Health inspection·May 1, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the care plan intervention of bilateral floor mats. This failure had the potential to result in Resident 3 being injured if she fell. Findings: During an observation on 4/24/2024 at 9:16 a.m. in Resident 3's room, there was no fall mat on the right side of the bed. The fall mat on the left side of the bed was closest to the roommate's bed. During an interview on 4/24/2024 at 12:00 p.m. with Registered Nurse (RN1), RN1 stated fall mats are placed to minimize injury by providing a cushion. During a concurrent interview and record review on 4/24/2024 at 12:16 pm with Licensed Vocational Nurse (LVN1), LVN1 showed RES3 had a doctor's order for fall mats on both sides of the bed while in bed. LVN1 states the fall mats were ordered to catch the resident if she slides off the bed. If the resident falls without the mat in place she can hit her head and need to go to the hospital. During a review of Resident 3's change of condition assessment dated [DATE], the assessment indicated Resident 3 was found with her body half dangling from the bed. The assessment form indicated the nurse received a doctor's order for bilateral floor mats when in bed. During a review of Resident 3's care plan dated 4/15/2024, the care plan indicated Resident 3 is at risk for falls or injury. Resident 3 is high risk. The care plan indicated the facility would provide an intervention of bilateral floor mats while in bed for safety precautions. During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of muscle weakness, hemiplegia (inability to move one side of the body), and dementia (loss of memory and problem solving). During a review of Resident 3's History and Physical (H&P) dated 4/7/2024, the H&P indicated RES3 does not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 4/8/24, the MDS indicated Resident 3 is dependent on staff to transfer from bed to chair, stand, and sit at the edge of the bed. Page 1 of 2 555128 555128 05/01/2024 Downey Community Health Center 8425 Iowa Street Downey, CA 90241

F 0656 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Falling Star Program, dated 9/21/2021, the P&P indicated the facility will use floor mats on each side of the bed for residents identified as high risk for falls. Residents Affected - Few 555128 Page 2 of 2