Health inspection·January 16, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview, the facility failed to implement fall care planned interventions for one of two sampled Residents (Resident 1). Residents Affected - Few This failure had the potential to lead to negative outcomes for Resident 1. Findings: During a review of Resident 1's Change in Condition Evaluation form, dated 12/2/24, indicated in part on 12/2/24, Resident 1 sustained a fall. The form indicated in part Heard loud noise in [Resident 1's] room. And nurse went to check, [Resident 1] was found lying on the floor, head by the door of the bathroom. During a review of Resident 1's Care Plan undated, indicated in part, Resident 1 was At risk for further falls due to decreased physical mobility, decreased endurance and weakness. Resident 1's Care Plan further indicated an intervention chosen for Q1H (Every one hour) rounding for anticipation of needs. During a concurrent interview and record review on 1/16/25, at 3:51 p.m., with the Director of Nursing (DON 1) and the Administrator (Admin 1), both the DON 1 and the Admin 1 were asked if the facility could provide documentation indicating staff were performing Q1H rounding for anticipation of needs for Resident 1 throughout 12/24. Both the DON 1 and Admin 1 verbalized the facility was unable to provide documentation indicating this care planned intervention was carried out for the entire month of 12/24. During a review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning dated 11/18, indicated in part It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. Based on record review and interview, the facility failed to implement fall care planned interventions for one of two sampled Residents (Resident 1). This failure had the potential to lead to negative outcomes for Resident 1. Findings: Page 1 of 2 056379 056379 01/16/2025 Oxnard Manor Healthcare Center 1400 West Gonzales Road Oxnard, CA 93036

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Change in Condition Evaluation form, dated 12/2/24, indicated in part on 12/2/24, Resident 1 sustained a fall. The form indicated in part Heard loud noise in [Resident 1's] room. And nurse went to check, [Resident 1] was found lying on the floor, head by the door of the bathroom. During a review of Resident 1's Care Plan undated, indicated in part, Resident 1 was At risk for further falls due to decreased physical mobility, decreased endurance and weakness. Resident 1's Care Plan further indicated an intervention chosen for Q1H (Every one hour) rounding for anticipation of needs. During a concurrent interview and record review on 1/16/25, at 3:51 p.m., with the Director of Nursing (DON 1) and the Administrator (Admin 1), both the DON 1 and the Admin 1 were asked if the facility could provide documentation indicating staff were performing Q1H rounding for anticipation of needs for Resident 1 throughout 12/24. Both the DON 1 and Admin 1 verbalzied the facility was unable to provide documentation indicating this care planned intervention was carried out for the entire month of 12/24. During a review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning dated 11/18, indicated in part It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. 056379 Page 2 of 2