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F0656
D

Failure to Update Care Plan for Resident with Hoarding Behavior

Glendora, California Survey Completed on 12-30-2025

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 reevaluate and update the care plan interventions for a resident exhibiting hoarding behavior, despite ongoing issues with clutter and refusal of assistance. The resident, who had diagnoses including bilateral primary osteoarthritis of the knee, COPD, anxiety disorder, and personality disorder, was observed to have intact cognition and the capacity to make medical decisions. The resident required setup or clean-up assistance with several activities of daily living. Observations revealed significant clutter in the resident's room, including boxes, clothing, personal items, and food scattered around the bed, with the call light cord not within reach. Interviews and record reviews indicated that the Social Services Director had discussed the hazards of the clutter with the resident in early September, but there were no further documented interventions or encouragement to address the issue in the following months. Nursing notes showed that the resident refused deep cleaning and continued to decline assistance, despite being educated on proper cleaning and hygiene. The care plan for hoarding, initiated in late July and last revised in early August, included interventions such as encouraging the resident to organize belongings, offering to clean and organize, explaining risks, and assisting with expired food, but these interventions were not updated or revised after the resident's continued refusal and persistent clutter. The facility's policy required ongoing assessment and revision of care plans when desired outcomes were not met or when there was a significant change in the resident's condition. However, the care plan for this resident was not reevaluated or updated in response to the lack of progress and continued safety hazards, resulting in a deficiency related to the failure to maintain a safe and clean environment for the resident.

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