Health inspection·August 6, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary services as ordered by the physician for one of eight sampled residents (Resident 6). Residents Affected - Few * The facility failed to ensure the psychiatric evaluation and treatment were provided to Resident 6 as ordered. This failure had the potential for the resident not to receive the necessary care and services. Findings: Medical record review for Resident 6 was initiated on 7/5/24. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P Examination dated 5/13/24, showed Resident 6 did not have a capacity to understand and make decisions. Resident 6's diagnosis included senile dementia with psychosis. The H&P examination further showed Resident 6 needed a psychiatry follow up. Review of Resident 6's MDS dated [DATE], showed Resident 6's cognition was moderately impaired. Review of Resident 6's Order Summary Report showed a physician's order dated 5/10/24, for psychiatric evaluation and treatment with Physician 1. Further review of Resident 6's medical record failed to show documented evidence Resident 6's was scheduled and/or seen for psychiatric evaluation and treatment. On 7/29/24 at 0918 hours, an interview was conducted with Resident 6. Resident 6 was asked if he had seen the psychiatrist, Resident 6 stated, no. On 7/31/24 at 1507 hours, an interview and concurrent medical record review was conducted with LVN 2. When asked if Resident 6 had a follow up with psychiatry, LVN 2 stated no. LVN 2 verified Resident 6 did not follow up with the psychiatrist and further stated the psychiatry consult should have been done. On 8/6/24 at 1037 hours, an interview and concurrent medical record review was conducted with the DON. The DONacknowledged the physician's order for Resident 6 to have a psychiatric evaluation and treatment with Physician 1 was not done. The DON further stated Resident 6 should have followed-up with the psychiatrist. 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 3 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 08/06/2024 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)