A resident’s care plan was not revised after new swallowing difficulty was observed and a modified diet plus SLP swallowing study were ordered. In a separate case, a scheduled care plan meeting for another resident with dementia and Parkinson’s disease was missed, and the SSD said it was not conducted due to human error; the resident’s family member also reported repeated attempts to reach the facility without response.
A resident’s care plan meeting was missed after the most recent MDS assessment. The record showed a prior care conference, but no subsequent care plan meeting after the latest MDS, and the SWD confirmed the meeting that should have followed the assessment did not occur.
Missed and Delayed Care Plan Meetings: The facility failed to hold required interdisciplinary care plan meetings after MDS assessments for two residents. One resident had a care plan meeting scheduled, but the surveyor found no documentation that it occurred after the meeting was moved at family request, and the resident also had a quarterly MDS. Another resident’s care plan meeting was conducted outside the required quarterly timeframe, with the SW acknowledging a seven-month gap between meetings and that the prior SW had not held meetings regularly.
Failure to provide a resident advance notice of care plan conferences. The resident stated that only the representative was notified of planned care plan meetings and the resident was informed afterward. Record review showed the notice was addressed to the representative, with no documentation that the resident received advance notice. The DSW confirmed the resident did not receive a letter after the most recent assessment.
Failure to Hold Required Care Plan Meeting: A resident did not have the required quarterly care plan meeting after an MDS assessment was completed. The resident reported that care plan discussions sometimes focused on meds rather than preferences, and record review showed the last documented meeting was months earlier. The SW, who was responsible for scheduling care plan meetings, confirmed no meeting had been held since the prior documented session and said the MDS was missed on the scheduling calendar.
Failure to hold and document care plan meetings: The facility did not hold interdisciplinary care plan meetings for a resident at the time of quarterly and annual MDS review and did not invite the resident or RP to the meetings. The record showed no evidence of meetings within the required timeframe, and the SWD later confirmed the findings after reviewing the chart.
A resident with osteoarthritis, reduced mobility, difficulty walking, a history of falls, and moderate cognitive impairment experienced a fall when they leaned to the side, tipped their wheelchair, and fell to the floor. Staff implemented an immediate intervention by placing a gel cushion in the resident’s wheelchair to help prevent further falls, and the cushion was observed in use. However, the resident’s fall-risk care plan, which addressed falls related to poor safety awareness and cognitive impairment, was never revised to include the gel cushion intervention, despite facility expectations that nurses and supervisors update care plans with new post-fall interventions.
The facility failed to review and revise care plans at least quarterly for multiple residents, with several care plans last updated well beyond the required timeframe. For one resident, family reported inconsistent assistance with drinking, staff were observed helping with water, and an IV was ordered for hydration, but the care plan did not identify hydration as a focus or include interventions to maintain or restore hydration.
The facility failed to keep a resident’s care plan consistent with the most recent MOLST, resulting in conflicting documentation where the MOLST indicated full code while the care plan and active orders still showed DNR, and the assigned nurse stated she would follow the outdated DNR status. In addition, the facility did not hold required interdisciplinary care plan meetings within the mandated timeframe after MDS assessments for two residents, with no care conference notes documented following those assessments and a social worker operating under an incorrect understanding of the timing requirements and the need for a guardian’s presence.
A resident did not receive documented quarterly care plan meetings as expected. The resident said it had been a while since the last meeting, and record review showed the last care plan meeting note was from 7/30/2025. The SS Director stated meetings were done quarterly after each quarterly comprehensive assessment, but the facility had no additional documentation showing another meeting had occurred, and the DON reviewed the concern.
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