F0656

E

Failure to Implement and Update Person-Centered Care Plans for Anemia, Behavioral Changes, and Vision Impairment

Rosemead, California Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans for three residents with identified needs. For one resident with acquired hemolytic anemia, the care plan initiated at readmission included detailed interventions to educate the resident and caregivers about expected stool changes and to monitor, document, and report specific signs and symptoms of anemia such as pallor, fatigue, dizziness, syncope, headache, palpitations, weakness, feelings of cold, low HGB/HCT, shortness of breath on activity, sore tongue, chest pain, tinnitus, and changes in condition. The resident’s MDS showed intact cognition and active diagnoses including anemia, heart failure, HTN, and renal insufficiency. A change of condition evaluation documented abnormal vital signs and a critical lab result that led to transfer to a GACH, and the care plan was later revised to note very low HGB and HCT values. However, there was no evidence that new or updated interventions were added after the hospitalization and readmission, and interviews with the ADON and nursing staff confirmed that, although routine labs were ordered every three months, there was no documented monitoring for the physical signs and symptoms of anemia as specified in the care plan.

For a second resident with schizophrenia, depression, and auditory hallucinations, the MDS indicated moderately impaired cognition and a need for supervision or touch assistance with most cares, and it documented that the resident did not exhibit verbal behavioral symptoms directed toward others at that time. The existing care plan addressed a mood disorder with interventions to monitor and report risks of harming others, such as increased anger, labile mood, agitation, feeling threatened, or thoughts of harming someone. Progress notes from a provider visit indicated no suicidal or homicidal ideations and no violent behavior. According to an LVN, about a month after admission the resident began expressing frustration by saying "I want to hit you" to staff, which was described as a new behavior. The LVN acknowledged there was no documentation of these verbal threats in progress notes, no change in condition form was completed, and the care plan was not updated to reflect the new threatening behavior or to prompt physician notification, despite facility protocol that residents expressing intent to harm themselves or others should be placed on one-to-one supervision and have a CIC completed. A later CIC documented that during a coffee social activity the resident stood up, spoke loudly, and threw a cup of coffee toward another resident, leading to notification of the NP and transfer to a GACH on a 5150 hold.

For a third resident admitted with schizophrenia, lack of coordination, depression, and anxiety, the MDS documented intact cognition and impaired vision, with the ability to see large print but not regular print. Observations during a karaoke activity showed the resident sitting close to the TV, holding a microphone, looking down, not singing, and stating to activity staff that he wanted to hear the song but could not sing along because he could not read the words on the TV; he was also observed squinting at the TV and at staff. In interviews, the resident reported being partially blind, having difficulty seeing, wanting to participate in more activities but being unable to due to impaired vision, and feeling that staff did not listen to his concerns. Activity staff reported that the resident often complained about not being able to see well, did not participate in some activities because of poor vision, and would not attend group activities that could not accommodate his visual impairment. The activities director stated that one-to-one activity visits were needed because the resident was not actively participating in group activities and presented with low self-esteem, expressing that he felt like a burden. During a record review, the DON confirmed there was no care plan addressing the resident’s poor vision, despite the facility’s policy requiring development and implementation of a comprehensive person-centered care plan to support residents in attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.