Health inspection·April 22, 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 a comprehensive, person-centered care plan for one of three sampled residents (Resident 1) who had a diagnosis of osteopenia (a decrease in bone mineral density and causes bones to get weaker). This deficient practice had the potential for staff not to properly care for Resident 1 and placed the resident at risk for further injuries and fractures (broken bone). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included fracture, contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that caused the joints to shorten and become very stiff) and other specified disorders of bone density and structure of the right shoulder. During a review of Resident 1's History and Physical (H&P), dated 1/14/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 was totally dependent on staff for activities of daily living (ADLs) such as eating, oral hygiene, toileting hygiene, showering, upper body dressing, bed mobility (the ability to roll from lying on back to left and right side and return to lying on back on the bed) and transfers. During a review of Resident 1's X-ray (image of the structures inside of the body, its organs and other internal structures for diagnostic purposes) Report dated 4/24/2021, the Report indicated Resident 1 had diffused osteopenia. During a review of Resident 1's care plan titled, Diffuse Osteopenia, Risk for: Joint deformities, pain, spontaneous fracture, decline Range of Motion (ROM), dated 3/15/2025, the care plan interventions included to handle resident gently during care especially when moving, turning and repositioning the resident and to observe for joint bone pain and stiffness and notify doctor accordingly. During an interview with the Director of Nursing (DON) on 5/5/2025 at 11:08 a.m., the DON stated the care plan for osteopenia did not have the location of the osteopenia. The DON stated the purpose of the care plan was to guide the care of the residents and the care plan should have been more Page 1 of 2 555348 555348 04/22/2025 Granada Post Acute 3565 E Imperial Hwy Lynwood, CA 90262

F 0656 specific for the resident. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Residents Affected - Few 555348 Page 2 of 2