Health inspection·June 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 provide a comprehensive person-centered care plan for one of four sample residents (Resident 1) who had used and tested positive for an illicit drug (a drug that is not allowed by the law). This failure had the potential to place Resident 1's overall health and safety at risk. Findings: During a review of Resident 1's admission Record (general demographics), the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses that included, shortness of breath, opioid use (a chronic condition that causes a person to have an uncontrollable urge to use unlawful drug), other acute and chronic respiratory failure (a condition that makes it difficult to breath on your own) and major depressive disorder a condition that affect how a person feels). A review of Resident 1's hospital records, titled, Discharge Summary page 4 of 36 indicated, Ms. [Name of Resident 1] is a 61 year with a history of stroke . and methamphetamine abuse who was brought to the Emergency Department from [NAME] Palms Skilled Nursing Facility on 02/24/25 for shortness of breath and altered mental status . On 02/27/2024 .She is to follow up with her primary care provider for management of her medical problems. During an interview on May 5, 2024, at 11:50 AM with the Licensed Vocational Nurse, when asked about Resident 1, the LVN 1 stated, We were not formerly informed about the resident's illicit drug condition. The daughter of the resident told me the mother had tested positive to illicit drug while in the hospital. During an interview on May 5, 2024, at 12:30 PM with the Director of Nursing (DON), the DON stated, We got a call from the acute hospital that the resident was returning to the facility and that she had tested positive for methamphetamine (a drug that is not allowed by the law). When asked if there was a plan of care in place to monitor resident for provide treatment, the DON stated, No we did not have a care plan. During a concurrent interview and record review on May 5, 2024, at 3:00 PM with the DON, the facility's policy and policy and procedure (P&P) titled, Behavioral Health Services dated February 2019 was reviewed. The P&P indicated, Policy Statement 1. The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care . Page 1 of 2 056024 056024 06/05/2024 Highland Palms Healthcare Center 7534 Palm Ave Highland, CA 92346

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5 . b. implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs . The DON stated, There should have been a care plan in place to monitor the resident. During a concurrent interview and record review on May 5, 2024, at 3:00 PM with the DON, the facility's policy and P&P titled, Behavioral Assessment, Intervention and Monitoring dated March 2019 was reviewed. The P&P indicated, . Policy Interpretation and Implementation .Assessment 1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder . Management 1. The interdisciplinary team (IDT) will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly . Monitoring .2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment . The DON stated, The IDT should have put in place a care plan for assessment, intervention and monitoring of the resident. 056024 Page 2 of 2