Health inspection·February 6, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a person-centered care plan was updated for one of three residents (Resident 1) reviewed with osteoporosis (bone disease; weak, brittle bones). This failure had the potential to miscommunicate care related to Resident 1 ' s health and safety when providing care, assistance, and repositioning for Resident 1. Residents Affected - Few Findings: A record review of Resident 1's face sheet (contains demographic information) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a serious health condition; difficulty breathing). A record review of Resident 1's Minimum Data Set (MDS; nursing assessment tool), section B0100, dated 11/14/23, indicated .comatose . persistent vegetative state /no discernible consciousness (individual does not show signs of awareness). This section was coded as yes. A record review of Resident 1's portable chest x-ray, signed by the medical doctor (MD), dated 1/5/23, indicated .Probable small bilateral pleural effusions (build-up of fluid in the tissues that line the lungs and chest). Bones are osteopenia (condition that occurs when the body does not make new bone) . A record review of Resident 1's x-ray of the left toe, signed by the MD, dated 8/3/23, indicated .osteopenia and flexion deformity of the toes . A record review of Resident 1's document titled Physician Progress Note, dated 1/15/24, indicated .The patient's left humerus fracture was most likely related [to] staff moving his left arm while turning, dressing, shifting in bed in combination with osteoporosis . An interview was conducted on 1/22/24 at 11:59 A.M. with CNA (certified nursing assistant) 3, in the conference room. CNA 3 stated that he worked with Resident 1 on 1/15/24, the morning of when the fracture was first discovered. CNA 3 stated that Resident 1 required two-person assistance with transfers, repositioning, and all care. CNA 3 stated Resident 1 was bed-bound (no longer able to move easily; confined to a bed). An interview was conducted on 1/22/24 at 12:21 P.M. with CNA 4, in the conference room. CNA 4 stated that Resident 1 used to transfer to a wheelchair with a Hoyer lift (mechanical lift that assisted with resident transfers) but stated that he has not seen Resident 1 out of bed, as of date. CNA 4 stated that after the incident with Resident 1's left arm fracture, that an in-service Page 1 of 2 555301 555301 02/06/2024 The Villas at Poway 15615 Pomerado Rd Poway, CA 92064

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (education/training) was conducted by the rehabilitation (rehab) team. CNA 4 stated that if he was not familiar with Resident 1's care, that he would seek the information from the licensed nurses (LN) to provide safe care. A concurrent interview and record review of Resident 1's medical record was conducted on 1/22/24 at 2:10 P.M., with the MDS nurse (MDS). The MDS nurse confirmed Resident 1 ' s chest x-ray with noted osteopenia by the MD on 1/5/23. The MDS nurse stated that Resident 1 was at risk for fractures and injuries due to brittle bones associated with osteopenia. The MDS nurse stated that Resident 1's care plan did not address the risks for injuries or fractures when assisting the resident with activities of daily living (ADL) care, and did not reflect rehab recommendations from the in-service. The MDS nurse stated that Resident 1's care plan should have been updated when there was a medical change, as noted in the chest x-ray dated 1/5/23, to ensure safety precautions were in place, due to osteoporosis risk factors. An interview was conducted on 1/22/24 at 2:59 P.M. with LN 1, in station C. LN 1 stated that it was important to include any new diagnosis such as osteoporosis, in a care plan. LN 1 stated that the care plan was important because it helped to communicate risk factors related to preventing injury of fragile bones and ensure safe care practices for the residents. An interview was conducted on 1/22/24 at 3:12 P.M. with LN 2, in the hallway outside of Resident 1's room. LN 2 stated it was important to know resident ' s change of conditions to help prevent injuries and provide safe care. LN 2 stated that risk factors should be personalized for Resident 1, due to Resident 1 ' s risk factors associated with osteoporosis, so that gentle care may be provided during ADL care. An interview was conducted on 1/22/24 at 4:30 P.M. with the DON, in the conference room. The DON stated it was her expectation that care plans were updated and personalized to provide a safe plan of care for Resident 1, and to help prevent future fracture injuries. Per the facility policy and procedure titled, Procedure: Care Planning and Assessment, revised 10/24/18 Rev 4 indicated .IV. Steps of procedure . F. The plan of care will be kept current during the patients stay and will be updated . if there is a medical change of condition, the members of the IDT will update and modify interventions . 555301 Page 2 of 2