Health inspection·April 24, 2025

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **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 the rehabilitation services were provided for one of four sampled residents (Resident 1). Residents Affected - Few * The facility failed to ensure Resident 1 received the PT and OT services for the planned duration and frequency as documented in the initial PT and OT evaluation. This failure had the potential for Resident 1 to decline in the resident's range of motion and mobility. Findings: Review of the facility's P&P titled Purpose and Objectives of Inpatient Rehabilitation Services revised 12/2022 showed it is the objective of the rehabilitation department to provide comprehensive and integrated therapy services to restore patients to their highest level of function. The therapists will develop an individualized plan of care upon evaluation and continuous assessment during treatment plan. Review of the facility's P&P titled Physician Orders for Rehab Services revised 12/2022 showed the evaluating therapist must establish the therapy plan of care after completion of initial assessment. The plan of care shall include at a minimum, short-term and long-term goals, treatment modalities, frequency and duration of treatment and treatment diagnosis. Closedmedical record review for Resident 1 was initiated on 4/15/25. Resident 1 was admitted to the facility on [DATE], and discharged on 3/14/25. Resident 1 had a diagnosis of spinal stenosis with neurogenic claudication. Review of the Order Summary Report showed the following physician's order dated 2/28/25: - to evaluate and treat for OT as needed for rehabilitation as indicated for three days; and - to evaluate and treat for PT as needed for rehabilitation as indicated for three days. Review of Resident 1's PT Evaluation and Plan of Treatment for the certification period for 3/1 to 3/30/25, showed the plan of treatment frequency for the therapeutic exercises, neuromuscular re-education, gait training therapy; PT evaluation: moderate complexity; and therapeutic activities with frequency of five times a week for the duration of two weeks. Review of Resident 1's OT Evaluation and Plan of Treatment for the certification period for 3/3 to 4/1/25, showed the plan of treatment for the therapeutic exercises, group therapeutic procedure; OT Page 1 of 2 555308 555308 04/24/2025 Trabuco Hills Post Acute 25652 Old Trabuco Road Lake Forest, CA 92630

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few evaluation: moderate complexity; and therapeutic activities with frequency offive times a week for the duration of two weeks. Review of Resident 1's Care Plan Report dated 3/5/25, showed a care plan problem addressing the alteration in musculoskeletal status related to muscle weakness, difficulty in walking, low back pain, spinal stenosis lumbar region with neurogenic claudication. Care plan interventions included to follow the physician's orders for weight bearing status. See physician's orders and/or treatment plan. a. Review of the Physical Therapy Treatment Encounter Note(s) showed Resident 1 received PT services for the following dates: 3/1, 3/3, 3/5 3/6, and 3/7/25. Further review of the PT Treatment Encounter Note(s) did not show PT treatment was rendered for the following dates: - for the week of 3/2 to 3/8/25, Resident 1 did not receive PT services on 3/4 and 3/8/25. - for the week of 3/9 to 3/15/25, Resident 1 did not receive PT services on 3/9, 3/10, 3/11, 3/12, and 3/13/25. Review of the Service Log Matrix for PT dated 3/1 to 3/31/25, showed Resident 1 did not receive PT services for the following dates: 3/4, 3/8, 3/10, 3/11, 3/12, and 3/13/25. b. Review of the OT Treatment Encounter Note(s) showed Resident 1 received OT services for the following dates: 3/3, 3/5, 3/6, and 3/7/25. Further review of the OT Treatment Encounter Note(s) did now show OT services were rendered for the following dates: - for the week of 3/2 to 3/8/25, Resident 1 did not receive OT services on 3/4 and 3/8/25. - for the week of 3/9 to 3/15/25, Resident 1 did not receive OT services on 3/9, 3/10, 3/11, 3/12, and 3/13/25. Review of the Service Log Matrix for OT dated 3/1 to 3/31/25, showed Resident 1 did not receive OT services for the following dates: 3/4, 3/8, 3/10, 3/11, 3/12, and 3/13/25. On 4/24/25 at 1139 hours, an interview for Resident 1 was conducted with the DOR. The DOR stated she assumed wrongly and assumed Resident 1 was plotted out for the maximum time he was to receive the PT and OT services; however, Resident 1 was not. The DORverified Resident 1's approved PT and OT sessions were not provided five times per week as planned. On 4/24/25 at 1703 hours, the interim Administrator and the DON acknowledged the above findings. 555308 Page 2 of 2