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F0656
D

Failure to Develop Care Plan After Room Change

El Monte, 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 and implement a person-centered care plan to monitor a resident's psychosocial well-being and satisfaction following a room change. The resident, who had diagnoses including depression, anxiety disorder, and schizophrenia, was admitted with mild cognitive impairment and required varying levels of assistance with daily activities. After the resident was moved to a new room, there was no care plan created to address the resident's adjustment or to monitor their psychosocial condition, as confirmed by review of the resident's records and interviews with nursing staff and facility leadership. Interviews with the LVN, ADON, and DON all confirmed that no care plan was developed after the room change, despite facility policy requiring comprehensive, resident-centered care plans that include measurable objectives and timeframes to meet each resident's needs. The absence of a care plan was also evident in the resident's current care plan documentation, which did not address the room change or the need to monitor the resident's psychosocial status following the move.

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