Health inspection·May 12, 2022

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 observation, interview, and record review, the facility failed to follow their policy and procedure titled Quality of Life - Dignity for two of 24 residents. (Resident 67 and Resident 55) when: 1. DSD informed Resident 67 he had to change rooms against his will. 2. Certified Nursing Assistant (CNA) 1 referred to Resident 55 in a disrespectful term. These failures had the potential to decrease Resident 67 and Resident 55's feelings of self-worth and self-esteem. Findings: 1. During a concurrent observation and interview on 5/9/22, at 10:26 AM, with Resident 67, Resident 67 stated, he was told by the charge nurse he had to move to another room today. Resident 67 stated, he liked his room, and he told the charge nurse he did not want to move. During an interview on 5/9/22, at 10:35 AM, with DSD, DSD stated, she was the charge nurse today for Resident 67. DSD stated, I convinced him (Resident 67) to move and told him it was only temporary. During an interview on 5/9/22, at 10:35 AM, with DSD and Resident 67, in Resident 67's room, Resident 67 told DSD he did not want to move. During a review of the facility's policy and procedure (P&P) titled Quality of Life- Dignity, dated 2/20, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem . 1. Residents are treated with dignity and respect at all times. 2. The facility culture is one that supports and encourages humanization and individuation of residents, and honors resident choices, preferences, values and beliefs . 7. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.2. During an observation on 5/9/22, at 12:29 PM, outside of room [ROOM NUMBER], Certified Nursing Assistant (CNA) 1 stated, She's [Resident 55] a feeder. During an interview on 5/9/22, at 12:31 PM, with CNA 1, CNA 1 stated, she had used the term feeder to describe a resident who needed to be fed. CNA 1 stated, this term did not respect a resident's Page 1 of 11 055448 055448 05/12/2022 Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618

F 0550 dignity. CNA 1 stated, this term should not be used. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/12/22, at 11:39 AM, with CNA 2, CNA 2 stated, using the term feeder to describe a resident who needed assistance eating was not dignified. CNA 2 stated, I don't think that is acceptable. CNA 2 stated, this was taught during monthly CNA in-services. Residents Affected - Few During an interview on 5/12/22, at 11:43 AM, with Director of Staff Development (DSD), DSD stated, using the term feeders to describe residents who are dependent on staff for dining was not appropriate. During an interview on 5/12/22, at 12:15 PM, with Director of Nursing (DON) and Administrator, DON and Administrator both stated using the term feeders to refer to dependent diners did not ensure residents' dignity. 055448 Page 2 of 11 055448 05/12/2022 Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Advance Directives to determine, on admission, whether residents had advance directives (a document indicating a person's wishes for end-of-life care) for two of 24 sampled residents (Resident 51 and Resident 68). This failure had the potential for residents' end-of-life care requests not to be honored. Findings: During a concurrent interview and record review, on 5/11/22, at 10:30 AM, with Social Services Assistant (SSA), Resident 51 and Resident 68's Acknowledgement of Receipt of Advance Directive Information (ARADI), dated 5/10/21 and 8/11/21, were reviewed. The ARADI indicated, An advance directive has ____ has not _____ been executed. SSA stated, this part of the form should be filled out to indicate if a resident has or has not executed an advance directive. SSA stated, this was left blank for Resident 51 and Resident 68. SSA stated, there was no way of knowing if these residents had executed advance directives. During a concurrent interview and record review, on 5/11/22, at 11:06 AM, with Business Office Associate (BOA), Resident 51 and Resident 68's ARADIs, dated 5/10/21 and 8/11/21, were reviewed. The ARADIs indicated, An advance directive has ____ has not _____ been executed. BOA stated, it was her responsibility as part of the admission process to obtain this information. BOA stated, she should have indicated on this form if these residents had or had not executed an advance directive. BOA stated, It was not acceptable [to leave the form blank]. During a concurrent interview and record review, on 5/11/22, at 11:28 AM, with BOA, the facility's policy and procedure (P&P) titled, Advance Directives, dated 12/16, was reviewed. The P&P indicated, Advance directives will be respected in accordance with state law and facility policy . 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directives. BOA stated, the P&P for advance directives was not followed for Resident 51 and Resident 68. 055448 Page 3 of 11 055448 05/12/2022 Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) to conduct and submit two of 24 sampled resident assessments (Resident 17 and Resident 83) in accordance with current federal and state submission timeframes. This failure had the potential to negatively affect the provision of individualized care and services. Findings: 1. During a concurrent interview and record review, on 5/11/22, at 8:30 AM, with MDS Coordinator (MDSC) Resident 17's admission MDS (AMDS), dated [DATE], was reviewed. The AMDS indicated, the facility admitted Resident 17 on 4/12/19 and completed Resident 17's assessment on 4/30/19. MDSC stated, the AMDS should be completed within 14 days (on 4/25/19). 2. During a concurrent interview and record review, on 5/12/22, at 11:05 AM, with Social Services Assistant (SSA), Resident 83's Minimum Data Set (MDS - a comprehensive assessment and screening tool) assessment, dated 10/16/21, was reviewed. The MDS indicated, Activities of Daily Living (ADLs -ability to eat, shower, walk, etc) and incontinence (inability to control bowels and urine) sections were assessed and dated 11/11/21. SSA stated, she identified Resident 83's ADLs and incontinence on 11/11/21, nearly a month late. During a review of the facility-provided Centers for Medicare and Medicaid Services (CMS) Final Validation Report (FVR), (undated), Resident 83's FVR indicated, Warning: Care plan completed late for this admission assessment, is more than 13 days after entry date. During a review of the facility's policy and procedures (P&P) titled, MDS Completion and Submission Timeframes, dated 7/17, the P&P indicated, Policy Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. 055448 Page 4 of 11 055448 05/12/2022 Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618

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 accurately document physical assessments on the Minimum Data Set (MDS- a comprehensive assessment screening tool) for two of 24 sampled residents (Resident 81 and Resident 79). This failure had the potential to negatively impact the care of Resident 81 and Resident 79. Residents Affected - Few Findings: 1. During a concurrent interview and record review, on 5/10/22, at 11:22 AM, with Licensed Vocational Nurse (LVN) 3, Resident 81's MDS, dated [DATE], was reviewed. Resident 81's MDS indicated, Resident 81 had an indwelling urinary catheter (tube in the bladder continuously draining urine). LVN 3 stated, [Resident 81] didn't have a catheter in place when she was moved to C wing and still doesn't. During an interview on 5/11/22, at 9:35 AM, with MDS Coordinator (MDSC), MDSC stated, Resident 81 was moved to C wing on 3/14/22. That [indwelling urinary] catheter noted to be in place on the MDS dated [DATE] is incorrect. During a concurrent interview and record review on 5/11/22, at 9:45 AM, with MDSC, the Resident 81's Medical Record was reviewed. a. Progress Notes (PN), dated 8/13/21, indicated, IDT (Interdisciplinary Team meeting) discussed bowel and bladder habits due to quarterly assessment due this month. After further review of bowel and bladder habits, resident is usually incontinent of bowel and bladder. Resident is alert and able to make simple needs known. After speaking to resident, per resident, she does not have feeling of when she defecates or urinates on self most of the time. PN, dated 11/10/21, indicated, resident is usually incontinent of bowel and bladder. PN, dated 3/14/22, indicated, incontinent of bowel and bladder, peri care [cleaning of the private area after urinating or bowel movement] is provided Q [every] 2 [two] hours and prn [as needed]. b. The MDS Section H Bladder and Bowel, (B&B) dated 8/7/21, indicated, Resident 81 had a Foley [indwelling urinary] catheter. The B&B, dated 11/7/21, indicated, Resident 81 had a Foley catheter. The B&B, dated 4/27/22, indicated, Resident 81 had a Foley catheter. c. The facility's Bowel and Bladder Program Screener, dated 8/7/21, indicated Resident 81 was: a.3 Always able to urinate without incontinence (indicated no Foley catheter). The facility's Bowel and Bladder Program Screener, dated 11/7/21, indicated, Resident 81 was: a.3 Always able to urinate without incontinence. The facility's Bowel and Bladder Program Screener, dated 2/2/22, indicated, Resident 81 was: a.3 Always able to urinate without incontinence. 055448 Page 5 of 11 055448 05/12/2022 Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDSC stated, she documented Resident 81's assessments on all facility forms. MDSC stated, Resident 81's assessments were different and not accurate. During a concurrent interview and record review, 5/11/22, at 9:45 AM, with MDSC, Resident 81's B&B, dated 4/27/22, was reviewed. The B&B indicated Resident 81 had an indwelling urinary catheter in place. MDSC stated the B&B assessment was inaccurate. 2. During multiple observations on 5/9/22, 5/10/22, and 5/11/22, throughout each day, in memory care unit wing C, Resident 79 continuously paced the full length of the unit, without staff assistance. Resident 79 responded to questions with mumbling. During a concurrent observation and interview, on 5/12/22, at 9:10 AM, with LVN 3, in memory care unit C, Resident 79 walked up and down the hallway, holding a male resident's hand. LVN 3 stated, Resident 79's behavior would be called wandering (traveling aimlessly from place to place). LVN 3 stated, Resident 79 does lie down to take a nap but mostly walks up and down the hall throughout the day. During an interview on 5/12/22, at 10:21 AM, with Activities Aide (AA) 2, AA 2 stated, Resident 79 walked without purpose. AA 2 stated, Today Resident 79 was coloring [a picture], but left to go walking. It happens most days. During an interview on 5/12/22, at 10:26 AM, with Certified Nursing Assistant (CNA) 3, CNA 3 stated, [Resident 79] wanders up and down the hallways; she does so on most days, without purpose. This was not new behavior for her. During a concurrent interview and record review, on 5/12/22, at 10:28 AM, with Social Services Assistant (SSA), Resident 79's MDS Section E, dated 4/27/22 and 1/17/22, were reviewed. The MDSs indicated, Resident 79 had not exhibited wandering behavior. SSA stated, she was the staff member who completed Section E900: has the resident wandered? SSA stated, she interviewed one staff member for Resident 79's wandering assessment. SSA stated, she did not consider Resident 79's behavior as wandering because Resident 79 did not enter other residents' rooms. During a review of the facility's policy and procedure (P&P) titled, MDS Completion and Submission Timeframes, dated 2017, the P&P indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. (RAI) version 1.17.1, 3.0 Manual, dated 10/19, the RAI indicated, Steps for Assessment. 1. Interact with the resident using his or her preferred language. Be sure he or she can hear you and/or has access to his or her preferred method for communication. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language, or cue cards. 055448 Page 6 of 11 055448 05/12/2022 Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop and update the person-centered comprehensive care plan for three of 24 sampled residents (Resident 7, Resident 51, and Resident 58). This failure had the potential for unmet care needs. Findings: 1. During a review of Resident 7's admission Record (AR), dated 2/2/17, Resident 7 was initially admitted to the facility with diagnoses including End Stage Renal disease (kidney failure) and diabetes. During a concurrent interview and record review, on 5/11/22, at 2:29 PM, with Director of Staff Development (DSD), Resident 7's Emergency Department Discharge Instructions (EDDI), dated 4/11/22, were reviewed. The EDDI indicated, Resident 7 was admitted to a local hospital for Altered Mental Status (AMS- alteration in mental status characterized by acute onset and impaired attention). DSD stated, Resident 7 was seen by the nurse lying in bed, with opened eyes but not verbally responding. DSD stated, Resident 7 was sent to the hospital and was diagnosed positive for Cannabis (marijuana). During an interview on 5/12/22, at 2:45 PM, with the Director of Nursing (DON), DON stated the family gave Resident 7 Cannabis gummies. DON stated, the facility's Interdisciplinary Team (IDT-different types of facility staff working together to share expertise, knowledge, and skills to impact patient care) should develop a care plan regarding Resident 7's change in condition to prevent rehospitalization. 2. During an interview on 5/10/22, at 2:25 PM, with Resident 51, Resident 51 stated he had diabetes. Resident 51 stated, he was aware he needed to take care of his eyes because of his diabetes. Resident 51 stated, he had glasses, but he hadn't seen anyone about his eyes since his admission almost a year ago. During an interview on 5/11/22, at 3:18 PM, with Social Services Assistant (SSA), SSA stated, We only use an optometrist (eye doctor). If the optometrist writes out a referral, then we send out to the community. Optometry comes quarterly and he was just here. SSA stated, she schedules residents to see the optometrist based on the MDS (Minimum Data Set- a comprehensive assessment screening tool) and the last time a resident was seen. SSA stated, Resident 51 had not been seen by the optometrist. SSA stated, The optometrist would catch any issues (with the eyes of diabetics). During a concurrent interview and record review, on 5/11/22, at 3:24 PM, with SSA, Resident 51's care plan (CP), dated 5/9/21, was reviewed. The CP indicated, The resident has Diabetes Mellitus . Goal. The resident will have no complications from diabetes through the review date. SSA stated, no interventions were found for monitoring Resident 51's eyes for complications from diabetes. SSA stated, there should have been an intervention related to monitoring eyes of diabetic residents in the care plan. 3. During a concurrent interview and record review, on 5/11/22, at 3:35 PM, with SSA, Resident 58's CP, dated 3/4/21, was reviewed. The CP indicated, The resident has Diabetes Mellitus . Goal. The resident will have no complications from diabetes through the review date. SSA stated, no interventions were found in Resident 58's diabetic care plan for monitoring eyes for complications of diabetes. 055448 Page 7 of 11 055448 05/12/2022 Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618

F 0656 SSA stated, a diabetic care plan should contain this intervention. Level of Harm - Minimal harm or potential for actual harm During a review of standards of care from the National Eye Institute titled, Diabetic Retinopathy, dated 3/25/22, the standards indicated, Diabetic retinopathy is the most common cause of vision loss for people with diabetes . Cataracts (the lens of the eye becomes cloudy causing blurred vision). Having diabetes makes you 2 to 5 times more likely to develop cataracts . Having diabetes nearly doubles your risk of developing a type of glaucoma (increased pressure in the eyeball causing gradual los of sight) called open-angle glaucoma . If you have diabetes, it's very important to get regular eye exams. Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated, A comprehensive, person-centered care plan that includes objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 8. The comprehensive, person-centered care plan will: . h. Incorporate risk factors associated with identified problems . m. Aid in preventing or reducing decline in resident's functional status and/or functional levels . o. Reflect currently recognized standard of practice problem areas and conditions . 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. A. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers . 14. The IDT must review and update the care plan: a. when there has been a significant change in condition. 055448 Page 8 of 11 055448 05/12/2022 Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for documenting telephone orders for one of 24 sampled residents (Resident 23). This failure had the potential to result in confusion regarding Resident 23's physician-ordered care. Residents Affected - Few Findings: During a review of Resident 23's Physician's Order Sheet (PO), dated 5/2/22, the PO indicated, 1. DC [discontinue] feeding tube. 2. DC Feeding Orders. 3. DC all routine labs and appointments. 4. DC acetaminophen [medication used to treat pain] tablet. 5. DC amlodapine (sic.) [medication used to treat high blood pressure] tablet. 6. DC aspirin [medication used to prevent blood clots]. 7. DC atorvastatin [medication used to reduce fats in the blood]. 8. DC carvedilol [medication used to slow heart rate]. 9. DC Imodium [medication used to treat diarrhea]. 10. DC lisinopril [medication used to lower blood pressure]. 11. DC multivitamin. 12. DC flush orders [orders to flush feeding tube with water]. The PO indicated, Physician (MD) 1 signed the order on 5/2/22. Handwritten in the lower left corner of the PO the words [MD 1] informed in agreement noted 5/2/22 [Licensed Vocational Nurse- LVN 1]. During a concurrent interview and record review, on 5/11/22, at 8:57 AM, with Director of Nursing (DON), Resident 23's Physician's Order Sheet (PO), dated 5/2/22, was reviewed. DON stated, this order required clarification. DON stated, a telephone order was not created that clarified the original order, just a nurse's note was written. During a concurrent interview and record review, on 5/11/22, at 9:05 AM, with DON, Resident 23's Progress Notes (PN), dated 5/2/22, at 11:33 AM, were reviewed. The PN indicated, Hospice nurse [HN] in facility to assess resident new order obtained to d/c [discontinue] PO [oral- by mouth] medication, d/c flush order, d/c enteral [tube] feed orders and d/c feeding. Writer [DON] contacted nurse for clarification on enteral feeding orders. Per [HN] disregard all enteral feed orders and clarification to be obtained after Md [physician] speaks with family. Per [HN] once clarification is obtained she will contact nursing for further orders. DON stated, this was the nurse's note she created clarifying the written order. During an interview on 5/11/22, at 9:42 AM, with DON, DON stated, the written PO was a legitimate physician's order that had been signed by MD 1 and noted by LVN 2. DON stated, a new order would need to replace this order. DON stated, she did not have another physician's order giving other directions, just the nurse's note. DON stated, writing a nurse's note clarifying a physician's order would not allow the physician the opportunity to sign it. DON stated, writing a nurse's note did not follow the P&P. During a review of the facility's policy and procedure (P&P) titled, Telephone Orders, dated 2/14, the P&P indicated, 1. Verbal telephone orders may only be received by licensed personnel . Orders must be reduced to writing by the person receiving the order, and recorded in the resident's medical record. 2. The entry must contain the instructions from the physician, date, time, and the signature of the person transcribing the information. 3. Telephone orders must be countersigned by the physician during his or her next visit. 055448 Page 9 of 11 055448 05/12/2022 Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide on-going activities based on comprehensive assessments and preferences for three of 24 sampled residents (Resident 29, Resident 25, and Resident 49). This failure had the potential to negatively affect residents' self-worth, psychosocial well-being, and satisfaction with daily living. Residents Affected - Some Findings: During an observation on 5/11/22, at 9:12 AM, in the Television (TV) room, Resident 29 was sitting in her wheelchair staring at the TV. The TV was on and the volume was low. During a concurrent observation and interview on 5/11/22, at 10:30 AM, with Activities Assistant (AA) 1, in the TV room, Resident 25 was observed sitting in her wheelchair. AA 1 stated, she (Resident 25) participated with activities before she fell, but now she only liked observing people passing by the TV room. During a concurrent observation and interview on 5/12/22, at 11 AM, with Certified Nursing Assistant (CNA) 4, in the hallway outside Resident 49's room, Resident 49 was sleeping in bed. CNA 4 stated, Resident 49 usually preferred to stay in her bed. During a concurrent interview and record review, on 5/12/22, at 11:20 AM, with Activity's Director (AD), in the TV room, Resident 25, Resident 29, and Resident 49's Comprehensive Activity Assessments (CAAs), were reviewed. The CAA's indicated preferences did not match actual activities. AD stated, the facility had general activities for all residents, such as coloring, nature walks, and massaging hands. AD stated, the residents' preferences from the families were not considered in the activity's assessment. AD stated, residents' preferences for activities would encourage more and frequent participation. During a review of the facility's policy and procedures (P&P) titled, Activity Program, dated 7/18, the P&P indicated, Policy Statement: Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. 1. The Activities Program is provided to support the well-being of residents and to encourage both independence and community interaction. 2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 055448 Page 10 of 11 055448 05/12/2022 Dinuba Healthcare 1730 South College Ave. Dinuba, CA 93618

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure staff did not use residents' nutrition freezer to store personal food items. This failure had the potential to cause food-borne illness and affect the residents' health. Findings: During a concurrent observation and interview on 5/10/22, at 9:55 AM, with Licensed Vocational Nurse (LVN) 2, at the C wing nurses' station, an unlabeled and undated frozen food bowl was observed in the freezer section of the residents' nutrition refrigerator. LVN 2 stated the frozen food bowl should have been dated and labeled. During an interview on 5/11/22, at 2:16 PM, with Director of Nursing (DON), the findings of a frozen food bowl in the C wing nurses' station freezer were reviewed. DON stated, the frozen food bowl was a staff member's food. DON stated, the residents' refrigerator/freezer was not to be used to store staff food items. DON stated, no frozen foods, requiring reheating, were to be stored in the residents' freezer. Staff were not allowed to reheat food items for residents. During a review of the facility's policy and procedure (P&P) titled, FOOD RECEIVING AND STORAGE OF COLD FOODS, dated 2018, the P&P indicated, Only foods purchased from vendors will be accepted into the Department of Food and Nutrition Services for storage. 055448 Page 11 of 11