Health inspection·August 20, 2024

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. Based on interview and record review, the facility failed to develop and implement a care plan for two of two sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to have unmet care needs. Findings: a. During a review of Resident 1 ' s S (Situation) B (Background) A (Appearance) R (Review and Notify) (SBAR), dated 8/9/24, the SBAR indicated, Writer was called to residents room by CNA (Certified Nursing Assistant), writer walked in and found resident sitting on the floor back up against the bed on the right side of bed, legs crossed. During a review of Resident 1 ' s Care Plan (CP), dated 8/9/24, the CP indicated, Resident had an unwitnessed fall and is at risk for change in neurological status, fear or falls.Interventions.Medication regiment review as indicated.Evaluation of medications for side effects that may increase fall risk. During a concurrent interview and record review on 8/20/24 at 10:47 a.m. with Director of Nursing (DON), Resident 1 ' s clinical record was reviewed. DON was unable to provide evidence the medication review was completed. During a review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing dated 3/2018, the P&P indicated, In conjunction with the attending physician, staff will identify and implement relevant interventions.to try to minimize serious consequences of falling. b. During a review of Resident 2 ' s SBAR dated 8/12/24, the SBAR indicated, Writer called into room by fellow nurses stating that resident had a unwitnessed fall.resident noted with bump to back of right side of head, c/o (complain of) hip pain to right hip, and skin tears x (times) 2 to right elbow and right lower extremity.MD notified and gave the following orders.cleanse skin tear to right lower leg with NS (normal saline), pat dry, apply TAO (triple antibiotic ointment), apply collagen (main protein found in skin and other connective tissues), apply dry dressing daily.cleanse skin tear to right elbow with NS, Pat dry, apply TAO, apply collagen, apply dry dressing. During a review of Resident 2 ' s CP ' s, on 8/20/24 at 10:49 a.m. with DON, Resident 2 ' s CPs were reviewed. There was no CP developed for Resident 2 ' s skin tears. DON stated there should have been a care plan developed. During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Page 1 of 2 555125 555125 08/20/2024 Linwood Meadows Care Center 4444 West Meadow Visalia, CA 93277

F 0656 Level of Harm - Minimal harm or potential for actual harm Person-Centered dated 3/22, the P&P indicated, The interdisciplinary (a group of professionals from different disciplines who work together to achieve a common goal) team should review and updates the care plan.when there has been a significant change in the resident ' s condition. Residents Affected - Few 555125 Page 2 of 2