Health inspection·February 5, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to follow their policy and procedure by failing to monitor one of two sampled residents (Resident 2) after a fall incident. Residents Affected - Few This deficient practice placed the resident at risk of not receiving appropriate care and services and the potential to result in undetected pain or injury after a fall incident. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 4/23/2020 with diagnoses that included polyosteoarthritis (five or more of your joints have arthritis [inflammation or swelling of one or more joints] at the same time), difficulty walking, and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/7/2024, indicated Resident 2 had severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS also indicated Resident 2 required supervision with eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 2 required moderate assistance with toileting and lower body dressing. During a concurrent interview and record review on 1/29/2024 at 1:45 p.m., with the MDS Nurse (MDSN), reviewed Resident 2's Change of Condition (COC- clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domain)/Interact Assessment form (Situation, Background, Assessment, Recommendation [SBAR- provides a framework for communication about a patient's condition]) dated 1/21/2024 at 8:30 p.m. and progress notes dated 1/21/2024 to 1/24/2024. Resident 2's COC form indicated an intervention to monitor the resident's vital signs (clinical measurements that indicate the state of a patient's essential body functions) and observe the resident. The MDSN stated that after a change of condition, monitoring should be documented in the progress notes by the assigned licensed nurses. The MDSN stated monitoring should be done every shift for 72 hours. The MDSN reviewed Resident 2's progress notes and stated that she was unable to find documented evidence of monitoring specific to Resident 2's fall incident for the following dates and shift: 1/21/2024, 11 p.m.-7 a.m. shift; 1/22/2024, 7 a.m.-3 p.m. shift; 1/22/2024, 3 p.m.-11 p.m. shift; and on 1/22/2024 11 p.m.-7 a.m. shift. The MDSN further stated monitoring residents' condition after a change in condition is important to see if there are any significant changes and if there are any significant changes, the licensed nurses will be able to communicate with the provider for further interventions. Page 1 of 2 055360 055360 02/05/2024 Oakpark Healthcare Center 9166 Tujunga Canyon Blvd Tujunga, CA 91042

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled, Falls- Clinical Protocol, reviewed date 10/25/2023, indicated the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, reviewed date 10/25/2023, indicated the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. A review of the facility's policy and procedure titled, Change in Resident's Condition or Status, reviewed date 10/25/2023, indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. 055360 Page 2 of 2