Health inspection·August 1, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the nursing staff failed to revise a care plan for falls for one of three sampled residents (Resident 1), who was found sitting on the floor at his bedside while attempting to ambulate to the restroom. This deficient practice had the potential to place Resident 1 at risk for recurrent falls. Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (a decrease in blood flow or oxygen to the brain), urinary tract infection (bacterial infection in any part of the kidneys, bladder, or urethra), and abnormality of gait and mobility. A review of the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/4/2023, indicated Resident 1 did not have the capacity to understand and make decisions. The MDS indicated Resident 1 required extensive assistance from one staff with bed mobility, locomotion (how resident moves in and around the facility), dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 1 required extensive assistance from two staff with transfers. A review of Resident 1's care plan tilted at risk for falls related to shortness of breath, urinary tract infection, generalized weakness, hypertension (high blood pressure) and cerebrovascular accident (damage to the brain by interruption of blood supply) dated 3/19/2022, indicated staff will assist Resident 1 with toileting, before and/or after meals, at bedtime and as needed. The interventions indicated staff will anticipate and meet the resident's needs and be sure the resident's call light is within reach and encourage resident to use it. A review of a Change in Condition Evaluation form indicated Resident 1 had a fall on 7/19/2023. A review of an interdisciplinary team ([IDT] a group of healthcare professionals from complementary fields who works together to treat a residents) conference record, dated 7/19/23, indicated Resident 1 was found sitting on the floor at his bedside on 7/19/2023. The IDT conference record indicated staff to offer toileting before/after meals, at bedtime and as needed to prevent reoccurring falls. On 8/1/2023 at 2:20 p.m., during a concurrent interview and record review of Resident 1's care plan with Registered Nurse Supervisor (RNS 2), RNS 2 stated staff would also initiate, update, and revise a resident's care plan and implement the interventions required. RNS 2 stated Resident 1 did not Page 1 of 2 056014 056014 08/01/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have a revised care plan after the fall that occurred on 7/19/2023. RNS 2 stated that Resident 1's care plan for falls should have been updated and revised. RNS 2 stated the risk of not updating or revising a care plan for a resident's change of condition could result in not providing the correct care needed by the resident. On 8/1/2023 at 12:55 p.m., during an interview, the Administrator stated a care plan should be completed or revised on admission and/or as soon as possible if a resident has any change of condition. The Administrator stated Resident 1's care plan should have been updated after the fall on 7/19/2023. The Administrator the risk of not having a care plan can cause us to miss helping/treating a resident and their condition. A review of the facility's policy dated 5/2019, titled Change of Condition Reporting, indicated it is the facility's policy to document resident change of condition and response in eInteract Change of Condition UDA and in nursing progress notes, and update resident care plan, as indicated. 056014 Page 2 of 2