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F0657
D

Failure to Revise Care Plan After Inappropriate Resident Behavior

Lynwood, California Survey Completed on 09-05-2025

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 revise the care plan for a resident after an incident of inappropriate touching was observed. Specifically, a resident with intact cognitive skills and independence in most activities of daily living was noted to have touched the legs of another resident. The care plan addressing inappropriate statements and touching had previously included interventions such as increased supervision and resident education. However, after the new incident, the care plan was only noted as revised, with no new goals or interventions developed to address the recurrence of the behavior. Record review and staff interviews confirmed that the care plan was not updated with new interventions following the incident, despite facility policy requiring care plan revisions when there is a significant change in a resident's condition or behavior. The DON stated that a revision should include new interventions when previous ones are ineffective, and failure to do so results in an outdated plan of care. The facility's policy also emphasized the need for ongoing assessment and timely updates to care plans as resident conditions change.

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