F0657

E

Failure to Review and Revise Person-Centered Care Plans After Changes in Condition and Services

Fort Belvoir, Virginia Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

Facility staff failed to review and revise person-centered care plans for multiple residents following significant changes in condition or services. One resident with Alzheimer's disease, heart failure, and diabetes, who had severely impaired cognition per a BIMS score of 3/15, was admitted to hospice services on 3/8/26 after a documented decline including decreased oral intake and episodes of MASD. Despite this, the active care plan with a target date of 3/26/26 did not include the resident's election and admission to hospice services.

Another resident with diabetes, hypertension with episodes of orthostatic hypotension, and impaired mobility and self-care after lumbar spine fusion had a BIMS score of 5/15, indicating severely impaired decision-making. This resident experienced an unwitnessed fall from the bed to the fall mat on 3/13/26, and nursing notes documented the fall and stated that no changes to the care plan were needed. The active care plan with a target date of 6/17/26 did not address the fall or the resident's episodes of orthostatic hypotension, despite the Rehab Director reporting that the resident was unable to tolerate therapy, resisted sitting up, had low blood pressure episodes, felt ill when upright, and vomited.

A third resident with vascular dementia, mild protein-calorie malnutrition, hearing loss, and severely impaired cognition (BIMS 0/15) had an MDS indicating minimal hearing difficulty, and the care plan stated the resident required assistance with dentures. However, the active care plan with a target date of 5/2/26 did not document that the resident did not tolerate dentures and a hearing aid. During multiple survey visits, the resident was consistently observed without dentures, placing unchewed food into napkins, and having extreme difficulty communicating due to inability to hear. A private duty sitter reported that the resident's son had said it was acceptable for the resident not to wear dentures and the hearing aid because the resident repeatedly removed and discarded them. Additionally, another resident with intact cognition (BIMS 15/15) and diagnoses including atrial fibrillation, stage 4 chronic kidney disease, and heart failure had an active care plan with a target date of 6/5/26 that incorrectly stated the resident was receiving hospice services, even though a nutrition note documented discharge from hospice on 3/4/25 and the DON confirmed the resident was no longer on hospice.