F0656

D

Failure to Develop Care Plans After Changes in Condition

Stockton, California Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop comprehensive care plans following documented changes in condition for two residents. For the first resident, who had diagnoses including mild chronic kidney disease, Parkinson’s disease, and dementia, an eINTERACT Change in Condition Evaluation dated 12/20/25 documented that the resident was noted with loose, mucus-like stool. During interview and concurrent record review, a licensed nurse stated that when a resident has a change in condition, the nurse is required to complete reports and update the resident’s care plans to include the new issue. Upon review of this resident’s care plans, the nurse confirmed that no care plan had been initiated to address the mucus in the stool following the documented change in condition.

For the second resident, who had diagnoses including type 2 diabetes mellitus and benign prostatic hyperplasia, an eINTERACT Change in Condition Evaluation dated 1/2/26 documented that the resident complained of not feeling well and that a CNA had reported dark-colored urine in the urinal and hematuria. In a subsequent interview and record review, a licensed nurse stated that this constituted a change in condition and that a care plan should have been created. Review of the resident’s care plans confirmed that no care plan was created to address the hematuria and associated symptoms. In a later interview, the DON confirmed that neither resident had a care plan created for their respective changes in condition and stated that her expectation was that a care plan be created for every change in condition. The facility’s Charting and Documentation policy required documentation of changes in condition and progress toward or changes in care plan goals and objectives in the medical record.