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F0656
D

Delayed Care Plan for Skin Breakdown Risk

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

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 a comprehensive care plan in a timely manner for a resident who was at risk for skin breakdown. The resident was admitted with diagnoses including right hemiplegia, hemiparesis, and muscle weakness, and was identified as being at risk for skin breakdown based on a Braden Scale assessment conducted at admission. Despite this assessment, the care plan addressing the risk for skin breakdown was not initiated until nearly a month after admission. Interviews and record reviews confirmed that interventions such as repositioning every two hours, maintaining cleanliness, and providing proper nutrition were not formally documented or tracked due to the delayed care plan. The facility's policy required that a comprehensive, person-centered care plan be developed within seven days of the required assessment, but this was not followed, resulting in a lack of timely preventative measures and monitoring for the resident.

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