Health inspection·December 18, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a physician's order to go out on pass (to leave the premises). This failure had the potential to compromise the resident's safey. Also for Resident 1, the facility failed to ensure a written summary of the baseline care plan (plan that includes the minimum information necessary to properly care for the resident upon admission) was given to the responsible party (RP, person designated to make decisions on behalf of the resident). This failure had the potential to compromise the resident's right to be informed of and participate in the plan of care. Residents Affected - Few Findings: 1. Review of Resident 1's medical record indicated she was admitted on [DATE] and had the diagnoses of hemiplegia (one side of the body is paralyzed), metabolic encephalopathy (a disease that affects brain function), and history of falling. Review of Resident 1's Progress Notes indicated she went out on pass on 11/1/23, 11/13/23, 11/15/23, 11/16/23, 11/20/23, 11/22/23, 11/24/23, 11/30/23, 12/4/23, 12/7/23, and 12/11/23. Review of Resident 1's physician's orders indicated she had an order, dated 10/24/23 for, Out o[n] pass on lunch time one time only until 10/24/23. There was no physician's order that indicated Resident 1 could go out on pass on any of the other dates mentioned above. During an interview and concurrent record review with licensed nurse A (LN A) on 12/14/23 at 11:15 a.m., LN A explained that in order for a resident to go out on pass, the physician has to give an order. LN A reviewed Resident 1's medical record and confirmed there was a one-time order to go out on pass on 10/24/23, but no order that indicated Resident 1 could go out on pass on any of the other dates mentioned above. 2. Review of Resident 1's medical record indicated she was admitted on [DATE] and had a RP. Review of Resident 1's Progress Notes, dated 8/8/23, indicated the facility developed a Baseline Care Plan Summary. On the bottom of the Baseline Care Plan Summary, there was a section titled signature, followed by a section titled, Relationship to Resident. Both of these sections were blank. Page 1 of 2 055800 055800 12/18/2023 Stonebrook Health and Rehabilitation 350 DE Soto Drive Los Gatos, CA 95032

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident 1's electronic and paper medical record indicated there was no documentation that indicated a copy of the Baseline Care Plan Summary was given to Resident 1's RP. During an interview and concurrent record review with LN A on 12/13/23 at 2:10 p.m., LN A confirmed that when the facility develops a Baseline Care Plan Summary, a copy should be given to the resident or RP. LN A reviewed Resident 1's Baseline Care Plan Summary and acknowledged the sections designated to obtain a signature and to specify the person's relationship to the resident were left blank. LN A further reviewed Resident 1's medical record for any documentation indicating a copy of the Basline Care Plan Summary was given to the RP. During a follow-up interview with LN A on 12/14/23 at 11:15 a.m., LN A confirmed they could not find any documentation that indicated a copy of Resident 1's Baseline Care Plan Summary was given to the RP. The facility's policy titled Care Plans - Baseline, revised 12/2016, indicated the resident and their representative will be provided a summary of the baseline care plan. 055800 Page 2 of 2