The Californian Pasadena Healthcare

During a concurrent interview and record review, on 8/28/2025, at 10:09 AM, with the DON and the ADON, Resident 1's care plan for risk for further falls and injuries related to (r/t) balance problem, gait abnormality (unusual pattern of walking), poor trunk control (difficulty maintaining upright posture, balance, and performing daily activities) , bowel/bladder incontinence (involuntary and unexpected passage of urine or stool), poor communication/comprehension, dated 8/10/2025 was reviewed.

The DON stated the care plan was not resident-specific and did not and should have included supervision and monitoring as an intervention to prevent Resident 1 from falling.

During a concurrent interview and record review, on 8/28/2025, at 10:50 AM, with the DON, the facility's Falling Star Program policy was reviewed.

The DON stated the Falling Star Program did not indicate what type of supervision or monitoring a resident receives once added to the program.

The DON stated both the facility's Falling Star Program and Resident 1's care plan for falls did not indicate what type of supervision and monitoring Resident 1 needed to prevent falls.

During a review of the facility's undated Policy and Procedure titled, Falling Star Program, the P&P indicated The IDT is responsible for implementing individualized interventions for each resident's fall risks.

During a review of the facility's P&P, titled, Managing Falls and Fall Risk, , revised 03/2018, the P&P indicated the following:1.

The staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. 2.

The staff, with the input of the attending physician, will implement a Resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

During a review of the facility's P&P, titled, Safety and Assistance of Residents, revised 02/2021, the P&P indicated the following:1.

Our facility strives to make the environment as free from accident hazards as possible.

Our residents' safety and needs to prevent accidents are facility-wide priorities.2.

Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.3.

The care team shall target interventions to reduce individual risks related to hazards in the environment, including assisting the residents as needed and assisting on any assistive devices.

During a review of the facility's P&P, titled, Care Plans, Comprehensive Person-Centered, undated, the P&P indicated the following:1. A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 2.

The comprehensive, person-centered care plan describes services that are to be furnished to attain or maintain the Resident's highest practicable physical, mental, psychosocial well-being.

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