Health inspection·August 5, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for one of three sampled residents This failure had the potential to place Resident 4 at increased risk for further falls and for injury from a fall. Findings During a review of the admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including epilepsy (seizures), extrapyramidal and movement disorder (involuntary movements that you cannot control), and schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior). During a review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 6/20/2024, indicated Resident 4 requires supervision with bathing, picking up objects, and walking 150 feet. During a review of Resident 4 ' s Care Plan titled for At Risk for Falls. initiated on 7/23/2024, indicated no new interventions after Resident fall on 8/1/2024. During a review of the facility ' s Incident Report, dated 8/5/2024, the Incident Report indicated Resident 4 had a witnessed fall with an abrasion (injury of the skin) noted to the back of her head on 8/1/2024. During a review of Resident 4 ' s Fall Risk Assessment, dated 7/21/2024, indicated Resident 4 was not a high risk for falls. On 8/1/2024, the Fall Risk Assessment indicated Resident 4 was a high fall risk. During a review of Resident 4 ' s Transfer Record, dated 8/1/2024 indicated Resident 4 was transferred to General Acute Care Hospital (GACH), for a fall and a small abrasion to the back of her head. During a concurrent observation and interview on 8/5/2024, at 12:15 p.m., Resident 4 was sitting up on the side of her bed with hand tremors. Resident 4 stated she fell and hit the back of her head a few days ago. Resident 4 stated she did not use her call light prior to getting out of bed and slipped and fell backwards. Page 1 of 2 055952 055952 08/05/2024 Torrance Care Center West, Inc 4333 Torrance Blvd Torrance, CA 90503

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/5/2024, at 1:10 p.m., with the Director of Nursing (DON), the DON stated Resident 4 ' s care plan did not have any new interventions after the fall. The DON stated the care plan should have new interventions in the care plan to prevent another fall. During a review of the facility ' s policy and procedure (P&P), titled Comprehensive Care Plan, (undated), the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the resident ' s comprehensive assessment. During a review of the facility ' s P&P, titled Fall Prevention Program, (undated), the P&P indicated When any resident experiences a fall, the facility will review the resident ' s care plan and update as indicated. 055952 Page 2 of 2