Health inspection·September 28, 2023

F 0550 Level of Harm - Potential for minimal harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure one of two residents (Resident 1) was treated with respect and dignity. * A male staff member entered the shower room when a female resident (Resident 1) was present in the shower room. Resident 1 stated she felt a bit uncomfortable. This had the potential to negatively impact the Resident 1's well-being. Findings: Review of the facility's document titled Shower Schedule and Monitoring dated 7/9/04, showed to make sure the same gender staff are monitoring the shower rooms during the shower times. The document further gave an example: if it is the time for female showers, it must be a female staff that must be monitoring the shower room and if it is male shower time, it must be a male staff that must be monitoring. The document also showed the facility must coordinate to make sure the privacy of the residents is maintained. Medical record review for Resident 1 was initiated on 9/25/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical Examination dated 12/9/22, showed Resident 1 didnot have the capacity to understand and make decisions. Review of the SOC 341 (a Report of Suspected Adult or Elder Abuse form) dated 9/14/23, showed a male staff member (CNA 1) entered the shower room while Resident 1 was in the shower room. On 9/25/23 at 1050 hours, an interview and concurrent document review was conducted with the Housekeeper. The Housekeeper was asked to discuss what had happened on 9/14/23, between CNA 1 and Resident 1. The Housekeeper stated on 9/14/23 around 0740 hours, she was standing by the janitordoor (across from the shower room) and saw CNA 1 holding towels while he was entering the shower room. The Housekeeperstated LVN 2 then borrowed the Housekeeper's key to open the shower room door. LVN 2 then walked in the shower room. The Housekeeper stated she then witnessed Resident 1 following LVN 2 out of the shower room. The Housekeeperstated CNA 1 was in the shower room for approximately less than fiveminutes. On 9/25/23 at 1142 hours, an interview was conducted with Resident 1. Resident 1 was asked to discuss what had happened on 9/14/23. Resident 1 stated after she finished taking a shower, CNA 1 came in (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: 555211 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 555211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Westminster 206 Hospital Circle Westminster, CA 92683 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)