Health inspection·November 20, 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 implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when staff did not implement Resident 1 ' s fall risk care plan to have Resident 1 thoroughly placed on the facility ' s Red Sneaker Program (RSP- the facility ' s fall prevention program which was characterized by a visual symbol of red sneakers placed by the resident ' s name placard outside the resident ' s room door, a symbol of red sneakers above the head of resident ' s bed and a red bracelet the resident wears). This failure placed Resident 1 at risk to experience another fall and had the potential to result in fall related injuries. Findings: During an interview on 11/20/24 at 9:35 a.m. with Director of Nursing (DON), DON stated, Resident 1 was admitted on [DATE] and had a fall in the facility on 11/17/24. DON stated, one of the interventions completed after Resident 1 ' s fall was the fall risk care plan was updated. During a concurrent observation and interview on 11/20/24 at 10:10 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 was laying in bed and was noted to have bruising to his forehead, bridge of nose and left hand. Resident 1 stated, he had fallen at home prior to admission to the skilled nursing facility (SNF) and recently had fallen at this SNF. Resident 1 stated, the most recent fall caused bleeding to his left pointer finger, forehead and nose. During an interview on 11/20/24 at 10:56 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 had a recent fall and new interventions were put into place. LVN 1 stated, Resident 1 was put on the RSP. LVN 1 stated, the RSP was for fall risk patients. LVN 1 stated, the RSP required the resident to wear a red bracelet and needed to have a red sneaker symbol next to the name placard outside the resident ' s room door. During a concurrent observation and interview on 11/20/24 at 11:30 a.m. with LVN 1 in Resident 1 ' s room, there were no red sneaker symbols noted to Resident 1 ' s room walls or next to the name placard outside Resident 1 ' s room. Resident 1 was not wearing a red bracelet. LVN 1 stated, there were no RSP indicators for Resident 1 which included the red sneaker symbols outside Resident 1 ' s room door and no red rubber bracelet on Resident 1. LVN 1 stated, Resident 1 should have had these RSP indicators in place. LVN 1 stated, Resident 1 should have had these interventions in place because he was identified as a fall risk and to prevent a future fall. Page 1 of 2 056281 056281 11/20/2024 Countryside Care Center 925 North Cornelia Fresno, CA 93706

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review with DON, Risk For Falls Assessment (RFA), dated 10/26/24, was reviewed. The RFA indicated, .Score: 13 .Resident at Risk .Total Score above 10 indicates high risk . DON stated, Resident 1 had a fall risk score of 13 on the RFA which indicated he was at a high risk of falls. During a concurrent interview and record review with DON, the Red Sneaker Program Policy (RSPP), 4/24/24, was reviewed. The RSPP indicated, Criteria for the Red Sneaker Program .Resident has had a fall in the last 90 days .Resident has a Fall Risk Assessment Score of above 10 .Common Red Sneaker Program Care Plan Implementation .Initiation of the Red Sneaker Program .Resident that are placed on the Red Sneaker Program will be identified by a Red Sneaker picture on their name plate outside of their door and above the resident ' s bed. Residents will be identified by RED band/bracelet .DON and IDT [Interdisciplinary Team] will make sure appropriate individualized CPs [Care Plans] and interventions are in place . DON stated, the RSP was for residents with a history of falls and to remind all staff that the resident was a fall risk. DON stated, a resident on the RSP should have had a sneaker symbol next to the name placard near the resident ' s room door, a sneaker symbol above the bed on the wall and also the resident wore a rubber red bracelet. DON stated, she was not sure why Resident 1 did not have any sneaker symbols above Resident 1 ' s bed on the wall, by Resident 1 ' s name placard outside the door or why he wasn ' t wearing a red bracelet. DON stated, each of the symbols and bracelet should have been in place because the RSP is the facility ' s fall prevention program. DON stated, the RSP was to prevent further falls and fall related injuries. DON stated, each of these RSP symbols and red bracelet should have been in place according to Resident 1 ' s care plan and the interventions outlined in the RSPP. During record review of Resident 1 ' s admission Record (AR- a document that provides resident contact details, a brief medical history), the AR indicated, Resident 1 had diagnoses which included .OSTEOMYELITIS OF VERTEBRA (infection of the bones in the spinal column) .MUSCLE WEAKNESS .COGNITIVE COMMUNICATION DEFICIT (altered ability to give information in an orderly and organized way) .END STAGE RENAL DISEASE (permanent condition that occurs when the kidneys are no longer able to function) . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 11/7/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 14 had no cognitive impairment. During a review of Resident 1 ' s Care Plan (CP), dated 10/26/24, the CP indicated, .I am at risk for falls and related injury d/t [due to] my generalized weakness with decreased overall strength & limited ROM [range of motion] on BUE [bilateral (both) upper extremities] & BLE [bilateral lower extremities] and this is related to my medical condition and co-morbidities. I have a history of fall prior to admit .Goal .No Falls and related injuries .Interventions .Facility Red Sneaker Program . During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, undated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . During a review of the facility ' s P&P titled, Safety and Supervision of Residents, undated, .The care team shall target interventions to reduce individual risks .ensuring that interventions are implemented . 056281 Page 2 of 2