Health inspection·May 7, 2025

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and 2) participated in care plan meetings to discuss her care and discharge goals. This deficient practice had the potential to violate Resident 1 and 2's right to be an active participant in her care. Findings: a. During a review of Resident 1's admission record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (blood flow to a part of the brain is blocked that leads to tissue death) affecting right dominant side and aphasia. During a review of Resident 1's History and Physical (H&P) dated 4/5/2025, the H&P indicated Resident 1 has limited decision-making capacity. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/14/2025, the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) were mildly impaired. The MDS indicated Resident 1 was dependent on chair/bed-to-chair transfer, toilet transfer, toileting hygiene, bathing, putting on shoes, lower body (below waist) dressing, and required moderate assistance (provide less than half the effort) for eating, oral hygiene, personal hygiene, and upper body (above waist) dressing. During an interview on 5/6/2025 at 2:44p.m. at Social Service Assistant (SSA), SSA stated the family decided to take her home on 5/5/2025 SSA stated the doctor tried explaining it to FM 1, but stated she wasn't understanding and indicated if Resident 1 continued to make progress during rehabilitation, they can continue billing the insurance, but if not, they cannot continue to bill the insurance as it would be considered fraudulent SSA stated IDT meeting discusses how the resident is doing and the Social Service (SS), nursing, activities, and dietary attend the meeting. SSA stated she would document when a resident had an IDT meeting, but indicated there were no IDT meetings done for Resident 1 as they did not want to appoint one person to be in charge. SSA stated IDT meetings are important when families are not decisive and would like all the residents to have one to eliminate any confusion. Page 1 of 3 056308 056308 05/07/2025 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/6/2025 at 3:38p.m. with FM 1, FM 1 stated GACH told her sister that Resident 1 was supposed to get four to six weeks of rehabilitation service at the facility. FM 1 stated when she spoke to the doctor from the facility, she informed her Resident 1 was not progressing. FM 1 stated her understanding that Resident 1 had four to six weeks at the facility, but it has only been there for three weeks and four days. FM 1 stated since the doctor from GACH said four to six weeks, the plan was to have Resident 1 stay for six weeks and bring her home. FM 1 stated the tone the doctor used was disrespectful, she was tapping on her screen, very contentious. FM 1 stated they felt like the doctor would not treat Resident 1 with dignity and respect that she deserves. FM 1 stated she does not know regarding the first IDT meeting as it was not offered and was mentioned to her, but it could have been mentioned to her other family members that live within the vicinity. b. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including muscle wasting, spinal stenosis (condition occurs when the space in the backbone narrows), and radiculopathy (nerve root in the spine is compressed or irritated). During a review of Resident 2's H&P dated 4/22/2025, the H&P indicated Resident 2 does not have the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE] the MDS indicated Resident 2's cognitive skills were mildly impaired. The MDS indicated Resident 2 was dependent in toileting hygiene, lower body dressing, putting on footwear, required maximal assistance (provides more than half the effort) for chair/bed-to-chair transfer, toilet transfer, bathing, and required supervision for eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 1 utilized a walker and a wheelchair. During an interview on 5/6/2025 at 3:23p.m. with SSA, SSA stated she does not recall doing an IDT meeting for Resident 2 and does not see any IDT meeting documentation. SSA stated she should have had an IDT meeting and realistically, all residents should have one. During an interview on 5/6/2025 at 3:10p.m. with Director of Nursing (DON), DON stated IDT meeting is composed of several different department heads to discuss care issues, concerns, or speak with the resident or family with plans or any ongoing concerns. DON stated they need to have IDT meetings for each resident in the facility and at minimum would do it quarterly or as needed if there are any concerns that have been identified. DON stated IDT meeting is done upon admission within 14 days. DON stated if the family prefers to have the IDT meeting earlier, they will accommodate as needed. DON stated discharge planning is discussed between IDT meetings and options are given. DON stated for custodial care (non-medical assistance provided to individuals who require help with daily activities due to physical, mental, or cognitive limitations) IDT meetings are done quarterly, however for residents who require skilled needs are here for a short period of time, so they do IDT meetings within the first 14 days with an active discussion about how the residents will be discharged . DON stated if there are no IDT meetings, the plan of care would not be as cohesive as they want it to be, questions or concerns would not be addressed in a timely manner, and expectations about care would not be discussed. During a review of the facility's Policy and Procedure (P&P) titled, Interdisciplinary Team Participation, undated, the P&P indicated it is the policy of this facility to have the Social Service Department participate in the Interdisciplinary team. According to CFR §483.20(k)(2), Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest 056308 Page 2 of 3 056308 05/07/2025 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0553 benefit to the resident. Level of Harm - Minimal harm or potential for actual harm Social Service staff. participate in all IDT functions, including but not limited to: 1) MOS 3.0 Assessment Residents Affected - Few 2) Care Planning 3) Behavior Management 4) Weight Variance, if requested 5) Restraint Review 6) All-Staff in-service education 7) Rehab Meeting, if requested 8) Discharge Planning meetings 9) Bioethics 10) Quality Assurance/Utilization Review During a review of the facility's P&P titled, Resident Rights, undated, the P&P indicated residents are entitled to exercise their rights and privileges to the fullest extent possible. During a review of the facility's P&P titled, SOCIAL SERVICE DEPARTMENT ROLE & FUNCTION/Medically-related Social Services, undated, the P&P indicated life in a skilled nursing facility, even for a short stay, can present psychosocial challenges which can impact a resident's ability to attain and maintain his or her highest level of psychosocial functioning. Social Service staff support residents in a variety of ways to prevent and minimize psychosocial decline and empower residents. Social Service interventions will be documented in the resident's care plan, with accompanying documentation in the Social Service progress notes in the medical record 056308 Page 3 of 3