Failure to Include Discharge Planning in Comprehensive Care Plans
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that comprehensive care plans included a discharge plan of care, as required by facility policy and regulatory standards. Medical record review for four residents admitted and/or readmitted during the review period showed that each had an admission MDS completed and an overall plan of care initiated and revised within the required time frames, but none contained a discharge planning component. These residents had various diagnoses including dementia, hypertension, type 2 diabetes mellitus, Parkinsonism, bipolar disorder, and atrial fibrillation, and some had documented impaired cognition on their admission MDS assessments. Despite these assessments and multiple admissions and readmissions in one case, no discharge care plans were initiated for any of the four residents. For one resident with dementia and multiple readmissions, the plan of care initiated shortly after admission and last revised several months later did not include any discharge planning. For three other residents, each with an admission and subsequent discharge during the review period, their plans of care similarly lacked any discharge planning component, regardless of whether cognition was impaired or intact. In each instance, the MDS RN confirmed during interview that a discharge care plan had not been initiated and acknowledged that it should have been included in the plan of care. Review of the facility’s “Care Plans, Comprehensive Person-Centered” policy, revised 12/2016, showed that comprehensive care plans were required to include the resident’s stated preference and potential for future discharge, which was not reflected in the care plans reviewed. This deficiency was identified incidentally during a complaint investigation.
Penalty
Resources
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The facility failed to revise nutrition care plans and ensure ordered weights were obtained for two residents experiencing or at risk for significant weight loss. One resident with multiple chronic conditions, including brain injury and major depressive disorder, had a documented 17.4% weight loss over time, with the RD noting significant weight loss, variable PO intake, and refusal of kcal supplements, yet the nutrition care plan remained focused on obesity and was not updated to reflect the new weight status or interventions. Another resident with complex cardiopulmonary disease and existing pressure ulcers was ordered house supplements, liquid protein, Juven, and weekly weights, and had a nutrition care plan calling for weekly then monthly weights, but no weights were obtained during the stay, and the RD later acknowledged being unaware of the missing weights and that the care plan did not reflect the resident’s admission with wounds.
A resident with osteomyelitis, type II DM, and dementia had an existing care plan identifying fall risk and a goal to remain free from fall-related injury. After the resident experienced a fall that led to hospital transfer, staff implemented new fall interventions such as bedside reorientation and visual cues to use the call light, but these interventions were not added to the written care plan until weeks later. The DON confirmed the care plan did not reflect the current fall interventions during this period, contrary to the facility’s care planning policy.
Surveyors found that the facility did not consistently review and revise care plans and discharge plans to reflect residents’ current needs and status. One resident with multiple chronic conditions had a care plan that still addressed infection risk from an indwelling catheter long after the catheter had been discontinued, and the care plan and active orders continued to require mechanical lift transfers even though the resident had been independently transferring for about two weeks per therapy direction. Another resident, cognitively intact and working toward discharge, had a discharge planning care plan that continued to list long-term placement due to needs exceeding community resources and was never updated to show that staff were actively assisting with discharge back to the community; the plan was only cancelled after the resident left the facility.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
The facility failed to conduct and document required initial and quarterly care conferences with residents and/or their representatives, as confirmed through record review and staff interviews. Several residents with complex conditions, including ESRD, dependence on dialysis, Alzheimer’s disease, heart disease, schizoaffective disorder, alcohol abuse, and anoxic brain damage, either had no initial care conference documented or missed multiple quarterly conferences. The Administrator acknowledged that quarterly care conferences were required and that there was no physical or electronic documentation to verify that these conferences occurred, despite a facility policy stating that residents and their representatives would be invited to care conferences with advance notice.
Surveyors found that the facility failed to revise a resident’s care plan to correctly classify a right buttock stage III pressure ulcer, which continued to be documented as a surgical wound despite wound assessments and staff acknowledgment that it remained a pressure ulcer. They also found that another resident with GERD and frequent reflux and swallowing difficulties had no individualized care plan interventions addressing reflux, vomiting of undissolved medications, or aspiration risk, and that an episode of vomiting medications and subsequent assessments were not documented in the clinical record.
Failure to Revise Nutrition Care Plans and Obtain Ordered Weights After Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to revise and update care plans in response to significant weight loss and nutritional risk for two residents. For one resident with anoxic brain damage, traumatic brain injury, legal blindness, psychosis, epilepsy, chronic pain, and major depressive disorder, the RD documented significant weight loss at the 180‑day marker, noting that the resident’s BMI had decreased from an obese range to overweight and that meal intakes were varied. The RD recorded that the resident refused nutritional supplements but would be monitored for continued weight loss and possible need for supplements. Despite a documented weight decrease from 168 pounds at admission to 138.7 pounds, representing a 17.4% loss, the nutrition care plan—last reviewed when the resident was still categorized as obese/overweight—was not revised after the significant weight loss was identified. The record for this resident also showed gaps in weight monitoring, with no weights obtained in two consecutive months, and the comprehensive MDS assessment indicated no significant weight loss, contrary to the later documented weight trend. The existing care plan focused on risk for altered nutrition related to obesity, with goals for adequate nutrition and no significant weight loss, and interventions including supplements per physician orders and RD notification if a 5% weight loss occurred. However, after the RD identified significant weight loss and noted the resident’s refusal of kcal supplements, the care plan was not updated to reflect the new nutritional status, the significant weight loss, or revised interventions. The RD acknowledged during interview that the resident’s weight loss was viewed as positive due to BMI, that she relied on nursing and an NP to notify her of significant weight loss, and that she had not updated the nutrition care plan. For a second resident admitted with acute and chronic respiratory failure with hypoxia, Influenza A, hypertension, heart disease, atrial fibrillation, pulmonary fibrosis, asthma, a pacemaker, depression, pneumonia, congestive heart failure, and oxygen dependence, the physician ordered house supplements with meals, weekly weights for four weeks, liquid protein three times daily, and Juven for wound healing. The RD’s initial nutrition assessment documented a normal BMI, variable meal intakes, no edema, and existing vitamin supplementation, and noted that the resident would be monitored as a new admit. The admission MDS showed the resident was cognitively intact, had two pressure ulcers on admission, and had no known weight loss or gain. A nutrition care plan was initiated indicating risk for altered nutrition related to a cardiac diet, with goals of adequate nutrition, no significant weight change, and no skin breakdown, and interventions including weekly weights for four weeks then monthly if stable. However, no weights were obtained at any time during the resident’s stay, and the RD later stated she was unaware that no weights had been taken and that the care plan should have reflected that the resident was admitted with existing skin breakdown.
Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s comprehensive care plan was revised in a timely manner to reflect current fall interventions after a fall event. The resident was admitted with diagnoses including acute osteomyelitis of the right ankle and foot, type II diabetes, and dementia. A care plan dated 03/10/26 identified the resident as being at risk for fall-related injury and falls due to history and fear of falling, with a goal to remain free from injury related to falls. A nursing note dated 03/25/26 documented that the resident went to the hospital, without additional information. In an interview, the resident reported having a fall that required hospital transfer, though he did not specify the date. Further review of the care plan showed that specific fall interventions, including reorienting the resident at bedside and providing a visual cue to use the call light for assistance, were created on 04/09/26 and were related to the fall that occurred on 03/25/26. In an interview, the DON confirmed that these interventions, which were implemented immediately after the fall, were not added to the written care plan until 04/09/26, leaving the care plan not up to date until that date. The facility’s “Care Planning” policy required that every resident have a person-centered care plan developed and implemented based on the comprehensive assessment, with measurable objectives and time frames to meet identified needs, but the resident’s care plan was not revised promptly after the fall as required.
Plan Of Correction
1. Resident #86 had their fall care plan updated on 4/9/26 by the Director of Nursing to reflect current fall interventions. 2. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC an audit of falls for the past 30 days will be completed by the Director of Nursing or designee to ensure fall care plans reflect current fall interventions. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Fall Management Policy to include updating the care plan with new interventions as appropriate. This education will be completed on or before 5/13/26. 4. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will audit new admissions, readmissions and residents who experience a fall weekly for four weeks, beginning 5/14/26 to ensure fall care plans reflect current fall interventions. Discrepancies noted during audits will be corrected with care plans updated to reflect current fall interventions. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Update Care and Discharge Plans to Reflect Current Resident Status
Penalty
Summary
The deficiency involves the facility’s failure to review and revise care plans after each assessment and in response to changes in residents’ needs, as well as failure to appropriately revise discharge plans of care. For one resident with diagnoses including acute systolic congestive heart failure, COPD, type 2 diabetes with polyneuropathy, muscle weakness, and a history of falls, the care plan revised on 03/04/26 still included a focus on risk of infection related to an indwelling medical device and an intervention to wear gown and gloves for high-contact care, despite the urinary catheter having been discontinued on 07/09/25 and no further catheter orders present. The same resident’s care plan and active orders required all transfers to be completed with a mechanical lift, with the mechanical lift intervention initiated on 01/18/26, yet on 03/30/26 the resident was observed independently transferring to a motorized scooter and into the restroom. A CNA confirmed the resident had been independently transferring for about two weeks based on therapy direction, but the order and care plan had not been updated. For another resident admitted with hypertension, anxiety, cerebral infarction, peripheral vascular disease, gangrene, and cardiomyopathy, the quarterly MDS assessment documented that the resident was cognitively intact for daily decision-making and had an active plan to discharge back to the community. However, the existing discharge planning care plan, dated 03/16/25, identified the resident as a long-term placement because his needs exceeded community resources and was not updated to reflect that the facility was assisting him with discharge back to the community. The discharge planning care plan remained unchanged and was only cancelled on 03/16/26 after the resident had already been discharged on 03/11/26, as confirmed by a nurse who verified that the discharge planning care plan was not revised when the facility assisted and ultimately discharged the resident back to the community.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Resident Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document timely initial and regular care conferences with residents and/or their representatives as required by regulation and facility policy. For one resident admitted with cerebral infarction, ESRD, and chronic congestive heart failure, the record showed only a single care conference held to discuss missing items, with no other documented care conferences. Another resident with acute respiratory failure, Alzheimer’s disease, and heart disease had no documentation of an initial care conference in the medical record. In each of these cases, the Administrator confirmed there was no physical or electronic documentation to verify that required care conferences had been conducted. Additional residents were affected by missed quarterly care conferences. One resident with ESRD and dependence on dialysis had only two care conferences documented in one year and none in the following year, leaving entire quarters without care conferences despite the Administrator’s acknowledgment that quarterly conferences were required. Another resident with schizoaffective disorder, alcohol abuse, and anoxic brain damage had no documented quarterly care conferences for the third and fourth quarters of a given year. Review of the facility’s policy on Resident Participation-Assessment/Care Plans showed that residents and/or their representatives were to be invited to care conferences with seven days’ advance notice, but the records and interviews demonstrated that this process was not followed for the affected residents.
Failure to Accurately Revise Wound Care Plan and Individualize GERD Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident care plans were accurately developed and revised based on comprehensive assessments. For one resident with multiple chronic conditions, including congestive heart failure, atrial fibrillation, diabetes, chronic kidney disease, and a history of chronic pressure ulcers on the buttocks and sacral areas, the care plan listed an alteration in skin integrity related to a surgical wound on the right buttock. However, wound assessments documented that the right buttock lesion was a stage III pressure ulcer that had been surgically repaired but remained a pressure ulcer, and observation showed a quarter-sized, approximately 1 cm deep pressure ulcer on the right buttock/sacral area with a red wound bed and scarred, very red surrounding skin. The wound nurse confirmed that the wound was misclassified as a surgical wound on the care plan and acknowledged that the plan of care needed revision to correctly identify it as a pressure ulcer. The deficiency also includes the facility’s failure to develop and individualize care plan interventions for another resident with a diagnosis of gastroesophageal reflux disease (GERD) and multiple comorbidities such as chronic kidney disease, atherosclerotic heart disease, cerebrovascular disease with prior stroke, diabetes, hypertension, and hypothyroidism. During a morning medication pass, the resident’s son reported to an LPN that the resident had vomited undissolved medications into a napkin. Although the clinical record contained a care plan for increased nutrition/hydration risk related in part to GERD, it did not include specific interventions addressing reflux, vomiting of medications, or aspiration risk. Nursing staff and a CNP acknowledged that the resident often experienced reflux and difficulty swallowing food and medications, that the vomiting incident and subsequent assessments were not documented in the clinical record, and that no care plan had been initiated to address the resident’s GERD with individualized interventions for reflux and vomiting of medications.
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