1:1 supervision as specified in the care plan.