Health inspection·January 4, 2024

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. Based on interview and record review, the facility failed to ensure a comprehensive resident centered care plan was developed for one of three sampled residents (Resident 1), when Resident 1's at risk for falls care plan did not list safety measures for the resident's gait and balance problem. In addition, Resident 1's risk for altered ADLs (activities for daily living) care plan did not have the resident's specific interventions addressing the needs for assistance with ambulation. This failure had the potential to have contributed to Resident 1's recent fall and placed her at risk for more falls. Findings: A review of the admission record for Resident 1 indicated she was admitted to the facility in 2023 with diagnoses which included muscle weakness, difficulty in walking, and dementia (a chronic disorder characterized by memory loss and impaired reasoning). A review of Resident 1's 'Fall care plan,' dated 1/15/23, indicated the resident was at risk for falls related to altered mental status, visual impairment, unsteady gait, altered balance while standing and/or walking, and decreased muscle coordination. The care plan interventions included keeping the bed in lowest position, orient to new environment and keeping the call light and personal item within reach. The care plan did not contain individualized, resident centered safety measures to prevent falls. A review of Resident 1's at Risk for altered ADLs care plan revised 10/30/23, indicated the resident had a decline in functional mobility, including turning, repositioning, getting in or out of bed, walking and locomotion. The care plan had the following list of possible levels of assistance the resident might have required, including supervision, limited, extensive and maximum assistance or total dependence. However, none of these levels were selected to indicate which specific level of assistance Resident 1 required. The care plan interventions instructed staff to provide assistance with ADLs, however it did not contain interventions that were specific and consistent with Resident 1's assessment and functional level. A review of the quarterly fall risk assessment, dated 11/27/23, indicated Resident 1 was at moderate risk for falls. A review of Resident 1's MDS (Minimum Data Set, an assessment tool) dated 11/28/23, indicated she had a severe cognitive impairment. The functional abilities on the MDS indicated that Resident 1 required supervision or touching assistance when staff provided verbal cues and/or touching/steadying Page 1 of 2 055497 055497 01/04/2024 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0656 and/or contact guard assistance for resident to ambulate. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/27/23, at 10:50 a.m., Physical Therapist 1 (PT 1) stated the resident required supervision when ambulating in the hall. PT 1 stated Resident 1 had severe cognitive impairment and was not able to retain knowledge on how to use a walker or wheelchair. Residents Affected - Few During an interview on 12/27/23, at 12 p.m., Licensed Nurse 1 (LN 1) stated Resident 1's gait was unsteady and shuffling (walking by dragging feet or without lifting the feet fully from the ground). LN 1 added, When we see her walking in the hall, we hold her arm to help her walk. During a phone interview and records review on 1/3/24, at 4:10 p.m., the Director of Nursing (DON) stated Resident 1's ADLs care plan was not customized to the resident's assessment. The DON confirmed that Resident 1's risk for falls care plan interventions to prevent falls were not resident-centered and not individualized. The DON stated that Resident 1's fall risk care plan focused on environmental measures, but lacked interventions that were specific and consistent with the resident's assessment and functional level. A review of the facility's ' Care Plans, Person-Centered ' policy with last revision date of 3/2022, indicated that the comprehensive, person-centered care plan will be initiated and implemented based on the assessed needs of the resident. The policy further directed that the care plan, should include measurable objectives and timetables to meet the resident's physical .and functional needs .describe the services that are to be furnished .to assist the resident to attain or maintain that level of physical .that is possible. 055497 Page 2 of 2