Health inspection·February 13, 2024

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who required hemodialysis (HD or dialysis – a process of purifying the blood of a person whose kidneys are not working normally through a machine that removes blood from your body, filters it through a dialyzer [artificial kidney] and returns cleansed blood back to the body) treatment, received care in accordance with standards of practice by failing to ensure Resident 1 ' s order for Vancomycin (a medication used to treat serious bacterial infections) intravenous (IV - a method of putting fluids, including drugs, into the bloodstream) therapy was transcribed (documented) in the resident ' s physician orders. Residents Affected - Few These deficient practices had the potential to place the resident at risk for unidentified complications of the antibiotic (medication that treats infection) medication administered during the dialysis treatment. Findings: A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 4/27/2023 and readmitted Resident 1 on 1/5/2024 with diagnoses that included end stage renal (kidney) disease (ESRD - kidneys are no longer able to work as they should to meet the body's needs) dependent on renal dialysis. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/6/2024, indicated Resident 1 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 1 had moderately impaired cognition (the mental actions or process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance from staff with mobility (movement). A review of Resident 1 ' s general acute care hospital 1 (GACH 1) Infectious Disease Progress Notes dated 1/5/2024 indicated that Resident 1 had Methicillin-Resistant Staphylococcus Aureus (MRSA - a type of bacteria that is resistant to several antibiotics) bacteremia (a medical condition wherein there is a presence of bacteria in the blood) and the treatment plan was to administer IV Vancomycin with hemodialysis for six (6) weeks starting from 12/27/2023. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 2/13/2024 at 11:47 a.m., RN 1 reviewed Resident 1 ' s physician orders from 1/5/2024 to 2/13/2024 and stated that there were no vancomycin orders for Resident 1. RN 1 stated that Resident 1 ' s IV vancomycin should be included in the physician orders of the facility even though the IV vancomycin is being administered at the dialysis center. RN 1 stated that since Resident 1 ' s IV vancomycin order was not entered in the physician order, licensed nurses from the facility might be unaware that Resident 1 is on Page 1 of 4 055146 055146 02/13/2024 North Valley Nursing Center 7660 Wyngate St Tujunga, CA 91042

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few antibiotic treatment. RN 1 stated that facility licensed nurses who are unaware that Resident 1 was receiving antibiotic treatment while at HD, would be unable to monitor for adverse reactions of vancomycin. During an interview and record review with Director of Nursing (DON) on 2/13/2024 at 12:25 p.m., DON stated, the facility did not include Resident 1 ' s IV vancomycin orders in the physician ' s orders because Resident 1 received medications during the dialysis treatment at the dialysis center. A review of the facility ' s policy and procedure titled, Hemodialysis last revised on 6/5/2023, indicated, The facility will coordinate and collaborate with the dialysis facility to assure that Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist (a medical doctor who specializes in diagnosing and treating kidney conditions), attending practitioner and dialysis team The licensed nurse will communicate to the dialysis facility via telephone communication or written format such as a dialysis communication form or other form, that will include, but not limit itself to Physician/treatment orders, laboratory values, and vital signs. 055146 Page 2 of 4 055146 02/13/2024 North Valley Nursing Center 7660 Wyngate St Tujunga, CA 91042

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to assess and document the dialysis access sites accurately and completely for two of two sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in confusion regarding Resident 1 and Resident 2 ' s access site condition and in identifying the patency of the dialysis access site that could lead to a delay in receiving hemodialysis (HD or dialysis – a process of purifying the blood of a person whose kidneys are not working normally through a machine that removes blood from your body, filters it through a dialyzer [artificial kidney] and returns cleansed blood back to the body) treatment. Findings: 1. A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 4/27/2023 and readmitted Resident 1 on 1/5/2024 with diagnoses that included end stage renal (kidney) disease (ESRD - kidneys are no longer able to work as they should to meet the body's needs) dependent on renal dialysis. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/6/2024, indicated Resident 1 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 1 had moderately impaired cognition (the mental actions or process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance from staff with mobility (movement). A review of Resident 1 ' s physician order dated 5/13/2023, indicated to monitor the resident ' s hemodialysis access site of arteriovenous fistula (AVF - a special connection that is made by joining a vein onto an artery for dialysis treatment) located on the left upper arm every shift and to document by using the values as follows: · R = Redness, S = Swelling, B = Bleeding, and P = Pain · For bruit (the sound of blood flowing) and thrill (a fine tremor or vibration): P = Present, A = Absent, notify the physician if absent. During a concurrent interview and record review with Licensed Vocational Nurse 2 (LVN 2) on 2/13/2024 at 9:42 a.m., LVN 2 reviewed Resident 1 ' s Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional at a skilled nursing facility) for the monitoring of Resident 1 ' s left upper arm AVF. LVN 2 stated that on 12/6/2023, 12/12/2023, and 12/14/2023, LVN 2 documented a plus sign (+) to indicate Resident 1 ' s bruit and thrill was present rather than using the values A for absent or P for present as indicated in the physician orders. LVN 2 stated that by using the values as per the instruction of the physician, it can lead to confusion in care and delivery of services to Resident 1. 2. A review of Resident 2 ' s admission Record indicated the facility originally admitted the resident on 5/10/2023 and readmitted Resident 2 on 1/7/2024 with diagnoses that included ESRD dependent on renal dialysis. 055146 Page 3 of 4 055146 02/13/2024 North Valley Nursing Center 7660 Wyngate St Tujunga, CA 91042

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 2 ' s MDS dated [DATE], indicated Resident 2 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 2 had moderately impaired cognition and required maximum assistance from staff with mobility. A review of Resident 2 ' s physician order dated 1/7/2024, indicated to monitor the resident ' s hemodialysis access site of AVF located on the left upper arm every shift and to document by using the values as follows: · For bruit and thrill: P = Present, A = Absent, notify the physician if absent. During a concurrent interview and record review with Licensed Vocational Nurse 3 (LVN 3) on 2/13/2024 at 10:46 a.m., LVN 3 reviewed Resident 2 ' s MAR for the monitoring of Resident 2 ' s left upper arm AVF. LVN 3 stated that on 1/9/2024 and 1/10/2024, LVN 3 documented the number zero (0) in each category to indicate that there were no issues noted during the assessment of Resident 2 ' s access site. LVN 3 stated licensed nurses should utilize the values as indicated in the physician order and that licensed nurses should document accurately in the MAR. During an interview with the DON on 2/13/2024 at 12:25 p.m., DON stated that when documenting on a resident ' s medical record, facility staff should use the instructed values on each form to ensure consistency throughout the duration of care, and to prevent confusion. A review of the facility ' s policy and procedure (P&P) titled, Hemodialysis last revised on 6/5/2023, indicated, The nurse will ensure that the dialysis access site is checked before and after dialysis treatments and every shift for patency (unobstructed) by auscultating (listening) for a bruit and palpating (feeling) for a trill. If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist. A review of the facility ' s P&P titled, Documentation in Medical Record last revised on 12/19/2022 and last reviewed on 1/10/2024, indicated, Each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care Only standardized terminology, acronyms, and symbols may be used. 055146 Page 4 of 4