Health inspection·November 26, 2024

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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plans (CP- a detailed approach to care customized to an individual resident's needs) for one of three sampled residents (Resident 1) when Resident 1 was bedbound for eight months and did not have an activity care plan. This failure resulted to Resident 1 spending her waking hours picking on her skin and resulted to excoriations to her various body parts, including her abdomen, left hip and right hip. Findings: During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/26/24, the AR indicated, Resident 1 was re-admitted from the home on 4/2/24 to the facility, with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), Congestive Heart Failure (CHF - weakness in the heart where fluid accumulates in the lungs), Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) Contracture of Muscle left and right lower leg (permanent tightening of the muscle tissues, causing the joints to shorten and become very stiff), and Paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 9/5/24, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 11 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a concurrent observation and interview on 11/26/24, at 9:00 a.m., with Resident 1, inside Resident 1's room. Resident 1 was observed staring at the ceiling and stated she was bored. Resident 1 was observed scratching her abdominal area using both of her hands, and the television set in the room was turned off. During a concurrent observation and interview on 11/26/24, at 10:50 a.m., with Licensed Vocational 1 (LVN) 1 and Infection Preventionist (IP), inside Resident 1's room. LVN 1 was observed conducting a skin assessment prior to changing Resident 1's wound dressing to her buttocks. LVN 1 stated, Resident 1 was bedbound due to paraplegia, pressure ulcer (open wound), and generalized weakness. LVN 1 stated, Resident 1 has multiple self-inflicted scratches to her abdomen, left hip and right hip. LVN 1 stated, Resident 1 stays in bed all day and with limited bed mobility. Page 1 of 4 055799 055799 11/26/2024 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 11/26/24 at 11:34 a.m., with the Activity Director (AD), Resident 1's current Care Plan (CP), undated was reviewed. The AD stated, she cannot find Resident 1's activity care plan and one should have been created at the time of admission. The AD stated, she was responsible in creating Resident 1's activity care plan and it was not done. The AD stated, the care plan should be tailored to Resident's interests and specific needs. The AD stated, Resident 1 was bedbound and her lack of activity care plan could result to boredom. The AD stated, Resident 1's behavior of picking on her skin could be a result of lack of activities. During a concurrent interview and record review on 11/26/24 at 11:40 a.m., with Licensed Vocational Nurse / Minimum Date Set Nurse (MDSN), Resident 1's current Care Plan, undated was reviewed. The MDSN stated, she cannot find Resident 1's activity care plan. The MDSN stated, Resident 1's activity care plan should include activities to address boredom, her likes and dislikes, such as watching TV shows, reading newspaper, listening to music, or participating in activities that she's interested in. The MDSN stated, Resident 1's behavior of picking on her skin could have been avoided if she was provided with appropriate activities. During a concurrent interview and record review on 11/26/24 at 11:46 a.m., with the Director of Nursing (DON) , Resident 1's CP, undated was reviewed. The DON stated a resident specific care plan should have been developed to address Resident 1's activity needs and it was not done. The DON stated without a resident specific activity care plan, Resident 1 could experience depression, boredom, restlessness, or agitation. During a review of Resident 1's Physician Order Summary (POS), dated 11/26/24, the POS indicated, . Scattered excoriations to abdomen cleanse with normal saline pat dry with 4x4 gauze and apply betadine topically . Order Date 11/15/24 . Scattered excoriations to left hip cleanse with normal saline pat dry with 4x4 gauze apply betadine topically . Order Date 11/15/24 . Scattered excoriations to right hip cleanse with normal saline pat dry with 4x4 gauze apply betadine topically . Order Date 11/15/24 . During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person Centered, dated 3/22, the P&P indicated, . The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 055799 Page 2 of 4 055799 11/26/2024 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a functioning communication system (call light system-an alerting device used by residents to request assistance) when seven (14 A, 14 B, 14 C, 13 A, 18 B, 19 B and 20 A) of 56 resident call lights were not functioning properly. Residents Affected - Some This failure had the potential for resident needs to go unmet and placed resident's health and safety at risk. Findings: During a concurrent observation and interview on 12/4/24 at 12:21 p.m. with Resident 2, a bell was heard ringing from the wing B hallway. Resident 2 stated she heard the bell ringing frequently. During an interview on 12/4/24 at 12:27 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated the bell sound was from the resident in room [ROOM NUMBER] A (Resident 5). CNA 2 stated the call light in 14 A had not functioned for a couple of months, so the resident used a handbell. During a concurrent observation and interview on 12/4/24 at 12:33 p.m. with CNA 2, in room [ROOM NUMBER] A, Resident 5 was in bed and the handbell was under his bed. Resident 5 stated he dropped the handbell. CNA 2 checked Resident 5's call light and the light did not light up or sound. Resident 5 stated the call light had not been working for several weeks so he was given the handbell to ring when he needed assistance. CNA 2 pressed the call light button for bed 14 B and 14 C, the call lights did not alert (make sound or light up). CNA 2 stated she did not know the call lights in 14 B and 14 C did not work. CNA 2 stated it was important for the call lights to work so the residents could call for help and to meet their needs. During a concurrent observation and interview on 12/4/24 at 12:38 p.m. with CNA 2, in room [ROOM NUMBER], CNA 2 pressed the 13 A call, and it did not alert. During a concurrent observation and interview on 12/4/24 at 12:44 p.m. with the Director of Maintenance (DOM), the bed call lights throughout the facility were tested. The DOM stated there was an issue with room [ROOM NUMBER] but the lights had been fixed a few weeks ago. The DOM stated he did not do routine checks of the call lights for function. The DOM stated he relied on the staff to report any issues. The DOM pressed the call lights for 14 A, 14 B and 14 C, the lights did not work. The DOM stated he did not know the call lights did not work. room [ROOM NUMBER] A was checked and did not work. The DOM stated he was unaware there was an issue with the call light. The DOM pressed the call lights for 18 B, 19 B and 20 A, the lights did not work. The DOM stated the call buttons were bad and needed to be replaced. The DOM stated he had not been notified there were call lights not working. The DOM stated the call lights needed to function properly to meet the resident's needs and not being able to call for help could affect a resident's life. During an interview on 12/4/24 at 1:39 p.m. with the Administrator (ADM), the ADM stated the call system was recently fixed because room [ROOM NUMBER] had not been functioning correctly. The ADM stated she was unaware there were multiple call lights in the facility not working properly. The ADM stated the call lights needed to function properly to meet resident needs. During an interview on 12/4/24 at 1:45 p.m. with CNA 3, CNA 3 stated she was assigned to room [ROOM 055799 Page 3 of 4 055799 11/26/2024 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some NUMBER]. CNA 3 stated the call lights in room [ROOM NUMBER] had not worked for two months. CNA 3 stated the call lights were important so the residents could call for help in case of an emergency. During an interview on 12/4/24 at 4:59 p.m. with the Director of Staff Development (DSD) the DSD stated she was assigned to do rounds on room [ROOM NUMBER] every day. The DSD stated during rounds she would check the room for trash, clutter and to see if call lights were within reach. The DSD stated she was aware the call light in 14 A did not work properly. The DSD stated Resident 5 had the handbell to call for help. The DSD stated the room [ROOM NUMBER] A call light would malfunction. The DSD stated, sometimes the lights do work and sometimes they don't. During a review of the facility's policy and procedure (P&P) titled Call Light System, undated, the P&P indicated, . Purpose . respond to resident's requests and needs . It is the policy of this facility that each resident's call light will be within reach, operable and will be answered by any staff . The facility is equipped with a resident all system that allows calls to be received at the nurse's station from a resident's room . The call light system is to be inspected routinely by a designee of the maintenance department to ensure it remains in good operation at all times. Staff are to report to the maintenance department any call light discovered to be non-operable . During a review of the facility's P&P titled, Maintenance Service, dated 12/2009, the P&P indicated, . Maintenance service shall be provided to all areas of the building . Functions of maintenance personnel include . maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines . maintaining the building in good repair . maintaining the paging system in good working order . 055799 Page 4 of 4