Federal inspectors found that Resident #2's last care plan meeting occurred in March 2025, despite facility policy requiring such meetings at least quarterly. The gap stretched until November 12, 2025, when inspectors were conducting their review.
Care plan meetings bring together the facility's interdisciplinary team, residents, and their families to discuss medications, treatments, dietary needs, and any concerns about care. The meetings are designed to ensure residents receive appropriate treatment and that families stay informed about their loved one's condition.
The facility's Director of Medicine acknowledged during an interview that "it had been a while" since Resident #2 had a care plan meeting and was unable to recall when her last meeting was held. He told inspectors that residents typically had care plan meetings "about every couple of months" and that the meetings were beneficial because "the facility would not know what was going on with the entire team if they did not have the meetings."
The facility's Director of Medicine said residents and some family members attended the meetings, with others participating by phone conference. During these sessions, staff discussed "everything from their care, medications, likes and preferences and anything that came up such as complaints or concerns and they tried to correct the issues."
A facility manager who had worked there since March 2025 told inspectors that residents should have care plan meetings quarterly. She said they had "missed one of Resident #2's meetings because she was in the hospital" but acknowledged that on the day of the inspection, November 12, they finally held a meeting with the resident and her responsible parties.
The manager explained that during meetings, each member of the interdisciplinary team discussed the resident's care and any changes, checking "if the resident was satisfied with their care." She warned that without regular care plan meetings, "residents would not get the care they needed or would not know what was going on or any changes."
The facility administrator confirmed that residents should have care plan meetings at least quarterly. She said the facility held care plan meetings every Wednesday and that she sometimes attended. During these meetings, staff discussed "the residents plan of care, risks, code status, dietary, updates, therapy services, and medications."
However, the administrator told inspectors she "was not aware that Resident #2's last care plan meeting was conducted in March 2025." She acknowledged that without regular meetings, "residents/families may not be informed on what was going on with them or not getting things addressed."
The administrator said she planned to ensure the MDS Coordinator followed the calendar to guarantee residents had care plan meetings quarterly and as needed. She identified the MDS Coordinator as responsible for conducting the meetings, which were based on MDS assessments.
Facility policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's physical, psychosocial and functional needs. The policy states that the interdisciplinary team, working with the resident and family or legal representative, develops and implements this care plan for each resident.
The policy specifically includes "the resident and the resident's legal representative (to the extent practicable)" as part of the interdisciplinary team responsible for care planning.
Federal regulations require nursing homes to hold care plan meetings at least quarterly to review and update each resident's comprehensive care plan. These meetings ensure that residents and their families remain informed about treatment decisions and can participate in care planning.
The violation represents a breakdown in the facility's care coordination system, potentially leaving Resident #2 and her family without crucial information about her treatment for most of 2025. While the facility held a meeting on the day of the inspection, the eight-month gap raises questions about how many other residents may have experienced similar lapses in required care planning meetings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Trinity Rehabilitation & Healthcare Center from 2025-11-12 including all violations, facility responses, and corrective action plans.
Additional Resources
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