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
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
056258
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056258
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Valley Healthcare & Wellness Centre, LP
2490 Court Street
Redding, CA 96001
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056258
If continuation sheet
Page 2 of 2
