Health inspection·February 15, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded. Specifically, MDS assessments did not reflect the use of oxygen for 1 (Resident #34) of 4 sampled residents reviewed for respiratory care and did not accurately reflect the discharge location for 1 (Resident #183) of 6 sampled residents reviewed for hospitalizations. Residents Affected - Few Findings included: A review of a facility policy titled, Certifying Accuracy of the Resident Assessment, revised in November 2019, revealed, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for the assessment. 1. A review of an admission Record revealed the facility admitted Resident #34 on 02/07/2013. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure, unspecified asthma, and emphysema. A review of Resident #34's Care Plan revealed a Focus area, initiated on 07/21/2019, that indicated the resident was at risk for an ineffective breathing pattern related to COPD. An intervention dated 07/21/2019 directed staff to administer oxygen as ordered or needed. A review of Resident #34's physician's orders revealed an active order started on 05/07/2023 for oxygen at 2 liters per minute (L/min) via nasal cannula routinely every shift. A review of an annual MDS, with an Assessment Reference Date (ARD) of 12/26/2023, revealed the assessment was not coded to reflect the resident's use of oxygen. During an interview on 02/15/2024 at 9:52 AM, the MDS Coordinator said Resident #34 had been receiving oxygen since 2020. After reviewing the resident's medication administration record (MAR), the MDS Coordinator confirmed Resident #34's MDS should have been coded to reflect the resident's use of oxygen. 2. A review of an admission Record revealed the facility admitted Resident #183 on 12/19/2023 with diagnoses that included pneumonia, chronic obstructive pulmonary disease, and hereditary and idiopathic neuropathy. Page 1 of 7 056082 056082 02/15/2024 Canyon Springs Post-Acute 180 North Jackson Avenue San Jose, CA 95116

F 0641 Level of Harm - Minimal harm or potential for actual harm A review of Resident #183's Progress Notes revealed a Social Service Note, dated 12/22/2023, that indicated the resident planned to discharge home on [DATE]. A review of Resident #183's Post-Discharge Plan of Care, effective 12/22/2023, revealed Resident #183 discharged to their Home/Community. Residents Affected - Few A review of Resident #183's discharge MDS, with an Assessment Reference Date (ARD) of 12/22/2023, revealed the resident was discharged from the facility on 12/22/2023. However, the MDS reflected the resident was discharged to a short-term general hospital, instead of home as indicated in their Progress Notes and Post-Discharge Plan of Care. During an interview on 02/15/2024 at 9:52 AM, the MDS Coordinator confirmed Resident #183 discharged home and said the resident's MDS was not coded correctly. During an interview on 02/15/2024 at 10:16 AM, the Director of Nursing (DON) stated she expected all MDS assessments to be accurate. During an interview on 02/15/2024 at 10:29 AM, the Administrator stated he expected all MDS assessments to be accurate. 056082 Page 2 of 7 056082 02/15/2024 Canyon Springs Post-Acute 180 North Jackson Avenue San Jose, CA 95116

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on record review, interviews, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to ensure 1 (Resident #117) of 8 sampled residents reviewed for PASRR requirements was referred for further evaluation after the addition of a new mental illness diagnosis. Findings included: Review of an undated facility policy titled, admission Criteria, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The policy further indicated, b. When/if the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative by the system for the Level II (evaluation and determination) screening process. Review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, dated 01/12/2023, revealed, The Level 1 Screening should always reflect the individual's current condition. We recommend checking if a Resident Review is needed during a facility's annual or quarterly MDS reviews. Review of an admission Record, revealed the facility admitted Resident #117 on 02/04/2022 with diagnoses that included major depressive disorder. Per the admission Record, the resident received a new diagnosis of anxiety disorder on 07/21/2023. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/11/2023, revealed Resident #117 had active diagnoses that included anxiety disorder, depression, and bipolar disorder. On 02/13/2024 at 3:10 PM, a copy of Resident #117's PASRR was requested. On 02/14/2024 at 10:42 AM, the facility provided a copy of a PASRR for Resident #117 dated 02/04/2022. No additional PASRRs were provided. Review of Resident #117's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 02/04/2022, revealed the screening did not reflect that the resident had a diagnosis of a serious mental illness. During an interview on 02/15/2024 at 8:40 AM, Assistant Director of Nursing (ADON) #5 stated she did not complete a new PASRR in July 2023 when Resident #117 received a new mental illness diagnosis. During an interview on 02/15/2024 at 8:51 AM, the MDS Coordinator stated new PASRRs were completed in situations such as a change in condition, admission to hospice, an improvement or decline in activities of daily living, and with any new diagnoses. During an interview on 02/15/2024 at 10:53 AM, the Director of Nursing (DON) stated a new PASRR should be completed if a resident started psychotropic medications or if they had a change in their diagnoses, such as a new mental illness. The DON further stated she expected staff to complete PASRRs 056082 Page 3 of 7 056082 02/15/2024 Canyon Springs Post-Acute 180 North Jackson Avenue San Jose, CA 95116

F 0644 as required. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/15/2024 at 11:11 AM, the Administrator stated he expected staff to complete PASRRs as required. Residents Affected - Few 056082 Page 4 of 7 056082 02/15/2024 Canyon Springs Post-Acute 180 North Jackson Avenue San Jose, CA 95116

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on record review, interviews, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR) Level 1 Screening for 1 (Resident #117) of 8 sampled residents reviewed for PASRR requirements. Specifically, the facility failed to ensure Resident #117's PASRR Level 1 Screening reflected the resident's diagnosis of major depressive disorder. Residents Affected - Few Findings included: Review of an undated facility policy titled, admission Criteria, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. Review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, dated 01/12/2023, revealed, Section III-Serious Mental Illness Questions 10-12 This section helps determine if the individual may have a serious mental illness and benefit from specialized services. Question 10. Diagnosed Mental Illness *Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? *If yes, there will be a text box question [to] provide the type of mental illness. Review of an admission Record, revealed the facility admitted Resident #117 on 02/04/2022 with diagnoses that included major depressive disorder. Review of Resident #117's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 02/04/2022, revealed Section III- Serious Mental Illness Screen, question #10 was answered No, and did not reflect the resident's diagnosis of major depressive disorder. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/07/2022, revealed Resident #117 had active diagnoses that included depression and major depressive disorder, recurrent. During an interview on 02/15/2024 at 8:40 AM, Assistant Director of Nursing (ADON) #5 confirmed question #10 should have been answered Yes on Resident #117's PASRR Level 1 Screening, which would have caused the PASRR to be positive, and a Level II would have been required. During an interview on 02/15/2024 at 8:51 AM, the MDS Coordinator confirmed question #10 should have been answered Yes on Resident #117's PASRR Level 1 Screening, since the resident had a diagnosis of depression, which would have made the PASRR positive and would have triggered the need for a Level II. During an interview on 02/15/2024 at 10:53 AM, the Director of Nursing (DON) stated she expected PASRRs to be accurate. During an interview on 02/15/2024 at 11:11 AM, the Administrator stated he expected staff to complete PASRRs as required. 056082 Page 5 of 7 056082 02/15/2024 Canyon Springs Post-Acute 180 North Jackson Avenue San Jose, CA 95116

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure 2 (Resident #106 and Resident #128) of 33 sampled residents' care plans reflected the residents' current conditions and needs. Findings included: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised in December 2016, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy further indicated, 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Additionally, the policy indicated, 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy further indicated, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. A review of Resident #106's admission Record, revealed the facility admitted the resident on 12/20/2023 with diagnoses that included cervical spinal stenosis and chronic kidney disease. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/23/2023, revealed Resident #106 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident required partial/moderate assistance from staff with bed mobility and transfers. An observation on 02/13/2024 at 3:07 PM revealed Resident #106 lying in bed. The resident had a laceration to the left side of their forehead with five sutures. A review of Resident #106's Progress Notes, revealed a note dated 12/25/2023 at 6:04 AM that indicated the resident was found on the floor, blood was noticed on the resident's forehead, and the resident was sent to the emergency room for evaluation. A review of an ED [Emergency Department] Provider Report, dated 12/25/2023, revealed Resident #106 had a two-centimeter (cm) laceration to the forehead with underlying hematoma (bruising) that required 12 sutures . A review of Resident #106's current comprehensive care plan for their 12/20/2023 admission revealed none of the Focus areas addressed the resident's forehead laceration with sutures, nor did any listed Interventions/Tasks direct staff regarding any needed treatments or follow-up for the sutures to the resident's wound. During an interview on 02/15/2024 at 11:19 AM, the MDS Coordinator confirmed that Resident #106's laceration was not reflected on the care plan but should have been included. She stated it should have been put on the care plan by the nurse that accepted the resident back from the hospital. During an interview on 02/15/2024 at 10:53 AM, the Director of Nursing (DON) stated some parts of 056082 Page 6 of 7 056082 02/15/2024 Canyon Springs Post-Acute 180 North Jackson Avenue San Jose, CA 95116

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #106's laceration had not healed well, so some sutures were removed, and others were left in to allow more time to heal. She indicated this information should have been reflected on the resident's care plan and said the floor nurse or wound nurse were responsible for updating the care plan. During an interview on 02/15/2024 at 11:10 AM, the Administrator stated he expected a laceration that required sutures and treatment to be included on the resident's care plan. 2. A review of Resident #128's admission Record, revealed the facility originally admitted the resident on 06/15/2023 and readmitted the resident on 09/14/2023 with diagnoses that included dysphagia (difficulty swallowing) following nontraumatic intracerebral hemorrhage, hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided weakness) affecting the left non-dominant side, and gastrostomy status (feeding tube). A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/2023, revealed Resident #128 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living. An observation on 02/12/2024 at 1:14 PM, revealed a suction machine on Resident #128's over-the-bed (OTB) table. An observation on 02/13/2024 at 3:08 PM, revealed the suction machine on Resident #128's OTB table with tubing and a suction tip in a bag next to the machine. There was clear fluid noted in the bottom of the suction machine canister. A review of Resident #128's physician's orders revealed an active order dated 09/14/2023 that directed staff to suction secretions for excess secretions as needed. A review of Resident #128's current comprehensive care plan for their 09/14/2023 admission revealed none of the Focus areas addressed the resident's excess secretions or need for suctioning. During an interview on 02/15/2024 at 11:19 AM, the MDS Coordinator confirmed that Resident #128's care plan did not reflect the resident's need for suctioning but should have. She further stated she should have caught that the suctioning was not on the care plan during the quarterly review, but she missed it. During an interview on 02/15/2024 at 10:53 AM, the Director of Nursing (DON) stated if a resident required suctioning, it should be included on their care plan. During an interview on 02/15/2024 at 11:10 AM, the Administrator stated if a resident required suctioning, he expected it to be included on their care plan. 056082 Page 7 of 7