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:
Failure to Document Representative Notification for Care Plan Meetings: A resident with dementia, DM2, and epilepsy had severe cognitive impairment and lacked decision-making capacity, with family involvement noted as very important. Interdisciplinary care plan meetings were held, but the facility could not provide documentation that the resident’s designated representative received advance notice or that attempts to notify the representative were documented; the representative stated they were not invited and wanted to participate.
Failure to Hold IDT Meeting for Nephrostomy Tube Noncompliance: A resident with UTI, CKD, and cervical cancer was observed with her nephrostomy tube touching the floor while the bag was hooked to her walker for convenience. Staff stated that noncompliance with a treatment plan or a resident preference for this setup required an IDT meeting and documentation, but no such meeting was conducted for the resident.
Resident Not Invited to Care Plan Conferences: A resident with a recent health decline and BIMS score of 6/15 was not invited to multiple care plan conferences and did not attend them, while the POA/family participated by phone or declined the meeting. Record review showed no resident signature or documentation that the resident was invited, and interviews confirmed the facility was basing attendance on BIMS score even though staff acknowledged residents do not give up the right to participate in their care plan.
A resident with vascular dementia and severe cognitive impairment had a care plan conference held without the RP being invited, identified for contact, or present by phone or in person. The resident’s sister, who was listed as the RP, said she was unaware of the meeting and would have attended to discuss PT concerns. Facility staff, including the TD, SSM, DON, and Administrator, acknowledged the RP should have been notified and allowed to participate.
Failure to Hold Required Care Conferences: The facility did not complete required care conferences quarterly and upon request for multiple residents with varied medical conditions, including dementia, stroke-related deficits, CHF, CKD, and Parkinson’s disease. Record review and staff/POA interviews showed missing or undocumented care conferences despite MDS findings showing cognitive impairment or care needs, and the facility’s own policy stated care conferences were to be held routinely and as needed with documentation of attendees and content.
Care conferences were not completed at least quarterly for two residents. One resident with dementia, bipolar disorder, and HTN had only two documented conferences, and a family member said staff never returned calls to reschedule after a missed meeting. Another resident with paraplegia, HTN, and legal blindness was transferred from another facility, but the record did not show a completed care conference after admission; the family member said staff never contacted her to conduct one.
Failure to Document Representative Notification for Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident or the resident’s designated representative was afforded the opportunity to participate in the resident’s person-centered care planning process. For Resident #101, who had diagnoses including dementia, Type 2 diabetes, and epilepsy, the Minimum Data Set documented severe cognitive impairment and that family involvement in care discussions was very important to the resident. A psychiatry evaluation documented that the resident lacked decision-making capacity. Social work progress notes documented interdisciplinary care plan meetings held in the resident’s room, and stated that the designated representative was invited but did not attend. However, the facility was unable to provide documentation showing that the designated representative received advance notice of either care plan meeting, or that staff attempted to provide advance notice before the meetings occurred. During interview, the designated representative stated they had not been invited to any care plan meetings and would have wanted to participate in the resident’s care planning. The Director of Social Services stated that telephone calls were made before each quarterly care plan meeting, but the designated representative did not answer, and acknowledged that these notification attempts were not documented.
Failure to Hold IDT Meeting for Nephrostomy Tube Noncompliance
Penalty
Summary
The facility failed to ensure an Interdisciplinary Team (IDT) meeting was conducted for Resident 25 regarding noncompliance with keeping her nephrostomy tube off the floor. Resident 25 was admitted and later readmitted with diagnoses including UTI, chronic kidney disease, and malignant neoplasm of the cervix uteri. Her MDS dated 4/30/2026 indicated she was cognitively intact, used a walker to ambulate, and required varying levels of assistance with activities of daily living, including toileting and dressing. During an observation on 6/22/2026, Resident 25's nephrostomy tube was touching the floor and the nephrostomy bag was hooked to her walker. The resident stated she placed the nephrostomy bag on the walker for convenience when ambulating to the restroom. Staff interviews indicated that when a resident is noncompliant with a treatment plan or prefers to keep a nephrostomy bag on a walker, an IDT meeting should be held and documented to ensure resident safety and consistent care. The DON also stated there could have been an IDT meeting for Resident 25 for noncompliance. The facility policy titled Interdisciplinary Team Skilled Review stated the IDT will gather information and collect data within 72 hours of admission to determine resident expectations and goals.
Resident Not Invited to Care Plan Conferences
Penalty
Summary
The facility failed to ensure that Resident Rights were honored as written for one sampled resident. The resident rights document stated that residents have the right to review and make changes to their own plan of care, to make choices about aspects of life in the facility, to be informed of health status and medical condition, and to participate in planning their own care. Record review showed that the resident was not invited to multiple care plan conferences and did not attend them, while family members or the resident’s representative participated instead. The Quarterly Care Plan Conference Summary dated 10/14/2025 stated that the resident was not invited to the care plan conference and did not attend. The Care Plan Acknowledgement Form dated 10/14/2026 showed the care plan was conducted over the phone with the POA/HPOA, with no resident signature and no evidence the resident attended or was invited. Additional Care Plan Acknowledgement Forms dated 11/4/2025 and 1/6/2026 stated the family declined the care conference and the IDT met to discuss the resident’s care, but there was no evidence the resident was invited or present. A Care Plan Conference Summary dated 3/3/2026 also stated the resident had not been invited to the care plan conference. The resident’s condition and ability to participate were discussed during interviews and record review. The resident had a BIMS score of 6/15 on 12/30/2025 and had increased confusion after a recent health decline, but during interview on 06/22/2026 the resident was able to discuss hospitalizations, meals, some medications, activities, infections, and diagnoses, yet had no knowledge of care plans or care plan meetings and stated no awareness of having attended any in the past. Staff interviews confirmed that residents do not give up the right to attend care plan meetings, but the facility had been basing invitations on BIMS score and, in practice, often held conferences by phone with the POA or family without the resident’s attendance or documented invitation.
Failure to Include Responsible Party in Care Plan Conference
Penalty
Summary
The facility failed to ensure a resident’s responsible party was invited to, attended, and/or participated in the resident’s care plan meeting. Resident #2 was admitted with vascular dementia and was identified in the admission packet as incapable of making medical decisions; the resident’s sister was listed as the responsible party. The resident’s MDS showed severe cognitive impairment, and the initial care plan addressed impaired cognitive function and/or impaired thought processes related to dementia. The resident’s care plan conference was held without the responsible party attending in person or by telephone, and the care conference planning form did not identify the sister as needing to be present and/or contacted. The resident’s sister stated she was unaware of the care plan conference and would have attended if notified to discuss physical therapy concerns. Facility staff, including the Therapy Director, Social Services Manager, DON, and Administrator, acknowledged that the responsible party should have been notified and allowed to attend the care plan conference.
Failure to Hold Required Care Conferences
Penalty
Summary
The facility failed to provide care conferences quarterly and upon request for seven residents reviewed for care planning. The deficiency was identified through record review, interviews, and review of the facility’s care conference policy, which stated that care conferences would be conducted routinely and as necessary to discuss and coordinate residents’ plans of care, care needs, and goals, with contents, attendees, and signatures documented. The facility record review showed that this policy was not implemented. Resident #14, admitted with diagnoses including hemiplegia and hemiparesis, depression, morbid obesity, spinal stenosis, and hyperlipidemia, had a quarterly MDS showing intact cognition and no rejection of care, yet no evidence of a care conference was found since the prior recertification survey. The Administrator and Corporate RN verified they could not locate evidence of any care conferences for this resident. Resident #10, who had vascular dementia, pulmonary hypertension, and hemiplegia/hemiparesis after cerebral infarction, had MDS findings of memory impairment, severe impairment in daily tasks, inattention, disorganized thinking, altered consciousness, and dependence for ADLs. Although a quarterly care conference was scheduled in the chart, progress notes and assessments from admission through the survey date showed no care conference occurred, and the POA stated the facility did not provide care planning or care conferences despite requests. Resident #17, with diagnoses including nontraumatic subarachnoid hemorrhage, hemiplegia, functional quadriplegia, and contracture of the right hand, had cognitive impairment and dependence for ADLs. A care conference had been requested by the designated care conference person, but no additional conferences were documented afterward, and the designated person stated the facility was canceling all care conferences due to surveyors being in the building. Resident #34, with hemiplegia/hemiparesis, tremor, contracture, malnutrition, dysphagia, and carpal tunnel syndrome, had some cognitive impairment and dependence for ADLs, yet no care conferences were documented after admission. Resident #46, with idiopathic normal pressure hydrocephalus, morbid obesity, CKD stage III, and CHF, had moderate cognitive impairment and dependence for toileting, bathing, lower dressing, and transfers; the interim SSD confirmed she could not provide evidence of a care conference after the resident’s quarterly MDS. Resident #65, with Alzheimer’s dementia, COPD, osteoarthritis, and repeated falls, had severe cognitive impairment and required supervision for most ADLs; the DON confirmed no care conference had been completed since January and that one should have occurred after the last quarterly MDS. Resident #87, who had CHF, gout, GERD, muscle weakness, and Parkinson’s disease with dyskinesia, had a cognitively intact MDS and care needs for bathing, transfers, ambulation, and toileting, but only one care conference was documented in the record, and Corporate RN verified the lack of care plan conferences.
Care conferences were not completed at least quarterly
Penalty
Summary
The facility failed to ensure care planning conferences were completed at least quarterly for two residents reviewed for care planning. Resident #10 was admitted with diagnoses including dementia, bipolar disorder, and essential hypertension. The record showed care conferences on 09/30/25 and 02/20/26, and the Annual MDS 3.0 assessment described severe cognitive impairment. A family member stated she missed the care conference and tried to reschedule, but the facility never returned her phone calls. A prior SSD confirmed the resident’s care conferences were not completed at least quarterly. Resident #111 was admitted on 03/13/26 as a transfer from a sister facility with diagnoses including paraplegia, essential hypertension, and legal blindness. The record included a social service progress note from 05/14/26 stating the clinical and administrative team gathered for a care conference at the daughter’s request, waited up to 15 minutes, and the daughter did not arrive; staff attempted to call her but did not reach her. The family member stated a care conference had not been completed since the transfer and that staff did not contact her to conduct one. The prior SSD confirmed the resident was transferred from a sister facility and the medical record did not show evidence that a care conference had been completed since admission.
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