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F0655
D

Failure to Initiate Timely Activities Care Plan for New Admission

El Cajon, California Survey Completed on 04-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to initiate an initial activities care plan within 48 hours for a newly admitted resident with a history of depression and severe cognitive deficits. The resident was admitted with significant communication challenges, being non-verbal and only oriented to person, and was observed to be withdrawn, frowning, and teary-eyed during multiple visits. Staff interviews revealed that the activities care plan was not started until three days after admission, despite facility policy requiring a baseline care plan within 48 hours. The Activities Assistant responsible for the care plan acknowledged the delay and stated that the resident was not evaluated until after the required timeframe, resulting in the resident remaining in bed without engagement in activities. Further interviews with the Activities Director and DON confirmed that the baseline care plan should have included communication and activity preferences to support the resident's psychosocial well-being. The Activities Director noted that if the resident was unable to verbalize preferences, the team should have communicated with the family to update the care plan accordingly. The delay in initiating the activities care plan meant that the resident's immediate needs for engagement and emotional support were not met as required by facility policy.

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