Health inspection·September 19, 2023

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the resident-centered activity programs to meet the residents' needs and interests for one sampled resident (Resident 2) and 22 nonsampled residents (Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, and V). This failure had the potential to negatively affectthe residents' psychosocial well-being. Residents Affected - Some Findings: Review of the facility's P&P titled Activities Program, Resident reviewed August 2023 showed a purpose to provide activities designed to appeal to the resident's interests and abilities to assist in achieving the highest level of physical, mental, and psychosocial well-being possible. The P&P also showed to develop the care plan designed to improve the resident's quality of life, develop and arrange suitable activities, and post the scheduled activities on the unit. On 9/7/23 at 1550 hours, an interview was conducted with the Subacute Unit Director. The Subacute Unit Director stated they did not currently have an Activities Director at the facility and were actively trying to fill the position. The Subacute Unit Director stated the MDS Coordinator had taken over the Family Council, one of the Activities Director's duties. The Subacute Unit Director stated the MDS Coordinator had not done any other activity duties. Medical record review for Resident 2 was initiated on 9/7/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's physician's orders showed an order dated 10/6/16, for the resident to participate in the activity program. Review of Resident 2's MDS dated [DATE], showed the following activities were very important to the resident: listening to music they enjoy, being around animals/pets, keeping up with the news, doing their favorite activities,and participating in the religious activities. Review of Resident 2's Care Plan showed an activity problem with a start date of 1/21/20, for diversional activity deficit related to physical limitations, inability to provide resident's own stimulation, inability to communicate, and institutionalization. The Care Plan's goal was for Resident 2 to receive the daily room visits to prevent social isolation and receive religious visits weekly. The approaches included to invite the resident to the activities daily or as scheduled, encourage the resident to attend activities in the day room (activity room) or patio as scheduled, get up in a geri-chair daily as tolerated, and include the resident in the religious visits. Page 1 of 3 555709 555709 09/19/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/7/23 at 1402 hours, an interview and concurrent observation was conducted with Resident 2. Resident 2 was in bed, wearing a religious pendant around their neck. Resident 2 stated they had not had activities in a while since the former Activities Director was at the facility. Resident 2 stated they did not get up and go out of their room anymore and would enjoy getting up in a chair. Resident 2 stated the religious activities were very important to him and they had not had any since the former Activities Director left. When asked how the lack of activities made the resident feel, Resident 2 replied they felt very lonely as the staff were busy and did not have time for personal relationships with him like the former Activities Director did. An 8.5x11 paper activity calendar for July 2023 was observed posted on the cork board across from the resident's bed, and no update activity calendar was observed. On 9/8/23 at 1113 hours, an observation of the facility's activity room was conducted. An 8.5x11 paper activity calendar for July 2023 was posted on the dry-erase board. No recent calendars were found in the activity room or around the facility. On 9/13/23 at 1132 hours, an interview was conducted with CNA 2. When asked who was doing the activities with the residents since the former Activity Director had left their position, CNA 2 replied no one. CNA 2 stated there were no 1:1 activity room visits or group activities. CNA 2 stated they used to get the residents up routinely in their wheelchairs or geri-chairs for activities, but not anymore since they had not been having any activities. Now, only a few residents got up in their chairs, and that was when their families were visiting. On 9/13/23 at 1136 hours, an interview was conducted with LVN 1. When asked who was doing the activities with the residents, LVN 1 replied the former Activity Director used to do room visits, play movies, and read books to the residents, but she had been gone for a few months. LVN 2 stated they had not seen any activities being conducted with the residents since the former Activity Director left. On 9/13/23 at 1142 hours, an interview was conducted with LVN 2. When asked what activities were being done for the resident, LVN 2 replied none since the former Activity Director left. On 9/13/23 at 1312 hours, an interview was conducted with the Subacute Unit Director. The Subacute Unit Director stated the former Activity Director's last day at the facility was 7/13/23, and that was why the posted activity calendars were from July 2023. The Subacute Unit Director stated they were actively trying to hire a new director. When asked about religious activities, the Subacute Unit Director stated there was a chaplain who came every one to two weeks though he was out for a bit after the former Activity Director had left. He was recently here for the resident visits, but the visits were not documented. When asked to show documentation that any activities were provided to the residents since the former Activity Director left, the Subacute Unit Director stated there were no records. On 9/13/23 at 1445 hours, a follow-up interview was conducted with the Subacute Unit Director. When asked which resident had the activity orders, the Subacute Unit Director stated all of their 23 residents should have the activity orders. Review of the physician's orders for Residents'2, A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, and V showed the orders for the residents to participate in the activity programs. On 9/20/23 at 0918 hours, a telephone interview was conducted with the Chaplain. When asked what type of visits the Chaplain had conducted after the facility's former Activity Director left on 555709 Page 2 of 3 555709 09/19/2023 Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869

F 0679 Level of Harm - Minimal harm or potential for actual harm 7/13/23, the Chaplain stated he stopped the resident visits there when the Director left and was going to resume once the facility hired a new Director. The Chaplain stated in August or early September 2023, he stopped by the facility, and they still did not have an Activity Director. The Chaplain stated they did not do any resident visits at that time. The Chaplain stated he went to the facility last week on 9/14/23, and did the resident visits for the first time since the former Activity Director left. Residents Affected - Some 555709 Page 3 of 3