Health inspection·June 20, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment for a left first toe fracture (break in bone) per physician's orders. Residents Affected - Few This deficiency had the potential for Resident 1's injury to get worse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including disorders of bone density and structure (condition where bones become weaker and more prone to fracture) and muscle wasting and atrophy (the loss of muscle mass and strength resulting in reduced physical function and mobility). During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/2/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to understand and process information) and required partial assistance (helper does less than half the effort) for personal hygiene and to walk 10 feet. During a review of Resident 1's Radiology Results Report (RRR) dated 6/6/2025, the RRR of Resident 1's left foot x-ray (test that captures images of the structures inside the body) indicated had a finding of diffuse osteopenia (condition where bone mineral density is lower than normal), with an acute fracture present at the base of the left first toe without significant displacement. During a review of Resident 1's Interdisciplinary Team Conference Record (IDTR) dated 6/9/2025, the IDTR indicated a Certified Nurse Assistant (CNA) noticed a bruise on Resident 1's left first toe and at the base of the left second toe without known cause or complaints of pain from Resident 1. The IDTR further indicated an x-ray was completed and resulted with an acute fracture of the left first toe and diffuse osteopenia. The IDTR indicated Resident 1's physician was made aware and instructed to tape the first toe to the second toe and an appointment for orthopedic (branch of medicine that deals with the musculoskeletal system) consult was scheduled for 6/13/2025 at 3:30 PM. During a review of Resident 1's Order Summary Reported (OSR) with active orders as of 6/20/2025, the OSR indicated to tape the first toe to the second toe until orthopedic consult was done. During a review of Resident 1's Progress Notes (PN) dated 6/18/2025, the PN indicated the facility received Resident 1's after visit progress note from Resident 1's orthopedic appointment scheduled 6/13/2025. The PN indicated the orthopedics' recommendation to buddy tape (the practice of bandaging an injured finger or toe to an uninjured one) or splint (medical device used to support and protect Page 1 of 2 056083 056083 06/20/2025 Woods Health Services 2600 A Street LA Verne, CA 91750

F 0684 an injured body part by immobilizing it) the left first toe fracture for four to six weeks. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 6/20/2025 at 10:47 AM with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1's left foot was observed. LVN 1 stated Resident 1's foot had discoloration on the left great toe, but it was very light and had improved since the discoloration was initially discovered. LVN 1 stated the left first toe was not currently taped to the second toe and LVN 1 did not know how many days Resident 1 had the toes taped without looking at the chart. Residents Affected - Few During an interview on 6/20/2025 at 11:20 AM with LVN 1, LVN 1 stated Resident 1's physician orders indicated to tape Resident 1's toes until the orthopedic appointment on 6/13/2025 and LVN 1 did not know if Resident 1's toes were taped after the appointment. During a concurrent interview and record review on 6/20/2025 at 1:45 PM with the Infectious Preventionist Nurse (IPN), Resident 1's orthopedic after visit notes titled, Orthopedic Clinical Encounter Summaries, (OCES) dated 6/13/2025 was reviewed. The OCES indicated a recommendation to buddy tape or splint the left great big toe fracture for four to six weeks and bear weight as tolerated. The IPN stated the nurse documented the recommendations in Resident 1's PN but did not transcribe the recommendations as a physician's order and it was not followed up afterwards. During an interview on 6/20/2025 at 2:35 PM with the Director of Nursing (DON), the DON stated there was no documentation to indicate when Resident 1's toes were taped together per physician orders. The DON stated when the nurse received the orthopedic doctor's after visit notes, the nurse should have written the orders to buddy tape or splint the first and second toe for four to six weeks. The DON stated orders should have been placed for treatment and monitoring to ensure the orthopedic doctor's recommendations were carried out and Resident 1's toes were stabilized. The DON stated Resident 1 had potential for further injury if treatment was not followed. During a review of the facility's policy and procedure (P&P) titled, Medication and Treatment Orders, dated 7/2016, the P&P indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. During a review of the facility's P&P titled, Charting and Documentation, dated 7/2017, the P&P indicated treatment or services performed is to be documented in the resident medical record. 056083 Page 2 of 2