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F0656
D

Failure to Timely Update Care Plan After Resident Grievance Against CNA

El Cajon, California Survey Completed on 12-11-2025

Penalty

Fine: $180,730
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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 a person-centered care plan in a timely manner after a resident filed a grievance requesting that a specific CNA not be assigned to her. The resident, who was cognitively intact and had the capacity to make decisions, filed a grievance stating that the CNA was too friendly and requested not to have this CNA provide her care. Despite this request, the facility did not update the resident's care plan to reflect her wishes, and the CNA continued to be assigned to her on at least two occasions after the grievance was filed. The care plan was not revised to specifically address the resident's request until several months later, and even then, it only generally noted that the resident had preferences for some CNAs over others without specifying the reason or naming the CNA in question. Interviews with facility staff, including the Medical Record Director and the DON, confirmed that the care plan was not promptly updated in response to the resident's grievance. The facility's own policy required care plans to be revised to accommodate resident needs, but this was not followed in this case.

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