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
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A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
Failure to Invite Residents and Representatives to Care Plan Meetings The facility did not document advance notice or invitations for care plan/IDT meetings for multiple residents, including residents with dementia, cognitive impairment, mobility limitations, pain needs, wounds, therapy services, and complex medical diagnoses. Interviews showed residents and family members were not invited to meetings, and staff stated the IDT discussed care plans internally while the DON called families with updates instead of holding or documenting formal care plan conferences.
A resident with post-polio syndrome and malignant neoplasm of the major salivary gland, who was cognitively intact per BIMS, was not afforded the right to participate in a required quarterly person-centered care plan conference. A care plan meeting was scheduled with the resident and the resident’s daughter, but the daughter requested to reschedule on the day of the meeting. Social Services left a voicemail offering alternative dates and times, yet there was no further documented follow-up, no rescheduled conference, and no evidence that the care plan meeting was conducted with the resident alone. The NHA and DON confirmed there was no documentation that the quarterly care plan conference was completed for this resident.
A resident with PAD, diabetes, and chronic toe wounds had a long-standing relationship with a podiatrist whose hospital consult specified detailed wound care with betadine, gauze between toes, and protective wrapping, and the MDS indicated it was very important for family to be involved in care discussions. On admission, initial wound care orders including dressing were quickly discontinued and replaced by a wound consultant’s order to paint the toes with betadine and leave them open to air, without documented consultation or notification of the resident or representatives. Family members repeatedly told nursing staff they wanted the resident’s podiatrist involved and the podiatrist’s wound care regimen followed, reported seeing the foot without wrapping despite prior instructions, and expressed frustration that staff did not listen until the wounds became infected. The DON later acknowledged that the hospital podiatry recommendations and family concerns were not documented as being considered and that there was no documentation that the resident or representatives were consulted when wound care orders were changed.
Failure to Hold Required Care Plan Conferences: The facility did not conduct required care plan conferences for multiple residents with varying needs, including residents with HTN, CVA, dementia, Alzheimer’s disease, and CHF. Records showed recent MDS assessments with needs for assistance with toileting, bathing, dressing, transferring, and eating, but the last documented care conferences were months earlier or absent altogether. The SSD stated care plan conferences were not completed during a staffing transition, despite the facility policy calling for regularly scheduled conferences and discussion of the plan of care with the resident and/or representative.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Invite Residents and Representatives to Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents had the right to participate in the development and implementation of their person-centered plans of care for 13 of 13 residents reviewed for comprehensive care plans. Record review and interviews showed that the facility did not document invitations for care plan meetings for Resident #1, Resident #2, Resident #20, or 10 additional confidential residents, and there was no documentation that these residents or their representatives were provided prior notice to participate in care plan meetings. Resident #1 was a female admitted with diagnoses including fracture of the right femur, anemia, pneumonia, hypertension, acute diastolic congestive heart failure, macular corneal dystrophy, history of cerebral infarction, and history of falling. Her admission MDS showed minimal hearing difficulty, impaired vision with corrective lenses, BIMS 11/15, limited to moderate ADL assistance needs, use of a walker and wheelchair, pain requiring PRN medication, a mechanically altered diet, wound care needs, and therapy services. Her care plan addressed triggered concerns from the admission MDS, and her overall goal was discharge to the community, but the record did not show any IDT or care plan meeting documentation between admission and the survey review period. During interview, Resident #1 stated she did not think she had participated in a care plan meeting, and a family member stated the facility communicated with him individually rather than through a care plan/IDT meeting. Resident #2 was a male with diagnoses including dementia, altered mental status, chronic hepatitis C, hyperlipidemia, depressive disorder, PTSD, polyneuropathy, osteoporosis, urethral fistula, and traumatic brain injury. His quarterly MDS showed impaired vision with corrective lenses, BIMS 5/15, wheelchair use, extensive ADL assistance, frequent bladder incontinence, an ostomy for bowel, falls, mechanically altered diet, skin tears and moisture associated skin damage, and use of antidepressant and antibiotic medications. His care plan addressed triggered concerns, but the record did not show any IDT or care plan meeting documentation during the review period. A family member stated he had not been invited to or attended any care plan/IDT meeting regarding Resident #2's care. Resident #20 had diagnoses including dementia, acute kidney failure, acquired absence of specified parts of the digestive tract, cholecystitis, atrial fibrillation, arthritis, type 2 diabetes mellitus, insomnia, depressive disorder, hypertension, and GERD. Her quarterly MDS showed impaired vision with corrective lenses, BIMS 6/15, wheelchair use, extensive ADL assistance, incontinence of bladder and bowel, medically complex conditions, scheduled pain medication, a mechanically altered diet, moisture associated skin damage, insulin injections, and antidepressant use. Her care plan addressed triggered concerns, but there was no documentation of an IDT or care plan meeting during the review period, and her family member stated she had never been invited to a care plan/IDT meeting. Interviews with staff showed the MDS Coordinator stated they did not send letters or have care plan meetings, and that the IDT team met to discuss the plan of care while the DON called families with updates. The DON stated the facility got the IDT team together, reviewed residents' care plans, and then called family members or responsible parties to discuss quarterly and annual assessments, but did not send letters to invite residents or family members to care plan meetings. The DON also stated that during COVID-19 the meetings were done by phone and never started back, and that she documented notifications on paper because the EMR did not have a place for notes. The Administrator stated she had been told the MDS nurse did not do care plan meetings and that the DON notified families with updates, and she acknowledged the importance of notifying residents and families and giving them a chance to talk to the IDT about questions or concerns. The facility policy stated residents have the right to participate in care planning, receive advance notice of care planning conferences, and have an explanation documented if participation is not practicable.
Failure to Conduct Required Quarterly Care Plan Conference With Cognitively Intact Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact resident was afforded the right to participate in the development and implementation of a person-centered plan of care, including completion of a required quarterly care plan conference. Facility policy required the interdisciplinary team, in conjunction with the resident and the resident’s family or legal representative, to develop and review a comprehensive care plan at least quarterly with the MDS assessment and after significant changes. The resident involved was admitted with post-polio syndrome and malignant neoplasm of the major salivary gland and had a BIMS score of 15, indicating intact cognition and ability to participate in care planning. A quarterly care plan conference was scheduled with the resident and the resident’s daughter for a specific date and time, but on the day of the meeting the daughter requested that it be rescheduled. Social Services documented leaving a voicemail for the daughter offering alternative dates and times, but there was no further documented follow-up, no evidence that the meeting was rescheduled, and no evidence that the care plan conference was conducted with the resident alone despite the resident’s ability to participate. During interviews, the Social Services Director, Nursing Home Administrator, and DON confirmed that no additional attempts were made to contact the daughter and that there was no documentation that a quarterly care plan conference had been completed for this resident, resulting in the failure to provide the resident the right to participate in the care planning process.
Failure to Incorporate Family Wound Care Preferences and Podiatry Oversight Into Plan of Care
Penalty
Summary
The deficiency involves the facility’s failure to incorporate a resident’s and resident representatives’ preferences for medical oversight and wound care into the person-centered plan of care. Resident 2 was admitted with peripheral arterial disease and diabetes, with a history of diabetic toe ulcerations that had been managed by an outpatient podiatrist. The admission MDS documented moderate cognitive impairment and that it was very important for the resident’s family to be involved in care discussions. The hospital podiatry consult specified a detailed wound care regimen, including betadine application to all toes and stable eschars, gauze in the web spaces, a sponge over the toes, and Kerlix wrap to protect the foot, with continuation of outpatient podiatry care after discharge. On admission, physician orders directed staff to apply betadine to the toes, place a dressing between toes 4 and 5, and cover with a light gauze dressing, but this order was discontinued the next day. A wound consultant then ordered the toes to be painted with betadine and left open to air, which differed from the hospital podiatrist’s wrapping instructions. There was no documentation that the resident or their representatives were consulted or notified when the original wound care orders were discontinued and the new open-to-air treatment was initiated. The DON later acknowledged that the hospital podiatry recommendations should have been considered on admission and when the family raised concerns, and that there was no documentation of consultation or notification regarding the change in wound care orders. Collateral contacts reported repeatedly expressing concerns and preferences for continued involvement of the resident’s long-standing podiatrist and adherence to that podiatrist’s wound care regimen. One family member stated the resident had been admitted with strict podiatry instructions and that the facility would not allow the podiatrist to treat the resident or follow the recommendations until the toe wounds deteriorated, describing significant frustration with nursing staff not listening. Another family member reported seeing the resident’s foot without wrapping despite prior instructions from the podiatrist to avoid sheet contact with the wounds, and stated they asked staff to involve the podiatrist and follow their treatment orders but felt they were ignored until the wounds became infected. Facility medical providers later stated they did not recall being aware of the long-standing podiatry relationship at the time of changing orders, and there was no documentation that the family’s expressed preferences for podiatry involvement and specific wound care were incorporated into the plan of care.
Failure to Hold Required Care Plan Conferences
Penalty
Summary
The facility failed to ensure quarterly care conferences were conducted for multiple residents as part of their person-centered plan of care. Resident 8, admitted with hypertension, had a Significant Change MDS dated 3/13/26 showing cognition not assessed, partial assistance needed for toileting, and substantial staff assistance for bathing, but the clinical record lacked a care plan conference since admission. Resident 7, with diagnoses including nontraumatic intracerebral hemorrhage and bipolar disorder, had a Quarterly MDS dated 2/11/26 showing intact cognition and dependence on staff for toileting and bathing, but the last care plan conference was on 11/25/25 and was attended by family. Resident C, with cerebrovascular disease, had a Quarterly MDS dated 3/4/26 showing cognition not assessed, setup assistance for transferring and eating, and substantial to maximal assistance for toileting, but the last care plan conference was on 10/14/25. Resident 25, with wedge compression fracture of L2, unspecified dementia, and Alzheimer’s disease, had a current Significant Change MDS showing intact cognition, set-up help for eating, partial to moderate assistance for dressing, hygiene, and toileting, and substantial to maximum assistance for transferring, but the last care conference was on 7/22/25. Resident 38, with muscle weakness and chronic combined systolic and diastolic heart failure, had a current Quarterly MDS showing intact cognition, set-up assistance for eating, substantial to maximum assistance for hygiene and dressing, and dependence for transferring, but the last care conference was on 12/23/25. The SSD stated in interview that care plan conferences were not completed during the period between the prior SSD leaving and his starting in the position. The facility policy stated the plan of care would be discussed with the resident and/or representative at regularly scheduled care plan conferences, initially, at routine intervals, and after significant changes.
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