**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey from 2/9/2022 to 2/16/2022, the facility did not ensure, to the extent practicable, that residents/resident representatives were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents and resident representatives were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. This was evident for 2 of 3 residents reviewed for Participation in Care Planning out of a sample of 38 residents. (Resident #40 and #62) The findings are: The facility policy and procedure titled Care Planning Progress dated 11/21 documented under section Procedure 5) Resident and/or designated representative will be informed of scheduled Care Plan Meetings, including the suggested date and time by the Social Services Department. The resident and/or designated representative will be invited to the meeting by phone call, in-person or written invitation. The invitation will be documented within the EMR and/or a copy of the written invitation maintained by the Social Services Department.10) The resident has the right to participate in establishing the expected goals and outcome of care, the type, amount, frequency and duration of care and any other factors related to the plan of care. 1. Resident # 40 was admitted to the facility with diagnoses that included Dementia, Cerebral Infarction, and Hypertensive Heart Disease with Heart Failure. The Quarterly MDS dated [DATE] documented Resident # 40 was rarely/never understood others or made self understood, had short and long-term memory problems, and cognitive skills for daily decision making was severely impaired. It also documented Resident # 40 participated in assessment, and the family representative did not participate. On 02/09/22 at 12:36 PM, family representative was interviewed and stated they were not invited to care plan meeting and was not sure when was the last time they were invited to care plan meeting. Family representative also stated they made decisions for Resident # 40. The social worker progress note dated 3/26/2021 documented family was invited to care plan meeting on 3/30/2021. There was no documented evidence that Resident # 40 or representative had been invited to participate in the quarterly care plan meetings on 6/1/2021 and 8/24/2021. There was an invitation letter dated 11/15/2021 that was mailed to family representative for quarterly care plan meeting on 11/23/2021. The Comprehensive Care Plan Meeting signing sheet for Resident # 40 documented family representative attended the annual care plan meeting on 3/30/2021 but not the quarterly ones on 6/1/2021, 8/24/2021, and 11/23/2021. It also documented Resident # 40 did not attend any of the care plan meetings. On 02/15/22 at 04:15 PM, family representative was interviewed again and stated they received a lot of calls and letters from the facility. Family representative confirmed they received the letter of invitation to care plan meeting scheduled on 11/23/2021. 2. Resident #62 was admitted to the facility with diagnoses that included Dementia, Heart Failure, and Muscle Wasting and Atrophy. The Quarterly MDS dated [DATE] documented Resident # 62 had severely impaired cognition. It also documented Resident # 62 participated in the assessment while the family representative did not. On 02/09/22 at 02:33 PM, Resident # 62 was interviewed and stated family representative and themselves were not invited to any care plan meeting. The Social worker note dated 6/3/2021 documented family was invited to attend annual care plan meeting on 6/8/2021. There was an invitation letter dated 11/22/2021 mailed to family representative for quarterly care plan meeting on 11/30/2021. There was no documented evidence that family representative and/or Resident # 62 was invited to quarterly care plan meeting on 3/9/2021 and 9/9/2021. The Comprehensive Care Plan Meeting signing sheet for Resident # 62 documented Resident # 62 and family representative did not attend the meetings on 3/9/2021, 6/8/2021, 9/9/2021, and 11/30/2021 On 02/15/22 at 03:44 PM, family representative was interviewed and stated they received the letter and call for invitation to care plan meeting scheduled on 11/30/2021. Family representative also stated they did not remember if they received the call or letter for other care plan meetings in 2021. On 02/14/22 at 03:11 PM, MDS Nurse (MDSN) was interviewed and stated the residents had care meetings for Admission, Annual, Quarterly, Significant Change, and As Needed. MDSN also stated MDS assessor, RN supervisor, Dietitian, Social Worker, Rehab Director, Recreation Director, CNA (Certified Nursing Assistant), resident and/or family representative attended the care plan meeting. MDSN further stated MDS department set up the care plan meeting schedule and Social Worker (SW) was responsible to invite resident and/or family representative at least 48 hours in advance by calling and the SW had to document the care plan meeting invitation in social worker note. On 02/14/22 at 03:34 PM, Director of Social Work (DSW) was interviewed and stated the care plan meeting was for Admission, Annual, Quarterly, Significant Change and As Needed. DSW also stated MDS assessor, RN supervisor, Dietitian, SW, Rehab Director, Recreation Director, CNA, resident and/or family representative attended the care plan meeting. DSW stated the SW invited family representative to care plan meeting by mail or by call a week in advance and documented the invitation in the social worker note. DSW also stated they did not invite Resident # 40 and/or family representative to the quarterly care plan meetings on 6/1/2021 and 8/24/2021; Resident # 62 and/or family representative to the quarterly care plan meetings on 3/9/2021 and 9/9/2021 because there was no significant change in Resident # 40 and Resident # 62's health status or care plan. DSW further stated the two quarterly care plan meetings for Resident # 40 and Resident # 62 were held amongst interdisciplinary team only. On 02/15/22 at 02:20 PM, Social Work Consultant (SWC) was interviewed and stated they recognized the importance of inviting resident and/or family representative to quarterly care plan meeting after their sister facility had the survey from the NYSDOH survey at the end of [DATE]. SWC stated they started inviting resident and/or family representative to quarterly care plan meeting on 11/8/2021. SWC also stated they revised the care plan meeting policy on 1/6/2022 after the plan of correction for the sister facility was accepted by NYSDOH in [DATE]. SWC further stated they revised SW note to indicate if resident and/or family representative was invited to care plan meeting and provided the in-service to SW on 1/24/2022 for Quarterly Care Plan - Policy update. SWC stated the resident and/or family representative were invited to care plan meeting by phone call, in-person or written invitation. SWC also stated they made copy of the invitation letter and kept the copy in the file in SW department and SW documented in SW note for invitation through phone call or in-person. Corrections taken for the past non-compliance: 1. Residents/representatives were invited to quarterly care plan meeting starting 11/8/21 2. QA Department audited to ensure all the residents/representatives due for quarterly care meeting in [DATE] were invited and continue the audit in [DATE]. 3. Revised the facility policy & procedure titled Care Planning Process with effective date 1/22 to include MDS will complete a Care Plan Review Meeting note to indicate the participation and/or attendance of the resident and/or designated representative for all meetings. 4. In-service for the topic Quarterly Care Plan - Policy Update was provided to all social workers on 1/24/22. 5. SW Social Work Assessment - V4 note was revised on 1/24/2022 to add the question for care plan invitation before the care plan meeting. 415.11(c)(2)(i-iii)