F0656

D

Cancelled Care Plan Leaves Resident Without Comprehensive Person-Centered Plan

Galveston, Texas Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical and cognitive needs. The resident was an adult male with diagnoses including convulsions, hypertension, and traumatic brain injury, and a Quarterly MDS showed a BIMS score of 3/15, indicating severely impaired cognition, with extensive to total assistance required for ADLs. Record review showed that this resident’s care plan was cancelled on 01/19/26, leaving him with no current care plan in place. The MDS Coordinator reported that she did not cancel the care plan and stated it had been cancelled by her supervisor, the MDS Supervisor, and that she was unaware it had been cancelled until the surveyor requested the care plan.

The MDS Coordinator stated that care plans were reviewed quarterly in conjunction with MDS completion and acknowledged she had completed the quarterly MDS earlier in the month but had not reviewed the care plan. She did not provide an explanation of how care would be provided without a care plan. The surveyor was unable to reach the MDS Supervisor by telephone. In an interview, the DON stated that care plans were the responsibility of the MDS Coordinator and that she did not know why the care plan had been cancelled, while acknowledging that the care plan was used to provide care for residents and that its absence could have affected this resident’s care. The Administrator similarly stated that the resident should have had a current care plan and that it was used to communicate with providers and nursing staff. The DON also reported that the facility did not have a care plan policy and followed the RAI manual, and that every resident should have had a care plan updated quarterly.