Health inspection·December 13, 2024

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 provide meal assistance for one of five sampled residents ' (Resident 1) when staff did not reposition Resident 1 higher in bed and did not assist in setup of meal tray for 30 minutes during dinner. Residents Affected - Few This failure prevented Resident 1 from finishing dinner because Resident 1 was in an uncomfortable position and could not reach or open food items on the meal tray, which had the potential for weight loss and low blood sugar. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of fall, fracture of lumbar vertebra (lower back bone), rib fractures, muscle weakness, and diabetes (long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1 ' s physician order set titled, Order Summary Report, dated 10/29/24, the order set indicated Resident 1 had an order for [Carbohydrate control] diet .assist with meal, dated 9/7/24. A review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide resident care), dated 9/13/24, indicated Resident 1 had a Brief interview for mental status score of 14 (BIMS, is a scoring system used to determine the resident ' s cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status), was able to make themself understood and was able to feed themself but required setup assistance for meals. During a phone interview on 10/17/24, at 3:40 p.m., with Resident Family (RF), RF stated Resident 1 had been calling RF complaining about lack of staff assistance during meals. RF stated Resident 1 said staff often left Resident 1 flat on the bed with the bed controls and/or bedside table out of reach. During an observation on 10/18/24, at 5:15 p.m., Resident 1 was in his room in bed, lying down with the head of the bed flat. A bedside table with the dinner meal tray was set up parallel to the bed. Resident 1 ' s feet were at the very end of the bed. The food items on the meal tray were covered and were not opened. Page 1 of 2 056475 056475 12/13/2024 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation, interview and record review on 10/18/24, at 5:45 p.m., with Resident 1, Resident 1 was in their room, in bed lying flat and Resident 1 ' s meal ticket for dinner, dated 10/18/24, was on the bedside table. The head of the bed was flat, and the bedside table was parallel to the bed. Resident 1 had finished a cup of fruit and dropped the cup while attempting to place it back on the bedside table. Resident 1 then attempted to reach another food item but was unable to reach anything else. Resident 1 was unable to reposition the bedside table and stated staff brought in the meal tray and left the table like this. The surveyor pushed a cup of soup to Resident 1 ' s reach, but Resident 1 was unable to remove the lid. The meal ticket indicated Resident 1 needed ASSIST W MEALS. Resident 1 stated staff always left food unopened and didn ' t assist with repositioning during meals because staff don ' t follow instructions. Resident 1 exclaimed: look at where my feet are and explained they were too low in the bed to be comfortable even if the head of the bed was raised. Resident 1 was not able to pull themself up higher in bed to reach the bed controls. Resident 1 stated they were uncomfortable and couldn ' t eat the rest of dinner. During a concurrent interview and record review on 10/29/24, at 2:10 p.m., with Dietary Manager (DM), Resident 1 ' s food preferences listed on a facility diet management program were reviewed. DM stated she recalled Resident 1 required assistance in opening food items and removing covers on food. DM stated the ASSIST w MEAL instructions printed on the meal ticket indicated staff were expected to assist Resident 1 with meals according to Resident 1 ' s needs. During a concurrent interview and record review on 10/29/24, at 2:22 p.m., with Certified Nursing Assistant 1 (CNA 1), Resident 1 ' s dinner meal ticket, dated 10/18/24, was reviewed. CNA 1 stated Resident 1 ' s meal ticket indicated Resident 1 needed assistance with meals and would need to ask the nurse or resident what assistance was needed when the meal was served. During an interview on 10/29/24, at 2:48 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 was admitted for rehabilitative therapy after a fall. LVN 1 stated Resident 1 needed to be positioned into a comfortable position due to back pain. LVN 1 recalled Resident 1 wanted the head of the bed elevated for comfort while eating. LVN 1 stated Resident 1 could use the bed controls but needed staff assistance for large position changes in bed such as sliding up in bed. During an interview on 10/29/24, at 3:50 p.m., with Director of Staff Development (DSD), DSD recalled the care needs for Resident 1. DSD stated Resident 1 required staff assistance with positioning and to have the bedside table comfortably within reach. DSD stated as long as the lids were open, Resident 1 was able to independently feed themself. During a record review of Resident 1 ' s care plan titled, ADL FUNCTIONING WITH SELF-CARE DEFICIT REQUIRES ASSISTANCE WITH ADL ' S, undated, the care plan indicated Resident 1 needs extensive assistance for . setup help for oral hygiene/eating. 056475 Page 2 of 2