Failure to Involve Resident in Person-Centered Discharge Planning
Summary
The deficiency involves the facility’s failure to ensure a resident was included in person-centered care planning and ongoing discharge planning. The resident was admitted for short-term rehabilitation with diagnoses including repeated falls, chronic kidney disease, and benign prostatic hyperplasia. A social work note documented that the resident was alert and oriented in all spheres, able to make needs known, and that the overall goal was to discharge to the community. The five-day MDS documented intact cognition, resident participation in assessment and goal setting, a goal to discharge to the community, and that active discharge planning was occurring. The care plan for discharge planning documented maintaining the resident’s customary routine/treatment and evaluating preferences and needs for possible transition to the community. However, there was no documented evidence that the resident or their representative was invited to participate in a comprehensive care plan meeting. The record further showed that the resident signed a Notice of Medicare Non-Coverage indicating Medicare coverage would end on 01/23/2026, and an appeal of this non-coverage was later denied. Despite these events, there was no documented evidence of an interdisciplinary care plan meeting to address discharge planning prior to the end of Medicare coverage or the start of private pay. In interviews, the resident did not recall having a care plan meeting and stated they planned to go home. The Director of Social Work stated that discharge plans start at admission and that they were aware the resident wanted to return home, but acknowledged that no care plan meeting had been held since admission and that there had been no further discharge planning until 02/12/2026. The Director of Social Work stated they should have planned a meeting sooner and could not explain why it was missed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with anoxic brain damage, pulmonary hypertension, and paraplegia was not shown to have participated, along with the RR, in the development and revision of the person-centered care plan during the review period. The record lacked documentation of notifications, invitations, or participation in care conferences between IDT meetings, and staff could not locate the quarterly care plan signature page that was supposed to show resident or RR review and input.
Failure to Hold and Notify Residents of Care Plan Conferences: The facility did not conduct required care plan conferences or ensure advance notification to the resident or resident representative for three residents. One resident with DM, HTN, and CAD, one resident with HTN, HF, and DM, and one resident with insomnia, anxiety, and ALS all had missing quarterly care conferences, and one resident stated he had only attended one conference since admission and had not been invited to others.
A resident with quadriplegia and aphasia, severe cognitive impairment, and dependence for all ADLs was not included with his guardian in facility care plan conferences. The EMR lacked documentation of facility staff care plan meetings, and the guardian reported she had never been invited to a meeting with facility staff and had only attended a meeting with PACE staff. Staff gave conflicting accounts about how care plan meetings were arranged and documented.
Failure to involve a resident in care planning: A resident with multiple chronic conditions and a BIMS of 14 had no admission paperwork in the record, no documented initial care conference, and no progress or IDT notes showing participation in the person-centered plan of care. The Administrator confirmed the missing admission documents and stated no other care conferences were held, while the resident did not recall being invited to attend care conference meetings.
Failure to include resident representatives in care planning. A resident with dementia, aphasia, impaired mobility, and a history of falls had 1:1 supervision reduced without documented family notification, even though staff had implemented the supervision at the family’s request and later noted the resident still required it for pica behavior. Another resident with severe neurologic and respiratory conditions did not have an initial team care plan meeting until six weeks after admission, despite policy and admin expectations for earlier family involvement.
Failure to involve a resident in person-centered care planning. A cognitively intact resident with schizoaffective disorder, psychotic disturbances, and multiple care needs was not offered a care conference or asked about personal, cultural, or religious preferences, other providers, medical needs, or concerns. The care plan lacked resident preferences and only addressed nutrition, while the charted care conference focused on goals, medical history, and orders without the resident’s preferences or goals.
Resident and Representative Not Included in Care Plan Revisions
Penalty
Summary
The facility failed to ensure Resident #40 and/or the resident representative were able to participate in the development and revision of the person-centered plan of care. Resident #40 was admitted with diagnoses including anoxic brain damage, pulmonary hypertension, and paraplegia. The resident had multiple MDS assessments completed during 2026, including a significant change assessment and quarterly assessments, and the care plan addressed psychosocial well-being concerns related to anxiety, depression, little interest or pleasure in doing things, and trauma-related experiences. The care plan was initiated on 4/30/25 and revised on 2/12/26, but the record did not show documentation that Resident #40 or the resident representative was notified of, invited to, or participated in care conferences between the January and August 2026 IDT meetings. The EMR showed IDT care conferences occurred on 1/15/26 and 8/13/26, and documentation supported resident and representative involvement at those conferences, but there were no other documented care conferences during that period. There was also no documentation that the resident or representative participated in the development or revision of the care plan during that time. During interviews, the Resident Advocate stated she generally scheduled the resident's IDT care conferences around the representative's availability and that the representative attended the 8/13/26 meeting, but she could not find notes explaining why meetings had been delayed or rescheduled. The Corporate Quality Assurance Nurse stated the facility used a Care Plan Summary Signature Page to show quarterly review with the resident or representative, but no such signed page could be located in the record for Resident #40. The MDS Coordinator stated she completed quarterly care plan reviews based on chart review, orders, nursing notes, and IDT notes when available, and if no IDT had been held she relied on the existing notes and orders.
Failure to Hold and Notify Residents of Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences and failed to ensure that residents or their resident representatives were notified in advance of care conference meetings for three residents. Review of the facility policy showed that an interdisciplinary plan of care was to be established and updated as indicated for every resident, with resident or representative participation included unless participation was not practicable and documented in the medical record. However, review of care plan conference records showed that Resident R26, who had diagnoses of diabetes, high blood pressure, and coronary artery disease, had a last documented care conference on 1/29/26 and no documented quarterly care conferences in April 2026 or July 2026. Resident R39, who had diagnoses of high blood pressure, heart failure, and diabetes, had an admission care conference on 10/1/25 with no attendee list except the staff member and no documented quarterly care conferences in January 2026 or May 2026. Resident R91, who had diagnoses of insomnia, anxiety, and ALS, stated during interview that he had only been to one care conference since admission and had not been invited to any others; records showed an admission care conference on 6/4/25 and no documented quarterly care conferences in September 2025, December 2025, March 2026, or June 2026. The Social Worker Aide confirmed the missing quarterly care conferences for all three residents, and the Nursing Home Administrator confirmed the facility failed to conduct care plan conferences and failed to ensure advance notification to the resident or resident representative.
Failure to Invite Resident and Representative to Care Plan Conferences
Penalty
Summary
The facility failed to include the resident or his representative in the development and planning of his person-centered care plan when it did not notify or invite them to care plan meetings. The resident had diagnoses of quadriplegia and aphasia, and his admission MDS documented that no BIMS interview was completed, he was rarely or never understood, staff assessed him as having severely impaired cognition, and he was dependent on staff for all ADLs. His Communication CAA noted he had a potential for decline in communication related to his diagnoses, but he could sometimes recognize family, answer yes or no questions, and understand some staff directions. The resident’s care plan instructed staff to use communication techniques, allow adequate time for responses, repeat as necessary, avoid rushing him, and face him while speaking. Although the EMR documented a care meeting with the resident, his guardian, and a PACE representative, it lacked documentation that care plan conferences occurred with facility staff. The guardian stated she had never been invited to a care plan meeting with facility staff since admission and had only attended a care plan meeting with PACE staff. Administrative nurses reported that care plan meetings were completed by the interdisciplinary team and that the SSD would call the family to set them up, but one nurse was not sure whether meetings occurred with the facility and guardian or with PACE, and another said the meetings were documented in a progress note.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to ensure Resident #12, who was admitted with diagnoses including major depressive disorder, history of falling, primary hypertension, hyperlipidemia, urinary incontinence, anemia, benign prostatic hyperplasia, and lower back pain, was afforded the opportunity to participate in the development and implementation of his/her person-centered plan of care. Record review showed the resident had clear speech, could make self-understood, understood others, and had a BIMS score of 14, indicating normal cognitive level with no impairments. However, the medical record contained no admission paperwork, including consent for treatment, the admission agreement, explanation of charges, acknowledgement of resident rights, or acknowledgement of the resident handbook. The record also showed only one care conference note, which was the discharge care conference, and there was no documentation of an initial care conference or other progress or interdisciplinary notes showing the resident was involved in care planning during the stay. The Administrator stated the facility could not provide the admission paperwork and confirmed there were no other care conferences held for the resident during the admission. The resident stated he/she did not recall attending or being invited to care conference meetings. The facility policy stated residents or responsible parties would be invited to participate in the scheduled care conference.
Failure to Include Resident Representatives in Care Planning
Penalty
Summary
The facility did not ensure that the resident and/or the resident representative participated in the development and implementation of the person-centered plan of care for two residents. For one resident with diagnoses including dementia, aphasia, and abnormal gait and mobility, the Minimum Data Set documented severely impaired cognition, dependence for many activities, and family participation in assessment and goal setting. The resident had a physician order for one-to-one supervision every shift and every day, but the facility removed the one-to-one supervision on the 7 AM to 3 PM shift without documented discussion with or notification to the family. Nursing, physician, social work, and progress notes from the period reviewed did not show evidence that the family was informed of the change, and later documentation showed the resident continued to require one-to-one supervision for pica behavior. During observations and interviews, the resident was seen lying in bed without supervision, and a CNA stated the resident was no longer on one-to-one supervision. The resident’s representative stated the facility would discontinue supervision without informing or consulting the family. Staff interviews indicated the resident had a history of falls, multiple falls after admission, and that one-to-one supervision had been implemented at the family’s request. Staff also stated they re-evaluated supervision and might adjust it, but could not provide specific dates when the family was informed, and the communication was not documented in the electronic medical record. For a second resident with chronic respiratory failure, trach dependence, anoxic brain damage, dysphagia with feeding tube, and persistent vegetative state, the baseline care plan was discussed with the representative, but the initial team care plan meeting did not occur until six weeks after admission. The facility’s policy stated the resident and representative were to be informed of the initial plan of care and invited to care plan meetings, and the administrator stated the initial team care plan meeting with family should occur within the first one to two weeks of admission. Staff explained the delay by citing staffing issues and the former director’s resignation, and the resident’s representative stated they had to wait six weeks for the meeting.
Failure to Involve Resident in Person-Centered Care Planning
Penalty
Summary
The facility failed to allow a resident to participate in the development and implementation of the resident’s person-centered plan of care. R5’s admission MDS indicated diagnoses of schizoaffective disorder and psychotic disturbances, that R5 was cognitively intact, had behavioral symptoms, used tobacco, ambulated 10 feet independently, and needed staff assistance with showering, putting on footwear, walking distances over 10 feet, and supervision with stairs. The MDS also showed R5 received antipsychotic, antidepressant, antibiotic, diuretic, and hypoglycemic medications, and care area assessments were triggered for multiple areas including cognitive loss/dementia, ADLs, mood state, falls, nutritional status, psychotic drug use, and return to community referral. R5’s care plan lacked resident preferences and only included nutrition. The chart contained a care conference note with the DON and R5 present, but it addressed goals, medical history, and orders without R5’s preferences, R5’s goals for herself, or any concerns. The DON stated R5 had been admitted over one month earlier but had never had a care conference and did not have a care plan, and that care was directed by physician orders. The administrator stated care plans were established by the admitting nurse talking with the resident and that care conferences were to be held within the first 14 days and then quarterly or as needed. RN-B stated care was directed by physician orders and the DON was responsible for setting up care conferences. R5 stated the facility had not asked about personal, cultural, or religious preferences, had not offered a care conference, had not asked about other providers or medical needs, had not offered a meeting to discuss concerns or needs, and had not provided a copy of a care plan.
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