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 (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 3 Event ID: 056372 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 056372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Healthcare Center 105 Terracina Blvd. Redlands, CA 92373 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)