Health inspection·October 17, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the care plan with resident-specific interventions for one of one resident reviewed for falls (Resident 1). This failure had the potential for Resident 1 to sustain further falls. Findings: According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, cognitive communication deficit (difficulty with memory and communicating needs) , and early onset Alzheimer ' s disease (a disease which affects memory). A review of Resident 1's MDS (Minimum Data Set, an assessment tool) indicated for showering, Resident 1 was dependent on staff. The MDS indicated, Dependent- Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. On 9/27/24 at 9:17 A.M., an interview was conducted with Resident 1. Resident 1 stated she had a fall in the shower, while sitting in a shower chair. Resident 1 stated Certified Nursing Assistant (CNA) 1 was standing next to her in the shower. Resident 1 stated, I think they should have two people showering me from now on so it doesn ' t happen again. On 9/27/24 at 10:07 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 1 was .alert, but can get forgetful and confused sometimes. LN 1 stated prior to the fall on 9/12/24, Resident 1 required the assistance of one staff member for activities of daily living (ADL ' s). LN 1 stated after the fall on 9/12/24, Resident 1 required two staff members for assistance. On 10/15/24 at 3:02 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the root cause of Resident 1 ' s fall was determined as .a sudden movement . by Resident 1. The DON stated interventions to prevent further falls included giving Resident 1 a bed bath instead of showers, and .educate the resident and staff . A review of Resident 1 ' s records indicated Resident 1 ' s care plan dated 9/16/24, was not updated with the interventions that addressed the root cause of the fall. Page 1 of 2 055182 055182 10/17/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0657 Level of Harm - Minimal harm or potential for actual harm A review of the facility ' s policy titled Falls Prevention dated 1/24 indicated, It is the policy of this facility to: .identify residents at risk for falls and determine appropriate interventions .Care plans will be revised and/or updated to reflect changes in intervention . Residents Affected - Few 055182 Page 2 of 2