Health inspection·March 10, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had adequate services to improve or maintain mobility when Resident 1 was discharged from physical therapy services after seven days out of a 60 day physical therapy plan and did not have recommendations at physical therapy service discharge to the physician or nursing staff to maintain or improve mobility. This failure placed Resident 1 at risk of impaired mobility and falls. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy after a right hip hemiarthroplasty (surgical replacement of the hip with an artificial hip). Resident 1 had a diagnosis of right femur fracture, artificial right hip joint and muscle wasting. During a record review of Resident 1's Hospitalist Discharge Summary, dated 1/4/24, Resident 1's hospitalization prior to admission to the facility was reviewed. The summary indicated Resident 1 was found at home with a right hip fracture and had surgery to treat the hip fracture. The summary indicated Resident 1 was able to ambulate with a walker at discharge. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 1/10/24, the MDS indicated Resident 1 had a Brief Interview for Mental Status score of 8 (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve is an indication of moderately impaired cognitive status). The MDS indicated Resident 1 was able to use a walker and did not have range of motion limitations for upper and lower extremities. The MDS indicated Resident 1 required substantial assistance from staff to sit up from a lying position. During a record review of Resident 1's physicians orders titled Order Summary Report, dated 3/11/24, the report indicated Resident 1 had an order for Eval and treat -PT [physical therapy], dated 1/4/24. During a record review of Resident 1's physical therapy plan titled, PT Evaluation and Plan of Treatment, dated 1/5/24, indicated physical therapy planned to work with Resident 1 three to five times a week for 60 days. The plan indicated Resident 1 was independent with walking and ambulation prior Page 1 of 3 555446 555446 03/10/2024 Rossmoor Post Acute 1226 Rossmoor Parkway Walnut Creek, CA 94595

F 0688 Level of Harm - Minimal harm or potential for actual harm to hospitalization. The plan indicated Resident 1 was agreeable to work to get stronger and be able to walk. The plan further indicated Resident 1 demonstrated good rehab potential as evidenced by ability to follow 1-step directions and recent onset. The plan indicated: without therapeutic intervention .Resident 1 was at risk for .decrease in level of mobility and falls. Residents Affected - Few During an observation on 2/21/24, at 11:00 a.m., in Resident 1's room, Resident 1 was in bed asleep. During an observation on 2/21/24, at 3:50 p.m., inside of Resident 1's room, Resident 1 was in bed with the covers on. Resident 1 was awake but did not answer questions. During an interview on 2/21/24, at 1:51 p.m., with Certified Nursing Assistant 1 (CNA-1), CNA-1 stated Resident 1 did not get out of bed often. CNA-1 did not know what rehabilitative plan was in place for Resident 1. During an interview on 2/21/24, at 4:00 p.m., with Certified Nursing Assistant 2 (CNA-2), CNA-2 stated Resident 1 was mostly in bed. During a concurrent interview and record review on 2/21/24, at 2:00 p.m., with Licensed Nurse 1 (LN-1), Resident 1's physicians orders and care plans were reviewed. LN-1 stated Resident 1 did not get out of bed except into a wheelchair for shower days. LN-1 stated Resident 1 did not have orders or a nursing care plan to maintain or improve mobility. LN-1 stated residents would have orders to be out of bed or for ambulation to maintain or improve mobility. During a concurrent interview and record review on 2/21/24, at 3:10 p.m., with physical therapist (PT), Resident 1's physical therapy notes titled Physical Therapy Treatment Encounter Notes and PT Discharge Summary from 1/5/24 to 1/12/24 were reviewed. PT stated Resident 1 had five physical therapy sessions from 1/5/24 to 1/11/24. PT stated the encounter notes indicated Resident 1 was able to stand with assistance for a session on 1/10/24. PT recalled Resident 1 would participate for one or two minutes in therapy and other times Resident 1 would refuse because Resident 1 had a fear of falling. PT stated Resident 1 was discharged from the physical therapy service on 1/12/24 but did not know why Resident 1 was discharged . PT stated the discharge summary indicated Resident 1 had not met planned therapy goals and did not have recommendations to nursing staff for follow up care. PT stated residents would be discharged from physical therapy if they had met goals, had plateaued after progressing or was unable to participate in care. During a concurrent interview and record review on 2/21/24, at 3:45 p.m., with Director of Rehabilitative Services (DRS), Resident 1's rehabilitative therapy records were reviewed. DRS could not find records on why Resident 1 was discharged from the physical therapy service. DRS could not find records about physical therapy service recommendations or plans for continuity of care. DRS stated upon discharge from rehabilitative services, recommendations were expected to be made to the physician or nursing staff to continue rehabilitative efforts. During a concurrent interview and record review on 2/21/24, at 4:08 p.m., with LVN-1, Resident 1's POC Response History, dated 2/21/24, was reviewed. LVN-1 stated the POC Response History was a record of certified nursing assistants (CNA) documentation on Resident 1's response to attempts of ambulation or rolling in bed. LVN-1 stated the responses were documented once a shift with three shifts in a day. LVN-1 stated Resident 1's documented response to Walk in Room for 1/23/24-1/31/24 indicated CNAs did not attempt to get Resident 1 to walk in the room for 23 out of 26 potential attempts. The 555446 Page 2 of 3 555446 03/10/2024 Rossmoor Post Acute 1226 Rossmoor Parkway Walnut Creek, CA 94595

F 0688 record indicated Resident 1 had refused for three out of 26 attempts made. Level of Harm - Minimal harm or potential for actual harm During a record review of Resident 1's POC Response History, dated 3/11/24, Resident 1's response to Walk 50 feet with two turns from 2/15/24 to 3/11/24 was reviewed. The document indicated on 2/29/24, at 2:09 p.m., Resident 1 was able to walk at least 50 feet with moderate assistance. Residents Affected - Few During a concurrent interview and record review on 2/21/24, at 4:40 p.m., with Assistant Director of Nursing (ADON), the ADON stated Resident 1 did not have a care plan or physicians order to maintain or improve mobility. ADON stated the nursing staff were expected to attempt to get residents up out of bed as part of general nursing care. During a concurrent observation and interview on 3/11/24, at 10:14 a.m., with Resident 1, Resident 1 was in the bed with the covers on. Resident 1 could not recall staff assisting with getting out of bed to stand or walk. Resident 1 recalled using a wheelchair but couldn't stay in it long because of broken bones . Resident 1 wanted to get up to walk, but the walker didn't give enough support. During an interview on 3/11/24, at 11:13 a.m., with Resident 1's primary physician (MD 1), MD 1 stated Resident 1 was admitted for rehabilitative therapy and was medically cleared to participate with rehabilitative therapy. MD 1 did not know why Resident 1 was discharged from the rehabilitative therapy services and did not receive rehabilitative recommendations for follow up care. MD 1 stated he had not focused on Resident 1's mobility and did not have knowledge of Resident 1's mobility progress. During a review of facility policy and procedure (P&P) titled, Functional Impairment - Clinical Protocol, dated 03/2018, the P&P indicated the staff and physician will collaborate to identify a rehabilitative or restorative care plan to help improve function and quality of life and meet a resident's goal and needs and attain other desired outcomes the physician will pay attention to the relevance and effectiveness of such interventions and will not just sign off therapy order perfunctorily staff and physician will identify individuals with potential for significant improvement in function or significant decline in function including the ability to perform activities of daily living. 555446 Page 3 of 3