Health inspection·March 11, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 2) received the appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: -Ensure Resident 1 received hand rolls (devices used to assist with finger extension [the act of straightening a finger at its joints] and prevent finger flexion contractures [a condition where one or more fingers become permanently bent in a flexed position]) in both her hands as ordered by the physician. -Ensure Resident 2 received a hand roll in her right hand as ordered by the physician. These deficient practices had the potential for Resident 1 and Resident 2 to develop worsened contractures and injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility re-admitted the resident on 1/20/2025 with diagnoses that included chronic respiratory failure (a condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period), hemiplegia (total paralysis of the arm, leg, and truck on the same side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body), cerebral infarction (stroke, loss of blood flow to a part of the brain), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the left hand, contracture of the right hand, tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to help you breathe), gastrostomy (G-Tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach), and dependence on the ventilator (a serious medical condition that occurs when a patient requires mechanical ventilation to breathe). During a review of the Physician's Order dated 1/21/2025, indicated for the Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) to don (put on) bilateral (both sides) hand rolls on at all times/or as tolerated for contracture management. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 2/21/2025, indicated the resident had severely impaired cognitive skills (never/rarely made decisions) for daily decision making. The MDS further indicated Resident 1 was dependent on help for oral hygiene, Page 1 of 3 056311 056311 03/11/2025 Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 1's Care Plan (CP) revised 2/26/2025, the care plan indicated the resident needed restorative nursing because the resident was at risk for developing contracture or a decrease in ROM. The CP indicated a goal for Resident 1 to maintain her current joint ROM. The CP further indicated interventions that included the RNA to don bilateral hand rolls on at all times/or as tolerated for contracture management. During a review of Resident 1's Restorative Nursing Assistant Record (RNAR) dated 2/1/2025-2/28/2025, the RNAR indicated on 2/1/2025, 2/6/2025, 2/7/2025, 2/13/2025, 2/15/2025, 2/18/2025, 2/21/2025, 2/23/2025, 2/27/2025, and 2/28/2025 there was no documentation bilateral hand rolls were donned for Resident 1. During a review of Resident 1's RNAR dated 3/1/2025 - 3/10/2025, the RNAR indicated on 3/4/2025 and 3/7/2025 there was no documentation bilateral hand rolls were donned for Resident 1. During a review of Resident 1's Progress Notes (PN) dated 2/1/2025 - 3/10/2025, the PN did not indicate there was documentation that the resident could not tolerate hand rolls. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 1/7/2025 with diagnoses that included chronic respiratory failure, cerebral palsy (a group of movement disorders that affect a person's ability to control their muscles, balance, and posture), contracture of other specified joint, tracheostomy, gastrostomy, intellectual disabilities (a lifelong condition that impacts a person's ability to learn and function in daily life), and dependence on supplemental oxygen. During a review of Resident 2's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition. The MDS further indicated Resident 2 was dependent on help for oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of the Physician's Order dated 1/9/2025, indicated the resident was to don right hand rolls on at all times or as tolerated while monitoring for skin breakdown and comfort. During a review of Resident 2's RNAR dated 2/1/2025-2/28/2025, the RNAR indicated on 2/1/2025, 2/13/2025, 2/15/2025, 2/21/2025, 2/23/2025, 2/27/2025, and 2/28/2025 there was no documentation that a hand roll was donned to Resident 2's right hand. During a review of Resident 2's RNAR dated 3/1/2025 - 3/10/2025, the RNAR indicated on 3/4/2025, and 3/7/2025 there was no documentation that a hand roll was donned to Resident 2's right hand. During a review of Resident 2's Progress Notes (PN) dated 2/1/2025 - 3/11/2025, the PN did not indicate there was documentation that the resident could not tolerate hand rolls. During a concurrent interview and record review on 3/11/2025 at 10:50 AM, Resident 1 and 2's physician's orders, RNAR dated 2/1/2025 - 2/28/2025, and RNAR dated 3/1/2025 - 3/10/2025 were reviewed with RNA 1. RNA 1 stated he performed RNA services for Resident 1 and Resident 2. RNA 1 stated Resident 1 and Resident 2 both had physician's orders for hand rolls; Resident 1 was to have bilateral hand 056311 Page 2 of 3 056311 03/11/2025 Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few rolls and Resident 2 was to have hand rolls in her right hand. RNA 1 stated if a resident was given hand rolls it would be documented on the RNAR. RNA 1 stated the days when there was no documentation on the RNAR means the resident did not receive hand rolls. RNA 1 stated hand rolls should be on every day 24 hours a day to prevent contractures from getting worse. During a concurrent observation and interview on 3/11/2025 at 11 AM, in Resident 2's Room, Resident 2 was observed with RNA 1 and the Interim Director of Nursing (IDON). Resident 2 was observed lying in bed on her back with pillows beneath her legs. Resident 2's right hand was observed without a hand roll. RNA 1 and the DON confirmed Resident 2 did not have a hand roll in her right hand. RNA 1 stated Resident 2 should have a hand roll in her right hand. RNA 1 stated hand rolls should be on at all times. During a concurrent observation and interview on 3/11/2025 at 11:25 AM, in Resident 1's Room, Resident 1 was observed with RNA 1. Resident 1 was observed lying in bed on her back. Resident 1's hands were observed without hand rolls. RNA 1 confirmed Resident 1 did not have hand rolls in her hands. RNA 1 stated that hand rolls were supposed to be on at all times to prevent contractures. During a concurrent interview and record review on 3/11/2025 at 2:11 PM, Resident 1 and Resident 2's physician's orders, RNAR dated 2/1/2025 - 2/28/2025, and RNAR dated 3/1/2025 - 3/10/2025 were reviewed with the IDON. The IDON confirmed Resident 1 and Resident 2 had physician's orders to don hand rolls at all times or as tolerated. The IDON confirmed during the observations of Resident 1 and Resident 2, both residents were observed without hand rolls. The IDON confirmed Resident 1 and Resident 2 had missing documentation for the donning of hand rolls on the RNARs dated 2/1/2025 - 2/28/2025 and 3/1/2025 - 3/10/2025. The IDON stated if a resident was not tolerating hand rolls it would have been documented in the nursing progress notes. The IDON further stated the hand rolls were supposed to be used to help prevent contractures from worsening. During a review of the facility's Policy & Procedure (P&P) titled, Range of Motion/Joint Mobility Management, reviewed 9/25/2024, the P&P indicated Purpose: To maintain the resident's optimal level of functioning, mental and psychosocial function to assist and achieve the resident's highest possible level of self-care, and functional independence and wellbeing. It is the policy that the Therapist will: Develop RNA program appropriate to the resident's identified needs. Develop specific measurable goals and document goals and interventions and implement on the resident's RNA care plan. Procedure: The therapist will assess the Range of Motion of each resident's extremities and document in the medical record to include range of motion with any limitations. The policy indicated the therapist will implement strategies for preventing further limitations and maintenance of the joint range of motion. The therapist will obtain a physician's order for RNA treatment (program). Implementation is guided from the assessment, reassessment and plan of care .Charge nurse is responsible to carry out the RNA orders and place the resident in the RNA program, and to initiate and maintain the Plan Of Care, to monitor the RNA personnel, and to communicate with physician and therapy service for resident ' s progress and condition .In the event when there is no RNA available, CNA and Charge Nurse are responsible to carry out the program for continuity of care. 056311 Page 3 of 3