Health inspection·April 13, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Conservator (person appointed by a judge to act or make decisions on behalf of another person who needed help) of changes in the care or treatment for one of three sampled residents (Resident 1). Resident 1 ' s Conservator designated a Caregiver to assist in feeding Resident 1 during meals and the facility stopped allowing this provision of care by the Caregiver without notifying the Conservator. Residents Affected - Few This deficient practice violated Resident 1 ' s Conservator ' s right to be informed, be an active participant in Resident 1 ' s care planning process and had the potential to cause feelings of rejection and discrimination. Findings: During a record review of Resident 1 ' s admission Record (AR), The AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including epilepsy (a group of disorders marked by problems in the normal functioning of the brain), visual loss and dysphagia (swallowing difficulties). The AR indicated Resident 1 had a private Conservator. During a record review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care planning tool) dated 3/2/2023, the MDS indicated Resident 1 had unclear speech, limited ability to making concrete requests and responded adequately to simple, direct communication only. The MDS also indicated Resident 1 required extensive assistance with eating, dressing and personal hygiene. During an interview on 3/28/2023 at 11:30 a.m. with the Conservator, the Conservator stated she was very frustrated with the facility for not allowing the caregiver to assist with feeding Resident 1. The Conservator also stated the facility never communicated to her about any issues with the caregiver feeding the resident. During a concurrent interview and record review on 4/10/2023 at 4:35 p.m. with the Caregiver, the Record of Inservice (ROI) was reviewed. The ROI indicated the topic included safe swallowing strategies, small bites, and feeding at a slow rate. The Caregiver stated after she completed the in-service training, she was allowed to feed Resident 1 then the facility changed the rules and had now refused to allow her to feed Resident 1. During interviews on 4/11/2023 at 10:05 a.m. and 4/17/2023 at 1:20 p.m. with the Director of Nursing (DON), DON stated, the change of not allowing Resident 1 ' s Caregiver to assist the resident with feeding during meals, was discussed during the Interdisciplinary Team meeting ([IDT]-structured meeting to address the needs of participants through frequent, organized, and documented communication Page 1 of 2 555881 555881 04/13/2023 Clear View Sanitarium 15823 So. Western Ave. Gardena, CA 90247

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few across disciplines and with the participant) on 12/8/2022 and believed to have notified the conservator at this time however could not find any documentation to indicate the notification was done. During a concurrent interview and record review on 4/17/2023 at 2:37 p.m. with Social Services Director (SSD), Resident 1 ' s Care Conference Notes dated 12/8/2022 and 3/2/2023 were reviewed. SSD stated, Resident 1 ' s Conservator was present during the meeting on 12/8/2022 and was not present during the meeting on 3/2/2023. SSD stated the notes did not indicate the IDT discussed Resident 1 ' s Caregiver not being able to assist in feeding the resident nor did she recall discussing this issue in the IDT meetings. During an interview on 4/13/2023 at 10:05 a.m. and 4/18/2023 at 2:59 p.m., with ADM, ADM stated he decided a couple of weeks ago to stop the caregiver from feeding Resident 1 because she had not completed the required state course. ADM stated he was not sure what date this change was made and was not sure when the Conservator was notified of the change. ADM stated there was no documentation that the facility notified the Conservator. ADM also stated it was important to provide notification to the Conservator to ensure R/P was informed, involved, and understood the plan of care and changes related to the resident. During a review of the facility ' s policy and procedure (P/P) titled, Policy on Resident Rights, undated, The P/P indicated the facility should provide each resident the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. This facility should promote the exercise of rights for all residents, including those who face barriers, such as communication problems, hearing problems and cognitive limitations, in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. In the event a resident is adjudged incompetent under the laws of the State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under the State law to act on the resident ' s behalf. During a review of the facility ' s P/P titled, Resident/Family Education, undated, the P/P indicated education was provided by the IDT members to appropriate residents and/or responsible party when applicable if it is felt that it would be efficacious in order to reduce a resident ' s stress or anxiety, or to increase the likelihood of adherence to therapeutic care plans, promote healthy lifestyles, and/or speed the resident ' s return to independence if discharge is appropriate/eminent. The P/P also indicated resident/family was provided with appropriate education and training about illness and care needs. 555881 Page 2 of 2