F0656

E

Failure to Develop Person-Centered Care Plans for Behavior, Pressure Ulcer Interventions, and Treatment Refusals

Burbank, California Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans addressing specific behaviors and clinical needs for two residents. For one resident with dementia, Alzheimer’s disease, and generalized weakness, the admission record showed the resident was admitted in September 2025, and a subsequent H&P documented that the resident lacked capacity to understand and make decisions. An MDS assessment later indicated the resident could sometimes understand others and make self-understood and required supervision with toileting and showering. Progress notes from early January 2026 documented that this resident became verbally and physically restless and had an anger outburst before a shower, then became physically aggressive during the shower, yelling and spitting at a CNA. Multiple staff, including the DSD and Administrator, confirmed that the resident had spit at the CNA, and the MDS nurse stated the resident had behaviors of spitting and kicking but acknowledged there was no care plan addressing the spitting behavior.

The facility also failed to develop a care plan for another resident’s use of a wedge pillow and for that resident’s refusal of repositioning. During observation in early February 2026, a wedge pillow was seen on the resident’s left side in the room. The treatment nurse explained that the wedge pillow was used to keep the resident’s sacral area off the bed to prevent worsening of a pressure ulcer, but confirmed there was no care plan for the use of the wedge pillow. The MDS nurse and RN 1 both reviewed the care plans and stated there was no care plan for the wedge pillow, and the MDS nurse stated there should be a care plan for its use because it guides nurses on how to care for the resident. The RN supervisor stated that interventions provided to address the resident’s pressure ulcer should have a care plan, and that without a care plan, nurses would not be able to evaluate if the intervention was effective and it could possibly cause worsening of the pressure ulcer.

In addition, the same resident was described by the treatment nurse as noncompliant with repositioning, and other staff confirmed ongoing refusals. The MDS nurse stated there was no care plan developed for the resident’s refusal to be repositioned and that a care plan helps minimize further decline or prevent worsening of pressure ulcers, and that without such a care plan the resident’s wound can worsen. An LVN reported that CNAs had informed her of the resident’s refusal to be repositioned; she spoke with the resident, who continued to refuse, but she did not develop a care plan and did not report the noncompliance to an RN, stating that RNs develop care plans. The LVN stated a care plan should have been developed and that without a care plan for refusal of repositioning, the resident’s wound could worsen. The RN supervisor similarly stated that a care plan should have been developed to address the resident’s refusal of repositioning to ensure resident rights for refusal were followed and to prevent worsening of the pressure ulcer. Facility policies on behavioral assessment, pressure ulcer prevention, wound care, and comprehensive person-centered care plans all required assessment of new behaviors, individualized interventions, documentation of refusals, and development and revision of care plans with measurable objectives and timeframes, which were not followed in these instances.