Health inspection·April 21, 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 and implement a resident centered Care Plan for one of three sampled residents (Resident 1) who had a diagnosis of left upper extremity (LUE) deep vein thrombosis ([DVT] a blood clot in a deep vein). The facility failed to: 1. Implement Resident 1's Responsible Party (RP) 1 request to display signage over Resident 1 ' s bed instructing nursing staff to avoid taking blood pressures in Resident 1's left upper extremity. 2. Ensure Resident 1's Care Plan included the location of Resident 1's DVT to include the LUE and specific instructions on how to assess for complications of a DVT, which included assessment of the area to detect pain, swelling, warmth, and discoloration in the affected extremity, as well as signs of pulmonary embolism ([PE] a serious condition where a blood clot or other substance obstructs an artery in the lungs, blocking blood flow and oxygen delivery, which are usually caused by a DVT) such as difficulty breathing, cough, and chest pain. These failures had the potential for Resident 1 to suffer complications from a DVT due to the staff not being aware or assessing Resident 1's DVT and placed Resident 1 at risk for PE, unnecessary hospitalizations, and/or death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and with diagnoses including atrial fibrillation (an abnormal heart rhythm), acute embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck) and thrombosis of the left upper extremity deep veins During a review of Resident 1's History and Physical (H&P) dated 3/20/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/24/2025, the MDS indicated Resident 1's cognitive skills for daily decision making were severely impaired. The MDS further indicated Resident 1 had active diagnosis of deep vein thrombosis ([DVT] a blood clot deep in a vein) during the assessment period. During a review of Resident 1's untitled Clinical Record (Care Plan section), Resident 1's Care Plans had no interventions indicating to place signage over Resident 1 ' s bed instructing nursing staff to avoid taking blood pressures in Resident 1's left upper extremity per RP 1's request nor had Page 1 of 3 055744 055744 04/21/2025 Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interventions indicating the location of Resident 1's DVT to include the LUE and specific instructions on how to assess for complications of a DVT, which included assessment of the area to detect pain, swelling, warmth, and discoloration in the affected extremity, as well as signs of pulmonary embolism such as difficulty breathing, cough, and chest pain. During an interview on 4/18/2025 at 10 a.m., RP 1 stated upon Resident 1's admission to the facility, she informed the nursing staff to place a sign over Resident 1's bed indicating not to take Resident 1's blood pressure on her left arm. RP 1 stated during her last visit, she did not see a sign over Resident 1's bed. RP 1 stated she was afraid the nursing staff will accidently take Resident 1's blood pressure on her left arm which could cause complications such as dislodging the clot. RP 1 stated she wanted the staff to respect and implement her wishes to keep Resident 1 safe. RP 1 stated I feel ignored and disrespected, I am afraid the staff will not properly assess Resident 1 for complications of a DVT. During a concurrent observation and interview on 4/21/2025, at 12 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, there was no sign above Resident 1's head indicating not to take Resident 1's blood pressure on her left arm. LVN 1 stated she was not aware nor informed that Resident 1 had a left arm DVT and of the RP 1's request to not take Resident 1's blood pressure on her left arm. LVN 1 stated taking Resident 1's blood pressure on her left arm placed Resident 1 at risk for DVT complications which include dislodgement of the clot and PE. LVN 1 stated if Resident 1 had an accurate Care Plan, she would be able to better provide resident centered care and assessments. During an interview on 4/21/2025 at 2:44. p.m., the MDS Nurse stated Resident 1's Care Plan did not include the location of Resident 1's DVT nor had interventions to include placing a sign over Resident 1's bed indicating not to take Resident 1's blood pressure on her left arm. The MDS nurse stated Resident 1's Care Plan was very generic and did not provide enough information for the nursing staff to properly care for and assess Resident 1. The MDS nurse stated Resident 1's RP request to place a sign over Resident 1's bed should be honored and implemented. During an interview on 4/21/2025 at 4:30 p.m., the Director of Nursing (DON) stated Resident 1's RP is part of the care planning process, and her request should be implemented in Resident 1's care. The DON stated failure to ensure Resident 1's Care Plan was accurate, complete, and resident centered, placed Resident 1 at risk for complications of a DVT which included PE. The DON stated Resident 1 did not receive appropriate assessments which included assessing her arm for swelling, warmth, decreased pulses and pain to her left upper arm due to the nursing staff not being aware of Resident 1's left upper arm DVT. During a review of an online article titled, Ankle Brachial Index, from the Journal of Wound, Ostomy and Continence Nursing (JWOCN), dated 2012, the article indicated applying compression with the blood pressure cuff may dislodge clot. https://web.as.uky.edu/biology/faculty/[NAME]/NSTA-2012-workshops/STEM%20cardio%20NSTA%20Workshop/ankle-bra During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 10/4/2016, the P&P indicated the resident (resident representative) has the right to be informed of and participate in, your treatment, including the right to participate in the development and implementation of your person-centered plan of care. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, revised 12/2023, the P&P indicated it is the policy of this facility that the interdisciplinary team (IDT) 055744 Page 2 of 3 055744 04/21/2025 Atlantic Memorial Healthcare Center 2750 Atlantic Avenue Long Beach, CA 90806

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The P&P further indicated the facility IDT includes but is not limited to the following professionals, attending physician, or non-physician practitioner involved in residents' care, registered nurse with responsibility for the resident, nurse aide with responsibility for the resident, member of the food and nutrition services staff, to the extent practicable, resident and or Resident representative, other appropriate staff or professionals as determined by the resident ' s needs or as requested by the resident. 055744 Page 3 of 3