Mesquite Post Acute Care

the facility care plan policy.

She stated although they discussed incidents involving residents daily in risk management the care plan revisions for Resident #1, Resident #2, and Resident #3 fell through the cracks.

The DON stated additionally they monitored care plan revisions through weekly SOC meetings that occur weekly (Wednesday) at 1:00 PM.

She stated the potential negative outcome for not revising care plan meetings was the staff may be unaware of incidents that happened or interventions that were needed.

The DON stated staff could miss resident care needs.

The DON stated she was unaware that the care plan revisions for all three incidents of aggression had not been completed.

She stated the system to monitor care plan revisions was that all residents were updated quarterly and annually.

She stated she had been trained about a couple of weeks ago and again on 09/25/25.

She stated she had been trained by her corporate management team that all incidents should be addressed by the IDT.

She stated all disciplines were involved but that the SW would address chronic issues and the clinical team would address acute issues.

She stated the MDS coordinator was responsible for care plan revisions and that they all review anything that fell under their discipline.

The DON stated she did not have an excusable reason why the care plan revisions were not completed.

During an interview on 9/25/25 at 10:21 AM the SW stated a care plan was a plan of care for each resident.

She stated it told staff what the plan of care was for each resident so that staff could provide appropriate care for each resident.

The SW stated behaviors should be care planned and revised so that all staff were aware of resident behaviors.

She stated care planning behaviors would help create interventions to help address resident behavior.

She stated care planning and revising resident behaviors would also assist with making necessary referrals that the residents may need.

The SW stated leadership, the facility aides, nurses and the entire IDT used the care plan to provide care for the residents.

The SW stated the clinical staff also received verbal instruction from the nurses about the residents' interventions and goals.

The SW stated she was familiar with the facility's care plan policy.

She stated the revised the care plan on a quarterly basis per the facility policy.

The SW stated this did not mean they would not look at the care plan before the quarter or annual because ideally, they should revise the care plan anytime an event or incident occurred.

The SW stated the potential negative outcome of not revising the care plan was that the resident may not receive appropriate care and what they need to address the situation identified.

She stated she was unaware care plan revisions had not been completed.

She stated she remember discussing the incidents of aggression involving Resident #1, Resident #2, and Resident #3 in morning meeting, b

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