Health inspection·March 4, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address the nutrition and hydration need of one of three residents (Resident 1) when: Residents Affected - Few • Resident 1's nutrition and hydration need, as recommended by the registered dietician (RD), was not implemented. • The interdisciplinary team (IDT - team of individual with different specialties) did not address Resident 1's weight loss. As a result, Resident 1 was found lethargic (lack of mental and physical energy) and hard to arouse (wake up). Resident 1 was sent to the hospital and diagnosed with acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), metabolic acidosis (a condition when the body produces too much acid) and dehydration (when a body does not have as much fluids as it needs; can lead to kidney damage, brain damage and even death). Resident 1 died, three days after admission to the hospital, due to septic shock (a widespread infection causing organ failure and dangerously low blood pressure), acute kidney failure, and severe dehydration. Findings: A record review of Resident 1's undated admission Record (a record which contains resident personal information) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included a history of moderate protein-calorie malnutrition (an energy deficit due to deficiency of all macronutrients, but primarily protein). Resident 1's historical record reviews did not include a diagnosis of kidney failure. A record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool that is used to develop a plan of care), dated 7/5/23, indicated a Brief Interview for Mental Status (BIMS - use to measure a resident's mental status) score of 5 points out of 15 possible points which indicated Resident 1 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits (problems). A record review of Resident 1's Nutritional Risk Assessment, completed by the RD, dated 7/3/23, was conducted. According to the assessment, Resident 1's nutritional needs and hydration needs included Page 1 of 11 055806 055806 03/04/2024 Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020

F 0692 the following: Level of Harm - Actual harm • Residents Affected - Few 1890-2205 total calories (unit of energy) per day • 1575-1890 milliliters (ml) of liquids per day A record review of Resident 1's care plan, dated 8/25/23, indicated that the resident had a nutritional problem due to inadequate nutrient intake related to decrease appetite . The care plan indicated that one of the interventions included, RD to evaluate and make diet change recommendations PRN (as needed). An interview with certified nurse assistant (CNA) 1 was conducted on 2/1/24 at 12:56 P.M. CNA 1 stated that she had taken care of Resident 1 and was familiar with her care needs. CNA 1 stated that Resident 1 required encouragement to eat during meals. CNA 1 stated at times, she would sit with Resident 1 to physically assist her with her meals. CNA 1 stated, If she [Resident 1] didn't eat, I would encourage her, and she would eat. I don't think the other CNAs did that with her, cause (because) they probably thought she would eat on her own. CNA 1 stated she notified the nurses when Resident 1 did not eat well. CNA 1 stated that CNAs documented the residents' meal intakes in the electronic medical record. CNA 1 stated that meal intakes were documented as, 0 for intakes of 0-25%; 1 for intakes of 26-50%; 2 for intakes of 51-75%; 3 for intakes of 76-100%. CNA 1 stated that if the resident ate 50% or less, an alternative meal or snack would be offered to the resident and documented on the meal intake electronic record. CNA 1 stated that an NA documentation would indicate that the alternate meal or snack was not offered, and a RR documentation would indicate that the resident refused the alternate meal or snack. CNA 1 also stated that a 0 documentation would indicate that the resident did not eat the alternate meal or snack. CNA 1 stated that Resident 1's fluid intake was documented in the electronic medical record. A record review of Resident 1's electronic meal intake documentation, from September 2023 to November 2023, was conducted. The dates listed below were dates when Resident 1 ate 50% or less: 9/6/23 - dinner: 1 (26-50%); NA - alternate or snack not offered 9/7/23 - lunch: 1; NA 9/11/23 - lunch: 1; NA 9/15/23 - breakfast: 0 (0-25%); NA 9/16/23 - lunch: 1; NA 9/19/23 - lunch: 1; NA 9/20/23 - lunch: 1; NA 9/23/23 - dinner: 1; NA 055806 Page 2 of 11 055806 03/04/2024 Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020

F 0692 9/24/23 - lunch: 1; NA Level of Harm - Actual harm 9/26/23 - lunch: 1; NA Residents Affected - Few 9/27/23 - lunch: 0; NA 9/30/23 - lunch: 1; NA 10/8/23 - lunch: 1; NA 10/8/23 - dinner: 0; 0 - did not eat alternate or snack 10/9/23 - dinner: 1; NA 10/11/23 - dinner: 1; NA 10/13/23 - lunch: 0; 0 10/13/23 - dinner: 0; 0 10/14/23 - lunch: 1; NA 10/15/23 - lunch: 1; NA 10/16/23 - dinner: 1; NA 11/1/23 - lunch: 1; NA 11/2/23 - breakfast: RR (resident refused); NA 11/2/23 - lunch: RR; RR 11/2/23 - dinner: RR; NA 11/3/23 - breakfast: RU (resident unavailable); 0 11/3/23 - lunch: NA; 0 11/4/23 - breakfast: 1; NA 11/4/23 - lunch: 0; NA 11/4/23 - dinner: RR; 0 11/5/23 - breakfast: 0; NA 11/5/23 - lunch: 1; NA 11/6/23 - lunch: 0; NA 055806 Page 3 of 11 055806 03/04/2024 Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020

F 0692 11/6/23 - dinner: RR; 0 Level of Harm - Actual harm 11/7/23 - breakfast: RR; RR Residents Affected - Few 11/7/23 - lunch: 1; NA 11/7/23 - dinner: 1; NA 11/10/23 - breakfast: 0; NA 11/10/23 - lunch: no documentation 11/10/23 - dinner: no documentation 11/11/23 - breakfast: 0; NA 11/11/23 - lunch: RR; RR 11/11/23 - dinner: 0; NA 11/12/23 - dinner: 0; NA 11/13/23 - dinner: 1; NA 11/14/23 - breakfast: RR; RR 11/14/23 - lunch: 0; NA 11/15/23 - breakfast: RR; 0 11/15/23 - lunch: RR; RR 11/16/23 - breakfast: 1; NA 11/16/23 - dinner: 0; NA 11/17/23 - breakfast: RR; 0 11/18/23 - breakfast: 1; NA 11/18/23 - lunch: 1; NA 11/19/23 - breakfast: 0; NA 11/19/23 - dinner: no documentation 11/20/23 - dinner: 1; NA 11/21/23 - breakfast: 1; NA 055806 Page 4 of 11 055806 03/04/2024 Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020

F 0692 11/21/23 - lunch: 1; NA Level of Harm - Actual harm 11/21/23 - dinner: RR; 0 Residents Affected - Few 11/22/23 - dinner: RR; 0 11/23/23 - dinner: RR; 0 11/24/23 - dinner: RR; 0 11/25/23 - dinner: RR; NA 11/26/23 - breakfast: RR; RR 11/26/23 - lunch: RR; RR 11/26/23 - dinner: no documentation 11/27/23 - breakfast: 0; NA 11/27/23 - lunch: RR; RR 11/27/23 - dinner: RR; 0 11/28/23 - breakfast: RR; NA 11/28/23 - lunch: RR; NA 11/28/23 - dinner: RR; 0 11/29/23 - breakfast: RR; RR 11/29/23 - lunch: RR; RR 11/29/23 - dinner: RR; 0 A record review of Resident 1's electronic fluid intake documentation, from September 2023 to November 2023, was conducted. The dates listed below were dates when Resident 1 did not meet the recommended daily fluid intake per RD's recommendation: 9/8/23: 720 ml/day 9/10/23: 720 ml/day 9/13/23: 840 ml/day 9/15/23: 880 ml/day 9/18/23: 800 ml/day 055806 Page 5 of 11 055806 03/04/2024 Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020

F 0692 9/20/23: 680 ml/day Level of Harm - Actual harm 9/26/23: 880 ml/day Residents Affected - Few 10/3/23: 720 ml/day 10/6/23: 480 ml/day 10/7/23: 640 ml/day 10/8/23: 920 ml/day 10/10/23: 480 ml/day 10/11/23: 820 ml/day 10/13/23: 940 ml/day 10/14/23: 860 ml/day 10/16/23: 880 ml/day 10/17/23 910 ml/day 10/18/23: 460 ml/day 10/19/23: 240 ml/day 10/20/23: 190 ml/day 10/23/23: 620 ml/day 10/24/23: 540 ml/day 1026/23: 720 ml/day 10/27/23: 760 ml/day 10/28/23: 720 ml/day 10/30/23: 480 ml/day 11/1/23: 840 ml/day 11/2/23: 240 ml/day 11/6/23: 600 ml/day 11/8/23: 630 ml/day 055806 Page 6 of 11 055806 03/04/2024 Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020

F 0692 11/9/23: 380 ml/day Level of Harm - Actual harm 11/10/23: 240 ml/day Residents Affected - Few 11/11/23: 360 ml/day 11/13/23: 360 ml/day 11/14/23: 680 ml/day 11/15/23: 840 ml/day 11/16/23: 930 ml/day 11/17/23: 240 ml/day 11/18/23: 720 ml/day 11/19/23: 730 ml/day 11/20/23: 840 ml/day 11/21/23: 600 ml/day 11/22/23: 860 ml/day 11/23/23: 600 ml/day 11/24/23: 880 ml/day 11/25/23: 590 ml/day 11/26/23: 120 ml/day 11/27/23: 498 ml/day 11/28/23: 520 ml/day 11/29/23: 280 ml/day A record review of Resident 1's weight from September 2023 to November 2023 was conducted. The record indicated the following weights: • 9/1/23: 139.6 lbs. (pounds) • 055806 Page 7 of 11 055806 03/04/2024 Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020

F 0692 10/1/23: 133.6 lbs. - 6 lbs. weight loss in a month or 4.8% weight loss in a month Level of Harm - Actual harm • Residents Affected - Few 11/1/23: 124.6 lbs. - 9 lbs. weight loss in a month or 6.7%. weight loss in a month A record review of Resident 1's IDT Note, dated 10/30/23 at 3:25 P.M. indicated, weight loss of Wt (weight) hx (history) [sic]: (10/1) 133.6lbs; (9/1) 139.6 lbs; (7/1) 138lbs. Noted -6lbs/-4.3% clinically insignificant wt loss x1 mo (in/over the course of one month). Average PO (oral) intake mostly 51-100% per tasks .Recommend: continue diet as ordered, texture per SLP (speech-language pathologist; expert who works with individuals in the treatment of communication and swallowing problems), monitor weekly weights x4 (over the course of four) weeks, continue fortified (extra calorie) foods at meals . A record review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, dated 11/2/23 at 12:53 P.M., indicated, .Resident lost weight 9lbs [sic] in one month due to not eating and drinking enough . A record review of Resident 1's weight loss care plan developed on 11/28/23 and revised on 11/30/23 indicated, Weight Loss: Resident has an actual significant weight loss of 9 lbs. 6.7%, which was unintended weight loss x1 month; Goal: will show a desirable weight gain of 2-4 lbs in a month. An interview and joint record review of Resident 1's medical record was conducted with licensed nurse (LN) 1 on 2/1/24 at 1:15 P.M. LN 1 stated she was aware that Resident 1 had episodes of poor meal and fluid intake. LN 1 stated she was aware that Resident 1 had weight loss. LN 1 could not find documentation that the resident's poor intake (meal and fluid) and weight loss were addressed. LN 1 was not able to find documentation that staff attempted to identify the cause of resident's poor meal and fluid intake. LN 1 reviewed Resident 1's weight record and stated that the resident's weight loss started on 10/1/23. LN 1 stated the care plan for weight loss was not developed until 11/28/23. On 2/7/24 at 8:33 A.M., an interview was conducted with the Speech Therapist (ST). The ST stated that Resident 1 was seen by ST from admission until the resident transitioned to restorative nursing assistant (RNA) program (acquire special knowledge skills, and techniques in rehabilitation) in October for exercises. The ST stated she was not aware of Resident 1's poor intake and weight loss. The ST stated if the IDT notified her of the resident's poor intake, they could have collaborated and identified interventions that could have helped address the resident's needs. The ST stated she would have recommended for Resident 1 to be placed on a RNA feeding program since the resident needed encouragement to eat and drink. An interview and joint record review of Resident 1's medical record was conducted with the RD on 2/7/24 at 9:27 A.M. The RD reviewed Resident 1's electronic meal and fluid intake documentation from September 2023 to November 2023. The RD stated she was aware of Resident 1's poor meal and fluid intake. The RD stated Resident 1's poor meal and fluid intake was not addressed timely. The RD stated staff should be offering other meal options and snacks, especially when a resident had a weight loss, to help encourage the resident to eat. The RD stated that she was aware of Resident 1's weight loss and that the resident's weight loss was not addressed timely. The RD stated that Resident 1's weight should have been monitored weekly x 4 weeks, as recommended by the IDT on 10/30/23. According to the RD, this recommendation was not implemented. 055806 Page 8 of 11 055806 03/04/2024 Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020

F 0692 Level of Harm - Actual harm Residents Affected - Few An interview with the Assistant Director of Nursing (ADON) was conducted on 2/7/23 at 10:20 A.M. The ADON stated Resident 1's poor meal and fluid intake should have been addressed timely to avoid weight loss. The ADON acknowledged that the recommended nutritional intake including fluid intake for Resident 1, was not implemented. The ADON stated Resident 1's weight loss should have been addressed timely to prevent a decline in resident's health. A record review of Resident 1's nurse's notes, dated 11/30/23 was conducted. According to the nurse's notes, Resident 1 was found lethargic and unresponsive at 9:30 P.M. The nurse's notes indicated Resident 1 was picked-up by ambulance at 10 P.M. and was taken to the hospital. A record review of Resident 1's hospital lab (laboratory) results indicated the following: 11/30/23 • Sodium: 153 H (high) • BUN (measures amount of nitrogen in the blood): 117 H (high) • Creatinine (waste product produced by muscles and excreted by the kidneys): 6.3 H (high) • Total Protein: 5.8 L (low) • Albumin (a type of protein in the blood): 3.3. L (low) • eGFR CKD-EPI (a measure that helps assess how well your kidneys are working): 6 L (low) • Lactic Acid (provides insights into the body's metabolism): 3.3 L (low) • Blood Gases (refers to the levels of oxygen and carbon dioxide in the blood for lung function) indicated Acidosis (may result from kidney issues. Occurs when there's too much acid in the body) 12/1/23 055806 Page 9 of 11 055806 03/04/2024 Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020

F 0692 • Level of Harm - Actual harm Lactic Acid: 9.8 C (critical) Residents Affected - Few A record review of Resident 1's hospital emergency note, dated 11/30/23, was conducted. The emergency note indicated, Patient presents to the hospital with complaints of dyspnea (difficulty breathing), rapid respiratory rate.She initially had some hypotension (low blood pressure) which was improved with IV (intravenous - fluids administered through the vein) fluid. I was initially concerned for sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection ) and treated the patient with broad-spectrum antibiotics along with 30 cc/kg (cubic centimeters/kilograms) IV fluid bolus (single dose) . Reviewing her laboratory tests I see that she had normal laboratory test back in June of this year, and yet now she has significant kidney disease with a creatinine of 6.3. She has hyponatremia (occurs when the concentration of sodium in your blood is abnormally low) without hyperkalemia (potassium in blood is abnormally high), I feel this is the cause of her elevated troponin (a protein that's released into the bloodstream during a heart attack) as her EKG (measures the heart's electrical activity) does not show ischemic (decrease blood flow) findings.I am concerned based on the patient's evaluation that she is quite dry and then acute kidney injury is related to volume loss which is why I treated with IV fluid . A record review of Resident 1's hospital History and Physical, dated 12/1/23, indicated, . In the ED (emergency department) the patient was intubated (inserting a tube through a person's mouth or nose) and placed on mechanical ventilation (machine breathing for the person) .Assessment . Acute Kidney Injury, Severe Dehydration . A record review of Resident 1's hospital Admission, Transfer/Discharge Note, dated 12/4/23, indicated, Date/Time of Death pronouncement: 12/4/23 02:23 (2:23AM). A record review of Resident 1's Death Certificate, dated 12/12/23, indicated that Resident 1's cause of death was septic shock, aspiration pneumonia (complication from inhaling of food or liquid into the lungs), severe dehydration, and acute kidney failure. On 2/7/24 at 2:51 P.M., a telephone interview was conducted with medical doctor (MD) 1. MD 1 stated that he was not aware that the RD's recommendations for weekly weights were not implemented. MD 1 stated that Resident 1's hospital lab results indicated dehydration and malnutrition (lack of proper nutrition). MD 1 stated Resident 1 was not given IV therapy at the facility. MD 1 stated that Resident 1's hospital lab results indicated decreased nutrition and hydration which resulted in acute renal failure. A telephone interview with the Director of Nursing (DON) was conducted on 3/1/23 at 3:02 P.M. The DON stated Resident 1's poor meal and fluid intake should have been addressed. The DON stated the CNAs should have offered alternate meals and snacks, as well as fluids that the resident preferred to eat and drink, to prevent weight loss and dehydration. The DON acknowledged that the RD's recommendation for Resident 1's caloric and fluid intake was not followed. The DON stated that Resident 1's weight loss should have been addressed as soon as the resident started losing weight to avoid further weight loss. The DON stated that a weight loss care plan should have been developed as soon as the weight loss was identified. The DON acknowledged that Resident 1's poor meal and fluid intake, as well as the resident's weight loss, were not addressed by the interdisciplinary team. The DON stated the RD should have identified and addressed Resident 1's poor intake to prevent weight loss. The DON stated that when Resident 1 started to lose weight, the RD should have intervened to prevent further 055806 Page 10 of 11 055806 03/04/2024 Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020

F 0692 Level of Harm - Actual harm weight loss. The DON stated the IDT, to include the direct staff, should have collaborated to identify possible interventions, such as 1:1 feeding assist and for family member to bring meals Resident 1 preferred to eat. The DON acknowledged that Resident 1's poor intake of food and fluids, and the resident's weight loss, were not addressed. Residents Affected - Few A document review of the facility's policy and procedure titled Nutrition (impaired)/Unplanned Weight Loss-Clinical Protocol, revised September 2017, indicated .1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. 2. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia (eating disorder), weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing weight gain or increasing the risk of anorexia or weight loss. A document review of the facility's policy and procedure titled Hydration-Clinical Protocol, revised September 2017, indicated, .Assessment and Recognition 1. The physician and staff will help define the individual's current hydration status (fluid and electrolyte balances or imbalances [too much or not enough minerals in the body]). a. The physician will distinguish various types of fluid and electrolyte imbalance (for example hyponatremia, hypernatremia, pre-renal azotemia [too much waste product in the blood], etc.) from true hydration (clinically significant loss of total body water) . Treatment/Management . For more severe or complicated fluid and electrolyte imbalance, . intravenous hydration may be needed . A document review of the facility's policy and procedure titled Weight Assessment and Intervention revised on 3/2002, indicated, . Weight assessment: . 5. The threshold for significant unplanned and undesired weight loss will be based on the following: a. 1 month - 5% weight loss is significant . 055806 Page 11 of 11