Health inspection·October 11, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. 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 restorative (RNA- nursing intervention to increase or maintain resident's mobility and prevent further decline in mobility) treatment and services for one of three sampled residents (Resident 2) when Resident 2 did not receive her ordered RNA therapy for the week of 9/23/24. This failure had the potential to result in a decline in physical functioning for Resident 2, resulting in a negative impact on Resident 2's health and well-being. Findings: A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility in 2024 with diagnoses that included difficulty in walking, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, also known as stroke) affecting the left side. A review of Resident 2's Order Summary Report, (list of physician orders) dated 10/11/24, indicated RNA therapy was ordered two times a week for both upper extremity active range of motion (AROM) and transfer training on 9/24/24. Further review of the record indicated RNA therapy was ordered three times a week for both upper extremity AROM on 9/28/24 and RNA therapy three times a week for transfer training to the bedside commode on 10/4/24. A review of Resident 2's Case Manager Note, dated 10/4/24, indicated, .Met with .res [resident] and spouse to review ending of skilled services and end of therapy .Discussed that res is now receiving RNA program . A review of Resident 2's Restorative Nursing Referral and Care Plan, dated, 9/24/24, indicated, .Type of Restorative Program .Therapeutic Exercise/ROM [range of motion] .Problem: Resident at risk for decline in ROM .Goals: Maintain/increase range of motion Maintain/increase muscle strength .Decrease c/o [complaint of] pain and discomfort Maintain/improve functional use of extremity Prevent/reduce risk of deformity [a distortion or disfigurement that changes the shape or size of a body part from what's normal] and/or contracture [where muscles, tendons, joints or other tissues tighten or shorten] Task: RNA 2x/week [2 times a week] for both upper extremity AROM .Type of Restorative Program: Transfer/Sit to Stand .Problem: Resident at risk for decline in transfers .Goals: Resident will maintain transfer status .Task: RNA: 2x/week for transfer training . During a concurrent interview and record review on 10/11/24, at 11:33 a.m., with Restorative Nurse Page 1 of 2 555190 555190 10/11/2024 English Oaks Convalescent & Rehabilitation Hospita 2633 West Rumble Rd Modesto, CA 95350

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. Assistant RNA (1) and RNA (2), Resident 2's electronic health record (EHR) was reviewed. RNA 1 stated RNA services were provided to residents on Sunday, Tuesday, and Friday of each week. RNA 1 confirmed there was no record of RNA services for the week of 9/23/24 in Resident 2's EHR. RNA 1 and RNA 2 stated they were not sure if Resident 2 received RNA services during the week of September 23rd. RNA 2 further stated that Resident 2's orders for RNA services were changed by the physician from two times a week to three times a week. RNA 2 stated that if Resident 2 received RNA services during the week of September 23rd, the documentation for RNA services would be in the medical record. During an interview on 10/11/24, at 12:17 p.m., with the Director of Rehabilitation (DOR), the DOR stated the original physician order for Resident 2's RNA services was received on 9/24/24 for RNA therapy two times a week. The DOR further stated that when RNA services were provided, they were documented in the EHR. The DOR stated the RNAs had a specific place in the EHR to document RNA services. The DOR stated that if the order for RNA services changed the documented services would still be part of the resident's EHR. During a concurrent interview and record review on 10/11/24, at 1:15 p.m., with the Asst ADM, Resident 2's EHR was reviewed. The Asst ADM confirmed there was no documentation for Resident 2 receiving RNA therapy from 9/23/24 through 9/28/24. The Asst ADM further confirmed there was no paper documentation of RNA services provided to Resident 2 from 9/23/24 through 9/28/24 in the medical record. The Asst ADM stated the risk for the resident not receiving RNA services was a decline in function and delayed recovery. During an interview on 10/11/24, at 1:45 p.m., with Resident 2 and Family Member (FM) 1, in Resident 2' s room, Resident 2 and FM 1 both stated RNA services started the week of 9/29/24. During a review of an undated facility policy titled, Restorative Nursing Services, indicated .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .It is the policy to assist each and every resident to achieve the highest level of self-care possible . During a review of an undated facility policy titled, Charting and Documentation, indicated .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record .1. Documentation in the medical record may be electronic, manual, or a combination .2. The following is to be documented in the resident medical record .c. Treatments or services performed .7. Documentation of procedures and treatments will include care-specific details, including a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care . 555190 Page 2 of 2