Health inspection·February 22, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote care in a manner that maintain resident dignity and respect for one of two residents (Resident 1) when certified nursing assistant C (CNA C) told Resident 1 to urinate in diaper instead of assisting her to the bathroom. This failure had the potential to affect Resident 1's self-esteem and feel less self-worth that may lead to emotional distress. Findings: Review of Resident 1's medical record indicated diagnoses that included compression fracture of fourth lumbar vertebrae, radiculopathy (lumbar region), sciatica, low back pain, calculus of gall bladder with chronic cholecystitis, diaphragmatic hernia, diabetes mellitus, neuralgia, neuritis, and depression. Review of Resident 1's minimum data set (MDS, a resident comprehensive assessment and care screening tool) dated 9/28/23 indicated her brief interview for mantal status' (BIMS) score was 8 (a score of 8-12, means resident cognition is moderately impaired). She can understand others and make herself understood by others. Review of Resident 1's bladder and bowel assessment dated [DATE] indicated she is alert and oriented and sometimes aware of need to toilet. She needed one-person assistance to go to bathroom. Resident 1 is potential for scheduled toileting. Review of Resident 1's nursing care plan dated 4/1/23 indicated, toilet Resident 1 upon rising and before or after meals, at bedtime and as needed as tolerated. Scheduled toileting plan and reinforce habit training. During an interview with CNA C on 1/3/24 at 7 :05 a.m., she stated she told Resident 1 to urinate in her diaper so CNA C can easily change Resident 1 in bed on 12/21/23 prior the episode of fall at 5:00 p.m. CNA C stated Resident 1 still insisted on going to the bathroom and urinated in the toilet. During an interview with the assistant director of nursing (ADON) on 1/24/24 at 11:46 a.m., ADON stated CNA C should have not encouraged Resident 1 to urinate in the diaper. ADON stated CNA C should have promoted Resident 1's dignity. During an interview with the director of nursing (DON) 2/22/24 at 10:52 a.m., DON stated it is not acceptable for CNA C to tell Resident 1 to urinate in diaper. The DON acknowledged CNA C should have promoted and maintained Resident 1's independence and dignity. Page 1 of 8 055315 055315 02/22/2024 Camino Ridge Post-Acute 1949 Grant Road Mountain View, CA 94040

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the revised facility's policy and procedure dated 11/13/17 titled Certified Nursing Assistant (CNA)-Key Job Function: General Care indicated, . Maintains privacy and dignity while providing care and services . Review of the facility's policy and procedures dated 2023, Promoting/Maintaining Resident Dignity indicated All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . 055315 Page 2 of 8 055315 02/22/2024 Camino Ridge Post-Acute 1949 Grant Road Mountain View, CA 94040

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party (RP, a person who makes healthcare decisions on patient's behalf) as soon as practicable of the hospital transfers due to fall for one of three residents (Resident 1). This failure resulted in Resident 1's RP not being informed and had the potential for Resident 1's RP's non-involvement in the urgent healthcare decision that may compromise Resident 1's health and safety. Findings: Review of Resident 1's medical record indicated, Resident 1 had an incident of witnessed fall on her room on 12/21/23 at 5:00 p.m. Resident 1 claimed she hit her head on the floor. Resident 1's physician was notified on 12/21/23 at 7:00 p.m. Resident 1 was transferred to the hospital for further evaluation and treatment as ordered by the physician. Resident 1 came back to the facility same day on 12/21/23. Further review of the Resident 1's medical record on 1/24/24 at 10:32 a.m. indicated, Resident 1's RP was notified the next day on 12/22/23 at 6:00 a.m. During an interview with the LN B on 1/24/24 at 1:42 p.m., LN B stated he did not notify Resident 1's RP via phone on 12/21/23. The LN B stated he notified the Resident 1's RP in person on 12/22/23 at 6:00 a.m. when she visited Resident 1 at the facility when Resident 1 was already back from the hospital. During an interview with the DON on 2/21/24 at 2:40 p.m., DON stated LN B should have notified Resident 1's RP as soon as the Resident 1 was transferred out to hospital on [DATE]. Review of the facility's policy and procedures dated 2010 Falls Management: Procedure for Responding to a fall indicated . Notify the .responsible party as soon as practicable following the fall . 055315 Page 3 of 8 055315 02/22/2024 Camino Ridge Post-Acute 1949 Grant Road Mountain View, CA 94040

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's minimum data set (MDS, a resident comprehensive assessment and care screening tool) accurately reflected the actual resident's condition status for one of two residents (Resident 1) on two MDS assessments completed. This failure had the potential to affect the care provided for Resident 1. Residents Affected - Few Findings: Review of Resident 1's medical record indicated diagnoses that included legal blindness (a level of visual impairment that limits the activities performed by individuals without assistance). Review of the MDS on 1/24/24 indicated Resident 1's vision status was coded adequate on 6/28/23 and 9/28/23. During an interview with the certified nursing assistant D (CNA D) on 2/20/24 at 2:23 a.m., she stated Resident 1 cannot see well and sometimes needed verbal cueing during activities of daily living (ADLs). During an interview with licensed nurse E (LN E) on 2/21/24 at 2:10 p.m., he stated Resident 1's vision was impaired. During an interview with the social service staff F (SSS F) on 2/21/24 at 2:34 p.m., SSS F stated she made mistakes in entering the vision status for Resident 1. The SSS F acknowledged she should have entered severely impaired vision instead of adequate in MDS dated [DATE] and 9/28/23. During a concurrent interview and record review with the MDS coordinator G (MDSC G) on 2/22/24 at 9:15 a.m., MDSC G confirmed the Resident 1's vision status was incorrectly entered by SSS F in MDS dated [DATE] and 9/28/23. The MDSC G acknowledged it should have been entered as severely impaired instead of adequate and would make the necessary MDS corrections. Review of the revised facility's policy and procedure dated 11/13/17 titled MDS Coordinator: Key/Essential Duties indicated, . Supervises additional department staff to ensure completion and accuracy of MDS completion and assigned tasks . Review of the revised facility's policy and procedure dated 11/13/17 titled Social Worker: Key/Essential Duties indicated Understand the MDS process and accurately assesses, documents, and provides interventions for assigned case load. 055315 Page 4 of 8 055315 02/22/2024 Camino Ridge Post-Acute 1949 Grant Road Mountain View, CA 94040

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services were provided to meet professional standard of practice for one of three residents (Resident 1) when: Residents Affected - Some 1. Licensed nurse A (LN A) did not check the vital signs and document the characteristics of the pain for Resident 1's during pain assessment, 2. LN A did not follow-up with Resident 1's physician regarding request for the order for pain medication, 3. Facility LNs did clarify with physician regarding Resident 1's pain management plan, and 4. Resident 1's nursing weekly summaries were not done consistently. These failures had the potential to compromise Resident 1's health and safety. Findings: 1. Review of Resident 1's medical record indicated diagnoses that included compression fracture of fourth lumbar vertebrae (one or more bones weaken and crumple in the spine), radiculopathy lumbar region (inflammation of the nerve root in the lower back), sciatica (compression of a spinal nerve root in the lower back), low back pain, calculus of gallbladder (blockage of the main opening of the gall bladder, an organ located under the liver that stores and releases the bile) with chronic cholecystitis (inflammation of gallbladder) , diaphragmatic hernia (abnormal opening in the diaphragm, a muscle between the lungs and stomach), diabetes mellitus (a group of diseases that result in too much sugar in the blood), neuralgia (pain due to nerve that's irritated od damaged) , and neuritis (inflammation of the nerve). Review of Resident 1's nursing interdisciplinary team (IDT, a group of healthcare professionals and direct care staff that have primary responsibility for the development of resident's plan of care) assessment and progress notes dated 9/28/23 and 12/15/23 indicated Resident 1's pain level was zero and frequency was none or rarely exhibiting pain. Review of Resident 1's progress notes dated 12/26/23 at 3:00 a.m. indicated Resident 1 complained of back pain but no current physician's order for pain medication to be given as needed. LN A notified Resident 1's physician to request for an order for Tylenol (medication for pain). Further review of Resident 1's medical record indicated there were no evidence of record that Resident 1's vital signs were checked and documented when the LN A assessed Resident 1 for the complaint of back pain on 12/26/23 at 3:00 a.m. Resident 1's clinical record indicated his pain level and location of pain; however, there was no documentation as to the characteristics of the pain (type of pain whether chronic or acute, location of pain was it localized or generalized,, aggravating factors to pain (what triggers the pain) etc. During an interview with the LN A on 1/24/24 10:56 a.m., LN A confirmed he did not check the vital signs when Resident 1 complaint of back pain on 12/26/23 just before 3:00 a.m. 055315 Page 5 of 8 055315 02/22/2024 Camino Ridge Post-Acute 1949 Grant Road Mountain View, CA 94040

F 0658 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the assistant director of nursing (ADON) on 1/24/24 at 11:46 a.m., ADON reviewed Resident 1's medical record and confirmed there was no evidence in Resident 1's medical record that LN A checked Resident 1's vital signs when LN A did pain assessment for Resident 1 on 12/26/23 at around 3:00 a.m. The ADON acknowledged LN A should have checked the vital signs and record it to know Resident 1's condition status. Residents Affected - Some During an interview with the director of nursing (DON) on 2/22/24 at 10:52 a.m., she acknowledged LN A should have checked the vital signs when LN A assessed Resident 1 for complaint of back pain on 12/26/23 at 3:00 a.m. Review of facility's policy and procedures dated 2016, Change of Condition indicated Purpose: To appropriately assess, document and communicate changes of condition . to the primary care provider. To provide treatment and services to address changes in accordance with the resident needs . Assessment guidelines may include, but not limited to vital signs . Review of the revised facility's policy and procedure dated 11/13/17 titled LVN/LPN: Key Job Function indicated .Utilizes professional standards in performing basic assessment and clinical monitoring in accordance with the scope of licensure . 2. Review of Resident 1's progress notes dated 12/26/23 at 3:00 a.m. indicated Resident 1's complained of back pain, but no PRN (as needed) pain medication included in the physician orders. LN A notified Resident 1's physician and requested for an order of Tylenol as needed for pain. During an interview with LN A on 1/24/24 10:56 a.m., LN A stated he notified Resident 1's physician regarding Resident 1's complaint of pain and requested for pain medication via text on 12/26/23 around 3:00 a.m. but Resident 1's physician did not call or text back until in the morning before Resident 1 was transferred to the hospital on [DATE] at 7:30 a.m. LN A confirmed he did not call again or follow up with Resident 1's physician regarding a request for pain medication after he first texted Resident 1's physician on 12/26/23 at 3:00 a.m. Reord review on 2/22/24 indicated Resident 1's progress notes dated 12/26/23 indicated there was no evidence that LN A made a follow up call with Resident 1's physician for the request of pain medication when Resident 1's complaint of pain on 12/26/23 at 3:00 a.m. There was no documentation that the Medical Director had been called or notified when the primary physician did not call back or respond when LN A requested for pain medication to address Resident 1's back pain. During an interview with the DON on 2/22/24 at 10:52 a.m., DON acknowledged LN A should have called or followed up again with the Resident 1's physician regarding complaint of pain and request for pain medication by calling through telephone and not by text after the Resident 1's physician did not call back or text back after the first notification on 12/23/23 at 3:00a.m. Review of the facility's policy and procedures dated 2016, Change of Condition indicated . Notify physician . of assessment findings. If unable to communicate with the patient's attending/on call physician, contact the facility Medical Director. 3. Review of Resident 1's medical record indicated diagnoses that included compression fracture of fourth lumbar vertebrae. Review of Resident 1's medical doctor/nurse practitioner (MD/NP) progress notes dated 12/8/23 and 055315 Page 6 of 8 055315 02/22/2024 Camino Ridge Post-Acute 1949 Grant Road Mountain View, CA 94040

F 0658 Level of Harm - Minimal harm or potential for actual harm 12/21/23 indicated pain management plan with Norco (pain medication) and Pregabalin (pain medication) for compression fracture. Review of Resident 1's physician's order summary on 2/22/24 for December 2023 indicated no order for Norco and Pregabalin. Residents Affected - Some Review of Resident 1's progress notes on 2/22/24 for December 2023 indicated no evidence of documentations that facility's LNs clarified the MD/NP's pain management plan of Norco and Pregabalin for Resident 1. During an interview with the DON on 2/22/24 at 10:52 a.m., she stated whenever the MD entered notes in resident's medical records, the nurse supervisor or case manager were responsible for reviewing MD progress notes. The nurse supervisor and/or case amanger should have reviewed MD's notes for accuracy, and clarify and discuss with MD for any discrepancy or issue. The DON acknowledged the facility's nurse supervisor or case manager should have clarified pain management plan of Norco and Pregabalin for Resident 1. Review of the revised facility's policy and procedure dated 11/13/17 titled Nursing Supervisor: Key Job Function indicated .Daily management and follow-up of changes-of-condition and other identified issues . 4. Review of Resident 1's medical record on 2/22/24 revealed there were no nursing weekly summaries done after 11/21/23. During a concurrent interview and record review with the DON on 2/22/24 at 1:36 p.m., she confirmed there were no nurses' weekly summaries done since 11/22/23 until 12/26/23. The DON expectations were facility's LN's to complete nurses' weekly summaries after 11/21/23 through 12/26/23, to monitor Resident 1's condition and determine if Resident 1 still needed 24-hour-care at the facility. Review of the revised facility's policy and procedure dated 11/13/17 titled LVN/LPN: Charting and documentation Functions: indicated Completes required documentation and assessments timely . 055315 Page 7 of 8 055315 02/22/2024 Camino Ridge Post-Acute 1949 Grant Road Mountain View, CA 94040

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 interview and record review, the facility failed to promote appropriate services to achieve or maintain as much as normal bladder function as possible when certified nursing assistant C (CNA C) encouraged one of two sampled residents (Resident 1) to urinate in diaper. This failure had the potential to result in losing and declining the current bladder function for Resident 1 that may lead to skin breakdown and urinary infection. (Cross reference to tag F550) Review of Resident 1's medical record indicated diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood), compression fracture of fourth vertebrae (one or more bones weaken and crumple in the spine), and radiculopathy of lumbar region (inflammation of the nerve root in the lower back). Review of the Resident 1's minimum data set (MDS, a resident comprehensive assessment and care screening tool) dated 6/28/23 and 9/28/28 indicated Resident 1 is frequently incontinent of bladder function. During an interview with certified nursing assistant H (CNA H) on 1/24/24 at 11:40 a.m., he stated Resident 1 is sometimes continent and incontinent of urinary function. During an interview with licensed nurse I (LN I) on 2/22/24 at 3:55 p.m., she stated Resident 1 sometimes incontinent and continent of urinary bladder function. Review of Resident bowel and bladder assessment dated [DATE] indicated Resident is occasionally incontinent of bladder function. Resident 1 is alert and oriented and sometimes aware of need to toilet. She needed one- person assistance to go to bathroom. Resident 1 potential for scheduled toileting. Review of Resident 1's nursing care plan dated 4/1/23 indicated, toilet Resident 1 upon rising and before or after meals, at bedtime and as needed as tolerated. Scheduled toileting plan and reinforce habit training. During an interview with CNA C on 1/3/24 at 7 :05 a.m., CNA C stated she told Resident 1 to urinate in her diaper so CNA C can easily change Resident 1 in bed on 12/21/23 prior to the episode of fall at 5:00 p.m. CNA C stated Resident 1 insisted on going to the bathroom and urinated in the toilet. Review of the revised facility's policy and procedure dated 11/13/17 titled Certified Nursing Assistant (CNA)-Key Job Function: General Care indicated . Toilet and utilize .incontinent care per plan of care (including assistance to promote continence) . Review of the revised facility's policy and procedure dated 6/2012 Continence Maintenance Program indicated, For Scheduled Toileting (Habit Training) . Toilet resident at regular intervals throughout the day to promote continent episodes through habit training at the following pre-planned times: Upon waking in the morning (prior to breakfast); after bathing and dressing activity; just prior to lunch delivery; just prior to dinner delivery; and just prior to bedtime at hour of sleep . 055315 Page 8 of 8