Health inspection·August 31, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plan for Resident 1 to receive a consult with psychiatric (specialist in providing mental, emotional, medical or behavioral care) services were implemented. This failure resulted in the potential for Resident 1 to have compromised psychosocial well-being and at risk of another altercation with another resident. Findings: Review of the clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others). A review of Resident 1's behavior care plan initiated on 7/11/23, by the Director of Nursing (DON), indicated Resident 1 was at risk of having psychosocial well-being problems because of an encounter with another resident. The care plan indicated an intervention for Resident 1 to have a consult with psychiatric services. A review of Resident 1's behavior care plan initiated on 7/16/23 by the DON, indicated Resident 1 had another altercation with another resident. The care plan again indicated the same intervention for Resident 1 to have consult with psychiatric services. During an interview on 7/31/23, at 2:22 p.m., with Licensed vocational nurse (LVN 1), LVN 1 stated, Resident 1 had a verbal altercation with Resident 2 on 7/11/23. LVN further stated Resident 1 had the behavior of getting verbally aggressive. During an interview on 7/31/23, at 2:55 p.m., with Social Services Director, SSD stated, Resident 1 has a behavior of picking a fight and wanted to go to anger management (class). SSD acknowledged that Resident 1 should have had the psychiatric services consultation. During an interview on 7/31/23, at 4:16 p.m., DON stated Resident 1 was not referred for psychiatric services yet. During a review of the facility's policy and procedure (P&P) titled, Care Planning-IDT Care Planning Conference, dated 2008, the P&P indicated, To assure that all residents care needs are identified through continuous assessments and that those needs are care planned with corresponding measurable Page 1 of 2 055241 055241 08/31/2023 Willow Pass Healthcare Center 3318 Willow Pass Road Concord, CA 94519

F 0656 objectives and adequate interventions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055241 Page 2 of 2