Health inspection·February 12, 2025

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and document review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for 1 (Resident #51) of 2 sampled residents reviewed for nutrition. Residents Affected - Few Findings included: [RAI] 3.0 User's Manual dated 10/2024, indicated, 03. Significant Change in Status Assessment The SCSA is a comprehensive assessment for a resident that must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. Per the manual, A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Required interdisciplinary review and/or revision of the care plan. According to the manual, a Decline in two or more of the following: included Any decline an ADL [activity of daily living] physical functioning area where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning; and Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days). An admission Record indicated the facility admitted Resident #51 on 06/26/2024. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, dementia, need for personal assistance, and dysphagia (difficulty swallowing). A quarterly MDS, with an Assessment Reference Date (ARD) of 09/26/2024, revealed Resident #51 was severely impaired in cognitive skills for daily decision making. The MDS indicated the resident required substantial/maximal assistance with eating and oral hygiene. Per the MDS, the resident weighed 125 pounds and did not have any weight loss. A quarterly MDS, with an ARD of 12/19/2024, revealed Resident #51 was severely impaired in cognitive skills for daily decision making. The MDS indicated the resident was dependent on staff for eating and oral hygiene. Per the MDS, the resident weighed 115 pounds and had weight loss of 5% or more in the last month or 10% or more in the last six months. Resident #51's care plan, included a focus area initiated 06/26/2024 and revised 07/11/2024, that indicated the resident had impaired nutritional and hydration status. Interventions directed staff to refer the resident to the registered dietician and/or the interdisciplinary team for significant Page 1 of 2 055517 055517 02/12/2025 Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032

F 0637 Level of Harm - Minimal harm or potential for actual harm with loss, poor hydration, poor meal intake, diet/texture intolerance or nutrition related problems (initiated 06/26/2024). Resident #51's care plan, included a focus area initiated 01/05/2025, that indicated the resident had weight loss. Interventions directed the staff to monitor and evaluate any weight loss (initiated 01/05/2025). Residents Affected - Few On 02/11/2025 at 11:29 AM, the Dietician stated Resident #51 had an unexpected significant weight loss, in which the resident lost 15.7 pounds in three months. On 02/11/2025 at 2:03 PM, Certified Nursing Assistant (CNA) #4 stated Resident #51 now required to be fed by staff. CNA #4 stated there was a change in the resident and the resident use to be able to do more. On 02/11/2025 at 2:05 PM, CNA #3 stated Resident #51 was now dependent on staff for eating. Per CNA #3, a couple of months ago, the resident was able to feed themselves. On 02/11/2025 at 2:13 PM, Restorative Nursing Assistant (RNA) #2 stated Resident #51 had to be fed by staff and was dependent on staff for all care. RNA #2 stated the resident use to be able to feed themselves, but now they could not. On 02/12/2025 at 8:03 AM, Registered Nurse (RN) #1 stated Resident #51 declined and was no longer able to participate in activities of daily living, such as eating. Per RN #1, the resident had to be fed all their meals by staff. According to RN #1, the resident also lost 15 pounds in three months. On 02/12/2025 at 8:07 AM, MDS Assistant #7 stated the identification of a SCSA was to make sure a resident maintained their quality of life and for the facility to attempt to rectify the change to help the resident recover and/or improve. MDS Assistant #7 confirmed Resident #51 had a change in their ability to feed themselves and experienced a significant weight loss. MDS Assistance #7 stated the resident qualified for a SCSA MDS and she missed it. On 02/12/2025 at 8:16 AM, the Director of Nursing stated she expected a SCSA MDS to be completed when a resident had a significant change in their status so that the IDT could meet and implement interventions to resolve the change. On 02/12/2025 at 11:08 AM, the Administrator stated he expected the MDS staff to follow the RAI and timely complete a SCSA MDS when needed. 055517 Page 2 of 2