F0689

D

Failure to Implement Care Plan to Control Clutter and Maintain Safe Environment

El Monte, California Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to implement the care plan interventions to maintain a safe, clutter-free environment for a resident at risk for falls. The resident was admitted with COPD, anxiety disorder, and depression, and had minor memory impairments but intact cognitive skills and independence with ADLs and mobility. The resident’s care plan documented a risk for falls related to incontinence and a history of falls, with interventions that included providing a safe environment free from spills and clutter. A separate care plan for hoarding behavior related to anxiety and depression directed the IDT to follow up with the resident regarding hoarding and to intervene as necessary to protect the rights and safety of others. Despite these identified needs and interventions, there were no updates or changes to the care plan after its initiation.

Social services documented that the resident had been educated about how excessive clutter around the bed posed a safety hazard to both the resident and roommates, and that the resident refused offers to store belongings in an alternate location. However, from that point through the survey period, there were no additional notes in the medical record indicating ongoing assistance or encouragement to remove clutter from the room. During observation, the resident’s bed was surrounded by stacked boxes, crates, and bags filled with clothes, leaving minimal space to access the roommate’s bed. The roommate and a CNA reported that staff had difficulty assisting other residents in the room due to the clutter around the resident’s bed. This demonstrated that the facility did not carry out the care-planned interventions to maintain a safe, clutter-free environment as required by its comprehensive care plan policy.