Health inspection·June 14, 2023

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 ensure one of five sampled resident's (Resident 1) Actual Fall care plan (CP, provides direction on the type of nursing care an individual needs that includes goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet a goal], and an evaluation plan) interventions were revised to reflect the current status of Resident 1 in accordance with the facility's policy and procedures (P&P). This failure had the potential to result with implementation of inadequate interventions for Resident 1 and a decline in Resident 1's physical well-being. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was originally admitted to the facility on [DATE] to Room A (Rm A). Resident 1 had multiple diagnoses including repeated falls, abnormalities of gait (a manner of walking or moving on foot), mobility, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness, and unsteadiness on feet. During a review of Resident 1's CP titled, Actual Fall, target date 12/5/22, the CP indicated the goal was to minimize risk of falls/injury and one of the interventions included, Place resident close to nursing station for close observation. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/9/23, the MDS indicated, Resident 1's cognitive (ability to think and process information) status was severely impaired. The MDS indicated, Resident 1 required one-person physical assistance for locomotion on unit (how resident moved between locations in his/her room and adjacent corridor on same floor). During an observation on 6/14/23, at 7:00 a.m., in the resident care area, Resident 1's room, (Rm A), was located on the west side at the end of hallway, adjacent to the activities and dining area, on the opposite end of the nursing station. During an interview on 6/14/23, at 7:15 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 stated, after every fall incident, care plans were updated and interventions that were in place were reviewed for effectiveness, reevaluated, and updated for new interventions if needed and any changes to be made. LVN 3 stated, it was important to revise care plans to prevent future falls and optimize care. Page 1 of 2 056291 056291 06/14/2023 Casa Bonita Convalescent Hospital 535 E Bonita Avenue San Dimas, CA 91773

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 6/14/23, at 8:50 a.m., with the Minimum Data Set Nurse (MDSN), Resident 1's CP titled, Actual Fall on 1/28/23, was reviewed. The CP indicated, the goal was to minimize risk of falls/injury and one of the interventions included Place resident close to nursing station for close observation. The MDSN stated, the MDSN was responsible for revising the care plan and I just missed it on that. The MDSN stated, Resident 1 was kept in Rm A since the room was suitable for her cuz she walks in the hallway, the nurses, activity always in that area. It [the intervention] should have been stated differently. During an interview on 6/14/23, at 11:03 a.m., with the MDSN, the MDSN stated, it was important for documentation to be accurate so it doesn't get confusing. During a concurrent interview and record review on 6/14/23, at 12:13 p.m., with the MDSN, the CP titled Actual Fall on 2/25/23 was reviewed. The CP indicated, the goal was to minimize risk of falls/injury through appropriate interventions and one of the interventions included Place resident close to nursing station for close observation. The MDSN stated, the intervention should have been worded, not to put close to nursing station cuz it [the intervention] was not suitable for her but keep resident in the same room [Rm A] where activity of the resident most of time happens, cuz always staff around. During a review of the facility's Daily Census (DC), dated 12/6/22, 1/29/22, 2/26/23 and 4/13/22, the DC indicated, Resident 1 was in Rm A. During a review of the facility's undated P&P titled, The Resident Care Plan, the P&P indicated, the care plan generally included Reassessment and change as needed to reflect current status. During a review of the facility's P&P titled, Charting and Documentation, revised 2017, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised March 2023, the P&P indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 056291 Page 2 of 2