Health inspection·February 22, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review for one of three sampled residents (Resident 1), the facility failed to follow their policy and procedure for: Residents Affected - Few a. Change of Condition for weight loss. b. To notify responsible party (RP) of left foot discoloration. This failure resulted in Resident 1 having unplanned weight loss and (RP) uniformed and unaware in foot discoloration changes. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on originally on October 30, 2021 and readmit August 20, 2023, with diagnoses to include: metabolic encephalopathy (chemical imbalance in the blood/brain), hemiplegia and hemiparesis following cerebral infarction (muscle weakness or paralysis on one part of body due to stroke), pyelonephritis (kidney infection), vitamin B12 deficiency (can lead to reduction on red blood cells). During a concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON), reviewed are as follows: 1. Cognitive patterns Section C, Brief Interview for Mental Status dated August 31, 2023, score 10. History and Physical dated November 09, 2022, decision making, fluctuating. 2. Weights October 01, 2023= 142 Lbs. (pounds), October 08, 2023=138 Lbs., October 22, 2023=125 Lbs., November 03, 2023= 119 Lbs. From October to November approximately a 16.19% weight loss. 3. Facility cannot provide documentation of a Change in Condition due to weight loss starting in October 2023 and continuing November 2023 and on. 4. Nurse Progress Notes dated November 21, 2023, at 20:28 .Patient family at beside concerned about patients decrease in weight. Doctor contacted and ordered Dietician consult and asked if family would consider PEG tube feeding (percutaneous endoscopic gastrostomy, feeding tube through stomach). Daughter will discuss with family members and let facility know about PEG tube feeding. 5. Careplan Weight Loss: Resident has an actual significant weight loss of 5 lbs. in 7 days. Date initiated December 13, 2023, Revision on December 13, 2023. Will have no significant weight change of Page 1 of 2 056024 056024 02/22/2024 Highland Palms Healthcare Center 7534 Palm Ave Highland, CA 92346

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5 % or more per month. Activities to promote intake. Administer medications as ordered, appetite stimulants as ordered, monitor for side effects, and notify physician if observed. House supplements as ordered. Labs as ordered. Report results to physician. Monitor vital signs per protocol. Report significant abnormalities to physician, RD to evaluate as indicated. 6. Progress Note: Skin/Wound Note dated January 06, 2024, at 10:08: New skin assessment completed with the following .Purple discoloration to left foot (Related To poor discoloration History of heart disease. Patient's legs and foot noted to be cold to touch .doctor notified, orders carried out . (NO FAMILY NOTIFICATION New Skin assessment and finding). During an interview with the Director of Nursing (DON), the (DON) stated, Sometime in November Resident 1 started losing a lot of weight. We had Registered Dietician (RD) do interventions when the ideal body is not met is when we did are Change of Condition (COC) and G-tube (feeding tube) interventions. Family was notified and documented December 13, 2023. We were waiting for the resident's family to make decision on feeding tube, the responsible party wanted to discuss with her family. She didn't think she was going to make it through the procedure. There is no COC on Oct to November 2023 regarding weight loss but there is RD notes regarding weight loss. I don't have a COC regarding the weight loss, it should have been done after the significant weight loss. We did not notify the daughter of the discoloration of her foot. The resident was refusing to have the skin assessment. The discoloration was due to arterial disease, that was part of disease process and was inevitable. We should have notified the daughter of this, and we did not. During a review of the facility's policy and procedure titled, Change in a Resident's Condition or Status revised February 2021, the policy and procedure indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . 1.The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition; 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting ); c. requires interdisciplinary review and/or revision to the care plan; and .3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status. During a review of the facility's policy and procedure titled, Weight Assessment and Intervention revised March 2022, the policy and procedure indicated, Resident weights are monitored for undesirable or unintended weight loss or gain. Care Planning 1. Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. 056024 Page 2 of 2