The woman, who holds power of attorney for Resident #150 at Diplomat Healthcare, last attended a care conference in March 2025. When federal inspectors interviewed her in November, she said she had been trying unsuccessfully to reach the new Director of Social Services.
"She was behind on scheduling and conducting resident care conferences," Director of Social Services #421 told inspectors on November 13. She admitted no care conference had been held for Resident #150 and confirmed his daughter had not been included in care decisions.
The director said she wasn't aware of any missed calls from the daughter.
Resident #150 has lived at the 108-bed facility since September 2019. His medical conditions include Parkinson's disease, schizophrenia, bipolar disorder, hypothyroidism, dementia, and muscle weakness. A cognitive assessment in August revealed he scored zero points, indicating severely impaired cognition and an inability to answer basic questions.
His care plan was updated four times between May and October 2025. But none of those changes involved his family.
A second resident faced the same problem. Resident #73 arrived at Diplomat Healthcare in July with dementia, muscle weakness, high blood pressure, and impulse control issues. Like Resident #150, he scored zero on cognitive testing, unable to complete assessment questions.
Staff held an admission care conference on July 22 with his spouse and facility staff. But when inspectors reviewed his records in November, they found no evidence of additional meetings despite a care plan update in October.
The social services director told inspectors that Resident #73's spouse "was not involved in his care conferences" and was "just the emergency contact." Federal regulations require facilities to include residents and their representatives in care planning "to the extent practicable."
Director of Social Services #421 explained the facility's policy requires care conferences at admission, quarterly, and whenever a resident's condition changes significantly. These meetings should include the resident, family members or guardians, nurses, and certified nursing assistants.
The facility's own policy, dated March 20, 2025, states that care plans must include "the participation of the resident and the resident's representative(s)" whenever practicable. If family participation isn't possible, staff must document the reason in the resident's medical record.
No such documentation existed for either resident.
The inspection stemmed from a complaint filed with state regulators. Both residents affected by the violations have severely compromised cognitive abilities, making family involvement in care decisions particularly crucial.
Resident #150's care plan history shows updates on May 23, August 19, September 19, and October 14 of 2025. Each change occurred without his daughter's input, despite her role as his power of attorney and her attempts to participate in his care.
The gap between Resident #150's last care conference in March and the November inspection represents eight months without family involvement in care planning. During that period, his cognitive assessment showed he remained unable to participate in decision-making about his own care.
For Resident #73, the situation was similar but compressed into a shorter timeframe. After his July admission conference, no additional meetings occurred despite care plan changes in October.
The social services director's admission that she was "behind" on care conferences suggests the problem extended beyond these two cases. Federal inspectors reviewed care planning for five residents total and found violations affecting two of them.
Both residents require extensive daily assistance due to their dementia and other medical conditions. Resident #150's combination of Parkinson's disease and severe cognitive impairment creates complex care needs that typically require ongoing family consultation.
The facility policy acknowledges that comprehensive care planning requires an interdisciplinary team approach. But the team failed to include the most important advocates for residents who cannot speak for themselves.
Resident #150's daughter made repeated attempts to participate in her father's care. Her unreturned calls to the social services director represent a breakdown in the facility's obligation to involve families in care decisions.
The inspection occurred on November 25, 2025, following the complaint. Inspectors classified the violations as causing minimal harm with the potential for actual harm to a few residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diplomat Healthcare from 2025-11-25 including all violations, facility responses, and corrective action plans.