Health inspection·March 21, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. 3. A review of Resident #89's admission Record revealed the facility admitted the resident on 10/31/2023. Per the admission Record, Resident #89 was their own responsible party. Residents Affected - Few A review of Resident #89's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/06/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. In an interview on 03/20/2024 at 3:25 PM, Resident #89 stated no one from the facility had talked with them about advance directives. In an interview on 03/21/2024 at 8:13 AM, the Director of Nursing stated she did not have much detail about advance directives. In an interview on 03/21/2024 at 8:58 AM, the Administrator stated advance directives should be discussed during the admission progress. Based on record reviews, review of the facility policy, and interviews, the facility failed to ensure there was documented evidence to indicate advance directives were discussed during the admission process for 3 (Residents #11, #31, and #89) of 5 sampled residents reviewed for advance directives. Findings included: A review of the facility policy titled, Advance Directives, reviewed in December 2020, revealed, Long Term Care Residents 1. During the admitting process the patient/family and/or surrogate decision maker will be asked if he/she has executed an Advance Healthcare Directive. This information will be recorded on the admission form and forwarded to Social Services. 1. A review of Resident #11's admission Record revealed the facility admitted to the resident on 06/15/2016. Per the admission Record, Resident #11 was their own responsible party. A review of Resident #11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. In an interview on 03/19/2024 at 11:51 AM, the social services (SS) staff person stated she was responsible for offering the advance directive form to the residents and/or their responsible party and for the discussion/education of the details with the resident and/or their responsible party. 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: 056155 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 056155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakdale Nursing and Rehabilitation Center 275 South Oak Avenue Oakdale, CA 95361 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)