Health inspection·October 17, 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 interview and record review, the facility failed to ensure one resident ' s (Resident 1) written care plan for transfers was consistently implemented. Resident 1 had an unwitnessed fall while transferring into a chair. Findings: A review of the admission Record for Resident 1 reflected Resident 1 was admitted to the facility on [DATE] with diagnoses that included: unspecified dementia (a condition of decline in thinking ability and memory); diabetic neuropathy (a severe condition caused by high blood sugar, and symptoms can include sensations of pain, numbness or burning, loss of balance or weakness). On 9/20/24 an unscheduled visit was made to the facility in response to a report of Resident 1 falling and fracturing her left wrist. On 9/20/24 at 12:10 P.M. Resident 1 was interviewed in her room. Resident 1 is sitting up in bed, with a clean cast on her left wrist. Resident 1 stated her arm and cast is very awkward, and needs extra care. Resident 1 stated she was still working with therapy as much as she could, since she wanted to be independent. Resident 1 recalled the incident: (The facility) was showing a movie and I wanted to see it. I was helped to the community room by the girl who was helping me and was going to lead the exercises for us. Resident 1 stated, they tell me that I reached back and missed the arm of the chair, and the girl was distracted and didn ' t make sure I got the arm of the chair. My hand slipped off and down I went. I guess neither of us did our job. I don ' t remember the fall, just that all of a sudden, I was on the floor. On 9/20/24 at 1:10 P.M. Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated Resident 1 walked with her walker until recently. Resident 1 now needs assistance for everything except eating, and gets around in a wheelchair pushed by staff. CNA 2 stated he would see Resident 1 walk with her walker and transfer herself without problems, it seemed ok. CNA 2 stated he has access to (any) resident care plan to review for changes or updates in care. CNA 2 stated he used the information from the nurses and other CNA ' s. On 9/20/24 at 1:30 P.M. CNA 3 was interviewed. CNA 3 stated Resident 1 was always walking with someone when CNA 3 saw her. Also, staff was there to remind her to reach back when sitting, or Resident 1 would forget. CNA 3 stated, without a reminder, Resident 1 would keep both hands on the walker and sit. On 9/20/24 at 1:50 P.M. a joint interview and record review was conducted. The Director of Therapy Page 1 of 2 555806 555806 10/17/2024 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (DPT) was interviewed, and recent therapy notes (Physical Therapy Treatment Encounter Notes and Occupational Therapy Treatment Encounter Notes) dated 9/1/24 through 9/5/24, and 9/8/24 were reviewed. The DPT stated Resident 1 prior to her fall needed to be assisted by 1 person when walking and transferring for supervision, reminders, and light touching assistance, if needed, for her safety. The DPT also stated Resident 1 was not walking safe or transferring by herself, nor any other Activities of Daily Living, such as bathing, dressing, and undressing. On 9/202/24 Resident 1's record was reviewed. Resident 1's Occupational Therapy Treatment Encounter Notes dated 9/2/24 and 9/4/24 reflected that Resident 1 needed education and reminders to feel for the chair with the back of her legs, lock her walker brakes, and reach back before sitting to increase safety. On 9/20/24 the nursing note dated 9/11/24 timed, 5:59 P.M. was reviewed. The note reflected Resident 1 was found lying on the floor in the sunroom with her walker next to her. The CNA stated she walked to the sunroom with the resident before finding Resident 1 on the floor. The activities assistant stated she saw Resident 1 try to sit down and slip and fall to the floor. On 9/20/24 the Care Plan for Resident 1 was reviewed. The Focus of .Dementia reflected the staff are to provide cuing, and reorientation as needed. The Focus of .risk for falls or injury. noted prior falls on 8/10/24 and 8/12/24. On 8/13/24 the care plan was revised for staff to provide partial to maximum assistance with ADL ' s (bathing, dressing, transfers, etc.).Offer toileting every contact to resident to be able to assist and avoid the tempt [sic] of self-transferring to toilet.be at standby assist to prevent fall and injuries. The Focus of ADL self-care deficit . : Staff assistance is listed as: TRANSFER: the resident (1) requires limited assistance by (1) staff to move between surfaces. 555806 Page 2 of 2