Health inspection·November 3, 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 implement a comprehensive, person centered care plan for one of three sampled residents (Residents 1) when Resident care plan intervention to have auto locks to wheelchair (device used to automatically lock the wheels whenever the person stands or sits) was not implemented to prevent falls. This failure placed Resident 1 at risk for falls. Findings: During an observation on 11/3/23, at 9:35 a.m., in Resident 1's room, a wheelchair with Resident 1's name on the back of the wheelchair was next to her bed. No auto lock device was attached to the wheelchair. During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included weakness and history of falling. During a concurrent interview and record review on 11/3/23 at 9:44 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Care Plan (CP), dated 10/23/23 was reviewed. The CP indicated, .[Resident 1] had an unwitnessed fall on 10/21/23 with injury .Auto-locks to wheelchair . LVN 1 stated Resident 1 had a fall from her wheelchair on 10/21/23 and the auto-lock to wheelchair was a new intervention. During a concurrent observation and interview on 11/3/23 at 10:39 a.m. with Physical Therapy Assistant (PTA) in Resident 1's room. PTA stated Resident 1's wheelchair did not have the auto-lock installed on her wheelchair. During a review of Resident 1's Interdisciplinary Team Note (IDT) , dated 10/23/23, the IDT indicated, .IDT Recommendations .Auto-lock brakes to wheelchair . During a concurrent interview and record review on 11/3/23, at 10:45 a.m., with the Director of Nursing (DON), the facility policy titled Falls and Fall Risk, Managing undated was reviewed. The policy indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055410 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brighton Post Acute 361 E. Grangeville Blvd Hanford, CA 93230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)