Arcadia Health Care Center

F-F689)

Findings:

a. During a review of Resident 120's AR, the AR indicated Resident 120 was admitted to the facility 6/28/2024 with diagnoses including spinal stenosis (the spaces in the spine narrow and create pressure on

the spinal cord and nerve roots), muscle weakness, and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).

During a review of Resident 120's care plan titled Bladder and Bowel Retraining, dated 6/28/2024, the care plan indicated facility staff should offer and assist Resident 120 use of the bathroom as needed.

During a review of Resident 120's care plan titled ADL and Functional Mobility, dated 6/28/2024, the care plan indicated facility staff should offer and assist Resident 120 with Activities of Daily Living (ADLs, activities related to personal care) as needed.

During a review of Resident 120's H&P dated 6/29/2024, the H&P indicated, Resident 120 had the capacity to make medical decisions.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 8 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

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)

F 0550 During a review of Resident 120's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/5/2024, the MDS indicated Resident 120 had no impairment in cognitive skills (the ability to Level of Harm - Minimal harm or make daily decisions). The MDS indicated Resident 120 was dependent on staff for toileting, dressing, and potential for actual harm bathing.

Residents Affected - Some During a review of Resident 279's Admission Record (AR) the AR indicated Resident 279 was admitted to

the facility on [DATE REDACTED] with diagnoses including osteoarthritis (type of joint disease that results from breakdown of joint cartilage [connective tissue] and underlying bone) of the left knee, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and hyperlipidemia ( high level of fat particles [lipids] in the blood).

During a review of Resident 279's care plan titled Bladder and Bowel Retraining, dated 7/20/2024, the care plan indicated facility staff should offer and assist Resident 279 use of the bathroom as needed.

During an interview on 7/22/2024 at 10:21 AM with Resident 279, Resident 279 stated on 7/21/2024, Resident 279 waited 45 minutes for staff to answer Resident 279's call light during the nighttime shift. Resident 279 stated Resident 279 had to go to the bathroom without assistance from staff because Resident 279 could not wait for staff any longer or Resident 279 would have bowel or bladder incontinence. Resident 279 stated the facility staff took a long time at night to come and help Resident 279. Resident 279 stated Resident 279 had to walk by herself to the bathroom.

During a review of Resident 279's History and Physical (H&P), dated 7/23/2024, the H&P indicated Resident 279 had the capacity to make medical decisions.

During an interview on 7/23/2024 at 2:56 PM with the Director of Nursing (DON), the DON stated call lights should be answered by facility staff immediately but no longer than five minutes. The DON stated residents (in general) could feel frustrated because the residents (in general) were not able to care for themselves. The DON stated residents (in general) would feel worthless if they have to wait too long for their call lights to be answered by staff.

During an interview on 7/24/2024 at 3:11 PM with Resident 120, Resident 120 stated sometimes Resident 120 waited up to 2 hours for facility staff to answer the call light during the night. Resident 120 stated during

these incidents, Resident 120 needed assistance with changing Resident 120's adult brief or assistance with moving Resident 120's legs because Resident 120's legs felt numb. Resident 120 stated Resident 120's legs would go numb because Resident 120 could not move Resident 120's legs due to a spinal cord injury (damage to any part of the spinal cord). Resident 120 stated when Resident 120's legs felt numb, Resident 120 needed help from staff to move the legs. Resident 120 stated moving his legs helped the numbness to go away. Resident 120 stated Resident 120 felt frustrated when Resident 120 waited a long time to get assistance from the facility staff.

b. During a review of Resident 13's AR the AR indicated Resident 13 was admitted to the facility on [DATE REDACTED] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 8 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

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)

F 0550 During a review of Resident 13's MDS, dated [DATE REDACTED], the MDS indicated Resident 13 had severely impaired cognitive skills. The MDS indicated Resident 13 was dependent on staff for toileting, dressing, and bathing. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 15's AR, the AR indicated Resident 15 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including type 2 diabetes mellitus (elevated blood sugar levels), Residents Affected - Some dementia (a group of thinking and social symptoms that interferes with daily functioning), and hypertension (high blood pressure).

During a review of Resident 15's MDS, dated [DATE REDACTED], the MDS indicated Resident 15 had severely impaired cognitive skills (the ability to make daily decisions). The MDS indicated Resident 15 was dependent (helper does all the effort) on staff for bathing, dressing, and toileting.

During a dining observation on 7/22/2024 at 12:56 PM, Resident 15 was sitting at a round table with four other residents (not identified). Speech Therapist 1 (ST 1) was standing at Resident 15's left side. ST 1 was feeding Resident 15 with lunch.

During an interview on 7/22/2024 at 1:05 pm with ST 1, ST 1 stated ST 1 needed to sit next to Resident 15 to be at eye level with the resident while feeding.

During an interview on 7/23/24 at 2:53 PM with the DON, the DON stated facility staff needed to sit down when feeding residents (in general) so the facility staff would be at eye level with the residents. The DON stated standing while feeding a resident would degrade (treat someone with contempt or disrespect) the resident.

During a concurrent observation and interview on 7/24/2024 at 1:11 PM with Activity Assistant 1 (AA 1) , AA 1 was feeding Resident 13 with lunch. AA 1 was standing next to Resident 13. AA 1 stated AA 1 needed to sit down next to Resident 13 when feeding Resident 13.

During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised February 2021, the P&P indicated, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example .promptly responding to a resident's request for toileting assistance . The P&P indicated, Staff are expected to knock and request permission before entering residents' rooms.

During a review of the facility's P&P titled, Answering the Call Light, revised September 2022, the P&P indicated, Answer the resident call system immediately.

During a review of the facility's P&P titled, Assisting the Resident During Meals, revised December 20I3, the P&P indicated, Staff must be seating when feeding residents.

42307

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 8 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

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)

F 0550 c. During a review of Resident 13's AR the AR indicated Resident 13 was admitted to the facility on [DATE REDACTED] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable Level of Harm - Minimal harm or movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic obstructive potential for actual harm pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and asthma (a condition in which a person's airways become inflamed, narrow and swell, and Residents Affected - Some produce extra mucus, which makes it difficult to breathe).

During a review of Resident 13's H&P, dated 9/23/2023, the H&P indicated, Resident 13 could not make decisions.

During a review of Resident 13's MDS, dated [DATE REDACTED], the MDS indicated Resident 13 had severely impaired cognitive skills. The MDS indicated Resident 13 was dependent on staff for toileting, dressing, and bathing.

During a review of Resident 75's AR, the AR indicated, Resident 75 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including end stage renal disease (ESRD, kidneys lose the ability to remove waste and balance fluids) and essential (primary) hypertension (high blood pressure).

During a review of Resident 75's H&P, dated 10/5/2023, the H&P indicated Resident 75 had the capacity to understand and make decisions.

During a review of Resident 75's MDS, dated [DATE REDACTED], the MDS indicated Resident 75 had intact cognition.

During a review of Resident 86's AR, the AR indicated, Resident 86 was admitted to the facility on [DATE REDACTED] with diagnoses including other specified diseases of liver, kidney failure and adult failure to thrive (a decline

in older adults that manifests as a downward spiral of health and ability).

During a review of Resident 86's MDS, dated [DATE REDACTED], the MDS indicated Resident 86 had severely impaired cognitive skills.

During a review of Resident 86's H&P, dated 6/6/2024, the H&P indicated, Resident 86 did not have the capacity to understand and make decisions.

During an observation on 7/23/2024 at 8:59 a.m. Resident 86 was in the room in bed and had a female visitor (unnamed). Resident 13 (Resident 86's roommate) was also in the room. Resident 13 was sitting up in

a wheelchair at Resident 13's bedside. LVN 2 and LVN 7 were observed entering and exiting Resident 86 and Resident 13's room twice without knocking. LVN 2 then opened the restroom without knocking and Resident 75 was inside using the restroom. LVN 2 and LVN 7 stated, staff needed to knock the door to maintain the resident's dignity.

During an interview on 7/24/2024 at 12:30 p.m. with the Director of Nursing, the DON stated, the facility's policy was for staff to knock before entering, introduce themselves and state their purpose. The DON stated,

it was important for staff to knock the door, to show respect to the residents, to maintain dignity and for those residents with impaired vision to identify who the staff was.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 8 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

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)

F 0550 During an interview on 7/24/2024 at 1:06 p.m. with Resident 75, Resident 75 stated, Resident 75 got startled when LVN 2 opened the door to the restroom where Resident 75 was using without LVN 2 knocking first. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Resident Rights, revised December 2019, the P&P indicated, employees should treat all residents with kindness, respect, and dignity. The P&P indicated, a list of Residents Affected - Some resident's rights including right to a dignified existence and be treated with respect, kindness, and dignity.

During a review of the facility's P&P titled, Dignity, revised February 2021, the P&P indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, one of the many policy interpretation and implementation included residents are treated with dignity and respect at all times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

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)

F 0578 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. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48729

Residents Affected - Some Based on interview and record review, the facility failed to ensure the resident's representative was provided education regarding the resident's right to formulate an Advance Directive (AD, a written instruction, such as

a living will or durable power of attorney [legal document that allows someone to act on your behalf in certain situations] for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) and the information was complete and accurate for two of eight sampled residents (Residents 4 and19).

These deficient practices had the potential for the residents to receive life-sustaining care and/or treatment against their will.

Findings :

a.During a review of Resident 4's Admission Record, (AR) dated 7/24/2024, the AR indicated Resident 4 was admitted to the facility on [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), type 2 diabetes mellitus (long term condition

in which a high level of sugar is present in the bloodstream), and heart failure (a condition that develops when one's heart doesn't pump enough blood for the body's needs).

During a review Resident 4's History and Physical (H&P) dated 5/9/2024, the H&P indicated Resident 4 did not have the capacity to understand or make decisions.

During a review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/14/2024, the MDS indicated Resident 4 required maximal assistance (helper does more than half of the effort) for toileting and personal hygiene.

During a concurrent interview and record review on 7/24/2024 at 12:18 PM with Admissions Coordinator (AC), Resident 4's Advance Directive Acknowledgement (ADA) dated 5/8/2024 was reviewed. The ADA indicated the purpose of the form was to acknowledge that the resident or resident representative had been informed of their rights and of all rules and regulations regarding decisions concerning their medical care.

The AC stated the ADA should be signed upon admission within three days. The AC stated the AC could not determine whether Resident 4's Representative understood the written materials provided or Resident 4's right's regarding decisions for their medical care based on the absence of check marks indicating the above.

During a review of the facility's Policy and Procedure (P&P) titled, Advance Directive, dated 12/2016, the P&P indicated upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The P&P further indicated if the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives and nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.

44027

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

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)

F 0578 b.During a review of Resident 19's Admission Record (AR), the AR indicated Resident 19 was admitted to

the facility on [DATE REDACTED] with diagnoses including malignant neoplasm of bronchus or lung (lung cancer), Level of Harm - Minimal harm or muscle weakness, and chronic obstructive pulmonary disease (COPD, a group of diseases that cause potential for actual harm airflow blockage and breathing-related problems). The AR did not indicate who was Resident 19's Responsible Party. Residents Affected - Some

During a review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/1/2024, the MDS indicated Resident 19 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). The MDS indicated Resident 18 was dependent (helper does all the effort) on staff for toileting, dressing, and bathing.

During a review of Resident 19's History and Physical (H&P), dated 6/28/2024, the H&P indicated Resident 19 did not have the mental capacity to understand and make medical decisions.

During a concurrent interview and record review on 7/24/2024 at 11:54 AM with RN 1, Resident 19's POLST, dated 6/24/2024, and Resident 19's Advanced Directive Acknowledgement, dated 6/24/2024, were reviewed. RN 1 and RN 3 signed the documents indicating RN 1 and RN 3 were Resident 19's representative and legally recognized decisionmaker. RN 1 stated RN 1 and RN 3 were instructed to sign Resident 19's documents. RN 1 stated Resident 19 did not have a responsible party to represent Resident 19. RN 1 stated RN 1 did not know if the facility had a Bioethics Committee to make decisions for residents (in general) who were not capable to make decisions and did not have representatives.

During an interview on 7/24/2024 at 12:00 PM with the facility's Administrator (ADM), the ADM stated if a resident was admitted to the facility and did not have a representative, but was self-responsible, the resident could sign their own admission documents (including POLST and AD Acknowledgment). The ADM stated if

the resident did not have a representative and did not have the capacity to make their own decisions, the facility would refer to the facility's Bioethics Committee. The ADM stated the Bioethics Committee would consist of different staff members representing different areas affecting the resident care. The ADM stated nurses alone ( RN1 and RN 3) were not capable to make decisions for the unrepresented resident (in general).

During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised December 2016, the P&P indicated, Upon admission, the resident will be provided with written information concerning

the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative.

During a review of the facility's policy and P&P titled, Bioethics, dated November 2021, the P&P indicated, It is the policy of this facility to uphold the rights of residents to participate in medical de cisions. Sometimes situations arise wherein the decisions may be too complex for the surrogate decision-maker, or there is no surrogate. The P&P indicated, The Bioethics Committee is comprised of at least one physician, facility administrator, and a representative from nursing, social service, activities, dietary, rehabilitation, [NAME] ness office, and other departments as indicated. Furthermore, any facility staff member who has knowledge of the resident may be invited to attend.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

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)

F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48729

Residents Affected - Few Based on interview and record review, the facility failed to notify one of one sampled resident (Resident 14)'s representative of the facility's policy for bed hold.

This failure had the potential for Resident 14's representative to be uninformed of their rights to return to the facility after discharge or transfer.

Findings:

During a review of Resident 14's Admission Record, (AR), the AR indicated Resident 14 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including type 2 diabetes mellitus (long term condition in which a high level of sugar is present in the bloodstream), liver cirrhosis (a type of liver disease where healthy cells are replaced by scar tissue) and hyperlipidemia (excess of fat in the blood).

During a review of Resident 14's History and Physical (H&P) dated 2/27/2024, the H&P indicated Resident 14 did not have the capacity to understand and make decisions.

During a review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 4/23/2024, the MDS indicated Resident 14 was dependent (helper does all the effort to complete

the activity) on staff for toilet use and personal hygiene.

During an interview on 7/25/2024 at 3:23 PM with Admissions Coordinator (AC), AC stated the facility's bed hold notification waw part of the admission's packet and the form needed to be signed again if a resident was discharged and readmitted . The AC further stated during readmission, nursing staff was responsible for communicating with the resident or representative to inform them of their rights. The AC stated the purpose of the bed hold notification form was to inform the resident with Medi-Cal or resident's representative that the facility will save the resident's bed for seven days if they were transferred out of the facility.

During a concurrent interview and record review on 7/25/2024 at 3:45 PM with Licensed Vocational Nurse 4 (LVN 4), Resident 14's Bedhold Notification (BHN) dated 1/31/2023 was reviewed. LVN 4 stated the form was incomplete as evidenced by the absence of Resident 14's representative's signature under Acknowledgement Upon Admission. LVN 4 stated LVN 4 obtained consent over the phone with Resident 14's representative but did not document. LVN 4 stated telephone consent should use two staff to verify consent and the document should be signed by each witness.

During a concurrent interview and record review on 7/25/2024 at 4:36 PM with Director of Nursing (DON), Resident 14's BHN was reviewed. Resident 14's BHN did not indicate consent was obtained from Resident 14's representative. The DON stated if resident's representative cannot come to the facility to obtain consent,

it can be obtained over the phone and staff should document who gave consent and add a signature of the witness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 555729