Health inspection·July 24, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct an accurate fall reassessment for one of seventeen residents (Resident 3), after a fall.This deficient practice had the potential for Resident 3 not to receive the proper interventions to prevent further falls and injuries. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including muscle weakness and diabetes mellitus (DM- abnormal blood sugar level), hemiplegia (paralysis on one side of the body).During a review of Resident 3's History and Physical (H&P), dated 10/17/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Fall Risk Evaluation dated 10/15/2024, the evaluation did not indicate Resident 3 had a fall in the past 3 months. The evaluation indicated Resident 3 was incontinent, had balance problems with standing/walking and required use of assistive devices (i.e. cane, walker, wheelchair). The evaluation indicated Resident 3 had a score of 12, indicating a high risk of fall. During a review of Resident 3's SBAR Communication Form ([Situation, Background, Assessment, Recommendations] form that ensures all relevant information is conveyed in a structured manner) dated 10/29/2024, the SBAR indicated Resident 3 was found sitting on the floor in the room, on his bottom touching the ground and leaning on his shoulder against the glass sliding door. During a review of Resident 3's Fall Risk evaluation dated 10/29/2024 at 5:40 p.m., the evaluation did not indicate Resident 3's fall on 10/29/2024. The fall risk evaluation score was 7, indicating Resident 3 was a medium fall risk. The evaluation did not include Resident 3's incontinence, and the use of assistive device (wheelchair).During a review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 4/19/2025, the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required set up for eating and oral hygiene. The MDS indicated Resident 3 was dependent (helper does all the effort, resident does not) for toileting hygiene and maximal assistance (helper does more than half the effort to complete the activity, helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bath, dressing, upper/lower dressing, and putting on taking off footwear. The MDS indicated Resident 3 required moderate assistance (helper does less than half the effort, helper lifts, holds or supports trunk or limbs, but provides less than half the half the effort) to roll left and right side, sit to lying, and lying to sit on side of bed. The MDS indicated Resident 3 required maximal assistance with sitting to stand, chair/bed to chair transfer, tub/shower transfer, and with walking 10 feet. During a concurrent interview and record review on 7/24/2025 at 3:00 p.m. with the MDS Nurse, the MDS Nurse stated the fall risk evaluation was not done properly and did not include Resident 3's incontinence and the resident's use of wheelchair. The MDS Nurse stated the fall risk re-evaluation score of 7 indicating medium fall risk, after the fall was incorrect. The MDS Nurse stated not having a complete and correct assessment could lead to improper care planning and interventions for Resident 3. The MDS Nurse stated, it could also Residents Affected - Few Page 1 of 3 056014 056014 07/24/2025 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0641 Level of Harm - Minimal harm or potential for actual harm lead to recurrent fall. The MDS Nurse stated the nurse (unidentified) should have completed an accurate reassessment, by determining the correct score, to determine the resident's risk of falling. During a review of the facility's Policy and Procedures (P&P) titled, Fall Management System, dated 12/2023, the P&P indicated the facility should provide each resident appropriate assessment and interventions to prevent falls and to minimize complications, if a fall occurred. Residents Affected - Few 056014 Page 2 of 3 056014 07/24/2025 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

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 interview and record review, the facility failed to develop a resident-centered plan of care after one of three sampled residents (Resident 3), had a fall.This deficient practice resulted in the facility not having a care plan to implement for the resident's safety after the fall and had the potential to cause recurrent falls.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including muscle weakness and diabetes mellitus (DM- abnormal blood sugar level), hemiplegia (paralysis on one side of the body).During a review of Resident 3's History and Physical (H&P), dated 10/17/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's SBAR Communication Form ([Situation, Background, Assessment, Recommendations] form that ensures all relevant information is conveyed in a structured manner) dated 10/29/2024, the SBAR indicated Resident 3 was found sitting on the floor in his room, on his bottom touching the ground and leaning on his shoulder against the glass sliding door.During a review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 4/19/2025, the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required set up for eating and oral hygiene. The MDS indicated Resident 3 was dependent (helper does all the effort, resident does not) for toileting hygiene and maximal assistance (helper does more than half the effort to complete the activity, helper lifts or holds trunk or limbs and provides more than half the effort) shower/bath, dressing, upper/lower dressing, and putting on taking off footwear. The MDS indicated Resident 3 required moderate assistance (helper does less than half the effort, helper lifts, holds or supports trunk or limbs, but provides less than half the half the effort) to roll left and right, sit to lying, and lying to sit on side of bed. The MDS indicated Resident 3 required maximal assistance for sitting to stand, chair/bed to chair transfer, tub/shower transfer, tub/shower transfer, and walk 10 feet.During a concurrent interview and record review on 7/24/2025 at 3:00 p.m. with the MDS Nurse, the MDS Nurse stated there was no care plan initiated for Resident 3's fall on 10/29/2024. The MDS Nurse stated the facility should have initiated a care plan with specific interventions to address Resident 3's fall. The MDS Nurse stated that not having a care plan for Resident 3 could result in a recurrent fall and could lead to injury and hospitalization.During a review of the facility's Policy and Procedures (P&P) titled, Fall Management System, dated 12/2023, the P&P indicated the facility should develop care plan interventions to prevent falls by addressing the risk factors and should consider the particular elements of the evaluation that put the resident at risk and update the care plan after a fall.During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, dated 12/2023, the P&P indicated the interdisciplinary team (IDT) should develop a comprehensive person centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 056014 Page 3 of 3