Health inspection·December 13, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview, facility document and policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to retransmit Minimum Data Set (MDS) assessments within required timeframes for 8 (Residents #86, #67, #121, #108, #136, #22, #56, and #65) of 29 residents reviewed for MDS requirements. Residents Affected - Some Findings included: A review of a facility policy titled, MDS, Minimum Data Set/Resident Assessment Instrument, effective on 05/27/2015, revealed, It is the policy of this facility to complete the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) in accordance with the regulations, timeframes and guidelines set forth by OBRA [Omnibus Budget Reconciliation Act]-required and Medicare-required assessments. A review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.18.11, revised in October 2023, revealed in Chapter 2: Assessments for the RAI that a Significant Correction to a Prior Quarterly assessment occurred. The manual further specified, a Significant Correction to Prior Comprehensive day after determination that significant error in prior comprehensive assessment occurred] + 7 calendar days. A review of an MDS 3.0 Final Validation Report revealed the following MDS assessments were Rejected on 11/04/2023: - Resident #86's quarterly MDS, with an Assessment Reference Date (ARD) of 10/25/2023; - Resident #67's quarterly MDS, with an ARD of 10/24/2023; - Resident #121's quarterly MDS, with an ARD of 10/26/2023; - Resident #108's annual MDS, with an ARD of 10/24/2023; - Resident #136's quarterly MDS, with an ARD of 10/27/2023; - Resident #22's quarterly MDS, with an ARD of 10/25/2023; Page 1 of 4 055211 055211 12/13/2023 Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087

F 0640 - Resident #56's quarterly MDS, with an ARD of 10/26/2023; and Level of Harm - Minimal harm or potential for actual harm - Resident #65's quarterly MDS, with an ARD of 10/26/2023. Residents Affected - Some During an interview on 12/13/2023 at 9:10 AM, the MDS Coordinator stated the facility received a validation report from CMS when they transmitted MDS assessments to let them know if there were any errors. He stated if there were any errors, they should be corrected and retransmitted right away. The MDS Coordinator said in October 2023, there was an issue when the MDS system changed, and he had to resubmit several MDSs. He further stated he missed resubmitting the rejected MDS assessments for Residents #86, #67, #121, #108, #136, #22, #56, and #65. During an interview on 12/13/2023 at 2:16 PM, the Administrator stated she expected MDS assessments to be submitted timely. 055211 Page 2 of 4 055211 12/13/2023 Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure podiatry care, specifically toenail care, was provided for 1 (Resident #130) of 2 sampled residents reviewed for activities of daily living (ADLs). Residents Affected - Few Findings included: A review of a facility policy titled, Fingernails and Toenails, Care of, effective 09/01/2013, revealed, Fingernails and toenails are cleaned and trimmed regularly. Only podiatrists, physicians or licensed nurses provide nail care to diabetic residents, or residents with severe circulatory impairment. A review of an admission Record revealed the facility admitted Resident #130 on 09/27/2023. According to the admission Record, the resident had a medical history to include a diagnosis of need for assistance with personal care. The admission Record did not reflect a diagnosis of diabetes, circulatory impairment, or any nailbed abnormalities. A review of Resident #130's Care Plan revealed a Focus area, initiated 09/27/2023, that indicated the resident had an ADL self-care performance deficit related to impaired physical mobility. Interventions directed staff to assist Resident #130 with personal hygiene and to check nail length and trim and clean as necessary on bath days. A review of an Order Summary Report, listing active orders as of 12/13/2023, revealed Resident #130 had an active order started on 10/03/2023 to Check resident's Nails and Trim/clip as appropriate, to be done every Tuesday. On 12/11/2023 at 1:35 PM, Resident #130 was observed to have long toenails on both feet. Their big toenails were approximately three quarters of an inch off the tips of the toes, and nails two through four were approximately a quarter of an inch off the tips of the toes. The fifth toenails on both feet were approximately a half an inch off the tips of the toes. During an interview on 12/12/2023 at 1:30 PM, Licensed Vocational Nurse (LVN) #5 stated that residents' nails were trimmed once per week. LVN #5 stated that the certified nursing assistants (CNAs) conducted nail care unless a resident had diabetes, noting nail care fell to the podiatrist for residents with diabetes. During an interview on 12/12/2023 at 1:40 PM, LVN #6 stated residents had their toenails trimmed every Tuesday. LVN #6 stated the CNAs were responsible for trimming the residents' toenails. During an observation on 12/13/2023 at 11:31 AM, LVN #2 checked Resident #130's feet and stated that their toenails were too long. During an interview on 12/13/2023 at 12:36 PM, the Assistant Director of Nursing (ADON) stated the nurses or podiatrist trimmed the toenails of diabetic residents and confirmed Resident #130 did not have a diagnosis of diabetes. The ADON confirmed staff could trim Resident #130's toenails. 055211 Page 3 of 4 055211 12/13/2023 Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, record review, and facility policy review, the facility failed to ensure the head of bed (HOB) was elevated 30 degrees during the infusion of enteral feeding as ordered by a physician for 1 (Resident #68) of 2 sampled residents reviewed for tube feeding management. Findings included: A review of a facility policy titled, Enteral Therapy (Tube Management, Feeding, Medications), effective on 09/01/2013, revealed, POLICY Enteral nutrition is provided in a safe and effective manner to promote nutritional well-being and prevent complications of enteral therapy, as ordered by the physician. The section of the policy titled II. Administration of Enteral Feeding / Nutrition, C. Procedure for Feeding Pump Method: specified, 3. Ensure head of bed is elevated minimum of 30-45 degrees before starting the feeding. A review of an admission Record revealed the facility admitted Resident #68 on 01/20/2022. According to the admission Record, the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing) and pneumonitis due to inhalation of food and vomit. A review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/2023, revealed a Staff Assessment for Mental Status (SAMS) concluded Resident #68 had a shortand long-term memory problems and severely impaired cognitive skills for daily decision making. According to the MDS, Resident #68 received 51 percent or more of their daily calories through a parenteral or tube feeding and 501 cubic centimeters per day or more of their average daily fluid intake per day by intravenous line or tube feeding during the entire seven-day assessment look-back period. A review of an Order Summary Report, listing active orders as of 12/13/2023, revealed a physician's order dated 09/19/2023 to Elevate HOB 30 degrees during feeding and one hour after feeding. On 12/13/2023 at 8:23 AM, Resident #68 was in bed while their tube feeding infused. Per the observation, the resident's HOB did not appear to be at the proper level. During an interview on 12/13/2023 at 8:58 AM, Licensed Vocational Nurse (LVN) #6 stated that the HOB should be elevated to prevent aspiration. LVN #6 stated that staff frequently checked the HOB by eyeballing it to ensure it was elevated appropriately. During an interview on 12/13/2023 at 9:06 AM, LVN #6 stated Resident #68's HOB was too low. During an interview on 12/13/2023 at 9:10 AM, LVN #2 stated that, during tube feedings, a resident's HOB should be elevated between 30 and 90 degrees beginning an hour before the tube feeding until an hour after the tube feeding was stopped. LVN #2 said staff checked the angle of the HOB visually and said if the HOB was not elevated high enough, there was a risk for aspiration. On 12/13/2023 at 1:38 PM, the Director of Nursing (DON) and Administrator were interviewed concurrently. They stated that when a tube feeding was given, the resident's HOB should be elevated 30 to 45 degrees. They stated the nurses did not measure the angle of a resident's HOB, but rather became familiar with what 30 degrees looked like. They stated that the nurses were supposed to check the elevation of a resident's HOB frequently. 055211 Page 4 of 4