Health inspection·April 11, 2019

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 interview and record review, the facility failed to update the plan of care for two of two sampled residents (Residents 47 and 62). Resident 47's hearing aids were missing and Resident 62 had untreated pain with movement. These failures resulted in a lack of comprehensive care plans for hearing and pain management that did not meet resident care needs. Findings: 1. Record review of the admission Record showed the facility admitted Resident 47 on 2/8/19. Record review of Resident 47's plan of care dated 1/23/19 showed, The resident has a communication problem r/t (related to) hearing deficit .Hearing Aid provided .hearing aids are kept with the nurses cart and given to resident each morning. In an interview on 4/8/19 at 10:34 a.m., Resident 47 stated she has difficulty hearing and wanted to know where her hearing aids were located. In a concurrent interview, Registered Nurse 1 (RN 1) stated Patient 47's hearing aids were lost during the time she was in and out of the hospital and were not stored in the medication cart. There was no updated care plan and interventions for the missing hearing aids. 2. Record review of the admission Record showed the facility admitted Resident 62 on 3/9/19. The diagnoses included muscle wasting. In an interview on 4/8/19 at 10:42 a.m., Resident 62 stated he has significant amount of shoulder pain when staff assists him with activities of daily living (ADL, consists of bathing, toileting, eating etc.) and turning in bed. In an interview on 4/9/19, at 2:30 p.m., the Physical Therapist 1 (PT 1) stated Resident 62 reported to him that he had pain in his shoulders whenever staff turned him. In an interview on 4/9/19 at 2:45 p.m., the Certified Nursing Assistant 1 (CNA 1) stated when assisting Resident 62 with care, she asks another staff person for help because Resident 62 was hesitant to turn. Record review of Patient 62's plan of care, Needs assistance with ADL . dated 4/6/19 did not Page 1 of 4 056096 056096 04/11/2019 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0656 identify pain with movement. Level of Harm - Minimal harm or potential for actual harm In an interview on 4/10/19 at 11:19 a.m., the Director of Nursing (DON) confirmed Resident 62's pain with movement was not in his plan of care. Residents Affected - Few Review of the policy and procedure, Care Plans, Comprehensive Person-Centered dated December 2016, showed 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. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 056096 Page 2 of 4 056096 04/11/2019 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility did not manage the pain for one (Resident 62) of two sampled residents in a timely manner. Resident 62 complained of pain when staff turned him in bed and during assistance with activities of daily living (or ADLs: bathing, toileting, feeding). Residents Affected - Few This failure resulted in Resident 62 experiencing unnecessary pain and discomfort. Findings: Record review of theadmission Record showed the facility admitted Resident 62 on 3/9/19. The diagnoses included muscle wasting and atrophy (gradual deterioration). Record review of the Minimum Data Set - Resident Assessment and Care Screening, dated 3/16/19, showed Resident 62 had clear speech, understood what others said to him, and was able to express his ideas and wants. In an interview on 4/8/19 at 10:42 a.m., Resident 62 stated he had a significant amount of pain in his shoulders when staff assisted him with his ADLs and turning in bed. In an interview on 4/9/19 at 2:30 p.m., the Physical Therapist 1 (PT 1) stated Resident 62 reported to him that he had pain in his shoulders when staff were turning him. In a concurrent interview on 4/9/19 at 2:30 p.m., the Registered Nurse 1 (RN 1) stated she was not aware Resident 62 had pain with movement. In an interview on 4/9/19 at 2:45 p.m., the Certified Nursing Assistant 1 (CNA 1) stated when assisting Resident 62 with care, she asks another staff person to help because Resident 62 was hesitant to turn. Record review of the medication administration record (MAR) dated April 2019 showed Resident 62 had Tylenol (pain medication) ordered PRN (as needed). There was no Tylenol given to Resident 62 for the month of April. Review of the facility's policy and procedure, Pain Assessment and Management dated March 2015, showed the purpose was to, Help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Under the section, Assessing Pain, staff were to identify Factors that precipitate or exacerbate pain. 056096 Page 3 of 4 056096 04/11/2019 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure drugs used in the medication room were not expired when one Ekit (An emergency container with equipment, supplies, and medications needed to provide care and manage life-threatening conditions) had expired medications in the refrigerator. This deficient practice had the potential to affect the potency and safety of the medication that could have harmful effects for all 70 residents in the facility. Findings: During an observation of the third floor medication room, on 04/10/19 at 12:55 P.M., an Ekit inside the medication's refrigerator included three tablets of lorazepam (antianxiety) 2 mg/ml (milligram/milliliter) that expired on 12/18 (December 2018). During an interview with the Registered Nurse 1 (RN 1) on 04/10/19 at 12:55 P.M., RN 1 confirmed the expired Ekit and stated the expired medication should not be stored in the medication room and they (staff) forgot to return the Ekit to the pharmacy. During a review of the policy and procedure, DISPOSAL OF MEDICATIONS dated 2007 indicated: . 8. Outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed . 056096 Page 4 of 4