Health inspection·August 6, 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 interview and record review, the facility failed to develop and implement a comprehensive (complete; including all or nearly all elements or aspects of something) and patient-centered care plan for one out of four sampled residents (Resident 1) following allegations of financial abuse and Resident 1 missing $ 11,000. This failure had the potential to result in Resident 1 repeatedly being placed at risk for financial abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertensive (high blood pressure) heart disease without heart failure, peripheral vascular disease (a reduced blood flow to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow and breathing problems). During a review of Resident 1's Minimum Data Set (Minimum Data Set [MDS] a standardized assessment and care screening tool), dated 4/21/2024, the MDS indicated Resident 1 was cognitively (the ability to think and reason) intact. Resident 1's MDS indicated Resident 1 required substantial/maximal assistance (staff does more than half the effort) for Activities of Daily Living (ADLs) such as sitting to lower body dressing (ability to dress and undress below the waist) showering/bathing self, and personal hygiene (ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands). During a review of Resident 1's care plan, dated August 2024, the care plan indicated Resident 1 was at risk for emotional distress or fear related to allegations of financial abuse due to suspicious activities made on his Chase Bank account. The care plan did not indicate to implement other focuses, goals, or interventions (actions) to further secure Resident 1's belongings or prevent further potential loss of money. During an interview on 8/7/2024 at 1:00 p.m. with Director of Nursing (DON), DON stated the purpose of a care plan is to create interventions for a certain problem. Care plans are to be updated as needed and when there is a new change of condition. Interventions are important to know what is to be done for the resident. During an interview on 8/12/2024 at 3:06 p.m. with MDS Coordinator, MDS Coordinator stated other departments are to also update their care plan depending on the issue. MDS Coordinator stated for any Page 1 of 2 056167 056167 08/06/2024 Centinela Skilled Nursing & Wellness Centre West 950 Flower Street Inglewood, CA 90301

F 0656 alleged abuse, it is to be expected that Nursing and Social Services department are involved. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 8/13/2024 at 10:36 a.m. with Social Services Director (SSD), Resident 1's care plan dated 8/7/2024 was reviewed. SSD stated there are other interventions that could be implemented to further secure Resident 1's belongings such as locking up their belongings or offering a trust to make sure financial theft, loss, or abuse does not happen. SSD stated Resident 1's care plan did not indicate other focuses or interventions to prevent financial abuse, theft, or loss from happening. SSD stated if interventions are not noted on the care plan, it is to be assumed that it is not being done or that other disciplines of the care team are not implementing the necessary interventions. Residents Affected - Few During a review of facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated November 2018, the P&P indicated, It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice of standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial wellbeing. The P&P also indicated, Additional changes or updates to the resident's comprehensive care plan will be based on the assessed needs of the care plan. 056167 Page 2 of 2