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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555688 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anaheim Point 3415 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)