The resident entered the facility with instructions for full resuscitation — meaning medical staff should use all available life-saving measures if the person stopped breathing or their heart stopped beating. But in October, the resident changed their directive to Do Not Resuscitate.
Nobody updated the care plan.
The Director of Nursing acknowledged the oversight during a January interview with inspectors. "I see that his Care Plan was not updated," she said. "He came in as a Full Code, and he changed it in October to a DNR."
The care plan still read that the resident "has an established CPR (Full Code) order in place" months after the change. The document was created when the resident was admitted and never revised to reflect their new wishes.
Federal regulations require nursing homes to honor residents' advance directives and maintain accurate care plans that guide daily treatment decisions. When a resident's code status changes from full resuscitation to DNR, that shift fundamentally alters how staff should respond to medical emergencies.
The facility's own policy, revised just weeks before the inspection, explicitly requires updating care plans when code status changes. "Social Services and nursing must document in a progress note that code status was changed as per resident/representative request and orders were obtained," the policy states. "Code status/advanced directives care plan must be updated."
Multiple staff members told inspectors they knew about the requirement but failed to follow it.
The Licensed Practical Nurse responsible for updating care plans said the change should have happened automatically. "When the order changes we should be updating the care plan, but that didn't happen," she told inspectors. "It's discussed in morning meetings and then we update the care plans."
The Social Worker Director, who attends daily clinical meetings where advance directives are reviewed, called the oversight a simple mistake. "I recall [the resident's name]. I attend the morning clinical meetings. We look at advanced directives. If the care plan was not updated, it must have been missed."
She described a system where staff regularly discuss code status changes during clinical meetings, then update care plans accordingly. "We all look at it in the clinical meeting. It was just probably missed. Care plans are reviewed and updated through the clinical meetings."
The failure occurred despite the facility's established procedures for tracking advance directive changes. Staff hold morning clinical meetings specifically to review these issues, according to interviews with multiple employees.
The inspection, conducted in response to a complaint, revealed the documentation error affected at least one resident among the four whose care plans inspectors reviewed for accuracy.
Care plans serve as roadmaps for daily treatment, informing nurses, doctors, and other staff about each resident's medical needs and preferences. When advance directive information remains outdated, staff may not know a resident's current wishes during medical emergencies.
The resident had been clear about wanting to change from full resuscitation to DNR status. Staff received and processed the order change in October. But the care plan that guides daily decisions never reflected the resident's updated wishes.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents. The finding demonstrates how administrative failures can create gaps between residents' stated preferences and the documentation that guides their care.
The facility's policy acknowledges that both social services and nursing staff must document code status changes and ensure care plans reflect current orders. The January inspection found that system broke down, leaving outdated resuscitation instructions in place for months.
Multiple staff members recognized the error during inspector interviews, each describing the same process that should have prevented the documentation failure but didn't work in this case.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lake Montgomery Health and Rehabilitation Center from 2026-01-29 including all violations, facility responses, and corrective action plans.