Health inspection·January 24, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the call light was within reach for one of two sampled residents (Resident 2). This failure had the potential for Resident 2 to not receive care and assistance when needed. Residents Affected - Some Findings: Review of the facility's P&P titled Call Light Answering revised 12/2023 showed the facility is to provide the resident a means of communication with nursing staff. One procedure includes to place the call device within resident's reach before leaving room. Medical record review for Resident 2 was initiated on 1/23/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 3/22/23, showed the resident did not have the capacity to understand and make decisions. Review of Resident 2's care plan titled Communication Deficit R/T English being not her primary language and advance age dated 12/3/21, showed the interventions included to keep the call light within reach. On 1/23/24 at 0905 hours, an observation and concurrent interview with LVN 2 was conducted in Resident 2's room. Resident 2 was observed in wheelchair by the foot of the bed with the call light on the floor near the head of the bed. LVN 2 verified Resident 2's call light was on the floor and not within reach. LVN 2 stated the call light was kept off the floor to maintain the infection control. LVN 2 further stated the call light was to ensure the resident's safety and allow the resident to communicate to staff. On 1/24/24 at 0911 hours, an observation and concurrent interview with RN 1 was conducted in Resident 2's room. Resident 2 was observed seated in the wheelchair by the foot of the bed with the call light on the bed, not within the resident's reach. RN 1 verified the call light was not within reach for Resident 2. RN 1 stated the call lights needed to be within reach for the residents to call staff when needed assistance. On 1/24/24 at 1335 hours, an interview with the Administrator and DON was conducted. The Administrator and DON verified above findings. Page 1 of 3 056271 056271 01/24/2024 Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683

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 observations, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was promptly assessed and notified to the physician and responsible party after a COC was identified as per the facility's P&P. This failure had the potential for the resident to not receive adequate care and risk for adverse complications. Residents Affected - Few Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised on 5/2017 showed the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The P&P also showed prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The P&P further showed the nurse will notify the resident's Attending Physician or physician on call when there has been a(an): (a) accident or incident involving the resident; (b) discovery of injuries of an unknown source; and/or (d) significant change in the resident's physical/emotional/mental condition. Closed medical record review for Resident 1 was initiated on 1/23/24. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital on 1/13/24. Review of Resident 1's H&P examination dated 1/8/24, showed the resident did not have the capacity to understand and make decisions. Review of Resident 1's Order Summary Report dated 1/13/24, showed a physician's order for Resident 1 to be transferred to the acute care hospital via 911 for the resident's bruising and swelling to the right cheek, receiving the blood thinner medication, and lethargy with low BP. On 1/24/24 at 1057 hours, an interview and concurrent closed medical record review with LVN 1 was conducted. LVN 1 stated CNA 3 notified her of Resident 1's swelling and discoloration to the right cheek on 1/13/24 at approximately 0830 hours. LVN 1 verified she did not assess, check the vital signs, or notify the physician and family member promptly as per the facility's P&P. LVN 1 also stated she did not notify the RN supervisor (RN 2) of Resident 1's COC. LVN 1 stated, He [Resident 1] looked fine to me, so I continued with med pass because he was having breakfast and then he got a shower. LVN 1 further stated she notified RN 2 of Resident 1's COC after Family Member 1 arrived at the facility on 1/13/24 at approximately 1000 hours, and requested information on Resident 1's swelling and discoloration to the right cheek and lethargic appearance. LVN 1 acknowledged she did not follow the facility's COC P&P, but should have to ensure the resident was kept safe and health was managed properly. On 1/24/24 at 1140 hours, an interview was conducted with RN 2. RN 2 stated the facility's COC protocol included assessing the resident and notifying the physician and responsible party. RN 2 stated Resident 1's lethargy, low BP, and discoloration and swelling to the right cheek were considered a COC and the facility was to follow the COC P&P. RN 2 further verified Resident 1's BP was assessed 056271 Page 2 of 3 056271 01/24/2024 Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683

F 0684 Level of Harm - Minimal harm or potential for actual harm once Family Member 1 arrived at the facility. RN 2 stated Resident 1 was transferred to the acute care hospital via 911 due to lethargy, low BP, and swelling and discoloration to the right cheek. On 1/24/24 at 1335 hours, an interview was conducted with the Administrator and DON. The Administrator and the DON verified the above findings. Residents Affected - Few 056271 Page 3 of 3