Health inspection·May 22, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 comprehensive person-centered care plans (CP) with regard to the Restorative Nursing Assistant (RNA- provides support and assistance to patients in their recovery and maintenance of physical function) program for fourteen sampled residents (Resident 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16). These failures increased the potential for Residents 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16 to not receive treatment and care according to their needs. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted on [DATE] with diagnoses including, Acute Chronic Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in your body), Amyotrophic Lateral Sclerosis (ALS; a disease that weakens muscles and impacts physical function), Chronic Obstructive Pulmonary Disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), among others. During a review of Resident 1's CP initiated on 02/13/2024, the CP indicated, Resident 1 is on a RNA program for Assisted Active Range of Motion (AAROM) bilateral upper extremities/lower extremities (BUE/LE) to maintain Range of Motion (ROM), and muscle strength. Interventions included, medications in the form of Baclofen (a muscle relaxant), back and forth (sic ambulation with wheelchair) in the hallway for one week, provide RNA as ordered three times a week for AAROM BUE/LE to residence tolerance to maintain ROM and muscle strength, monitor resident's comfort and progress, monitor tolerance, and RNA weekly summary. During an interview on 05/22/2024 at 10:43 a.m. with Resident 1, Resident 1 stated RNA exercises have not been provided since the RNA went on vacation. During a review of Resident 1's Attending Physician (AMD orders), dated 02/09/2024 and 04/10/2024 the AMD order indicated in part, RNA order 3 times a week for AAROM BUE/LE to residence tolerance to maintain ROM and muscle strength, and RNA Program every day 3 times a week for AAROM BUE/LE and propel self in wheelchair as tolerated to maintain ROM and muscle strength. During a review of Resident 1's RNA Flow Sheet, the RNA Flow Sheet indicated, there was no evidence of documentation that RNA was provided for the dates of 05/09/2024 to 05/21/2024. (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 4 Event ID: 555066 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 555066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fillmore, LLC 118 B Street Fillmore, CA 93015 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)