Health inspection·April 4, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 inform the residents' responsible party (RP, an individual authorized to act for the resident as an official delegate or agent) of the room changes of the two of four residents investigated, (Residents 1 and 2) when: Residents Affected - Few 1. Resident 1's RP was not informed of the room change when Resident 1 was exposed to Cornavirus disease (COVID-19, an infectious disease caused by a new strain of coronavirus) and 2. Resident 2's RP was not informed of the room change after her isolation (being separated from other residents) due to testing positive for COVID-19. This deficient practice resulted to Resident 1 and 2's RP, to be unaware of the changes and not able to participate in their care and treatment. Findings: 1. During a concurrent observation and interview with Resident 1 on 3/22/23 at 10:45 a.m., Resident 1 appears calm, alert, oriented and responsive to questions. Resident 1 verified that he had a few room changes recently. Review of Resident 1's clinical records indicated, he was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (severe mental health condition with symptoms of delusions and hallucinations). Review of Resident 1's progress notes indicated, Resident 1 had room changes on 1/31/23, for altercation with other resident, on 2/14/23, for exposure to positive COVID-19 resident and on 2/23/23, after Resident 1 finished his isolation. Further review of Resident 1's clinical records indicated, there were no RP notifications for the room transfers on 2/14/23 and 2/23/23. During a review and concurrent interview with the infection preventionist (IP) on 3/22/23 at 1:40 p.m., the IP reviewed Resident 1's clinical records and confirmed, there were no documentation indicating the RP was notified for Resident 1's room changes on 2/14/23 and 2/23/23. During a review and concurrent interview with the director of nursing (DON), on 3/22/23 at 3:45 p.m., the DON verified, there were no documentation indicating Resident 1's RP was notified during room changes on 2/14/23 and 2/23/23. The DON further stated, the RP should be notified during a room Page 1 of 2 056058 056058 04/04/2023 Almaden Health and Rehabilitation Center 2065 Los Gatos-Almaden Road San Jose, CA 95124

F 0552 change and it should be documented in the progress notes. Level of Harm - Minimal harm or potential for actual harm 2. During an observation of Resident 2 on 3/22/23 at 11:40 a.m., Resident 2 was walking in the hallway by herself. Resident was calm, alert but confused. Residents Affected - Few Review of Resident 2's clinical records indicated, she was readmitted to the facility on [DATE] with diagnoses including unspecified dementia (loss of memory) with behavioral disturbance. Review of Resident 2's progress notes indicated, Resident 2 had room transfers on 12/5/22 for testing positive of COVID-19 and on 12/19/22, after her isolation due to testing positive for COVID-19. Further review of Resident 2's clinical records indicated, there was no RP notification for the room transfer on 12/19/22, after Resident 2's isolation. During a review and concurrent interview with the IP on 3/22/23 at 1:15 p.m., IP reviewed Resident 2's clinical records and verified, there were no progress notes, indicating the RP was notified during a room change on 12/19/22. During a review and concurrent interview with the DON, on 3/22/23 at 3:50 p.m., the DON verified, there was no documentation indicating Resident 2's RP was notified during a room change on 2/19/23. The DON further stated, the RP should be notified during a room change and it should be documented in the progress notes. Review of the facility's undated policy, Resident Care: Changes in Resident Condition, indicated, The resident, attending physician and resident representative (if resident has no capacity to make health care decisions or if resident opts to notify a designated family member), are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and direct care staff is also important to ensure that consistency and continuity of care are maintained. The resident and/or resident representative and attending physician are notified by the licensed nurse/company designee, when there is a change in room or roommate assignment. Changes in the resident status are documented in the progress notes. 056058 Page 2 of 2