Health inspection·March 7, 2025

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who were unable to carry out activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received the necessary services to maintain good personal hygiene. Residents Affected - Few This deficient practiced resulted in Resident 1 having long facial hair and overgrown fingernails and had the potential to negatively impact Resident 1's quality of life. Findings: During a review of Resident 1 ' s admission record (facesheet) dated 2/5/2025, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection/inflammation in the lungs), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), sepsis (a life-threatening blood infection), urinary (UTI-an infection in the bladder tract infection/urinary tract), and hypertension (HTN-high blood pressure). During a review of Resident 1 ' s minimum data set (MDS - a standardized assessment and care planning tool) dated 2/8/2025, the MDS indicated Resident 1 ' s cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated that Resident 1 required moderate assistance by staff for oral hygiene and dependent on staff for toileting hygiene and showering. During a review of Resident 1 ' s ADL log (a documentation tool completed by staff to record activities of daily living that were completed), dated February 2025 , the ADL log indicated, Resident 1 ' s personal hygiene including combing hair, brushing teeth, shaving and washing and drying face and hands was completed by the staff daily. During an interview on 3/4/2025 at 9:40 a.m. with Responsible Party (RP) 1, RP 1 stated that Resident 1 was admitted to the facility on [DATE] after being hospitalized for several weeks. RP 1 stated that RP 1 requested for ADL care to be provided to Resident 1 upon admission. RP 1 stated that Resident 1 remained admitted in the facility until 2/13/2025 and was not provided ADL care including facial grooming and trimming of fingernails by staff. During an interview on 3/6/2025 at 3:00 p.m. with the Director of Staff Development (DSD), the DSD stated that Certified Nursing Assistants (CNA) are required to provided ADL care to residents on daily basis. The DSD stated that CNAs are responsible to provide grooming to residents including Page 1 of 2 555738 555738 03/07/2025 Terrace Post Acute 7447 Sepulveda Blvd Van Nuys, CA 91405

F 0676 shaving and trimming of the fingernails. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/7/2025 at 10:10 a.m., CNA 1 stated that she was assigned to Resident 1 several times during the day shift (7 a.m. to 3 p.m.) during Resident 1 ' s admission to the facility. CNA 1 stated that she did not provide facial grooming and trimming of the fingernails to Resident 1. Residents Affected - Few During an interview with on 3/7/2025 at 11:15 a.m. with the Director of Nursing (DON), DON stated that the correct process for ADL care is for residents to have ADL care performed by the CNA staff, which includes, showering, shaving, trimming of fingernails, and oral care including bushing of the teeth. DON confirmed Resident 1 should have had facial grooming and fingernail trimming completed during his admission to the facility. The DON confirmed that if a resident does refuse ADL care than it should be documented on the ADL log to reflect that the resident did refuse the care. During a review of the facility policy and procedure (P&P) titled Activities of Daily Living with a revision date of 1/16/2025, the policy and procedure indicated, residents will be provided with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). 555738 Page 2 of 2