Health inspection·September 1, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to give appropriate care to Resident 1 ' s indwelling catheter tubing (a tube secured inside the bladder to drain urine into a bag outside the body). This failure resulted in Resident 1 having a urinary tract infection (UTI, an infection in any part of the urinary tract - kidneys, bladder, or urethra). Findings: A review of Resident 1's admission Record dated 7/14/23, indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of a history of UTI. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/2/23, indicated the resident was usually able to understand others and usually understood by others. Resident 1 was totally dependent on one-person for toilet use (how resident cleanses self after elimination). Resident 1 had an indwelling urinary catheter, and the resident was always incontinent (unable to control) of bowel movement. A review of Resident 1's care plan titled, Indwelling Catheter, dated 5/26/23, indicated Resident 1 had an indwelling urinary catheter placed due to urinary retention (inability to empty all the urine from the bladder). The care plan indicated a long-term goal to show no signs and symptoms(s/sx) of urinary Infection through the review date. The target date was 8/14/23. The interventions included to clean peri-area (perineal which is the sensitive skin between the anus and vaginal opening), front to back, monitor/record/report to MD for s/sx of UTI: pain, burning, blood-tinged urine, cloudiness, no output, and deepening of urine color. During a review of Resident 1 ' s physician ' s orders dated 7/14/23, indicated the following orders: 1. indwelling catheter size Fr.(french) 18/30 (size or gauge/ milliliter- amount to inflate the retention balloon to prevent catheter from being expelled), 2. secure indwelling catheter to an anchoring device/leg strap to prevent movement of the catheter; and 3. to cleanse indwelling catheter site with water and soap every shift. Furthermore, Resident 1 was to receive antibiotics (antibacterial medication) for UTI, on 5/24/23, 6/24/23, and 7/12/23, indicating Resident 1 had three repeated episodes of acquiring a UTI in the span of three months after being admitted to the facility. During an interview on 8/7/23 at 3:05 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, he was the current regular night shift CNA assigned to Resident 1 and had been taking care of Resident 1 for a few months. CNA 1 stated, he never gave peri-care (cleaning of the private area) and Page 1 of 4 055212 055212 09/01/2023 The Vineyards Healthcare Center 76 Fenton Street Livermore, CA 94550

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indwelling catheter care to Resident 1 because she did not have a bowel movement on all the nights when CNA 1 was taking care of the resident. CNA 1 further stated he was only supposed to give peri-care if Resident 1 had a bowel movement. CNA 1 also stated, he did not receive training on indwelling catheter care. Review of the CNA night shift monthly schedule for the months of, June 2023 and July 2023, indicated CNA 1 worked in the facility for 16 nights out of 30 days in June 2023 and 18 nights out of 31 days in July 2023. During a concurrent observation and interview on 8/10/23, at 9:33 a.m., in Resident 1's room, with Director of Staff Development (DSD), DSD looked at Resident 1's indwelling catheter tubing. DSD stated the indwelling catheter attached to the resident was size Fr.16/30 (smaller sized catheter than the physician ' s order size of Fr.18/30). DSD looked if the indwelling catheter was securely anchored and stated that the indwelling catheter was not securely anchored to an anchoring device. DSD acknowledged that the indwelling catheter size should be the correct size ordered by the physician due to the risk of leaking of urine from the urethra if the catheter was smaller. DSD further stated, the risk of the indwelling catheter not being securely anchored was for Resident 1 to experience pain and dislodgement (accidental removal) of the catheter if the catheter was accidentally pulled. During an interview on 8/10/23, at 10:37 a.m., with Director of Nursing (DON), DON stated, she expected the CNA to give peri-care for residents with indwelling catheter 2 times in every shift by using soap and water to prevent UTI. Stated the indwelling catheter of Resident 1 should be the correct size ordered by the physician. DON further stated the indwelling catheter should be anchored to prevent bleeding from the urethra if the catheter was pulled accidentally. During a review of the facility ' s policy and procedure (P&P) titled, Catheter Care, Urinary, dated 2014, indicated, . Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site . catheter tubing should be strapped to the resident ' s inner thigh . Wash the resident ' s genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry . 055212 Page 2 of 4 055212 09/01/2023 The Vineyards Healthcare Center 76 Fenton Street Livermore, CA 94550

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure CNA 1 had the appropriate competencies and skills sets for providing proper care of the indwelling catheter (a tube secured inside the bladder to drain urine into a bag outside the body). This failure did not ensure Resident 1 received indwelling catheter care per physician's order and contributed to acquiring a urinary tract infection. (UTI), an infection in any part of the urinary tract - kidneys, bladder, or urethra. Findings: A review of Resident 1's admission Record dated 7/14/23, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of having a history of UTI. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 5/2/23, indicated Resident 1 was totally dependent on one-person for toileting. The MDS also indicated Resident 1 had an indwelling urinary catheter and resident was always incontinent (unable to control) bowel movement. During a review of Resident 1 ' s physician ' s orders, dated 7/14/23, indicated orders of: 1. indwelling catheter size Fr. 18/30, 2. secure indwelling catheter to an anchoring device/leg strap to prevent movement of the catheter; and 3. to cleanse indwelling catheter site with water and soap every shift. (Fr. Is short for French gauge, Fr. is commonly used to measure the size of a catheter; an anchoring device prevents the accidental pulling of the catheter and protects the resident ' s urethra, urethra is the opening that lets urine out of the body). The physician ' s orders also indicated Resident 1 received antibiotic (antibacterial medication) treatment for UTI on 5/24/23, 6/24/23 and 7/12/23, for three prior episodes of UTIs since admission. During an interview on 8/7/23 at 3:05 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, he was the current regular night shift CNA assigned to Resident 1 and had been taking care of the resident for a few months. CNA 1 stated, he never gave peri-care (cleaning of the private area) and indwelling catheter care to Resident 1 because she did not have a bowel movement on all of the nights when CNA 1 was taking care of the resident. CNA 1 further stated he was only supposed to give peri-care if Resident 1 had a bowel movement. CNA 1 also stated, he did not get training on indwelling (Foley) catheter care from the facility. Review of CNA night shift monthly schedule for the months of June 2023 and July 2023 indicated, CNA 1 worked in the facility for 16 nights out of 30 days in June 2023 and 18 nights out of 31 days in July 2023. During a concurrent interview and record review on 8/10/23, at 9:33 a.m., with Director of Staff Development (DSD), Inservice Training's for Certified Nurse Assistants for Peri-care (cleaning genital/urinary area) and Foley Catheter Care Attendance Sheets,dated 4/6/23 and 6/29/23 were reviewed. The inservice training attendance sheets indicated CNA 1 was not present on both training dates. DSD acknowledged, CNA 1 did not have peri-care and Foley catheter care training. Furthermore, DSD stated the risk of not having the training indicated CNA 1 was giving poor catheter care to residents with a 055212 Page 3 of 4 055212 09/01/2023 The Vineyards Healthcare Center 76 Fenton Street Livermore, CA 94550

F 0726 Foley catheter. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/10/23, at 10:37 a.m., with Director of Nursing (DON), DON stated, she expected the CNA to give peri-care for residents with indwelling catheter two times, every shift by using soap and water to prevent UTI. Residents Affected - Few During a review of the facility ' s policy and procedure (P&P) titled, Urinary tract infections (catheterassociated), guidelines for preventing, dated 2017, indicated, .Do not insert or maintain a urinary catheter unless you have been properly trained and demonstrated competency in this area. 055212 Page 4 of 4