Health inspection·November 30, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the responsible party and physician for one of 26 sampled residents (Resident 5) were notified when Resident 5 refused to receive the COVID-19 vaccine. This failure resulted in Resident 5's physician and responsible party not being aware of change in the care of Resident 5, which had the potential to negatively affect the resident's well-being. Findings. Medical record review for Resident 5 was initiated on 11/27/23. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's History and Physical examination dated 10/15/23, showed Resident 5 did not have the capacity to understand and make medical decisions. Review of Residents 5's MDS dated [DATE], showed mild cognitive impairment. Review of Resident 5's vaccination record showed on 9/19/22, a family member (Family Member 1) gave verbal consent for Resident 5 to receive the vaccination. Review of Resident 5's Medication Administration Record for October 2022 showed a physician's order dated 10/7/22, to administer Pfizer-BioNTech COVID-19 0.3 ml intramuscular one time to Resident 5. Further review of the record showed Resident 5 refused the vaccine. Further review of Resident 5's medical record failed to show documentation Resident 5's physician and family member were notified of Resident 5 refusing the COVID-19 vaccine. On 11/22/23 at 0828 hours, a telephone interview was conducted with Resident 5's Family Member 1. Family Member 1 stated he had given the facility permission to administer the COVID vaccine to Resident 5, but he was not informed that Resident 5 had refused the vaccine until the staff called him on 11/20/23, to inform him that Resident 5 was positive for COVID-19. Family Member 1 stated if he had known Resident 5 had refused the vaccine, he would have gone to the facility and made sure Resident 5 received it. On 11/27/23 at 1330 hours, an interview and concurrent medical record review was conducted with the IP. The IP verified the above findings and stated Resident 5's vaccination record showed Resident 5 refused the vaccine on 10/7/22. The IP stated both the family and the physician should have been notified. Page 1 of 3 555257 555257 11/30/2023 Palm Terrace Healthcare & Rehabilitation Center 24962 Calle Aragon Laguna Hills, CA 92637

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of 26 sampled residents (Residents 2 and 4) were monitored every shift for at least 72 hours following the fall incidents. This failure had the potential to not provide the necessary care and services timely for the residents. Findings: Review of the facility's P&P titled Change of Condition Reporting revised 2/2023 showed the licensed nurse responsible for the resident will continue assessment and documentation every shift for at least seventy-two (72) hours or until condition has stable. Review of the facility's P&P titled Fall Management System (undated) showed when a resident sustains a fall, a physical assessment will be completed by a licensed nurse with the results documented in the medical record. Follow-up documentation will be completed for a minimum of 72 hours following the incident. 1. Medical record review for Resident 2 was initiated on 11/20/23. Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's MDS dated [DATE], showed Resident 2 was cognitively intact. Review of Resident 2's Progress Notes dated 10/30/23, showed Resident 2 went to a medical appointment outside the facility and reportedly slid out of her wheelchair. Review of Resident 2's Change in Condition dated 10/30/23, showed Resident 2 reportedly had an unwitnessed fall while out for her appointment. Review of Resident 2's plan of care failed to show a care plan problem to address Resident 2's unwitnessed fall that occurred on 10/30/23. Further review of Resident 2's medical record failed to show Resident 2 was continuously monitored every shift for at least 72 hours after the unwitnessed fall had occurred. On 11/20/23 at 1412 hours, an interview and concurrent medical record review was conducted with LVN 4. When asked, LVN 4 defined a change of condition as a skin change or a fall occurrence. LVN 4 was asked what she did when a resident fell. LVN 4 stated when a resident had a fall, LVN 4 would provide immediate interventions, including updating the resident's care plan to include new interventions for the resident. LVN 4 reviewed Resident 2's medical record and verified Resident 2 did not have an updated plan of care to address Resident 2's recent unwitnessed fall. On 11/20/23 at 1457 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings and stated the licensed nurses were expected to document for 72 hours after the fall incident. 2. Medical Record review for Resident 4 was initiated on 11/22/23. Resident 4 was admitted to the 555257 Page 2 of 3 555257 11/30/2023 Palm Terrace Healthcare & Rehabilitation Center 24962 Calle Aragon Laguna Hills, CA 92637

F 0689 facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of the progress notes showed Resident 4 had an unwitnessed fall in the bathroom on 11/2/23 at around 0425 hours. The progress notes showed the physician was notified and Resident 4 was sent to the acute care hospital. Further review of the progress notes showed Resident 4 suffered an L4 compression fracture (a fracture of one of the bones in the lower back region). Residents Affected - Few Further review of Resident 2's medical record failed to show Resident 2 was continuously monitored every shift for at least 72 hours after the unwitnessed fall incident. On 11/22/23 at 1300 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the nursing staff were required to document every shift for 72 hours regarding a resident's change of condition such as a fall. The DON confirmed the nursing documentation regarding Resident 4's fall was missing for the night shift from 2300 hours on 11/2/23, to 0630 hours on 11/3/23; and the day shift on 11/3/23, from 0630 to 1430 hours. The DON also confirmed the findings. 555257 Page 3 of 3