Health inspection·June 12, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that one of two sampled residents, Resident 1, received care in accordance with his comprehensive person-centered care plan based on his comprehensive assessment and per his doctor's orders regarding Resident 1's medical diagnosis of dysphagia (difficulty swallowing), when on 5/24/24, Certified Nursing Assistant A (CNA A) offered Resident 1 ice chips (considered as Transitional Food- Food that starts at one texture (e.g. firm solid) and changes into another texture specifically when moisture (e.g. water or saliva) is applied or, when a change in temperature occurs (e.g. heating). This failure had the potential to result in aspiration pneumonia (Aspiration pneumonia occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) to Resident 1. Residents Affected - Few Findings. A review of Resident 1's hospital Discharge Summary Notes, dated 5/24/24, at 3:29 p.m., indicated Resident 1 was admitted to this hospital from [DATE] to 5/24/24. Resident 1's discharge diagnoses included a recurrent aspiration pneumonia and was treated with different kinds of antibiotics. Resident 1's post -discharge orders indicated that he should be on a Dysphagia Diet, with food consistency of Level 4 (Puree) and liquids at Level 3 (Moderately/Honey Thick). A review or Resident 1's admission Record, indicated he was readmitted back to his former facility on 5/24/24. A review of Resident 1's MDS (Minimum Data Set-is part of the federally mandated process for assessing individuals receiving care in certified skilled nursing facilities regardless of payer source) dated April 30, 2024, Section I, Active Diagnoses, indicated, Resident 1 had Dysphagia, oral phase (swallowing problems occurring in the mouth and/or the throat). A review of Resident 1's Order Summary Report, dated and signed by his attending physician on 5/29/24, indicated under Dietary-Diet, Low fat/Low cholesterol/NAS (No Added Salt) diet, Pureed texture, Moderately thick (L3-level 3 honey) consistency. A review of Resident 1's dysphagia focused Care Plan, initiated on 5/25/24, by the facility's Speech Therapist, indicated the goal of this care plan, Resident (Resident 1) displays ability to safely swallow, as evidenced by absence of aspiration, no evidence of coughing or choking during eating, ability to ingest foods/fluids through the next review date of 9/1/24, indicated under interventions/tasks, Diet as ordered, .Diet texture modifications indicated, .Thickened liquids Honey, During an interview on 6/12/24, at 3:40 p.m., with CNA A, he stated he came on his PM (afternoon) Page 1 of 2 055093 055093 06/12/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift and did not know that that Resident 1's diet had changed. CNA A stated Resident 1's brother talked to him about Resident 1 being given ice chips. CNA A stated he admitted to Resident 1's brother that he gave the ice chips to Resident 1. CNA A stated that he did not get report from the outgoing certified nursing assistants or the nurse in charge that Resident 1's diet had changed. During an interview on 6/12/24, at 4:55 p.m., with the facility's RD (Registered Dietitian), she stated if Resident 1 was given ice chips while his diet order stated honey thick, Resident 1 could have aspiration pneumonia again. The RD stated that ice chips was not a honey thick consistency liquid. During an interview on 8/20/24, at 11:53 a.m., with the facility's DON (Director of Nursing) she stated that it was her expectation that the facility's nursing staff are following diet orders and implementing the care plans of the residents. The DON stated that it was the responsibility of the nurse in charge to let the aides (Certified Nursing Assistants) know if there were changes in the diet orders or changes in a resident's care plans. During an interview on 8/20/24, at 1:18 p.m., with Resident 1's Attending Physician, she stated she expected the facility staff to follow the physician's orders and care plans for Resident 1. A review of a facility policy and procedure (P&P) titled, Therapeutic Diets, (A therapeutic diet is a meal plan that controls the intake of certain foods or nutrients. It is part of the treatment of a medical condition and are normally prescribed by a physician and planned by a dietician. A therapeutic diet is usually a modification of a regular diet) are prescribed by the Attending Physician to support the resident's treatment and plan of care in accordance with his or her goals and preferences. A review of the Complete IDDSI (International Dysphagia Diet Standardization Initiative) Framework Detailed Definitions 2.0, dated July 2019, indicated that ice chips, was classified under transitional foods. 055093 Page 2 of 2