Health inspection·September 30, 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 interview and closed record review, the facility failed to ensure a care plan was followed according to the facility's policies and procedures (P&P) for one of three sampled Residents (Resident 1) when: 1. There were no documentation of neuro checks and floor mats. 2. There were missing documentation for monitoring intake and recording of every meal. These failures had the potential to adversely affect the health and safety of one resident, Resident 1, by placing Resident 1 at risk of increased malnutrition (not enough nutrients in the body) and further potential injuries from another fall. Findings: 1.During a review of Resident 1's clinical record, the admission Record (contains demographic and medical information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease (unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), cognitive communication deficits (difficulty with thinking and how someone uses language), Coronavirus Disease 2019 (COVID-19- a mild to severe respiratory illness), type 2 diabetes (high sugar level), and depression (feeling of sadness). During a closed record review on September 20, 2023, at 2:12 PM, with the Minimal Data Set Coordinator (MDS Coordinator), Resident 1's care plan (summary of a resident's specific care needs and current treatments), date initiated on February 11, 2023, indicated, .Has had an actual fall with 4 inch (unit of measurement) laceration to forehead and laceration on nose, heavy bleeding d/t poor balance, unsteady gait (walking) .interventions: .Floor mats .Monitor/document/report to MD for s/sx [signs and symptoms]: Pain, bruises, Change in mental status .Neuro-checks [ checking mental status and level of consciousness] as ordered . During a concurrent interview and closed record review on September 20, 2023, at 2:25 PM, with the MDS Coordinator, Resident 1's clinical record was reviewed and the MDS Coordinator stated she was unable to find documented evidence of Resident 1's neuro checks and floor mats and stated there should have been documentation because it was in the care plan. During a concurrent interview and closed record review on September 20, 2023, at 4:22 PM, with the Director of Nursing (DON), Resident 1's medical record was reviewed and the DON stated she was unable to find documented evidence to indicate the interdisciplinary team (IDT-team from different areas Page 1 of 3 056372 056372 09/30/2023 Brookside Healthcare Center 105 Terracina Blvd. Redlands, CA 92373

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of expertise coming together to set goals for the resident) had an investigation documented in Resident 1's medical records after the fall. The DON verified there should have been one. During a concurrent interview and record review on September 20, 2023, at 4:25 PM, with the DON, the facility's P&P titled, Fall Management System, undated, indicated, .5. The investigation will be reviewed by the Inter Disciplinary Team. Results of the investigation will be documented in the resident's medical record . The DON stated the policy was not followed. During a concurrent interview and record review on September 20, 2023, at 4:28 PM, with the DON, the facility's P&P titled, Care Planning, undated, indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents right, that includes measurable objectives and times to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . A summary of the IDT Care Plan review shall be documented in the medical records . The DON stated the P&P was not followed. 2.During a closed record review on September 20, 2023, at 3:47 PM, with the DON, Resident 1's care plan, date initiated on February 10, 2023, indicated, .Resident is at increased risk for malnutrition r/t [related to] chronic disease process of Parkinson's, Depression, Acute illness of COVID, Poor PO [mouth] intake of meals .Interventions .Monitor intake and record q [every] meal . During a concurrent interview and closed record review on September 20, 2023, at 3:49 PM, with the DON, Resident 1's Dietary- Amount Eaten, dated February 18, 2023, through March 3, 2023, had missing documentation for the following dates and times: A. February 18, 2023, for breakfast and lunch meal. B. February 19, 2023, for breakfast and lunch meal. C. February 20, 2023, for breakfast and lunch meal. D. February 21, 2023, for breakfast meal. E. February 22, 2023, for breakfast meal. F. February 24, 2023, for breakfast meal. G. February 25, 2023, for breakfast and lunch meal. H. February 26, 2023, for breakfast and lunch meal. I. February 27, 2023, for breakfast, lunch, and dinner meal. J. February 28, 2023, for breakfast meal. K. March 1, 2023, for breakfast meal. The DON verified the missing meals and stated there should not be any missing documentation of meals because the care plan indicated to monitor intake and record every meal. 056372 Page 2 of 3 056372 09/30/2023 Brookside Healthcare Center 105 Terracina Blvd. Redlands, CA 92373

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on September 20, 2023, at 4:17 PM, with the DON, the facility's P&P titled, Care Planning, undated, indicated, It is the policy of this facility that the interdisciplinary team (IDT- team from different areas of expertise coming together to set goals for the resident) shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents right, that includes measurable objectives and times to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . The DON stated the policy was not followed. 056372 Page 3 of 3