Health inspection·February 10, 2023

The following reflects the findings of the California Department of Public Health during Survey Re-Certification Event ID: 974U11. Representing the Department, Nutrition Consultant #34975. State Citation B was written. §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Title 22, § 72501 - Licensee -General Duties (a) The licensee shall be responsible for compliance with licensing requirements and for the organization, management, operation and control of the licensed facility. The delegation of any authority by a licensee shall not diminish the responsibilities of such licensee. (b) The licensee, if an administrator, may act as the administrator or shall appoint an administrator, to carry out the policies of the licensee. A responsible adult who is knowledgeable in the policies and procedures of the licensee shall be appointed, in writing, to carry out the policies of the licensee in the absence of the administrator. If the administrator is to be absent for more than 30 consecutive days, the licensee shall appoint an acting administrator to carry out the day-to-day functions of the facility. (c) The licensee shall delegate to the designated administrator, in writing, authority to organize and carry out the day-to-day functions of the facility. (d) Except where provided for in approved continuing care agreements, or except when approved by the Department, no facility owner, administrator, employee or representative thereof shall act as guardian or conservator of a patient therein or of that patient's estate, unless that patient is a relative within the second degree of consanguinity. (e) The licensee shall employ an adequate number of qualified personnel to carry out all the functions of the facility and shall provide for initial orientation of all new employees, a continuing in-service training program and competent supervision. (f) If language or communication barriers exist between skilled nursing facility staff and patients, arrangements shall be made for interpreters or for the use of other mechanisms to ensure adequate communication between patients and personnel. (g) The Department may require the licensee to provide additional professional, administrative or supportive personnel whenever the Department determines through a written evaluation that additional personnel is needed to provide for the health and safety of patients. (h) The licensee shall ensure that all employees serving patients or the public shall wear name and title badges unless contraindicated. On 12/12/22, an unannounced visit for a recertification survey was conducted to verify facility compliance with federal conditions of participation. The recertification survey continued until 12/16/22. The facility failed to ensure nursing staff demonstrated appropriate competencies and skillsets necessary to care for residents' needs when: 1. The physician prescribed food texture was not verified before serving food to residents. 2. Certified Nursing Aide 3 (CNA 3) did not have the knowledge to identify the appropriate food texture in accordance with the diet order before serving food to a resident. These failures had the potential for Resident 34, a resident with known swallowing difficulties, to aspirate (to breath foreign objects into the lungs) when he was served a regular diet instead of the physician prescribed full liquid diet (A full liquid diet are foods that are liquid and/or turn into a liquid when at room temperature and/or body temperature.) which had the potential to result in pneumonia, hospitalization and death. Review of the document titled, "Admission Record," showed Resident 34 was admitted to the facility on 12/4/2022 with diagnoses including but not limited to dysphagia pharyngoesophageal phase (difficulty or discomfort in swallowing when food passes into the esophagus, the tubular passage that runs from the throat to the stomach), dysphagia oropharyngeal phase (swallowing difficulty occurring in the mouth and/or throat), malignant neoplasm of the esophagus (cancer of the esophagus), severe protein-calorie malnutrition (a condition expressed if the patient has two or more of the following characteristics: obvious significant loss of muscle; less than 50 percent of recommended nutritional intake for at least 2 weeks; bedridden or significantly reduced functional capacity; significant weight loss), and cachexia (a general state of ill health involving marked weight loss and muscle loss). Review of the Minimum Data Set (an assessment tool used to guide care) dated 12/6/22, showed Resident 34 had a Brief Interview for Mental Status score of 11. (The Brief Interview for Mental Status is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A score of thirteen to fifteen is an indication of intact cognitive status; a score of 11 is an indication of moderate impairment.) Review of the document from the hospital titled, "Discharge Instructions/Summary," dated 12/4/22, showed the discharge diet for Resident 34 was "full liquid diet". Review of the document titled, "Progress Notes," dated 12/4/22, showed a hospital discharge note from a physician. The note showed Resident 34 was in the hospital with malnutrition from chronic esophagitis (inflammation that damages the esophagus), and esophageal stricture (abnormal narrowing of the esophagus). Review of the documentation titled "Order Summary Report," dated 12/15/22, showed a diet order with a start date of 12/13/2022 and no end date for "Full liquid diet, Full Liquid Texture, Nectar consistency (a liquid that is easily pourable and comparable to heavy syrup found in canned fruit)." Review of the document titled, "Nutritional Risk Assessment," dated 12/12/2022, showed under the section "D. Goal/Interventions" a diet order for Resident 34 of "Full Liquid, NTL (Nectar Thick Liquids)." On 12/13/22 at 12:21 p.m., observation and concurrent interviews with Certified Nursing Assistant 3 (CNA 3) and Licensed Vocational Nurse 1 (LVN 1), showed carts holding resident meal trays left the kitchen. One cart was wheeled to the end of the hallway and CNA 3 served the meal trays from the cart to residents in their rooms. One tray on this cart was for Resident 34. The tray ticket showed diet order for this resident was "Full Liquid." CNA 3 removed the tray from the cart and served the tray to the resident who was in his bed. CNA 3 removed the lid from the plate of food and set up the resident's drinks. The food on the resident's plate included a chicken enchilada (an enchilada is a rolled tortilla with a filling such as meat or cheese and served with a chili sauce) with melted cheese on top and the edges of the enchilada appeared it was cook well with brown, crispy edges; a scoop of rice mixed with pieces of corn; and refried beans. The surveyor asked CNA 3 if the texture of food was correct for this resident. CNA 3 stated yes, it was pureed food, so it was okay. The resident began to eat. The surveyor asked the CNA to stop the resident from eating until the diet could be clarified. The surveyor immediately asked Licensed Vocational Nurse 1 (LVN 1), who was in the hallway, to check Resident 34's tray for accuracy. LVN 1 stated the tray was incorrect and removed the food from the resident's room; LVN 1 stated Resident 34 had received a Regular tray instead of a Full Liquid tray. LVN 1 stated it was not her job to check all resident trays for accuracy before they were served, the certified nursing assistants were expected to check the trays. In an interview on 12/13/22 at 12:40 p.m., CNA 3 stated she did not know what a full liquid diet was. Review of the facility document, "Diet Manual for Long Term Care and Residential Facilities 2020," signed by the RD on 11/17/21, showed the Full Liquid diet consisted of foods which are liquid or become liquid at body temperature and are easily digested. In an interview on 12/13/22 at 3:30 p.m., the DON stated she expected nursing staff to lift-up the lid on the plate and compare the texture of the food to the diet order on tray ticket to ensure the texture was correct. In an interview on 12/14/22 9:20 a.m., Resident 34 stated since he got back from the hospital, staff always took away food that was served to him saying he could not have it. In an interview on 12/15/22 at 9:25 a.m., Registered Dietitian 1 (RD 1) stated Resident 34 came into the facility from the hospital on a full liquid diet, and she had completed Resident 34's Nutrition Risk Assessment on 12/12/22. RD 1 stated in her assessment she had recommended Resident 34 continue the full liquid diet, which was in accordance with the recommendation from the hospital discharge summary and the speech therapist (expert in helping people with speech impediments and/or swallowing disorders), who had both recommended Resident 34 be on a full liquid diet. Review of the document titled, "Speech Therapy SLP (Speech and Language Pathologist) Evaluation and Plan of Treatment," dated 12/7/22, showed in the Assessment Summary, "Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: ... aspiration." Under recommendations, the diet recommendation showed for solid food "puree consistencies (smooth texture food that chewing is not required. This texture is held together with just enough structure and is slippery enough so the food can be moved from the front of the mouth to the back and swallowed with minimal effort)." In an interview on 12/16/22, at 11:41 a.m., the Speech and Language Pathologist (SLP) stated her swallow evaluation for Resident 34 showed he could tolerate a pureed diet. The SLP stated she had not recommended Resident 34's diet be upgraded from Full Liquid to Pureed because she was told the gastroenterologist (physician trained to diagnose and treat problems in the stomach, intestines, and liver) wanted Resident 34 to remain on a Full Liquid diet until the gastroenterologist could evaluate Resident 34, who had ongoing vomiting issues. Review of the policy and procedure titled, "Tray Identification," dated 2001 and revised April 2007, showed, "Nursing staff shall check each food tray for the correct diet before serving the residents." Review of the Academy of Nutrition and Dietetics Nutrition Care Manual, accessed 12/20/22, indicated thicker and harder food items require greater effort in oral processing and swallowing, and providing hard or complex-textured food to people with dysphagia has resulted in death. Review of a published article located in the National Institute of Health, National Library of Medicine, "Nutritional Intake and Meal Composition of Patients Consuming Texture Modified Diets and Thickened Fluids: A Systematic Review and Meta-Analysis," dated 2020, indicated dysphagia can lead to negative complications such as aspiration pneumonia (pneumonia caused by breathing in foreign objects into the lungs) or sudden death from choking. The article indicated use of texture-modified foods can reduce aspiration and choking risks in patients with oropharyngeal dysphagia. In violation of the above cited standards, the facility failed to ensure nursing staff demonstrated appropriate competencies and skillsets necessary to care for residents' needs when: 1. The physician prescribed food texture was not verified before serving food to residents. 2. Certified Nursing Aide 3 (CNA 3) did not have the knowledge to identify the appropriate food texture in accordance with the diet order before serving food to a resident. These failures had the potential for Resident 34, a resident with known swallowing difficulties, to aspirate (to breath in or inhale foreign objects into the lungs) when he was served a regular diet instead of the physician prescribed full liquid diet, (A full liquid diet are foods that are liquid and/or turn into a liquid when at room temperature and/or body temperature.) which had the potential to result in pneumonia, hospitalization, and death.