Health inspection·October 7, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, medical record review, and facility P&P review, the facility failed to provide the necessary interventions and services for two of four sampled residents (Residents 1 and 2) to prevent further decline in their ROM functions. This failure posed the risk of the decline to the residents' ROM functions. Findings: Review of the facility's P&P titled Restorative Nursing Program Guidelines dated 9/19/19, showed the RNA carries out the restorative program according on the care plan. The RNA documents the frequency of the program, the amount of time the resident spent in the activity and their tolerance to the program. In addition, the RNA completes a written weekly summary for all the residents on a Restorative Nursing Program. The Restorative Nursing Program Coordinator co-signs the weekly progress note. 1. Medical Record review of Resident 1 was initiated on 10/2/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report dated 10/2/24, showed the following physician's order dated 1/19/24: - to provide RNA services for the assisted active ROM to the bilateral lower extremities five times per week every day or as tolerated during the day shifts. - to provide RNA services for sit to stand with a front wheel walker five times per week every day or as tolerated during the day shifts. Review of the Restorative Nursing Program for July 2024 showed to provide RNA services to Resident 1 for sit to stand with a front wheel walker five times per week every day or as tolerated. The section to show the RNA services were provided to Resident 1 on 7/30/24, was blank. Review of the Restorative Nursing Program for August 2024 showed to provide RNA services to Resident1 for assisted active ROM to the bilateral lower extremities five times per week every day or as tolerated. The section to show the RNA services were provided to Resident 1 on 8/6/24, was blank. Review of the Restorative Nursing Program for September 2024 showed to provide RNA services to Resident 1 for sit to stand with a front wheel walker five times per week every day or as tolerated. The (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055206 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Healthcare Center 1209 Hemlock Way Santa Ana, CA 92707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)