Health inspection·August 29, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the resident's responsible party (RP) 1 was informed about dental treatment recommendations for one of two sampled residents (Resident 85). This deficient practice violated the resident's and RP 1's right to make an informed decision regarding dental treatment. Residents Affected - Few Findings: A review of Resident 85's admission Record indicated the facility admitted the resident on 4/17/2020 with diagnoses including Type II diabetes mellitus (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), need for assistance with personal care, difficulty walking, major depressive disorder (causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working), and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). The admission Record indicated RP 1 was the responsible party for Resident 85. A review of Resident 85's History and Physical (H&P) dated 5/17/2023 indicated the resident did not have capacity to understand and make decisions. A review of Resident 85's Dental Notes dated 2/6/2024 indicated the resident was seen for an initial exam and treatment recommendations included surgical extraction of three teeth, if the resident's responsible representative agreed. A review of Resident 85's Dental Notes dated 3/29/2024 indicated the resident was seen for a reevaluation and treatment recommendations included surgical extraction of four teeth if the resident's responsible representative agreed. A review of the Minimum Data Set (MDS - a standardized resident assessment and care screening tool) dated 5/30/2024, indicated the resident was cognitively intact (a person's ability to think, learn, remember, use judgement, and make decisions) and required setup or clean-up assistance with eating, personal, oral, and toilet hygiene. During a concurrent interview and record review on 8/28/2024 at 11:11 AM with Social Worker 1 (SW 1), Resident 85's Dental Note dated 2/6/2024 and 3/29/2024 were reviewed. SW 1 stated there was no documentation that RP 1 was informed about the dental treatment recommendations for the resident. The SW 1 confirmed Resident 85 did not have capacity to make decisions and stated RP 1 should have been informed. SW 1 stated it was important to inform RP 1 so they were aware of what was going on with the residents dental care. Page 1 of 11 056337 056337 08/29/2024 Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd. Panorama City, CA 91402

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a phone interview on 8/28/2024 at 11:49 AM, RP 1 stated and confirmed she was Resident 85's responsible party and that she was not aware Resident 85 was receiving dental services. RP 1 confirmed social services had not informed her about Resident 85's dental visits or treatment recommendations. During a concurrent interview and record review on 8/29/2024 at 12:37 PM with the Social Service Director (SSD), Resident 85's electronic health record was reviewed. The SSD stated RP 1 was the resident's responsible party and that there was no documentation indicating RP 1 was informed of the dental visits or dental treatment recommendations. The SSD stated it was important to inform the responsible party because there was a risk for weight loss. During a concurrent interview and record review on 8/28/2024 at 1:01 PM with the Director of Nursing (DON), Resident 85's electronic health record was reviewed. The DON stated and confirmed Resident 85 did not have capacity to make decisions. The DON stated there was no documentation showing RP 1 had been informed of Resident 85's dental visits or dental treatment recommendations and stated the social service office was responsible for communicating and following up if there were any consents needed for extractions or surgical procedures. The DON stated it was the responsible party's right to be informed and be aware of the resident's plan of care. The DON stated there was a potential for delay of care because the responsible party was not informed. A review of the facility's policy and procedure (P&P) titled, Social Services Documentation, revised 1/2024, indicated medically related social service needs were to be provided, regardless of the size of the facility. These services were to be provided by the facility's staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. The policy indicated these services might include assisting staff to inform residents and those they designate about the residents health status and healthcare choices and their ramifications, and when provided, were to be documented in the health record. The policy indicated factors with potentially negative effect on the resident, needing follow up included dental/dental care. 056337 Page 2 of 11 056337 08/29/2024 Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd. Panorama City, CA 91402

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of two sampled residents (Resident 87). This deficient practice resulted in Resident 87 being unable to call a health care worker for help as needed. Residents Affected - Few Findings: A review of Resident 87's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including, Type II diabetes mellitus (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), need for assistance with personal care, and contracture unspecified joint (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). A review of Resident 87's Minimum Data Set (MDS - a standardized resident assessment and care screening tool) dated 8/7/2024, indicated the resident had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident required substantial / maximal assistance with personal, oral, and toilet hygiene and partial / moderate assistance with eating. During a concurrent observation in Resident 87's room and interview on 8/29/2024 at 12:57 PM, Resident 87 stated he wanted more coffee, but could not call the staff because he could not reach his call light. Resident 87 was observed sitting in his wheelchair and call light was not within reach. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 4 on 8/26/2024 at 12:59 PM, LVN 4 stated and confirmed Resident 87's call light was not within reach. LVN 4 stated it was important the residents call light was in reach so the resident could call for assistance. LVN 4 stated there was a potential the resident could have an injury and could not call for help from the staff. During an interview on 8/29/2024 at 2:01 PM, the Director of Nursing (DON) stated it was important for residents to have their call light within reach so the resident can call for help. The DON stated there was a risk that residents could not communicate their needs to the staff. A review of the facility's policy and procedure titled, Call Light, revised 1/2024, indicated it was the policy of the facility to provide the resident a means of communicating with nursing staff. Procedures included leaving the resident comfortable and placing the call device within residents reach before leaving room. 056337 Page 3 of 11 056337 08/29/2024 Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd. Panorama City, CA 91402

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and update the care plan after a change of condition (an improvement or worsening of a patient's condition which was not anticipated) for one of three sampled residents (Resident 71 ). This deficient practice had the potential to result in Resident 71 receiving inadequate care and supervision at the facility. Findings: A review of Resident 71's admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including diabetes mellitus Type II (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and end stage renal disease (when the kidneys permanently fail to work). A review of Resident 71's Care Plan revised on 11/27/2023, indicated the resident had risk for episodes of hyperglycemia and hypoglycemia (when the blood sugar level is lower than normal) related to diabetes. The care plan goal for the resident was to be free from sign and symptoms of hyperglycemia. The interventions indicated to avoid exposure to extreme heat, check the body for skin breakdown, discuss mealtimes, portion sizes, dietary restrictions, provide snacks and to offer substitutes for foods not eaten. A review of Resident 71's Minimum Data Set (MDS- standardized assessment and care planning tool) dated 8/14/2024, indicated the resident's cognitive skills (ability to think, read, learn, remember, and make decisions) for daily decision making was intact (decisions consistent/reasonable). A review of Resident 71's Situation-Background-Assessment and Recommendation (SBAR - a written communication tool that helps provide important information) Communication Form dated 7/27/2024, indicated the resident had hyperglycemia (when there is too much sugar in the blood) with an elevated blood sugar of 446 milligrams per deciliter (mg/dl-unit of measurement [ normal range for a diabetic according to American Diabetes Association: 80-130 mg/dl]) at around noon. During a concurrent interview and record review on 8/28/2024 at 9:50 AM with Registered Nurse 1 (RN 1), Resident 71's care plans and SBAR forms were reviewed. RN 1 stated the resident's risk for episodes of hyperglycemia and hypoglycemia care plan was initiated on 4/6/2023. However, this care plan was not revised after 11/27/2023. RN 1 stated care plans are reviewed or revised as needed, with a change in condition, and every three months. RN 1 stated Resident 71 had a change of condition on 7/27/2024 for hyperglycemia and his care plan was not reviewed or revised after this change of condition. RN 1 stated the potential outcome was inability to evaluate the effectiveness of care plan interventions. During a concurrent interview on 8/29/2024 at 1:39 PM, with the facility's Director of Nursing (DON), the DON stated Resident 71's risk for hyperglycemia care plan was not reviewed or revised after the resident's hyperglycemia episode on 7/27/2024. The DON stated resident's care plans were required to be reviewed and revised as needed quarterly, and with every change of condition. The DON further stated the purpose of reviewing and re-evaluating the care plans was to check the effectiveness of the care plan interventions and make sure the residents were receiving appropriate care and services. The DON stated the potential outcome was inadequate care and supervision. 056337 Page 4 of 11 056337 08/29/2024 Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd. Panorama City, CA 91402

F 0657 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Care Planning, revised March 2024, indicated a comprehensive care plan was developed within seven days of completion of the resident MDS. The revision or updating of the care plan will occur with quarterly, annually, upon significant changes of condition, or as requested by resident / resident representative or as deemed necessary by the Interdisciplinary Team. Residents Affected - Few 056337 Page 5 of 11 056337 08/29/2024 Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd. Panorama City, CA 91402

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were provided communication devices in the language that the residents were able to understand for two of two sampled residents (Resident 105 and Resident 107). These deficient practices prevented the residents from being able to communicate with the staff and had a potential to delay receiving appropriate care and treatment the residents needed. Residents Affected - Few Findings: A review of Resident 105's admission Record (Face Sheet) indicated the facility originally admitted Resident 105 on 12/27/2021, and readmitted on [DATE], with diagnoses including unspecified dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that the loss interferes with a person's daily life and activities), and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability). A review of Resident 105's Minimum Data Set (MDS- standardized assessment and care planning tool) dated 7/25/2024, indicated the resident's cognitive skills (ability to think, remember and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS further indicated Resident 105 received hospice care. A review of the Social Service Assessments dated 4/25/2024, and 7/25/2024, indicated Resident 105 verbalized the need of an interpreter to communicate with a doctor or healthcare staff. The Assessment further indicated Resident 105's primary language was Armenian. A review of the At Risk for Communication Problem care plan initiated on 5/7/2024, and revised on 7/24/2024, indicated Resident 105 had highly impaired hearing, was rarely / never understood, and Had no speech. The interventions indicated to assist with word finding as needed, to anticipate and meet the resident's needs, and to monitor / document and to report any changes in her ability to communicate to the physician. During an interview on 8/28/2024 at 1 PM, with Resident 105 inside her room, Resident 105 did not respond to questions when spoken to in English. However, when asked in the Armenia language how she was doing the resident replied good. When asked if she was in pain in the Armenia language, the resident replied No. During a concurrent observation and interview on 8/29/2024 at 8:40 AM, with the Director of Nursing (DON) at Resident 105's bedside, the DON stated there was no communication board or devices available at the bedside. The DON stated, Resident 105 was mainly Armenian speaking. However, the resident was not speaking most of the time. Sometimes she spoke a world or two. The DON stated, A board with pictures could be beneficial for the resident to communicate her needs to the staff. The DON stated the potential outcome of not having a communication board available and accessible to Resident 105 who was not able to verbally communicate effectively was insufficient care. b. A review of Resident 107's admission Record (Face Sheet) indicated the facility admitted the resident on 8/20/2021, with diagnoses including need for assistance with personal care, difficulty walking, and fall. 056337 Page 6 of 11 056337 08/29/2024 Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd. Panorama City, CA 91402

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 107's MDS dated [DATE], indicated the resident's cognitive skills for daily decision making was intact (decisions consistent / reasonable). The MDS further indicated Resident 105's preferred language was Shanghainese (a type of Chinese language or dialect). A review of the History and Physical (H&P) dated 2/20/2024, indicated Resident 107 could not make her own decisions and was Korean speaking. A review of the Social Service assessment dated [DATE], indicated Resident 107 verbalized the need of an interpreter to communicate with a doctor or healthcare staff. The assessment indicated that Resident 107's primary language was Chinese and that Resident 107 only speaks Chinese but was able to communicate through language services. A review of Resident 107's at risk for communication problem care plan initiated on 8/21/2021, indicated the resident had minimal hearing difficulty, and was speaking Shanghainese with limited English words. The care plan goal for the resident was to make basic needs known on a daily basis. The care plan interventions were to anticipate, and meet resident's needs, and to provide translator as necessary to communicate with the resident. During a concurrent observation and interview with on 8/29/2024 at 8:47 AM, with the DON inside Resident 107's room, Resident 107 was observed sitting on her wheelchair. Resident 107 was able to say hi in English. However, when asked how she was doing, the resident started speaking Chinese and making gestures to communicate that she did not understand. The DON stated there was no communication board at Resident 107's bedside for her to use when she needs something. The DON stated the facility was required to provide a communication board to non-English speaking residents. During an interview on 8/29/2024 at 9:06 AM, the DON confirmed that the communication boards were in the nursing station and were not provided to or accessible by Resident 105 and Resident 107. A review of the facility's policy and procedure titled, Quality of Life-Non-English and Aphasic Residents-Communication for, revised 3/2024, indicated social services will supply residents and/or family members with the use of a communication board that has universally known drawings, whenever desired. All attempts will be made to write, in the resident's native tongue, the name of each pictured item, using available staff, family members, and community resources, as appropriate. Resident, family, and staff caring for the resident will be familiarized with the communication tool. The tool will be kept at resident's bedside. An additional copy will be attached to the resident's wheelchair if the resident is wheelchair bound. 056337 Page 7 of 11 056337 08/29/2024 Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd. Panorama City, CA 91402

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess one of three sampled residents (Resident 144) with an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) upon admission and readmission to the facility. This deficient practice had the potential to lead to the inadequate care of Resident 144. Findings: A review of Resident 144's admission Record (Face Sheet) indicated the facility originally admitted the resident on 8/5/2024, and readmitted on [DATE], with diagnoses including calculus (stone) in bladder (organ in the lower part of the abdomen that stores urine before it leaves the body), and obstructive and reflux uropathy (when the urine instead of flowing from your kidneys to your bladder, flows backward, or refluxes, into your kidneys because of an obstruction). A review of Resident 144's Licensed Nurse-Initial admission Record dated 8/5/2024, indicated the resident did not have urinary retention and there was no urinary catheter in place. A review of Resident 144's Minimum Data Set (MDS - an assessment and care screening tool) dated 8/12/2024, indicated the resident's cognitive skills (ability to think, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS dated 8/22 and 8/12/2024 indicated Resident 144 had an indwelling catheter. A review of Resident 144's Physician's Orders dated 8/6/2024, indicated presence of an indwelling catheter to closed drainage system and to change the catheter as needed when dislodged (removed from its place). A review of Resident 144's Treatment Administration Record (TAR) for the month of August 2024, indicated the resident received indwelling catheter care from 8/6/2024 until 8/27/2024. A review of Resident 144's Care Plan initiated on 8/6/2024, indicated the resident was at risk for urinary retention (the inability to empty the bladder completely) related to benign prostatic hyperplasia (BPH- a condition in which prostate enlarges in size and blocks the urine flow) with obstruction and neurogenic bladder (a condition caused by the nerves along the pathway between the bladder and the brain not working properly. This can be due to a brain disorder or bladder nerve damage.). The care plan goal was for the resident to be free from any abdominal discomfort related to urinary retention. The care plan interventions indicated to provide catheter care, cleanse with soap and water and pat dry, perform abdominal assessment for tenderness or bladder distention (becoming large), and to also provide and offer adequate (enough) fluids if not contraindicated (not advised). A review of Resident 144's Licensed Nurse-Initial admission Record dated 8/20/2024, indicated the resident did not have urinary retention and there was no urinary catheter in place. During a concurrent interview and record review on 8/28/2024 at 11:33 AM, with the facility's Treatment Nurse (TN), Resident 144's Licensed Nurse-Initial Assessment Records were reviewed. The TN stated Resident 144 was admitted to the facility on [DATE], with an indwelling catheter. However, the initial assessment dated [DATE], indicated the resident did not have an indwelling catheter. TN 056337 Page 8 of 11 056337 08/29/2024 Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd. Panorama City, CA 91402

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few further stated Resident 144 was readmitted to the facility on [DATE], with an indwelling catheter. However, the initial assessment completed on 8/20/2024, indicated the resident did not have an indwelling catheter. The TN stated, Both assessments were completed incorrectly. The TN further stated the potential outcome of an incorrect assessment was providing wrong information about the resident status. During a concurrent interview and record review on 8/29/2024 at 1:30 PM with the facility's Director of Nursing (DON), Resident 144's initial assessment records were reviewed. The DON stated Resident 144 was admitted and readmitted to the facility with an indwelling catheter. However, the Initial Assessments completed on 8/5/2024 and 8/20/2024 indicated the resident did not have an indwelling catheter. The DON stated that licensed staff were required to conduct a thorough assessment when a resident was admitted or readmitted to the facility. The DON further stated the potential outcome of an incorrect resident assessment upon admission was the inability to provide the appropriate care and services to the resident. A review of the facility's policy and procedure titled, Assessment Nursing, revised 3/2024, indicated it was the policy of this facility to complete a nursing assessment within twenty-four (24) hours of admission. The purpose was to establish parameters and gather vital information that will be relevant in maintaining and/or reaching the resident's highest practicable physical, mental, or psychosocial well-being. Assessments done by the licensed nurse will be documented in the medical record using Initial admission Record UDA. Any finding will be reported to the attending physician accordingly. 056337 Page 9 of 11 056337 08/29/2024 Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd. Panorama City, CA 91402

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Social Services department completed their admission assessment for two of two sampled residents (Resident 29 and Resident 301). This deficient practice had the potential for delay in the delivery of care and services. Residents Affected - Few Findings: a. A review of the admission record for Resident 301, it indicated the was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain), COVID-19 (acute disease caused by a coronavirus), pneumonia (lung inflammation cause by a bacterial or viral infection), need for assistance with personal care, difficulty in walking, dysphagia (difficulty swallowing), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 8/19/2024 indicated Resident 301 had moderate cognitive impairment, had minimal difficulty hearing in some environments, and the resident did not have hearing aids. A review of Resident 301's care plan for a communication problem was initiated on 8/15/2024 and revised on 8/24/2024 indicated the resident had minimal difficulty hearing and the interventions included a referral to the ENT (physician who specializes in the ears, nose, and throat) as needed and to use touch, facial expression, tone, and body language to enhance communication. The goal was for the resident to make their basic needs known daily. During an observation on 8/26/24 at 9:07 AM in Resident 301's room, the resident was sitting up in be alert and oriented. During a concurrent interview, Resident 301 was unable to understand and pointed to their ears. Resident 301 stated that they did not have hearing aids on and stated that a nurse was supposed to get them and put them back on. The resident stated she did not know what was going on. During an interview on 8/26/2024 at 11:30 AM, Licensed Vocational Nurse (LVN) 3 stated Resident 301 lived at the facility for 11 days and came to the facility with hearing aids. LVN 3 stated if a resident needs hearing aids, the staff would first ask their family or representative if they have them and if they do not, they would obtain an order from the physician (MD) for a consultation. LVN 3 stated the social worker was responsible for arranging all consultations and not having hearing aids could make it difficult for a resident to communicate their needs. A review of Resident 301's medical chart on 8/28/2024 indicated there was no social services initial assessment documented. During a concurrent interview and record review on 8/28/2024 at 1:35 PM the Social Worker (SW) stated the initial assessment should be completed and documented within 7 days from the admission date of the resident. When asked if they were aware of any issues with Resident 301's hearing, the SW stated Resident 301's hearing aids were left at the assisted living facility that she was residing in and that Resident 301 did not verbalize any issues with not having the hearing aids. The SW stated that not having hearing aids could affect a resident's ability to communicate. The SW was unable to 056337 Page 10 of 11 056337 08/29/2024 Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd. Panorama City, CA 91402

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few provide Resident 301's social services initial assessment and stated it was important to make sure the documentation was complete in a timely manner to ensure other disciplines were aware of any issues that the resident could potentially have. During an interview on 8/28/2024 at 2:24 PM, the Social Services Director (SSD) stated all initial social services assessments should be completed and documented within 7 days and that a resident should be seen within 2-3 days upon admission. A review of the facility's policy and procedure titled, Social Services Documentation, revised 1/2024, indicated a social service assessment would be completed by the Social Service Designee or Social Service Designee Assistant within seven days of admission. b. A review of Resident 29's admission Record indicated the facility admitted the resident on 8/1/2024 with diagnoses including difficulty in walking, need for assistance with personal care, dysphagia (difficulty swallowing), major depressive disorder (causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working), and unspecified dementia (a brain disorder that affects a person's ability to carry out daily activities and that may cause changes in mood and personality). A review of Resident 29's History and Physical (H&P) dated 8/1/2024, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 29's MDS dated [DATE], indicated the resident required substantial / maximal assistance with personal and oral hygiene and was dependent with eating. During an interview on 8/28/2024 at 10:16 AM, Social Worker (SW) 1 stated social services should have completed a social service assessment within seven calendar days for newly admitted residents. During a concurrent interview and record review on 8/26/2024 at 11:11 AM with SW 1, Resident 29's electronic health record was reviewed. The SW 1 stated and confirmed Resident 29 was initially admitted [DATE], was discharged to the hospital on 8/4/2024 and returned on 8/5/2024. SW 1 confirmed Resident 29's social service assessment on admission was not in the electronic health record. During an interview on 8/28/2024 at 2:25 PM, the Social Services Director (SSD) stated the initial social service assessment must be completed within seven days and entered in the resident's electronic health record. The SSD stated she was not sure why Resident 29's initial social service assessment was not in the resident's electronic health record. During a concurrent interview and record review on 8/29/2024 at 12:32 PM with the Director of Nursing (DON), the facility's Social Services Documentation Policy was reviewed. The DON stated and confirmed a social services assessment was to be completed within seven days of admission. The DON stated it was important to complete the social service assessment to know the resident's discharge plan, psychosocial, and social needs. The DON stated there was a risk of delayed care and unknown resident needs when the social service assessment was not completed. A review of the facility's policy and procedure (P&P) titled, Social Services Documentation, revised 1/2024, indicated a social service assessment would be completed by the Social Service Designee or Social Service Designee Assistant within seven days of admission. 056337 Page 11 of 11