Health inspection·October 23, 2024

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 facility failed to update care plans (a plan that outlined resident goals, care needed, and support the facility staff would provide) for two out of three sampled residents (Residents 2 and 7) when Licensed Nurses (LN) did not update the care plan after Residents 2 and 7 had a fall. This had the potential for an increase in falls and injuries. Findings: A review of the facility ' s policy and procedure (P&P) titled, Fall Prevention and Management Program, revised, 8/1/14, indicated, after a resident fell, the care plan would be initiated or updated. A review of the facility ' s P&P titled, Comprehensive Person-Centered Care Planning, revised 11/1/18, indicated, Additional changes or updates to the resident ' s comprehensive care plan will be made based on the assessed needs of the resident. A review of the undated admission Record, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of dementia (memory loss), epilepsy (brain disorder that caused uncontrolled seizures [uncontrolled shaking of body]), and muscle weakness. Resident 2 was not her own responsible party (RP, decision maker). A review of resident 2 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/20/24, indicated, Resident 2 had no previous falls in the facility and required supervision when walking 10 feet or more. A review of the undated admission Record, indicated, Resident 7 was admitted to the facility on [DATE] with the diagnoses of syncope and collapse (fainted and fell), amputation (removal) of left lower leg below the knee, repeated falls, and muscle weakness. Resident 7 was not his own RP. A review of Resident 7 ' s MDS, dated [DATE], indicated, Resident 7 required the use of a walker (a frame that was held onto while walking that provided support), wheelchair, or limb prosthesis (an artificial body part, used in place of Resident 7 ' s amputated left leg) to move about the facility and required substantial assistance from staff to utilize the bathroom. The MDS indicated, Resident 7 had not had any previous falls in the facility. During an interview on 10/23/24 at 1:19 pm, LN A stated, after a resident in the facility fell, the LN was responsible to initiate an Actual Fall care plan. LN A stated, the Interdisciplinary Team Page 1 of 2 056258 056258 10/23/2024 River Valley Healthcare & Wellness Centre, LP 2490 Court Street Redding, CA 96001

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (IDT, group of facility staff with knowledge of the resident that met to discuss resident care needs and update care plans as needed) would meet and determine if the care plan needed to be revised and IDT made care plan changes as necessary. During an interview on 10/23/24 at 1:33 pm, LN C stated, after a resident fell, the LN was responsible to revise or initiate a care plan. LN C stated, LNs were required to utilize a fall packet (documentation that was required from the LN regarding the fall) and the fall packet included a check list for the LN to follow. A review of the undated document titled, Fall Incident Checklist, indicated, LN was responsible for initiating an Actual Fall care plan after a resident experienced a fall. During a concurrent interview and record review on 10/23/24 at 3:09 pm, with Director of Nursing (DON), Resident 7 ' s Post Fall Evaluation, dated 10/2/24 and care plans dated 2/8/24 through 10/23/24 was reviewed. DON stated, the Post Fall Evaluation, indicated, Resident 7 had an actual fall on 10/2/24. DON confirmed, after a resident experienced a fall, the LN was responsible for initiating an Actual Fall care plan and IDT would evaluate the care plan and make changes to the care plan if needed. DON reviewed Resident 7 ' s care plans and confirmed, there was no Actual Fall care plan present regarding Resident 7 ' s fall on 10/2/24 and stated, there should have been. During a concurrent interview and record review on 10/23/24 at 3:09 pm, with DON, Resident 2 ' s Post Fall Evaluation, dated 10/14/24, and care plans, dated 1/11/23 through 10/23/24 was reviewed. DON stated, the Post Fall Evaluation, indicated, Resident 2 had an actual fall on 10/14/24. DON stated, there was no Actual Fall care plan present and there should have been. DON reviewed Resident 2 ' s care plan titled, Moderate Fall Risk, dated 1/11/23 and stated, the LN could have updated the Moderate Fall Risk care plan and did not. 056258 Page 2 of 2