Health inspection·May 20, 2025

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 record review, the facility failed to develop an individualized care plan for one of three sampled residents (Residents 1) after Resident 1 had a change of condition, exhibited behavior of kneeling and placing self on floor, and was a high risk of falls. This failure had the potential to result in Residents 1's needs not being met, unidentified interventions and falls for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (a brain disorder caused by problems in the body's chemistry, leading to changes in brain function) fracture (broken bone) of the right ulna (long bone in the forearm) and unsteadiness on feet. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 1 had severe (serious) cognitive impairment (problems with the ability to think, learn, use judgement, and make decisions). The MDS indicated Resident 1 was dependent (staff does all the effort) for Activities of Daily Living (ADLs) such as showering/bathing self and toileting hygiene. During a review of Resident 1's fall risk assessment dated [DATE], the fall risk assessment indicated Resident 1 was a high fall risk for falls. During a review of Resident 1's care plan dated 4/23/2025, the care plan indicated Resident 1 was at risk for falls related to medication use, incontinence (unable to voluntarily control urination or defecation), impaired physical function and cognition and disease process. The care plan interventions indicated to anticipate and meet the resident's needs. The care plan did not specify the type of supervision or monitoring Resident 1 needed. During a review of Resident 1's SBAR (Situation, Background Assessment, Recommendation- a communication tool used by healthcare workers when there is a change in condition among the residents) dated 4/24/2025, the SBAR indicated Resident 1 had episodes of placing self on floor. The change of condition also indicated to monitor Resident 1's behaviors. During a review of Resident 1's care plan dated 4/24/2025, the care plan indicated Resident 1 had episodes of kneeling/placing self on the floor. The care plan goal indicated Resident 1 would be free Page 1 of 2 555112 555112 05/20/2025 El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from future falls and complications due to a fall for 72 hours. The care plan interventions indicated frequent visual monitoring and place the resident close to the nursing station for closer supervision. The care plan did not indicate a how often frequent visual monitoring should be done for Resident 1. During an interview on 5/20/2025 at 1:51 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was confused most of the time and would take his left leg and put himself on the floor and a staff member (unnamed) was assigned to perform 1:1 monitoring (one staff/caregiver provides constant monitoring for resident) of the resident on 4/24/2025. During an interview on 5/20/2025 at 2:19 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had to monitor Resident 1 had the nurse's station during her shift to ensure Resident 1 did not fall. During a concurrent interviews and record reviews on 5/21/2025 at 10:14 a.m. and 5/21/2025 at 2:52 p.m., with the Director of Nursing (DON), Resident 1's care plan dated 4/24/2025 was reviewed. The DON stated resident care plans were created to address a resident's identified problems and should be specific to the resident. The DON stated the intervention for frequent visual monitoring did not identify a specific time frame of how often Resident 1 should be monitored. The DON stated residents should be monitored at least every two hours and Resident 1 needed more frequent monitoring due to the resident's behavior. During a review of facility's policy and procedure (P&P) titled, Nursing Manual – Care Plan, dated 3/1/2014, the P&P indicated, It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that fits 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 psychological well-being. 555112 Page 2 of 2