F 0551
Give the resident's representative the ability to exercise the resident's rights.
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 two of three sampled residents (Resident 1 and
Resident 2) Responsible Representative (RR 2 and RR 3) were notified and informed of changes made
with the existing Physician Orders for Life-Sustaining Treatment (POLST-a focused type of advance
directive used in critical situations where immediate medical decisions are needed). This failure resulted in
Resident 1 being intubated (involves inserting a plastic tube into the airway to help breath) without consent.
Residents Affected - Few
Findings:
During an interview on [DATE] at 8:45 a.m. with RR 1, RR 1 stated on [DATE], Resident 1 signed an
Advance Health Care Directive (AHCD-legal document outlining a person's healthcare wishes) and
appointed RR 2 to be her POA (Power of Attorney) to make healthcare decisions. RR 1 stated Resident 1
had always wished for her code status to remain a DNR (Do Not Resuscitate-allow natural death). RR 1
stated on [DATE], Resident 1 became unresponsive and was transferred to the emergency room (ER). RR
1 stated Resident 1's POST form brought to the ER indicated Resident 1 wished to be a full code (full
resuscitation without limitations). RR 1 stated Resident 1 was intubated because of the new code status.
RR 1 stated Resident 1 did not have the mental capacity to make any decisions. RR 1 stated Resident 1's
POA (RR 2) was not notified or informed and did not give consent of the changed made on Resident 1's
POLST.
During a review of Resident 1's clinical records, the admission Record indicated Resident 1 had a
diagnosis of Vascular Dementia (a progressive state of decline in mental abilities). Resident 1's Minimum
Data Set (MDS-a federally mandated resident assessment tool) dated [DATE], indicated Resident 1 had a
BIMS (Brief Interview for Metal Status-an assessment tool used by facilities to screen and identify memory,
orientation, and judgement status of the resident) score of 11 (score range from 8-12 s moderate
impairment). Resident 1's ACHD dated [DATE] indicated Resident 1's End of Life Decisions Choice Not To
Prolong Life. Resident 1's POLST form dated [DATE] signed by POA indicated Do Not Attempt
Resuscitation/DNR (Allow Natural Death) and Do not intubate. Resident 1's new POLST dated [DATE]
signed by Resident 1 indicated Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation), full treatment
including use intubation.
During a review of Resident 2's clinical records, the MDS dated [DATE], indicated Resident 2 had a BIMS
score of 7 (score range from 0-7 severe cognitive impairment). Resident 2's POLST form dated [DATE]
signed by RR 3 indicated Do Not Attempt Resuscitation/DNR. Resident 2's new POLST dated [DATE]
signed by Resident 1 indicated Attempt Resuscitation/CPR.
During an interview on [DATE] at 11:18 a.m. with Administrator and Director of Nurses (DON),
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555125
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555125
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Linwood Meadows Care Center
4444 West Meadow
Visalia, CA 93277
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0551
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Administrator and DON stated changes made on Resident 1 and Resident 2's POLST form were completed
between Resident 1 and Resident 2 and their Attending Physician (AP). DON reviewed Resident 1 and
Resident 2's clinical records. DON stated Resident 1 and Resident 2 did not have the mental capacity to
understand and make decisions including making changes with their POLST. DON stated it was facility
practice to notify and inform residents RR of any changes made regarding residents' medical care. DON
stated Resident 1 and Resident 2's RR should have been notified and informed when changes were made
on Resident 1 and Resident 2's POLST.
During a review of the facility's policy and procedure (P&P) titled, Resident Representative dated 2/21, the
P&P indicated, 2. If the resident is determined to be incompetent under the laws of the state by a court of
competent jurisdiction the rights of the resident will devolve to and will be exercised by the resident
representative appointed to act on the resident's behalf. 3. The term ' resident representative is defined as:
a. an individual chosen by the resident to act on behalf of the resident in order to support the resident in
decision-making: access medical, social or other personal information of the resident; manage financial
matters; or received notifications;
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555125
If continuation sheet
Page 2 of 2
