Health inspection·January 24, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in range of motion (ROM) for one out of five sampled residents (Resident 5) when Resident 5's frequency for Physical Therapy Rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) were not followed. This failure had the potential for Resident 5 to experience decline in range of motion or impairment in mobility. Findings: A review of Resident 5's clinical record indicated Resident 5 was admitted May of 2024 and had diagnoses that included polyosteoarthritis (a chronic condition that causes the cartilage and bone in joints to break down in at least five joints at the same time), fusion of spine (permanently joined two or more backbone), and chronic pain syndrome (a condition that occurs when chronic pain causes other symptoms that interfere with daily life). A review of Resident 5's Minimum Data Set (MDS- a federally mandated assessment tool) Cognitive Patterns, dated 11/19/24, indicated Resident 5 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 5's MDS Functional Abilities, dated 11/19/24, indicated Resident 5 needed Partial/moderate assistance with lower body dressing and putting on/taking off footwear, and supervision or touching assistance with toilet transfer, shower transfer, and walking 10 to 50 feet. During an interview on 1/23/25 at 12:11 p.m. with Resident 5, in Resident 5's room, Resident 5 stated she was on Physical Therapy (PT) before, but she only had a few days of the therapy sessions. Resident 5 stated she needed more Physical Therapy exercises so she could improve her leg functions. During a concurrent interview and record review on 1/23/25 at 2:09 p.m. with Physical Therapist Assistant (PTA) 1, Resident 5's therapy records were reviewed. PTA 1 confirmed that Resident 5's PT certification period of 6/16/24- 7/15/24 indicated Resident 5 should have five times a week therapy for four weeks. PTA 1 then confirmed that Resident 5 only had therapy on 6/17, 6/18, 6/20, 6/21, 6/24, 6/25, 7/2, 7/4, 7/10 and had documented missed visits on 6/19, 7/3, and 7/9. PTA 1 also confirmed that Resident 5's PT certification period of 7/11/24- 8/9/24 indicated Resident 5 should have five times a week therapy for four weeks. PTA 1 then confirmed that Resident 5 only had therapy on 7/11, 7/16, 7/18, 7/23, 7/24, 7/25, 7/29, 7/30, 7/31, 8/5, 8/8, 8/9 and had documented missed visits on 7/17, and 8/1. PTA 1 further confirmed that the PT frequency on the 6/16/24- 7/15/24 and 7/11/24- 8/9/24 Page 1 of 2 056304 056304 01/24/2025 Mission Carmichael Healthcare Center 3630 Mission Avenue Carmichael, CA 95608

F 0688 Level of Harm - Minimal harm or potential for actual harm certification period were both not followed. PTA 1 stated the frequency should have been followed because there would be a risk for the resident to not improve her condition. During an interview on 1/23/25 at 4:11 p.m. with the Director of Nursing (DON), the DON stated the assessed frequency of therapy visits by the Physical Therapist should be followed. Residents Affected - Few During an interview on 1/24/25 at 2:56 p.m. with the DON, the DON stated the facility should always follow the indicated frequency of therapy visits and if the resident refuse, it should be documented. A review of the facility's policy and procedure (P&P) titled, INPATIENT REHABILITATION SERVICES, revised 3/23/16, indicated, It is the objective of the rehabilitation department to provide comprehensive and integrated therapy services to restore patients to their highest level of function. Therapist will develop an individualized plan of care upon evaluation and continuous assessment during treatment plan. A review of the facility's P&P titled, Physician Orders for Rehab Services, revised 12/19/22, indicated, The evaluating therapist must establish the therapy plan of care after completion of initial assessment. The plan of care shall include at a minimum .frequency and duration of treatment . 056304 Page 2 of 2