Health inspection·June 11, 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 observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions when a resident was wrapping the bed remote cord around his arms for one (1) of two (2) sampled residents (Resident 1). This deficient practice has the potential to delay in the necessary care and services for Resident 1 which resulted in skin discoloration on both arms. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a progressive state of decline in mental abilities), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), depression (a mental health condition characterized by a persistent feeling of sadness and loss of interest in activities), and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/16/2025, the MDS indicated the resident is moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk and limbs, but provides less than half the effort) with eating, oral hygiene, upper body dressing and personal hygiene but required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, and lower body dressing. During a concurrent observation and interview on 6/11/2025 at 11 AM in Resident 1's room, Resident 1 was observed with purple skin discolorations on his right forearm. Resident 1 stated he got the skin discolorations because of the bed remote and because he would hit his arm on the bed side rail. During a concurrent observation and interview on 6/11/2025 at 11:14 AM in Resident 1's room, Resident 1 was observed with skin discolorations on both arms. Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 has a tendency to wrap the bed remote cord around his arm. LVN 1 also stated that LVN 1 have observed Resident 1 wrap the bed remote cord around the resident's arm. Page 1 of 2 555338 555338 06/11/2025 Brighton Care Center 1836 N. Fair Oaks Ave Pasadena, CA 91103

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/11/2025 at 11:39 AM in Resident 1's room, Certified Nursing Assistant 2 (CNA 2) stated Resident 1 tends to wrap the bed remote cord around the resident's arm. CNA 2 also stated Resident 1 started wrapping the bed remote cord around his arm on 5/3/2025. CNA 2 stated the skin discoloration is only on the resident's arms. During a concurrent record review and interview on 6/11/2025 at 11:45 AM with the Director of Nursing (DON), Resident 1's care plans dated 5/3/2023 to 6/11/2025 were reviewed. Resident 1 care plan did not indicate care plan to address Resident 1's behavior of wrapping the bed remote cord around the resident's arms. The DON stated Resident 1 does not and should have a care plan regarding the bed remote cord wrapping around the resident's arm. The DON also stated LVN 1 should have but did not make a care plan for Resident 1 when the behavior was initially noted. The DON also stated having a care plan is important because it tells the staff how to care for the resident and for the continuity of care. During a concurrent observation and interview on 6/11/2025 at 2 PM in Resident 1's room, Treatment Nurse (TN) stated Resident 1's right forearm has three (3) skin discolorations that measure 4.5centimeters (cm - unit of measure) x 2.5cm, 2cm x 2cm, and 3.5cm x 2cm. TN also stated Resident 1's left forearm has 3 skin discolorations that all measure at 1cm x 1cm. TN stated, these discoloration could have been a result of Resident 1 wrapping the bed remote cord around the resident's arms. During a review of the facility' s Policy and Procedure (P&P), revised 12/2016, the P&P indicated the care planning process will incorporate identified problem areas, incorporate risk factors associated with identified problems. The P&P also indicated areas of concern that are identified during the resident assessment will be evaluated and interventions are added to the care plan. 555338 Page 2 of 2