Health inspection·March 14, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and the facility P&P review, the facility failed to provide the written information regarding the rights to formulate the advance directives for one of ninesampled residents (Residents 1). In addition, facility failed to ensure the POLST was completed for Resident 1. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advanced Directive revised July 2018 showed upon admission, the admission staff or designee will provide written information to the resident concerning his or her right to make decision concerning medical care, including right to accept or refuse medical or surgical treatment, and the right to formulate advance directive. The P&P further showed during the social services assessment process, the Director of Social Service designee will also ask the resident whether he or she has a written advance directive. Closed medical record review for Resident 1 was initiated on 3/12/24. Resident 1 was admitted to the facility on [DATE], and discharged on 2/26/24. Review of Resident 1's Physician History and Physical examination dated 11/2/23, showed Resident 1 was capable of participating in the plan of care. Review of Resident 1's Clinical admission form dated 11/1/23, showed Resident 1 wasalert and oriented x three (oriented to person place, and time), communicated verbally withclear speech, able to understand, and be understood when speaking. Further review of Resident 1's closed medical record failed to show if Resident 1 and/or Resident 1's representative was asked whether Resident 1 had formulated an advance directive or was provided with the information regarding their rights to formulate anadvance directive. Further review of Resident 1's medical record did not show the POLST was completed. On 3/12/24 at 1510 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the SSD. The SSD verified the above findings and stated she was not able to find documented evidence if Resident 1 and/or Resident 1'srepresentative was asked whether Resident 1 has formulated an advance directive or wasprovided with the written information regarding their rights to formulate anadvance directive. Moreover, the SSD was not able to show if the POLST was completed for Resident 1. The SSD stated upon admission, the residents were asked if they had an advance Page 1 of 4 555688 555688 03/14/2024 Anaheim Point 3415 W Ball Road Anaheim, CA 92804

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few directive or if they were interested in formulating an advance directive. The SSD stated the social services should provide information and assist with the completion of the advance directive. The SSD further stated the physician should initiate and complete POLST for residents. On 3/12/24 at 1551 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON verified and acknowledged above findings 555688 Page 2 of 4 555688 03/14/2024 Anaheim Point 3415 W Ball Road Anaheim, CA 92804

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 interview, medical record review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 1) was provided the necessary treatment and services to maintain and improve his ROM functions. * The facility failed to ensure the physician was notified of Resident 1's refusal of the PT and OT services and failed to develop the care plan problem to address Resident 1's refusal of the PT and OT services. These failures posed the risk for Resident 1 to develop complications from immobility leading to muscle atrophy and contractures (shortening of the tendons and muscles causing the joints to become stiff and unable to fully function). Findings: Review of the facility's P&P titled Refusal of Treatment revised 1/1/12, showed the facility will honor a resident's request not to receive medical treatment as prescribed by their attending physician, as well as care services outlined on the resident's assessment and care plan. Under the section for procedure showed the attending physician will be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the refusal. The P&P further showed the interdisciplinary team will assess the resident's needs and offer the resident alternative treatment while continuing to provide other services in the care plan. Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised November 2018 showed the facility is to ensure that a comprehensive person-centered care plan is developed for each resident. Further review of the P&P showed the comprehensive care plan will be periodically reviewed and revised by the IDT after each assessment which means after each MDS assessment as required, except discharge assessment. In addition, the comprehensive care plan will also be reviewed and revised at the following times: - onset of new problems; - change of condition; - in preparation for discharge; - to address changes in behavior and care; and - other times as appropriate or necessary. Closed medical record review for Resident 1 was initiated on 3/12/24. Resident 1 was admitted to the facility on [DATE], and discharged on 2/26/24. Review of Resident 1's Physician History and Physical examination dated 11/2/23, showed Resident 1 was capable of participating in the plan of care. Review of Resident 1's Clinical admission form dated 11/1/23, showed Resident 1 wasalert and oriented to person, place, and time;communicated verbally with clear speech; able to understand; and be 555688 Page 3 of 4 555688 03/14/2024 Anaheim Point 3415 W Ball Road Anaheim, CA 92804

F 0688 understood when speaking. Level of Harm - Minimal harm or potential for actual harm Review of the Resident 1's PT Evaluation and Plan of Treatment dated 12/1/23, showed Resident 1 was referred to the PT due to decline in strength, static balance, coordination, functional ambulation, and functional mobility. The document further showed the plan of treatment approaches may include therapeutic exercises, neuromuscular reeducation, gait training therapy, and therapeutic activities to be done daily five times a week for 27 days from 12/1 to 12/27/23. Residents Affected - Few Review of the Resident 1's OT Evaluation and Plan of Treatment dated 12/2/23, showed theplan of treatment approaches may include therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training to be done daily five times a week for 26 days from 12/2 to 12/27/23. Review of Resident 1's Order Summary Report showed the following physician's orders: - On 12/1/23, for PT services to be provided everyday five times a week for four weeks for therapeutic exercise, neuromuscular reeducation, therapeutic activities, and gait training; and - On 12/4/23, for OT services to be provided everyday fivetimes a week for four weeks for therapeutic exercises, therapeutic activities, neuromuscular reeducation, and self-care training effective 12/2/23. Review ofResident 1's PT Missed Visit Details showed Resident 1 refused the PT services despite multiple attempts and encouragement on 12/6, 12/7, 12/8, 12/9, 12/12, and 12/13/23. Review ofResident 1's OT Missed Visit Details showed Resident 1 refused the OT services on 12/6, 12/7, 12/8, 12/11, 12/12, and 12/13/23. Further review of Resident 1's closedmedical record did not show the physician notification of Resident 1's multiple refusal of the PT and OT services. In addition, review of Resident 1's Care Plan did not show the care plan problem was developed to address Resident 1's multiple refusal of the PT and OT services. On 3/13/24 at 1110 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with PhysicalTherapist 1. Physical Therapist1 verified the above findings and stated Resident 1's PT and OT services were terminated after 2/13/24, due to frequent refusal of the PT and OT services. However, PhysicalTherapist 1 was not able to find the documentation if the physician was notified regarding Resident 1's multiple refusal of treatments before the termination of the PT and OT services. On 3/13/24 at 1315 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the Rehabilitation Director. The Rehabilitation Director verified the above findings and stated the physician should have been notified when Resident 1 refused PT and OT services multiple times. The Rehabilitation Director further stated the care plan should have been revised to address Resident 1's frequent refusal of the PT and OT services. On 3/13/24 at 1436 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 555688 Page 4 of 4