Health inspection·June 25, 2025

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 comprehensive, resident-centered care plan for one of three residents (Resident 1), who had a physician's order for fluid restriction (the amount of water the resident can drink in a day). This failure had the potential to result in Resident 1 not receiving the care and services the physician had ordered and placed the resident at risk to worsening clinical condition. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1 had a history of edema (swelling, abnormal accumulation of fluid in body tissues), chronic heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and chronic kidney disease (kidneys malfunctioning over a prolonged period, sometimes resulting in fluid retention). The admission Record indicated Resident 1 was discharged on 5/14/2025. During a review of Resident 1's History and Physical (H&P), dated 5/6/2025, the H&P indicated Resident 1 was able to understand and make medical decisions. During a review of Resident 1's Physician Orders, dated 5/6/2025, the Physician Orders indicated fluid restriction of 1.5 liters (L - metric unit of measurement, for liquids) per 24 hours. During a review of Resident 1's Physician Orders, dated 5/8/2025, the Physician Orders indicated fluid restriction of 1500 milliliters (ml, a unit of measurement) a day, indicating the following: for dietary= 1,020 ml/ day (breakfast-420 ml; lunch= 240 ml; dinner= 360 ml). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/11/2025, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and or contact guard assistance to complete the activity) to eat (the ability to bring and/or liquid to the mouth and swallow food and/or liquid). During a review of Resident 1's Change of Condition Evaluation (COC), dated 5/11/2025 at 3:34 p.m., the COC indicated Resident 1 was observed with peripheral (referring to arms and legs) edema, abnormal lung sounds, weight gain of three pounds, and vesicles (small, fluid-filled sacs) on the skin of the right and left lower legs. Page 1 of 2 056220 056220 06/25/2025 Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Physician Orders, dated 5/12/2025, the Physician Orders indicated Resident 1's fluid restriction was reduced to 1 Liter of fluids per day. The Physician Orders indicated Resident 1 was ordered to have a condom catheter (external urine collection device) for intake and output (I&O - monitoring of fluids moving in and out of the body). During a review of Resident 1's COC, dated 5/14/2025, the COC indicated Resident 1 developed respiratory distress and severe back pain. The COC indicated Resident 1 was breathing at 30 breaths per minute (normal breathing rate is 12-20 breaths per minute) with an oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage. Normal range is 95-100%) of 89%. The COC indicated 911 (emergency services) was notified and Resident 1 was transferred to the hospital via 911 due to respiratory distress. During a concurrent interview and record review on 6/16/2025 at 3:48 p.m. with Registered Nurse (RN 1), Resident 1's Physician Orders dated 5/6/2025 and 5/12/2025, all active and revised care plans were reviewed. RN 1 stated the Physician Orders indicated Resident 1's fluid restriction was decreased from 1.5 L on 5/6/2025 to 1 L on 5/12/2025. RN 1 stated there was no care plan for the fluid restrictions. RN 1 stated a care plan should have been created to provide safe care to Resident 1. RN 1 stated Resident 1 was at risk of not adhering to his fluid restrictions and was at risk of being hospitalized for fluid overload and respiratory distress if the fluid restriction was not followed. During a concurrent interview and record review on 6/25/2025 at 10:40 a.m. with the Licensed Vocational Nurse (LVN 1), Resident 1's active and revised care plans, and the facility's P&P titled Care Plans, Comprehensive, Person-Centered dated 3/2022, were reviewed. LVN 1 stated Resident 1's physician-ordered condom catheter should have been care planned to ensure Resident 1 had a condom catheter applied, education, and monitoring. During a concurrent interview and record review on 6/25/2025 at 2:45 p.m. with the Director of Nursing (DON), Resident 1's COC dated 5/11/2025, Physician Orders for 5/2025, active and revised care plans, and the facility's P&P titled Care Plans, Comprehensive, Person-Centered dated 3/2022, were reviewed. The DON stated the P&P indicated Resident 1's care plan should have been created and updated to address the Resident 1's care need. The DON stated the physician orders indicated Resident 1 should have a condom catheter and 1 L fluid restriction. The DON stated the facility did not create a care plan for Resident 1's fluid restriction nor a care plan revised to address Resident 1's new symptom (peripheral edema, abnormal lung sounds, weight gain of three pounds, and vesicles on the skin of the right and left lower legs, respiratory distress and severe back pain) and orders from 5/11/2025 and 5/12/2025. The DON stated other Resident 1's care plan were not specific and resident centered. During an interview on 6/26/2025 at 4:30 p.m. with the DON, the DON stated Resident 1 had no additional care plans existed. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P indicated every resident must have person-centered care plans that include measurable objectives and timetables to meet a resident's physical and functional needs. The P&P indicated care plans must describe all services that are to be furnished to attain and maintain the resident's highest practicable well-being. The P&P indicated assessments must be revised as information about the residents and the residents' conditions change. 056220 Page 2 of 2