Health inspection·September 21, 2023

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, medical record review, and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for one of three sampled residents (Resident 2). * Resident 2's care plan for hearing had an incorrect intervention. This failure had the potential risk of not providing the appropriate and individualized care for Resident 2. Findings: Review of the facility's P&P titled Care Plan and Care Plan Update revised 2/2022 showed the facility will assure the completion of the resident assessment process enabling the development of an individualized comprehensive care plan for the resident. Medical record review for Resident 2 was initiated on 9/20/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's History and Physical examination dated 5/5/23, showed Resident 2 had blindness and hearing loss. Review of Resident 2's MDS dated [DATE], showed Resident 2 had severely impaired vision and minimal difficultly for hearing. Review of Resident 2's plan of care dated 8/28/23, showed the facility developed a care plan problem addressing a risk for communication problem related to hearing deficits. The care plan interventions for Resident 2 included to communicate by lip reading, writing, using gestures, and sign language. On 9/21/23 at 1235 hours, an interview was conducted with Resident 2. When asked about the extent of her visual impairment, Resident 2 stated she only could see a white screen in front of her. Resident 2 stated she was unable to see shadows, people, or objects. On 9/20/23 at 1607 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON stated the care plans were to be individualized and tailored to every resident. The DON also stated the care plan intervention for Resident 2 was incorrect because Resident 2 was blind and would not be able to communicate with lip reading writing, using gestures, or sign language. The DON further stated it should be removed. 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: 055983 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 055983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802 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)