Failure to Invite Residents and Representatives to Care Plan Meetings
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility did not conduct required care conferences for two residents with multiple psychiatric and medical diagnoses, including one who was cognitively intact and another with severely impaired cognition requiring ADL assistance. Record reviews with SS staff showed no documentation of any care conferences for either resident, and SS confirmed that none were held. This was inconsistent with the facility’s Comprehensive Care Plans policy, which requires resident participation in person-centered care planning or documented reasons and efforts when participation is not practicable.
The facility did not conduct routine care plan conferences for two residents with severe cognitive impairment, resulting in a lack of participation by their representatives in the care planning process. Despite care plan updates, the responsible parties were not included in ongoing conferences, and the Director of Social Services acknowledged delays and missed communications.
The facility did not consistently offer or hold care plan meetings for several residents, as confirmed by record reviews and interviews. Cognitively intact residents and their representatives were not invited to participate in care planning beyond initial meetings, and staff acknowledged the lack of a systematic process for scheduling these meetings, contrary to facility policy.
The facility did not ensure that residents and their legal representatives were properly notified or involved in care conferences, as required by policy. Multiple residents with cognitive impairments and their guardians or POAs were not invited to participate in care planning, and there was no documentation of notification or attendance. Staff interviews confirmed that notifications were not consistently documented, and representatives reported not being informed about care meetings or changes in care.
A resident's responsible party was not included in the development or review of the resident's baseline care plan, as required. Medical records and staff interviews confirmed that neither the resident nor their POA participated in the initial care planning process, and no documentation or signatures were obtained to show their involvement.
A facility failed to involve a resident's Power of Attorney in care planning, affecting a resident with severe cognitive impairment and multiple diagnoses. Despite the facility's policy to include responsible parties in care conferences, the resident's representative was not contacted about changes in the resident's condition or invited to care meetings. Facility staff confirmed the lack of documentation for such invitations, and a care conference was missed.
Failure to Conduct Care Conferences and Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure residents were allowed to participate in the development and implementation of their person-centered plans of care by not conducting required care conferences. For one resident with chronic viral hepatitis C, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression, and venous insufficiency, record review showed admission and subsequent discharge against medical advice with no guardian at the time of discharge. The most recent MDS 3.0 assessment documented moderately impaired cognition with varying levels of assistance needed for ADLs, and a later BIMS score of 13 indicated the resident was cognitively intact. Review of this resident’s medical record with Social Services staff revealed no evidence of any care conferences, and the Social Services staff member confirmed that none had been conducted. For another resident with diagnoses including mood disorder, bipolar disorder, cauda equina syndrome, catatonic schizophrenia, and major depressive disorder, the most recent MDS assessment showed severely impaired cognition and a need for assistance with ADLs. Review of this resident’s medical record with Social Services staff likewise revealed no documentation of any care conferences, and the Social Services staff member verified that none had been held. The facility’s Comprehensive Care Plans policy states that each resident’s comprehensive person-centered care plan must be consistent with the resident’s right to participate in the planning process, and that if resident or representative participation is not practicable, an explanation and the steps taken to include them must be documented in the medical record. Such documentation was not present for these residents. This deficiency was cited under Complaint Number 2691577.
Failure to Conduct Routine Care Plan Conferences and Involve Resident Representatives
Penalty
Summary
The facility failed to ensure that routine care plan conferences were conducted for two residents with severely impaired cognition. For one resident with diagnoses including Parkinson's disease, schizophrenia, bipolar disorder, hypothyroidism, dementia, and muscle weakness, the care plan was updated multiple times, but the resident's Power of Attorney (POA) reported that no care conference had been held since March, despite attempts to contact the new Director of Social Services. The resident was unable to participate in care planning due to cognitive impairment, making POA involvement essential. Another resident with dementia, muscle weakness, hypertension, impulse disorder, and insufficient sleep syndrome had an admission care conference with their spouse, but no further care conferences were documented after the initial one, despite care plan updates. The spouse, listed as the responsible party, was not involved in subsequent care conferences. The Director of Social Services confirmed being behind on scheduling and conducting care conferences and was unaware of missed communications from the POA. Facility policy requires resident and representative participation in care planning to the extent practicable, with documentation if not possible, but this was not followed.
Failure to Offer or Hold Care Plan Meetings for Residents
Penalty
Summary
The facility failed to ensure that residents were offered or included in care conference meetings as part of their person-centered care planning. Record reviews and interviews revealed that four residents, all of whom had quarterly Minimum Data Set (MDS) assessments completed and were either cognitively intact or had a representative, did not have documented care plan meetings beyond their initial or early admission meetings. For example, one resident was only invited to a single meeting after admission, which he missed, and had no further documented invitations. Another resident and his mother reported not receiving invitations to care plan meetings for an extended period, and the last documented meeting was several months prior. A third resident's family stated they were not contacted or invited to participate in care planning, and the last meeting on record was also several months old. The fourth resident, who was cognitively intact, reported not being involved in any care plan meetings during his year-long stay, with the last documented meeting occurring months before the review. Interviews with facility staff, including a licensed social worker and an LPN, confirmed that care plan meetings were not consistently offered or held for all residents as required. The social worker identified issues related to staffing changes and lack of a systematic approach to scheduling these meetings. The facility's own policy stated that residents and their representatives should be included in all aspects of care planning and be given opportunities to participate, but this was not followed in practice. The deficiency was identified during a complaint investigation and affected four out of four residents reviewed for participation in care planning.
Failure to Notify and Involve Residents and Representatives in Care Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited to participate in care conferences as required by policy. In multiple cases, there was no documented evidence that residents or their legal representatives were notified of or attended care plan meetings. This deficiency was identified through record reviews, interviews, and examination of care conference attendance records and facility policies. For example, one resident with multiple diagnoses including COPD, dementia, and chronic respiratory failure, had a legal guardian who reported never being invited to or attending a care conference. The resident herself also stated she did not attend care plan meetings, and documentation confirmed the absence of invitations or attendance records for both the resident and her guardian. Another resident, who was cognitively intact but had a legal guardian, similarly had no documentation of being invited to care conferences, and the guardian stated he was not notified of meetings unless he initiated contact with the facility. Additional cases included residents with moderate to mild cognitive impairment and their representatives, who reported never being invited to care conferences or informed of changes in care. Facility staff interviews revealed that notifications were often made verbally and not documented, with staff relying on memory rather than maintaining records as required by facility policy. The policy specified that a seven-day notice should be provided and documented, including the method of contact and any input or refusal, but this was not followed in the reviewed cases.
Failure to Involve Responsible Party in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's responsible party participated in the development and implementation of the resident's person-centered care plan. Medical record review showed that the baseline care plan for a resident with diagnoses including heart disease, acute and chronic respiratory failure, seizures, and COPD was not reviewed with the resident or their Power of Attorney (POA) as required. Staff interviews confirmed that there was no documentation or signature indicating the POA was informed or involved in the initial care planning process, despite the facility's usual practice of obtaining such signatures to demonstrate participation.
Failure to Involve Resident's Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's responsible party was included in the development and revision of the care plan. This deficiency affected a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, anxiety disorder, chronic ischemic heart disease, and type two diabetes. The resident required assistance with certain activities of daily living (ADLs) and had a care plan that included interventions for neurological deficiencies and ADL self-care deficits. Despite these needs, the facility did not involve the resident's Power of Attorney (POA) in care planning discussions. The facility's records showed that the resident's care plan was reviewed and updated, and the resident and family were informed of changes. However, there was no evidence that the resident's representative was included in the quarterly assessments related to care planning. The resident's POA reported not being contacted about changes in the resident's condition or invited to care conferences, except for one near the time of admission. The POA expressed difficulty in communicating with facility staff and a desire to discuss the resident's placement in a secured unit. Interviews with facility staff revealed that care conferences were supposed to occur every three months and that responsible parties were to be invited via phone calls or emails. However, the staff confirmed that there was no documentation of such invitations for the resident's care conferences, and a care conference that should have occurred in October did not take place. The facility's policy emphasized the importance of involving residents and their representatives in care planning, but this was not adhered to in this case.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
