Health inspection·August 8, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure behavioral monitoring for one of three residents reviewed. (Resident 1) This failure had resulted to Resident 1 had eloped from the facility on 7/03/23 sustained mid nose abrasion and then was sent to acute hospital for evaluation. Findings: During record review of Resident 1 ' s clinical record, Resident 1 was admitted on [DATE] with diagnoses of congestive heart failure (heart cannot supply enough blood for the body), dementia (memory loss), metabolic encephalopathy (brain dysfunction due to metabolism). Review of Resident 1 ' s care plan dated 6/12/23 addressing falls indicated Monitor every two hours Review of Resident 1's treatment administration record dated 6/2023, indicated there was no evidence of documentation Resident 1 was monitored every two hours. Interview with director of nursing (DON) on 9/01/23, at 2:45 pm, DON acknowledged that there was lack of documentation that Resident 1 was monitored every two hours. During interview with Registered Nurse 1 (RN) on 8/11/23 at 10:58am, stated Based on my assessment I knew that resident is a risk for elopement and needed supervision. I told Director of Nursing (DON) and I was redirected to Assistant Director of staff development (ADSD) the need for sitter, and I was told that no one was available. Review of the facility Policy and Procedure (P&P) dated March 2018 titled Falls, Clinical protocol indicates 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Page 1 of 2 055968 055968 08/08/2023 Golden Heights Healthcare 35 Escuela Drive Daly City, CA 94015

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on interview and record review, the facility failed to provide food prepared in a form designed to meet resident's individual needs for one of three residents reviewed (Resident 2). This failure had the potential to result to Resident 1's choking accident. Findings: During review of Resident 2's clinical record, indicated, Resident 2 was admitted with diagnoses included dementia (memory loss), anxiety (feeling of fear) and dysphagia (difficulty of swallowing). During an interview with registered nurse 2 (RN 2) on 8/08/2023 at 2:37 PM, RN 2 stated that there were times facility staff were not serving the appropriate meal because it was not matched to the meal ticket. Sometimes the physician changes the diet order after hours however the dietary supervisor do not update on their system. During review of the speech therapist note dated 3/24/2023, indicated discharge recommendations, DietMechanical Soft textures, Thin liquids To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: general swallow techniques /precautions upright posture during meals and upright posture for >30mins after meals. Review of the physician's order dated 3/27/2023, diet order indicated Regular diet, pureed texture, nectar thick consistency. There was a discord between physician's diet order and speech therapist diet recommendation. 055968 Page 2 of 2