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F0656
D

Failure to Develop Individualized COVID-19 Care Plans

Los Angeles, California Survey Completed on 08-12-2025

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 develop and implement individualized care plans for three residents who tested positive for COVID-19. Each of these residents had complex medical histories, including conditions such as hypertension, hyperlipidemia, polyarthritis, schizoaffective disorder, cerebral palsy, and transient ischemic attack. Despite documented positive COVID-19 test results and varying levels of assistance required for activities of daily living, there was no evidence in their records that care plans specific to COVID-19 infection were created. This was confirmed during interviews and record reviews with nursing staff, who acknowledged the absence of such care plans. The facility's own policy required the development of comprehensive, person-centered care plans with measurable objectives and timeframes to address residents' medical, nursing, and psychosocial needs. However, for these three residents, the care plans did not include interventions or monitoring related to their COVID-19 status. Nursing staff stated that care plans should have been created and updated to guide care and monitor health status, but this was not done for the affected residents.

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