Health inspection·February 3, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for ankle-foot orthotic (a device to provide support and stability to the ankle and foot, correct foot and ankle deformities, improve walking and mobility, reduce pain and inflammation, and control muscle spasms) device, before being implemented to one of three residents (Resident 1). Residents Affected - Few This failure resulted in Resident 1 wearing ankle foot orthosis without an order. This failure placed Resident 1 at risk to receive inappropriate care resulting in skin breakdown and joint complications. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1 had a history of dementia (a progressive state of decline in mental abilities) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 1's History and Physical (H&P), dated 1/3/2025, the H&P indicated Resident 1 had a history of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left side (arm and leg). The H&P indicated Resident 1 was able to make decisions. During a review of Resident 1's active physician orders, dated February 2025, the physician orders did not indicate an order for a medical device on the left leg. During a concurrent observation and interview on 2/3/2025 at 9:23 a.m. with Licensed Vocational Nurse (LVN 1) in Resident 1's room, Resident 1 had an ankle-foot orthotic on the left leg. LVN 1 stated Resident 1 wore the ankle-foot orthotic any time Resident 1 was out of bed. LVN 1 stated staff must follow Resident 1's physician orders to guide application of orthotics. During an interview on 2/3/2025 at 11:46 a.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 1's ankle-foot orthotic helped to maintain neutral ankle position and should be applied any time Resident 1 walked or stood. The DOR stated Resident 1 needed the orthotic device when out of bed to prevent abnormal positioning and injury. During a concurrent interview and record review on 2/3/2025 at 12:50 p.m. with LVN 1, Resident 1's active physician orders dated 2/2025 and care plans dated 2/2025 were reviewed. LVN 1 stated the ankle-foot orthotic was a medical device and should have a physician's order and care plan to avoid Page 1 of 4 555340 555340 02/03/2025 Marina Pointe Healthcare & Subacute 5240 Sepulveda Blvd Culver City, CA 90230

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few improper use, skin breakdown, and joint complications. LVN 1 stated Resident 1 did not have a physician orders or care plans for an ankle-foot orthotic. During a concurrent interview and record review on 2/3/2025 at 3:15 p.m. with the Director of Nursing (DON), the policy and procedure (P&P) titled Care Plans, Comprehensive, Person-Centered, dated December 2016 was reviewed. The DON stated the P&P indicated care plans must describe all services to be provided to a resident. The DON stated Resident 1 did not have a care plan for the ankle-foot orthotic. The DON stated licensed nurses should have updated Resident 1's care plans to include ankle-foot orthotic use. During a review of the P&P titled Care Plans, Comprehensive, dated 12/2016, the P&P indicated care plans must identify and describe services provided to prevent decline of the resident's functional status. The P&P indicated care plans will reflect currently recognized standards of practice for problem areas and conditions. During a review of the P&P titled Attending Physician Responsibilities, dated 8/2014, the P&P indicated the physician will identify and verify treatments and services, including rehabilitation services, are medically necessary and appropriate with each individual's diagnosis, condition, and wishes. 555340 Page 2 of 4 555340 02/03/2025 Marina Pointe Healthcare & Subacute 5240 Sepulveda Blvd Culver City, CA 90230

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 record review, the facility failed ensure the physician's order to apply buddy strap (a hook and loop straps used to treat injured fingers by taping them to an uninjured finger) to one of three residents (Resident 1), were implemented for nine (9) days (from 1/21/2025 through 1/29/2025). Residents Affected - Few The failure had the potential to delay the healing of Resident 1's right index finger (finger next to thumb) fracture (broken bone) and placed the resident at risk for complications. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1 had a history of dementia (a progressive state of decline in mental abilities) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 1's History and Physical (H&P), dated 1/3/2025, the H&P indicated Resident 1 had a history of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left side (arm and leg). The H&P indicated Resident 1 was able to make decisions. During a review of Resident 1's physician orders, dated 1/20/2025, the physician's order indicated for Resident 1 to wear a buddy strap during the day for Resident 1's right index finger fracture. During a review of Resident 1's Treatment Administration Record (TAR) for 1/2025, the TAR dated 1/21/2025 through 1/29/2025 were blank (did not indicate staff initials). During an interview on 2/3/2025 at 11:46 a.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 1's buddy strap was to promote bone healing by keeping the fractured bones aligned. The DOR stated Resident 1's fracture could heal incorrectly or slowly if the buddy strap was not applied. During a concurrent interview and record review on 2/3/2025 at 2:15 p.m. with Licensed Vocational Nurse (LVN 3), Resident 1's TAR, for 1/ 2025 was reviewed. LVN 3 stated the blank spaces on the TAR from 1/21/2025 through 1/29/2025 indicated the buddy strap was not applied to Resident 1's right index finger for 9 days. LVN 3 stated buddy strap was a type of splint (a medical device used to stabilize and hold a part of the body in place). LVN 3 stated the licensed nursing staff were responsible to ensure Resident 1 had the buddy strap on the right index finger. LVN 3 stated Resident 1 was at risk for contractures (joint deformity), pain, and limited mobility if the buddy strap was not provided according to physician's order. During a concurrent interview on 2/3/2025 at 3:15 p.m. with the Director of Nursing (DON), the DON stated the treatment nurse, and licensed vocational nurses were responsible for providing and documenting the ordered treatment for Resident 1's buddy strap to the right index finger. During a review of the Treatment Nurse Job Description, dated 2003, the job description indicated the Treatment Nurse was responsible to provide therapeutic services and assist in resident rehabilitative services. 555340 Page 3 of 4 555340 02/03/2025 Marina Pointe Healthcare & Subacute 5240 Sepulveda Blvd Culver City, CA 90230

F 0684 Level of Harm - Minimal harm or potential for actual harm During a review of the Charge Nurse LVN Job Description, dated 2003, the job description indicated charge nurses must coordinate nursing services to maintain a resident's total regimen and ensure all nursing prescribed treatments and rehabilitative programs were administered. Residents Affected - Few 555340 Page 4 of 4