Other·November 27, 2019

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE AMENDED The following reflects the findings of the California Department of Public Health during a Federal Recertification survey. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 38528 HFEN, 26819 HFEN, 38970 HFEN, 40186 HFEN, 40585 HFEN, 41600 The facility census was 43. The sample size was 16.

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 01/14/2020 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure dignity was promoted for 1 of 16 sampled residents (Resident 22) when Resident 22's urinary catheter bag was exposed. These failures had the potential to negatively impact the residents' psychosocial well-being. Findings: Resident 22 was admitted to the facility in the middle of 2016 with diagnoses which included retaining urine and urinary tract infection. 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of Resident 22's Minimum Data Set (MDS, an assessment tool), dated 6/16/19, indicated he had an indwelling urinary catheter (a tube inserted into the bladder to drain urine). In a concurrent observation and interview on 10/21/19 at 9:25 a.m., a urinary catheter bag hung at the bedside was found with no label and was uncovered. Resident 22 stated, "The doctor put me on this catheter for a long time and I wanted it to be removed. The staff don't even take care of it. They don't even cover it." In an interview on 10/21/19 at 9:28 a.m., Licensed Nurse 3 (LN 3) verified there was no label or cover for the catheter bag. LN 3 stated, "There should have been a dignity bag to cover it." In an interview on 10/21/19 at 9:35 a.m., LN 1 verified the indwelling catheter had no cover. LN 1 stated, "We are supposed to label it every time we change. It should have been labeled, dated, and covered with a dignity bag." In an interview on 10/23/19 at 1:48 p.m., the DON, when asked about catheter bags stated, "...staff should cover them for privacy and dignity." In an interview on 10/24/19 at 1:24 p.m., LN 2 stated, "When we receive a resident with a catheter...cover with a dignity bag and assess for signs and symptoms of infection." In an interview on 10/24/19 at 1:32 p.m., the MDS Coordinator stated, "We would follow the standard procedure, label with name and date when the catheter was inserted, cover the catheter with a clothing bag for dignity." A review of the facility's policy and procedure 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE titled, "Resident Rights," revised 11/16, indicated, "Employees shall treat all residents with kindness, respect, and dignity...Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity."

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 01/14/2020 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to consult with the resident's physician when 1 of 16 sampled residents (Resident 46) had a significant change in health status and failed to notify the physician promptly when Resident 46 died. This failure potentially decreased the opportunity for Resident 46 to receive prompt medical attention from the physician. Findings: Resident 46 was admitted to the facility in the fall of 2019 with diagnoses which included heart disease, lung disease, and cancer. 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Review of Resident 46's clinical record revealed: Nurses' notes dated 9/9/19 to 9/20/19 indicated Resident 46 was alert and fully oriented, had no signs of difficulty breathing, and had no significant changes. Nurses' notes dated 9/21/19 to 9/29/19 indicated Resident 46 became confused, lethargic (sluggish), weak, tried to remove her supplemental oxygen, refused her meals, and developed an open wound to her sacrum (the lower back). Nurses notes dated 9/21/19 to 9/29/19 did not contain documented evidence the physician or the nurse practitioner (NP) were notified of Resident 46's significant change in condition. A NP note dated 9/23/19, indicated, "Care plan was discussed in detail with the patient, nursing as well as rehabilitation staff." The NP note did not contain documented evidence of Resident 46's significant change of condition, as assessed by the licensed nurses. A nurses' note dated 9/30/19 at 5:30 p.m., indicated, "Resident noted to be in Chain (sic) Stokes Breathing [type of abnormal breathing characterized by a gradual increase in breathing, and then a decrease]...Resident is actively dying. Attempt made to contact next of kin. Contact made with former caregiver. Daughter unavailable." A nurses note dated 9/30/19 at 7:12 p.m., indicated, "Resident observed to be not breathing, [no] heart beats noted,...Time of death: 1912 hrs [7:12 p.m.]...CNAs [Certified Nurse Assistants] too (sic) clean and prepare remains for pick up by responsible party." 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Nurses' Notes dated 9/21/19 to 9/30/19 did not contain documented evidence the physician or the NP were notified of Resident 46's death. During an interview with the Director of Nursing (DON) on 10/24/19 at 9:42 a.m., the DON stated they had spoken to Resident 46 about going on hospice (supportive care to people in the final phase of a terminal illness focused on comfort and quality of life, rather than cure) but she did not choose hospice services at that time. The DON reviewed Resident 46's medical record and confirmed there was no documented evidence the physician or the NP were notified of Resident 46's change of condition or death. A facility policy and procedure titled, "Change in a Resident's Condition or Status," dated 9/05, indicated, "The Nurse Supervisor shall notify the resident's attending physician...when...There is a significant change in the resident's physical, mental, or psychosocial status..."

F583 SS=D Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii)

F583 01/14/2020 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to provide privacy to 10 residents in a census of 43 (Residents 5, 8, 11, 12, 21, 29, 32, 295, 297, and 298), when window blinds in resident rooms were in disrepair. This failure had the potential to negatively impact the residents' psychosocial well-being and placed them at risk for violation of their personal privacy. Findings: On 10/21/19 at 7:51 a.m., sections of the window blinds in room 114 were observed to be missing. The front yard of the facility and surrounding public walkway was visible through the closed blinds. Resident 295 verified the missing sections and stated she was able to 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE see outside when the blinds were closed. On 10/21/19 at 7:58 a.m., window blinds in room 110 were observed to be broken and bent. Portions of the center courtyard were visible from the room through the closed blinds. Resident 297, admitted in summer of 2019, stated, "They are all bent and broken. They have been like that since I arrived." On 10/21/19 at 8 a.m., the window blinds in room 111 were observed to have portions that were missing and/or bent allowing the courtyard to be visible when the blinds were closed. Resident 298, admitted to the facility in mid 2019, verified the damaged blinds and stated they were like that when he arrived. On 10/21/19 at 8:29 a.m., the window blinds in room 112 were observed to have portions missing. The courtyard could be seen through the missing sections when the blinds were closed. In a concurrent observation and interview on 10/21/19 a 3:43 p.m., Certified Nurse Assistant 5 verified the window blinds in room 112 were damaged. In an interview on 10/21/19 at 4 p.m., the Administrator verified the damaged window blinds and stated window blinds could have been replaced easily. Review of an undated facility document titled "RESIDENT BILL OF RIGHTS," indicated "Patients shall have the right to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs." Review of a facility policy titled "Quality of LifeDignity," dated 1/11 indicated "Staff shall 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE promote, maintain and protect resident privacy, including bodily privacy..."

F585 SS=D Grievances CFR(s): 483.10(j)(1)-(4)

F585 01/14/2020 §483.10(j) Grievances. §483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. §483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. §483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident. §483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE summary of the pertinent findings or conclusions regarding the resident's concerns (s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to maintain evidence of documentation for the investigation and resolution of all grievances for a period of three years for a census of 43. This failure had the potential to delay the identification of ongoing resident concerns and track the resolution of grievances as required by law. Findings: A review of the facility's grievance binder and concurrent interview with the Social Services Director (SSD) were conducted on 10/22/19 at 11:15 a.m. The SSD stated she only had the grievance logs for the last 2 years in the binder and thought the previous years were in storage. The SSD stated she was not aware 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE they were required to keep the documents for 3 years. In an interview on 10/22/19 at 11:36 a.m. the Administrator stated he was unable to locate the grievance log information for 2017.

F636 SS=E Comprehensive Assessments & Timing CFR(s): 483.20(b)(1)(2)(i)(iii)

F636 01/14/2020 §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. §483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. §483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) (iii)Not less than once every 12 months. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure comprehensive assessments were performed in accordance with regulatory time frames for 5 of 43 sampled residents (Resident 3, 145, 146, 147 and 246), when their admission or annual Minimum Data Set (MDS, an assessment tool) assessments 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE were not completed. This failure increased the potential for unmet resident care needs. Findings: Resident 3 was admitted in the middle of 2013 with diagnoses which included multiple sclerosis (progressive deterioration of the muscles of the body), hand contracture (shortening of the muscles and tendons) and anxiety. Resident 145 was admitted to the facility in late 2019 with diagnoses which included traumatic bodily injury with multiple fractures. Resident 146 was admitted to the facility in late 2019 with diagnoses which included heart failure. Resident 147 was admitted to the facility in late 2019 with diagnoses which included alcoholic liver disease and muscle weakness. Resident 246 was admitted to the facility in late 2019 with diagnoses which included stroke and chronic kidney disease. A review of the computer system which contained the facility's residents MDS assessments on 10/21/19 revealed there was no annual MDS assessment for Resident 3, and there were no admission MDS assessments for Residents 145, 146, and 147 in the system. In an interview on 10/21/19 at 3:43 p.m., the MDS Resource Nurse (MDSRN) indicated after admission, the facility should complete a 14day MDS comprehensive assessment, and annual MDS assessments. The MDSRN 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE stated, "The previous MDS Coordinator could not keep up with the assessments and the transmission of completed MDS. I would agree that the assessments and the transmissions are not up to date." In an interview on 10/21/19 at 4:45 p.m., the MDSRN verified and confirmed the annual MDS assessment for Resident 3, and the admission assessments for Resident 145, 146, and 147 were not completed. In an interview on 10/23/19 at 8:32 a.m., the MDSRN verified and confirmed the admission MDS for Resident 246 was not completed. In an interview on 10/23/19 at 1:57 p.m., the Director of Nursing stated, "I expect the MDS Coordinator would be tracking the assessments when they were due, when they were completed and when they were transmitted." In an interview on 10/28/19 at 2:18 p.m., the Administrator stated, "I am not sure of the issue on the MDS. I know the last MDS Coordinator left and we have a new one on board and I brought in a new MDS Resource Nurse who helps in correcting the issue about MDS."

F637 SS=D Comprehensive Assessment After Signifcant Chg CFR(s): 483.20(b)(2)(ii)

F637 01/14/2020 §483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.) This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to comprehensively assess 1 of 16 sampled residents (Resident 42) after a significant change in health status when Resident 42: 1. Lost 10 percent (%) of body weight in two months; and 2. Developed two new pressure injuries and her existing pressure injury got worse. These failures increased the potential for Resident 42's care plan to not address current health care needs. Findings: Resident 42 was admitted to the facility in the summer of 2019 with diagnoses which included heart disease, kidney disease, dementia (progressive memory loss), and surgical wound healing. Review of Resident 42's medical record revealed the following: A Minimum Data Set (MDS, an assessment tool), dated 8/30/19, indicated Resident 42 weighed 101 pounds and had one unhealed pressure ulcer at stage 1 (skin intact and reddened). A physician order, dated 9/10/19 indicated, "... 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE [left] BUTTOCK STAGE 2 [pressure injury] CLEAN WITH NS [normal saline], PAT DRY, APPLY MEDI HONEY [ointment], COVER WITH DRY DRESSING." A nutritional progress note by the Registered Dietician (RD), dated 9/19/19, indicated Resident 42 had increased calorie and protein needs for wound healing. The RD made recommendations to change to a higher protein content nutrition shake. A document titled, "WEEKLY PRESSURE INJURY REPORT," indicated Resident 42 developed pressure injuries to her left and right heels on 9/24/19. A Weekly Weight Log for 9/19, indicated Resident 42 weighed 96 pounds (4.95 % loss of body weight) on 9/30/19. A document titled, "SPECIALTY PHYSICIAN WOUND EVALUATION & MANAGEMENT SUMMARY," dated 10/1/19, indicated the wound care physician (WCP) was treating Resident 42's wounds, which included an "UNSTAGEABLE (DUE TO NECROSIS [the death of body tissue]) OF THE RIGHT HEEL," with a duration of greater than seven days. The document indicated Resident 42 had a "STAGE 4 [full thickness tissue loss with exposed tendon, muscle, or bone] PRESSURE WOUND OF THE LEFT HEEL," with a duration of greater than seven days. A Weekly Weight Log for 10/19, indicated Resident 42 weighed 90 pounds on 10/21/19, which signified a 10.98 % loss of body weight in less than two months. Review of the completed MDS assessments for Resident 42 revealed no documented evidence a Significant Change in Status Assessment 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE was conducted. During an interview with the Director of Nursing (DON) on 10/24/19 at 12:15 p.m., the DON stated, "If we notice more than two significant changes,...we do a significant change of condition. The IDT [Interdisciplinary Team] will come together after seventy-two hours of monitoring for the changes, and we'll decide whether it is really a significant change to trigger a new comprehensive assessment for a significant change of condition." The DON agreed Resident 42 had two significant changes in health status that should have triggered a significant change in condition assessment.

F638 SS=E Qrtly Assessment at Least Every 3 Months CFR(s): 483.20(c)

F638 01/14/2020 §483.20(c) Quarterly Review Assessment A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) assessments were performed at least every 3 months for seven residents (Residents 15, 148, 22, 2, 149, 12, and 13) in a census of 43, when the quarterly assessments were not completed. This failure increased the potential for residents to have unmet care needs. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Findings: Resident 15 was admitted to the facility in late 2011 with diagnoses which included below the knee amputation of the left leg. Resident 148 was admitted to the facility in early 2015 with diagnoses which included brain injury. Resident 22 was admitted to the facility in the middle of 2016 with diagnoses which included urine retention and urinary tract infection. Resident 2 was admitted in the late 2017 with diagnoses which included difficulty walking and muscle weakness. Resident 149 was admitted to the facility in early 2018 with diagnoses which included memory impairment and right foot pain. Resident 12 was admitted to the facility in early 2019 with diagnoses which included chronic pain syndrome. Resident 13 was admitted to the facility in early 2019 with diagnoses which included below the knee amputation of the left leg and muscle weakness. A review of the facility computer system which contained the residents' MDS assessments on 10/21/19 revealed there were no quarterly MDS assessments for Residents 15, 148, 22, 2, 149, 12, and 13 in the system. In an interview on 10/21/19 at 3:43 p.m., the MDS Resource Nurse (MDSRN) stated, "I would agree that the assessments and the transmissions are not up to date." 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE In an interview on 10/21/19 at 4:45 p.m., the MDSRN verified and confirmed the quarterly MDS assessments for Residents 15, 148, 22, 2, 149, 12, and 13 were not completed. In an interview on 10/23/19 at 1:57 p.m., the Director of Nursing stated, "I expect the MDS Coordinator would be tracking the assessments when they were due, when they were completed and when they were transmitted." In an interview on 10/28/19 at 2:18 p.m., the Administrator stated, "I am not sure of the issue on the MDS."

F640 SS=E Encoding/Transmitting Resident Assessments CFR(s): 483.20(f)(1)-(4)

F640 01/14/2020 §483.20(f) Automated data processing requirement§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. §483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE edits defined by CMS and the State. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. §483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents' completed annual comprehensive assessments were encoded and transmitted to the CMS (Centers for Medicare and Medicaid Services) System within the required time frame for five residents (Residents 12, 39, 148, 15, and 11) in a census of 43. This failure had the potential to negatively affect residents' care and care planning. Findings: 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of the Minimum Data Set (MDS, an assessment tool) for each of the five residents on 10/23/19, revealed the following: Resident 12's annual MDS was not promptly transmitted after the assessment reference date (ARD) of 12/16/18. The MDS was due for transmission 12/30/18 and was transmitted 7/12/19. Resident 39's annual MDS was not transmitted promptly after the ARD of 1/12/19. The MDS was due for transmission 1/16/19 and was transmitted 5/22/19. Resident 148's annual MDS was not transmitted promptly after the ARD of 2/4/19. The MDS was due for transmission 2/28/19 and was transmitted 6/13/19. Resident 15's annual MDS was not transmitted promptly after the ARD of 6/16/19. The MDS was due for transmission 6/30/19 and was transmitted 7/16/19. Resident 11's annual MDS was not transmitted promptly after the ARD of 8/1/19. The MDS was due for transmission 8/15/19 and was transmitted 10/18/19. In an interview on 10/21/19 at 3:43 p.m., the MDS Resource Nurse (MDSRN) indicated there were 14 days to transmit completed MDS to the CMS, and stated, "I would agree that the assessments and the transmissions are not up to date." In an interview on 10/23/19 at 9:41 a.m., the MDSRN verified and confirmed the completed annual MDS assessments for Residents 12, 39, 148, 15, and 11 were not transmitted [within the correct timeframe]. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE In an interview on 10/23/19 at 1:57 p.m., the Director of Nursing stated, "I expect the MDS Coordinator would be tracking the assessments when they were due, when they were completed, and when they were transmitted." In an interview on 10/28/19 at 2:18 p.m., the Administrator stated, "I am not sure of the issue on the MDS."

F655 SS=E Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 01/14/2020 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to provide and/or develop a baseline care plan for 3 of 16 sampled residents (Resident 196, Resident 145 and Resident 146) when the facility did not provide a: 1. Respiratory baseline care plan for Resident 196; and 2. Summary of the baseline care plan for Resident 145 and Resident 146. These failure had the potential to leave residents without information summarizing their goals, medications, diet and treatment. Findings: 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 1. Resident 196 was admitted to the facility in the fall of 2019 with diagnoses which included lung disease. Review of Resident 196's medical record revealed the following: A nurses note dated 10/11/19, at 6 p.m., indicated, "...resident [with] admitting diagnosis of pulmonary sarcoidosis [small lumps of inflamed cells in the lungs], chronic hypoxia [low oxygen levels in the tissues], COPD [chronic obstructive pulmonary disease, a group of progressive lung diseases]...continuous [oxygen] @ 2 L/min [liters per minute] via nasal cannula [plastic tubing delivering oxygen through the nostrils]..." A Baseline Care Plan dated 10/12/19 revealed no documented evidence of a care plan for Resident 196's respiratory care needs. Nurses' notes dated 10/12/19 to 10/13/19 (48 hours) indicated Resident 196 was receiving oxygen at 2 L/min continuously. During an interview with the Director of Nursing (DON) on 10/24/19 at 12 p.m., the DON stated the licensed nurse who admitted Resident 196 to the facility would have developed an admission care plan based on his care needs at the time of his admission. The DON stated the Interdisciplinary Team (IDT) reviewed the baseline care plan on the following weekday. The DON confirmed Resident 196 was admitted with lung problems and was on continuous oxygen therapy. The DON confirmed Resident 196's baseline care plan did not include care for his respiratory problems. A review of the facility policy and procedure titled, "Care Plan - Baseline," dated 8/06, 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE indicated, "The baseline care plan is developed within 48 hours of a resident's admission...A summary of the baseline care plan will be provided to the resident and/or the resident's representative by completion of the comprehensive care plan." 2. Resident 145 was admitted to the facility in late 2019 with diagnoses which included traumatic bodily injury with multiple fractures. A review of Resident 145's clinical record titled, "Baseline Care Plan," dated 9/20/19 revealed signatures of the IDT who contributed to discussion of the baseline care plan. There was no documented evidence a copy of the baseline care plan was provided to the resident and/or there representative. A review of Resident 145's Minimum Data Set (MDS, an assessment tool), dated 9/27/19 indicated Resident 145 had mild memory impairment. In an interview on 10/22/19 at 9:10 a.m., Resident 145 stated, "I was in a car accident...Nobody talked to me about my plan of care...I never had a meeting with the staff...I met with them individually but not in a meeting to plan my care." Resident 146 was admitted to the facility in late 2019 with diagnoses which included heart failure. A review of Resident 146's clinical record titled, "Baseline Care Plan," dated 10/1/19 revealed one signature from the IDT who contributed to discussion of the baseline care plan. There was no documented evidence a copy of the baseline care plan was provided to Resident 146 and/or Resident 146's representative. In an interview on 10/22/19 at 10:02 a.m., 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident 146 stated, "I have not talked with any staff regarding my care...I don't know what the plan is but I'm trying to get out of here...I just don't know when I will be out of here." In interview on 10/24/19 at 12:15 p.m., the DON when asked about the process of the admission care plan, the DON stated, "We have the baseline care plan and the admission nurse develops it within 48 hours. The baseline care plan is explained and discussed by the IDT with the resident or the responsible party and signed if they understood and received a copy of the plan of care. If it was not signed, a copy was not provided to the resident or the responsible party and was not explained."

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 01/14/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: 3. Resident 17 was admitted to the facility in 2015 with diagnoses which included heart disease, and major depression. An annual MDS, dated 6/16/19, indicated Resident 17's preferred language was other than English, and she needed or wanted an interpreter to communicate with a doctor or health care staff. The MDS indicated a Brief Interview for Mental Status (BIMS, a brief screening aid for detecting cognitive impairment) was conducted, and Resident 17 scored 11 (moderate cognitive impairment). There was no documented evidence an interpreter was used to complete the BIMS on Resident 17. A care plan for impaired communication, dated 9/30/19, indicated Resident 17's primary language was Vietnamese, and the facility provided the resident a Vietnamese and 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE English communication board. During an observation of Resident 17's room on 10/21/19 at 2:23 p.m., Resident 17 was awake and lying in her bed. Resident 17 was alert, but was unable to answer questions in English. Observations of Resident 17's living space revealed no evidence of a communication adaptive device. During an interview with CNA 6 on 10/21/19 at 3:43 p.m., CNA 6 stated Resident 17 used hand gestures to communicate her needs to the staff. When asked if Resident 17 had a communication board, CNA 6 searched Resident 17's drawers and closet, and stated she was unable to locate a communication board. During an interview with the Director of Nursing (DON) on 10/23/19 at 10:17 a.m., the DON stated she expected her nurses to use a communication board with Resident 17 when they attempted to understand her care needs. The DON stated the communication boards were available from Social Services, and were to be kept at the resident's bedside. A facility policy and procedure titled, "Residents with Communication Problems," dated 6/08, indicated, "Staff will provide adaptive devices as needed to enable the resident to communicate as effectively as possible. The following are examples of adaptive devices the staff can provide the resident...communication board...interpreter services for foreign languages..." 4. Resident 42 was admitted to the facility in the summer of 2019 with diagnoses which included heart disease, kidney disease, dementia (progressive memory loss), and surgical wound healing. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A pressure ulcer care plan, dated 8/26/19, indicated Resident 42 was at risk of developing a pressure ulcer due to her inability to move independently in bed. The care plan indicated staff was to ensure the resident obtained the appropriate nutrition to enhance the healing process. A nutrition care plan, dated 8/29/19, indicated Resident 42 "had actual nutrition alteration less than body requirements manifested by a reported food intake of less than 75 [percent]." The care plan indicated Resident 42 was to receive house supplements, which included "[brand name of nutrition shake] TID [three times daily]." Review of the weekly weight logs for 8/19, 9/19, and 10/19, indicated Resident 42 weighed 101 pounds on 8/26/19, 96 pounds on 9/30/19, and 90 pounds on 10/21/19, which totaled a 10 percent loss of body weight in two months. On 10/23/19 at 7:55 a.m., a breakfast tray was observed on Resident 42's bedside table. The meal tray included a nutrition shake different from the one specified in the nutrition care plan. On 10/24/19 at 7:49 a.m., and at 12:36 p.m., Resident 42 was observed drinking a nutrition shake different from the one specified in the nutrition care plan. During an interview with the Registered Dietician (RD) on 10/28/19 at 8:45 a.m., the RD confirmed she recommended Resident 42 drink (brand name for nutrition shake) for her weight loss and wound care needs. The RD stated the nutrition shake differed in volume, calories, and amount of protein. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of the facility policy and procedure titled, "Care Plan - Comprehensive," revised 10/10, indicated, "An individualized comprehensive care plan that includes measurable objectives and timetable to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident."Based on observation, interview and clinical record and facility policy review, the facility failed to develop and implement comprehensive care plans for six residents (Residents 22, 39, 17, 42, 12, and 29) in a census of 43 when: 1. Resident 22 had no care plan developed for the use of a urinary catheter; 2. Resident 39 had no care plan developed for smoking activities; 3. Resident 17's care plan for communication was not implemented; 4. Resident 42's care plan for pressure ulcer was not implemented; 5. Resident 12 had no care plan developed for respiratory care; and 6. Resident 29 had no care plan developed for lactulose (used to lower high levels of ammonia, a waste product, in the blood). These failures had the potential to negatively affect the residents' ability to attain or maintain their highest physical, mental and psychosocial well being. Findings: 1. Resident 22 was admitted to the facility in the middle of 2016 with diagnoses which included urine retention and urinary tract infection. A review of Resident 22's Minimum Data Set (MDS, an assessment tool), dated 6/16/19, 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE indicated he had an indwelling urinary catheter (a tube inserted into the bladder to drain urine). In a concurrent observation and interview on 10/21/19 at 9:25 a.m., a urinary catheter bag was observed hanging at the bedside. Resident 22 stated, "The doctor put me on this catheter for a long time and I wanted it to be removed. The staff don't even take care of it. They don't even cover it." In an interview on 10/21/19 at 9:35 a.m., Licensed Nurse 1 (LN 1) indicated Resident 22 just came back from the hospital and the catheter came from the hospital, and stated, "We are supposed to label it every time we change. It should have been labeled, dated and covered." In an interview on 10/24/19 at 1:24 p.m., LN 2 stated, "When we receive a resident with a catheter, we document assessment in the chart and develop a care plan for catheter management." When asked to find the care plan for catheter management in Resident 22's clinical record, the LN verified that there was no care plan developed for the resident. In an interview on 10/24/19 at 1:32 p.m.,the MDS Coordinator (MDSC) stated, "We assess for signs and symptoms of infection, and develop or create a care plan for catheter management that includes goals and intervention to prevent the resident from infection." The MDSC verified that there was no catheter management care plan developed for Resident 22 and could not find it in Resident 22's clinical record. 2. Resident 39 was admitted in the middle of 2015 with diagnoses which included depression, muscle weakness, difficulty 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE walking and anxiety. In an interview on 10/21/19 at 8:38 a.m., Resident 39 asked Certified Nursing Assistant 1 (CNA 1) when was the next scheduled smoking time. Resident 39 stated, "We have scheduled smoking times and I follow the schedule, but I don't know when." In an interview on 10/21/19 at 8:41 a.m., CNA 1 stated, "[Resident 39] smokes but sometimes she is confused and does not know the schedule most of the time. She is always confused and asks when and where to smoke." In an interview on 10/24/19 at 3:59 p.m., when asked if a care plan for smoking was developed for Resident 39, the MDSC stated, "I saw the smoking assessment but I could not find the care plan." The MDSC verified there was no current smoking care plan for Resident 39. 5. Resident 12 was admitted to the facility in 2013 with diagnoses which included chronic obstructive pulmonary disease (COPD, a progressive lung disease characterized by increasing breathlessness). Resident 12's MDS, dated 5/25/19, indicated Resident 12 needed oxygen therapy. In an interview and concurrent review of Resident 12's medical record on 10/24/19 at 12:02 p.m., the DON verified there were no respiratory care plans in Resident 12's clinical record and stated, "PRN [as needed] 02 [oxygen] and respiratory care plans should be in the chart." The DON stated she would expect him to have one due to his respiratory problems. She stated residents with COPD and asthma should have care plans for each problem as well as a care plan for oxygen. 6. Clinical record review indicated Resident 29 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE was admitted to the facility from an acute care hospital in mid May 2013 with diagnoses which included feeding difficulties, muscle weakness, dementia and Parkinson's Disease. Resident 29's admission Physician Orders included an order, dated 10/30/18, for lactulose 45 ml (milliliter, unit of measure for volume) by mouth three times a day for "increase ammonia." Review of Resident 29's laboratory assessments since 10/18 did not include a serum ammonia assessment. A review of Resident 29's quarterly Minimum Data Set (MDS-an assessment tool) indicated Resident 29 did not have any Care Area Assessment (CAA) Summary in Section V specifically related to elevated ammonia. Review of Resident 29's current clinical record care plans indicated the IDT (Interdisciplinary Team) had not developed a plan of care for Resident 29's increased ammonia or use of lactulose. A review of the facility policy and procedure titled, "Care Plan - Comprehensive," revised 10/10, indicated "An individualized comprehensive care plan that includes measurable objectives and timetable to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident." During an interview on 10/24/19 at 3:21 p.m., the DON confirmed facility licensed staff had not developed a care plan for Resident 29's lactulose, which would have included monitoring parameters for resident's diagnosis of elevated ammonia. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG

F677 ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 SS=D DEFICIENCY) COMPLETE DATE 01/14/2020 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a haircut and shave for 1 of 16 sampled residents (Resident 32) when oral care and grooming was not provided. This failure had the potential to negatively impact the resident's physical and psychosocial well being. Findings: Resident 32 was admitted to the facility in 2019 with diagnoses which included liver failure and muscle weakness. A review of a facility document titled, "Skin Monitoring: Comprehensive CNA [Certified Nurse Assistant] Shower Review" for Resident 32 dated 8/16/19, indicated, "Refused shower x3 [times three] & Bed Bath...Prefer am [morning] shower." No documented evidence was found for an intervention or follow-up. Review of a facility document titled, "Department Response Form," dated 8/20/19, indicated Resident 32 requested haircut services. There was no documented evidence the resident ever received the requested service. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of facility documents titled, "Skin Monitoring: Comprehensive CNA Shower Review," for Resident 32 dated 8/20/19, 8/30/19, 9/20/19, 9/23/19, 10/11/19, 10/4/19, and 10/18/19 indicated no documented evidence Resident 32 was shaved. The documents indicated the resident refused a shower on three of the seven days and there was no documented evidence of interventions. The Minimum Data Set (MDS, an assessment tool), dated 8/22/19, indicated Resident 32 had moderate memory impairment and needed assistance with personal hygiene. In a concurrent observation and interview on 10/21/19 at 7:30 a.m., Resident 32 was seated in his wheelchair in his room. Resident 32's face was unshaven, his beard was approximately two inches in length and his hair was uncombed. Resident 32 stated, "I haven't had a shave or a haircut since I came in...I could really use one, I'd feel better." Resident 32 stated he was never offered a shave or haircut and was never assisted with oral care. He stated he did not remember the last time he was helped to brush his teeth and did not even know if he had a toothbrush. In an interview on 10/23/19 at 7:12 a.m., CNA 4 stated, "[Resident 32] is up early and usually in the dining room when I get here...I help him when he asks...I don't do anything with his oral care...shaves are usually done on shower days. His showers are on Tuesdays and Fridays." In an interview on 10/23/19 at 7:39 a.m., Licensed Nurse 2 (LN 2) stated, "It [shaves] should be on [documented on] the shower sheet." 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE In a concurrent interview with the Director of Staff Development (DSD) and the Director of Nurses (DON) on 10/23/19 at 9:05 a.m., the DSD stated Activities of Daily Living (ADL) care included assisting residents to brush their teeth and comb their hair. The DON stated, "If showers are refused they [CNAs] should offer to shower them on a different day. They should always document on the shower sheet if a shave is done." The DSD stated nail clipping and shaves can be done by any CNA. In an interview with the DSD on 10/23/19 at 10:46 a.m., when asked about her expectations of the CNAs and ADL care, the DSD stated, "The CNAs should do rounds in the morning and give ADL care each day which includes brushing teeth or caring for dentures and combing hair." Review of a facility policy titled, "Quality of LifeDignity," Revised 1/11, indicated, "Residents shall be groomed as they wish to be groomed (hair...facial hair, etc.)."

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 01/14/2020 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Based on observation, interview, and record review, the facility failed to provide personal choice of activities for 1 of 16 sampled residents (Resident 147), when the resident was not able to watch movies on the television in his room. This failure increased the potential for negative impact on the resident's psychosocial wellbeing. Findings: Resident 147 was admitted to the facility in the middle of 2019 with diagnoses which included muscle weakness and communication problem. A review of Resident 147's clinical record titled, "BASELINE CARE PLAN," dated 8/31/19, indicated, "Resident will be assessed for Activity preferences: [Resident 147] will participate in activities of choice." A review of Resident 147's clinical record titled, "ACTIVITY ASSESSMENT," dated 9/4/19, indicated activity interest included watching science fiction and action movies on television. The Activity Director (AD) assessment note indicated, "Resident 147 prefers 1x1 [one to one] and not into social activities." A review of Resident 147's "Activity Care Plan," dated 9/4/19, indicated, "Alterations in Activity pursuit patterns R/T [related to] resident prefers 1x1 activity." A review of Resident 147's admission Minimum Data Set (MDS, an assessment tool) dated 9/5/19, indicated Resident 147 had a very mild memory impairment. In a concurrent observation and interview on 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 10/21/19 at 9:04 a.m., Resident 147 was in his room watching a fuzzy black and white television (TV) screen. Resident 147 stated, "That TV has been from the last century...It is an old TV and you can't expect a lot from it. I'm not going to be here that long but I cannot watch TV when it is like that." A review of the facility's document titled, "Maintenance Log," dated 10/15/19, indicated on 10/21/19 a problem was reported by the day shift, Resident 147 complained there was only one channel on his television. In an interview on 10/22/19 at 8:10 a.m., the AD indicated upon admission she did an activity assessment, and stated, "I definitely would have asked the resident if he wanted a television that works, but I did not ask [Resident 147] about his TV." In a concurrent observation and interview on 10/22/19 at 10:39 a.m., Resident 147 had a telephone conversation at the nurse's station, screamed on the phone and yelled, "I never watch the news. I only got 1 channel on my TV." When asked what was happening, Resident 147 stated, "I am talking with my family. I told the staff that my TV has only 1 cable channel and they have not done nothing." In an interview on 10/22/19 at 2:39 p.m., the Administrator (ADM) verified and acknowledged there was a problem with Resident 147's television. When asked what the facility does when there was a complaint about a television, the ADM stated, "If I knew the issue I would have gone and got a new TV for the resident." A review of of the facility policy and procedure titled, "Activity Programs," revised 8/06, 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE indicated, "Activity programs designed to meet the needs of each resident are available on a daily basis...Activities are not necessarily limited to formal activities being provided only by activities staff...Adequate space and equipment are provided to ensure that needed services are identified in the resident's plan of care are met."

F684 SS=E Quality of Care CFR(s): 483.25

F684 01/14/2020 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide nursing services in according with professional standards for four of 16 sampled residents (Resident 17, Resident 197, Resident 43, and Resident 247) when: 1. A licensed nurse (LN) failed to assess Resident 17 when the resident was exhibiting signs of pain and distress; 2. Newly admitted Resident 197 did not have an identification band, and received an unlabeled bottle of enteral nutrition through his gastrostomy tube (g-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach); 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 3. LNs failed to notify the physician of a new skin condition for Resident 43; and 4. A LN failed to notify the physician of an elevated blood glucose level for Resident 247. These failures increased the potential for residents to receive treatments in error, and to not receive the medical attention they required to reach their highest practicable physical wellbeing. Findings: 1. Resident 17 was admitted to the facility in 2015 with diagnoses which included heart disease, and major depression. An annual Minimum Data Set (MDS, an assessment tool), dated 6/16/19, indicated Resident 17's preferred language was other than English, and she needed an interpreter to communicate with a doctor or health care staff. The MDS indicated Resident 17's cognition was moderately impaired. A care plan for impaired communication, dated 9/30/19, indicated Resident 17's primary language was other than English, and the facility provided the resident a communication board. During observations on 10/23/19 at 9:50 a.m., Resident 17 motioned for surveyor to enter her room. Resident 17 grabbed the surveyor's hand, placed it on her abdomen, and winced. Resident 17 brought the surveyor's hand to her forehead and continued to wince. Resident 17 made a hand gesture to her mouth and nose. The LN assigned to Resident 17 was notified. When LN 5 came to Resident 17's bedside, Resident 17 grabbed LN 5's hand, squeezed it, and winced and moaned. When Certified Nursing Assistant 7 (CNA 7) entered Resident 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 17's room. CNA 7 told LN 5 Resident 17 had abdominal pain because she was trying to have a bowel movement. CNA 7 asked LN 5 if Resident 17 had received a laxative. LN 5 left Resident 17's room and returned with a laxative medication. LN 5 attempted to administer the laxative to Resident 17 who refused it and continued to wince and moan. LN 5 did not assess Resident 17, nor did she attempt to use a communication board to ask Resident 17 about her pain. During an interview with the Director of Nursing (DON) on 10/23/19 at 10:17 a.m., the DON stated she expected LNs to assess their residents when they appear in pain or distress. The DON stated, when a resident was nonEnglish speaking, she expected her LNs to perform a head to toe body assessment and to use the language communication board. 2. Resident 197 was admitted to the facility in the fall of 2019 with diagnoses which included a stroke, and had a g-tube. During a concurrent observation and interview with CNA 8 on 10/21/19 at 8:30 a.m., Resident 197 was not wearing an identification bracelet, nor was one found on his bed, wheelchair, or bedside dresser. A bottle of enteral feeding (nutritional formula) was infusing through Resident 197's g-tube. The bottle did not indicate documented evidence of the resident's name, the prescribed dose, or the time the infusion started. CNA 8 confirmed the observations, and went to the nurses station to learn the resident's name. During an interview with the DON on 10/21/19 at 9 a.m., at Resident 197's bedside, the DON confirmed Resident 197 was not wearing an identification bracelet, and there was no label on the enteral feeding bottle. The DON stated 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE she expected staff to provide residents with an identification bracelet, and to label enteral feeding bottles. A facility policy and procedure titled, "Enteral Tube Feeding via Continuous Pump," dated 12/11, indicated, "On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order." A facility policy and procedure titled, "Administering Medications," dated 4/08, indicated, "Should the resident's identity be questionable, the individual administering the medication must verify the resident's identity before administering the medication." 3. Resident 43 was admitted to the facility in fall of 2019 with diagnoses which included congestive heart failure (weakness of the heart which can lead to fluid buildup in the lungs and body tissue). A review of Resident 43's clinical document titled, "Resident Admission Assessment," dated 9/24/19, indicated, "Physical examination showed no major pressure sores or surgery sites, arms do show exensive (sic) scares (sic) ..." A review of Resident 43's Interdisciplinary Team Baseline Care Plan, dated 9/24/19, indicated, "Notify MD [physician] ...for any change of condition." A review of Resident 43's clinical document titled, "NURSES NOTES," dated 10/12/19, indicated, "CNA notified Tx [Treatment] nurse about an open skin area on pt's [patient's] [right] back thigh noticed during shower. Nurse/Tx assessed the area ...Shift nurse notified ...Open area noted by AM [morning] shift nurse on pts [patient's] lower [right] 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE ankle...Area assessed by Tx nurse." A review of Resident 43's clinical document titled, "NURSES NOTES," dated 10/13/19, indicated, "Dressing on [right] leg hamstring changed cleansed [with] NS [normal saline], patted dry & Dry dressing applied. DON notified about it. Care plan initiated & incident report made as advised." A review of Resident 43's clinical document titled, "PHYSICIAN'S TELEPHONE ORDERS," dated 10/18/19, indicated, "Start tx: [right] Shin blister: clean [with] NS, pat dry, apply DD [dry dressing] QDay [once a day]. [Right] Lateral Thigh skin tear: clean [with] NS, pat dry, apply [name brand of a honey ointment], cover [with] DD QDay." During an interview with the Treatment Nurse (TN) on 10/22/19 at 2:11 p.m., the TN stated Resident 43's wounds were discovered on 10/12/19. The TN stated on 10/18/19, he received telephone orders for the treatment of the wounds. During an interview with the DON on 10/22/19 at 2:54 p.m., the DON confirmed there was no documented evidence the physician was notified upon discovery of the skin condition. The DON stated the physician should have been notified right away. During an interview with the Medical Director (MD) on 10/28/19 at 1:10 p.m., the MD stated the physician should be notified by the nurses or the DON when a new skin condition was found. A review of the facility policy titled, "Change in a Resident's Condition or Status," revised 9/05, indicated, "The facility shall notify the 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE ...attending physician...of changes in the resident's condition and/or status ...The Nurse Supervisor shall notify the resident's attending physician ...when: a. The resident is involved in any accident or incident which results in an injury including injuries of an unknown source ...Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's condition or status." 4. Resident 247 was admitted to the facility in the fall of 2019 with diagnoses which included diabetes mellitus II (DM2, a condition whereby the body ineffectively metabolizes sugar). A review of Resident 247's Physician's Orders with a start date of 10/4/19, stipulated, "[name brand for insulin aspart, a short-acting medication to quickly lower blood sugar] ...INJECT 1-12 UNITS FOR DM2 Subcutaneous [tissue beneath the skin] Insulin before Bkfst [breakfast], Lun [lunch], Din [dinner]. PER SLIDING SCALE [the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges] 151-200= 2 UNITS, 201250=4 UNITS, 251-300=6 UNITS, 301-350=8 UNITS, 351-400= 10 UNITS, 401 < [401 and greater] 12 UNITS AND NOTIFY MD [physician]." Review of Resident 247's Medication Administration Record (MAR) from 10/4/19 to 10/23/19 indicated the following: On 10/6/19 at 5:30 p.m., the documented BG was 401; and On 10/19/19 at 5:30 p.m., the documented BG was 433. A review of Resident 247's clinical documents 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE titled, "NURSES NOTES," from 10/6/19 to 10/21/19, indicated no documented evidence the physician was notified of Resident 247's elevated BGs per the physician's order. During an interview with the DON on 10/28/19 at 7:12 a.m., the DON confirmed Resident 247's physician orders stipulated physician notification for BGs of 401 or higher. The DON confirmed there was no documented evidence the physician was notified on 10/6/19 and 10/19/19 regarding BGs of 401 or higher. The DON stated, she expected the staff to address the episode (of elevated BGs, by administering the correct sliding-scale insulin dose), contacting the physician for orders, and reassessing the resident. A review of the facility policy titled, "Change in Resident's Condition or Status," revised 9/05, indicated, "The facility shall notify ...his or her attending physician ...of changes in the resident's condition and/or status ...The Nurse Supervisor shall notify the resident's attending physician ...when ...There is a significant change in the resident's physical...status." The "California Nursing Practice Act" enacted on 1/1/13, indicated "...The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following:...Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures."

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 01/14/2020 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to prevent the development and worsening of pressure ulcers in one of 16 sampled residents (Resident 42) when: 1. Orders for a low air loss mattress, and a nutrition shake to enhance wound healing were not followed; and 2. The pressure ulcer on the coccyx (tailbone) 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE was not reported to the wound care physician, reviewed by the Interdisciplinary Team, and the treatment nurse did not document on the progress of the pressure ulcer to treatment. These failures resulted in Resident 42 developing two new, avoidable, pressure ulcers to the right and left heels, and the worsening of one pressure ulcer to the coccyx while at the facility. Findings: 1. The National Pressure Ulcer Advisory Panel (NPUAP, professional organization dedicated to the prevention and management of pressure injuries) 2016 definition of pressure injuries indicated "A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence ... The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear." A pressure injury may also be referred to as a pressure ulcer, pressure sore, pressure wound, decubitus ulcer, and bedsore. Resident 42 was admitted to the facility in the summer of 2019 with diagnoses which included heart disease, kidney disease, dementia (progressive memory loss), and a surgical wound to her right lower leg. Review of Resident 42's clinical record revealed the following: A document titled, "Skin & Body Assessment," dated 8/23/19, indicated Resident 42 returned from the hospital with several wounds, which included a wound with a bandage and surgical staples, bruises, and swelling of her lower right leg. The assessment did not contain 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE documented evidence of wounds to the right or left heels. A Pressure Ulcer Risk Care Plan, dated 8/25/19, indicated Resident 42 was at risk of developing pressure ulcers due to her inability to move independently in bed, and her dementia. The care plan interventions included a pressure relieving mattress to the bed, repositioning every one to two hours, and dietary supplements per orders. A Pressure Ulcer Care Plan, dated 8/26/19, indicated, "PRESSURE ULCER AS MANIFESTED BY: bed mobility [the ability to move independently in bed]." The care plan interventions included staff were to encourage Resident 42 to turn or reposition at least every two hours, ensure the resident obtained appropriate nutrition to enhance the healing process, and keep the physician informed of the progress and response to the treatment plan. The care plan did not specify the number or location of any pressure ulcers. A Minimum Data Set (MDS, an assessment tool), dated 8/30/19, indicated Resident 42 was non-ambulatory, and required extensive assistance with bed mobility and transfers from her bed to her wheelchair. The MDS indicated Resident 42 had one unhealed pressure ulcer at stage 1 [non-blanchable reddened area usually over a bony prominence]. A Nurses Note, dated 9/11/19, at 12 p.m., indicated, " ...Discoloration noted on bilateral [both] heels. Continued to elevate feet when in bed. Will continue to monitor." A Nutrition Note by the Registered Dietician (RD), dated 9/19/19, indicated Resident 42 had increased calorie and protein needs for wound healing. The RD made recommendations, 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE which included changing her current nutrition shake with 6 grams of protein per serving to a nutrition shake with 9 grams of protein per serving, at each meal. A physician's order, dated 9/23/19, indicated, "[Name brand for nutrition shake with 9 grams of protein] GIVE 1 CAN Oral With Bkfst [breakfast], Lun [lunch], and Din [dinner] AS SUPPLEMENT." A document titled, "WEEKLY PRESSURE INJURY REPORT," dated 9/24/19, indicated Resident 42 acquired pressure injuries to her left and right heels. The report indicated the right heel was considered a deep tissue injury (DTI, intact or non-intact skin with localized area of persistent non-blanchable, deep red, maroon, or purple discoloration), and the left heel was considered unstageable (UTD, obscured full-thickness skin and tissue loss). A Nurses Note, dated 9/24/19, at 2 p.m., indicated, "[New Order] Received by [name of wound care physician] to start tx [treatment] for [right] heel UTD DTI and to start tx for [left] heel UTD ..." A physician's order, dated 9/26/19, indicated, "LOW AIR LOSS MATTRESS [designed to prevent and treat pressure wounds]." A document titled, "SPECIALTY PHYSICIAN WOUND EVALUATION & MANAGEMENT SUMMARY," dated 10/1/19, indicated Resident had an "UNSTAGEABLE (DUE TO NECROSIS [dead tissue cells]) OF THE RIGHT HEEL," with a duration of greater than seven days, and a "STAGE 4 [full thickness tissue loss with exposed tendon, muscle, or bone] PRESSURE WOUND OF THE LEFT HEEL," with a duration of greater than seven days. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A "SPECIALTY PHYSICIAN WOUND EVALUATION & MANAGEMENT SUMMARY," dated 10/15/19, indicated Resident 42 had a "STAGE 3 [full thickness tissue loss, but no tendon, muscle or bone is exposed] PRESSURE WOUND OF THE RIGHT HEEL," with a duration of greater than 21 days, and a "STAGE 4 PRESSURE WOUND OF THE LEFT HEEL," with a duration of greater than 21 days. During a concurrent observation and interview with the treatment nurse (TN) on 10/21/19 at 10:15 a.m., the TN provided wound care to Resident 42. The resident did not have dressings on the left and right heels. The TN stated the heels should have been covered with dressings. The TN stated Resident 42 acquired her pressure wounds to her heels while at the facility. During a concurrent observation and interview with the wound care physician (WCP) and the TN on 10/22/19 at 3:30 p.m., the WCP confirmed Resident 42 was not lying on a low air loss mattress. The WCP recommended a low air loss mattress for her bed, a specialized pressure relieving cushion for her wheelchair, and time in her wheelchair limited to 60 consecutive minutes. During an observation on 10/23/19, at 7:55 a.m., Resident 42 was observed eating her breakfast in bed. Her breakfast items included a nutritional shake with 6 grams of protein, and not the ordered nutrition shake with 9 grams of protein. During a concurrent observation and interview with CNA 2 of Resident 42's breakfast on 10/24/19 at 7:49 a.m., Resident 42 was observed drinking a nutrition shake with 6 grams of protein per serving, rather than the 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE ordered nutrition shake with 9 grams of protein. When asked about the resident's nutrition shake, CNA 2 stated she would encourage Resident 42 to drink her nutrition shake and would offer her pudding or Jell-O, because Resident 42 liked those food items. During an interview with the TN on 10/24/19 at 9:20 a.m., the TN stated he was not sure why Resident 42 did not receive a low air loss mattress when it was ordered on 9/26/19. The TN stated he thought the mattress was not available at that time, and then the order was forgotten about. During a concurrent observation and interview with CNA 3 of Resident 42's lunch on 10/24/19 at 12:36 p.m., Resident 42's meal included a nutrition shake with 6 grams of protein per serving, rather than the ordered nutrition shake with 9 grams of protein. CNA 3 stated she planned on encouraging Resident 42 to finish her nutrition shake, and would also offer her a second nutrition shake. During an observation of Resident 42's breakfast meal on 10/28/19 at 7:30 a.m., Resident 42's breakfast tray included a nutrition shake with 6 grams of protein, not the nutrition shake ordered with 9 grams of protein. During an interview with the RD on 10/28/19, at 8:45 a.m., the RD stated she recommended the change in nutrition shakes on 9/19/19 when Resident 42 had significant weight loss and wound healing needs. 2. A document titled "Skin & Body Assessment," dated 8/23/19, indicated Resident 42 returned from the hospital with several wounds, which included redness over the coccyx area with a puncture to the left buttock. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A Treatment Record for 8/19 indicated Resident 42 began treatment for a "Left buttock stage 1 [pressure injury]" on 8/28/19. Review of the Nurses Notes from 8/25/19 to 10/5/19, which included progress notes written by the TN, revealed no documented evidence of Resident 42 having a left buttock pressure injury. A physician's order, dated 8/29/19, indicated, "Start tx [treatment] order: [left] Buttock stage 2 [partial thickness skin loss, presenting as a shallow open ulcer with a red pink wound bed, or an intact or open fluid filled blister] clean with NS [normal saline], pat dry, apply medi honey [ointment], cover [with] DD [dry dressing]." A Treatment Record for 9/19 indicated Resident 42 received treatment for a "left buttock stage 2 [pressure injury]." A physician's order, dated 9/10/19, indicated " ...[left] BUTTOCK STAGE 2 CLEAN WITH NS, PAT DRY, APPLY MEDI HONEY, COVER WITH DRY DRESSING." A Treatment record for 10/19 indicated Resident 42 received treatment for a left buttock stage 2 (pressure injury). A document titled, "SPECIALTY PHYSICIAN WOUND EVALUATION & MANAGEMENT SUMMARY," dated 10/1/19, did not have documented evidence of Resident 42's left buttock stage 2 pressure injury. A document titled, "SPECIALTY PHYSICIAN WOUND EVALUATION & MANAGEMENT SUMMARY," dated 10/15/19, did not have documented evidence of Resident 42's left buttock stage 2 pressure injury. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident 42's clinical record did not contain documented evidence that indicated the Interdisciplinary Team (IDT) reviewed Resident 42's left buttock stage 2 pressure injury on 9/24/19, 10/1/19, 10/8/19, and 10/15/19 when they met to review Resident 42's pressure injuries. During multiple observations of Resident 42 on 10/21/19 between 9 a.m. and 4:30 p.m., the resident was observed lying in bed on her back, with the head of her bed elevated, and her heels resting on pillows. During a concurrent observation and interview with the TN on 10/21/19 at 10:15 a.m., the TN changed a dressing on the resident's coccyx region (tailbone), and stated her coccyx pressure ulcer was acquired before her admission to the facility. During an interview with the WCP and the TN on 10/22/19 at 1:30 p.m., the WCP stated he was not aware Resident 42 also had a pressure injury over her coccyx region. The TN stated he did not notify the WCP of the coccyx pressure injury, and he was responsible for notifying him when new wounds developed. During a concurrent observation and interview with the WCP and the TN on 10/22/19 at 3:30 p.m., the WCP assessed Resident 42's pressure wound to the coccyx region and stated the wound was unstageable. The WCP recommended a low air loss mattress for her bed, a specialized pressure relieving cushion for her wheelchair, and time in her wheelchair limited to 60 consecutive minutes. The TN stated he was sure Resident 42's coccyx pressure ulcer worsened because the resident sat in her wheelchair for long periods of time. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During an interview with the Director of Nursing (DON) on 10/22/19 at 4:17 p.m., the DON stated she expected the TN to notify the DON and the WCP whenever a resident developed a new wound. During intermittent observations on 10/24/19 between 9 a.m. and 12:55 p.m., Resident 42 was observed seated in her wheelchair. Between 1 p.m. and 4 p.m., Resident 42 was observed lying in bed, on her back, with the head of her bed elevated and her heels resting on pillows. During an interview with the RD on 10/28/19, at 8:45 a.m., the RD stated she attended the IDT wound care committee meetings, and was not informed of a pressure injury to Resident 42's coccyx. During an interview with the Medical Director (MD) on 10/28/19 at 1:10 p.m., the MD stated he expected the facility staff to notify the WCP of all wounds. A facility policy and procedure titled "Prevention of Pressure Ulcers," dated 8/13, indicated "General Prevention Measures...For a person in (sic) confined to bed...Change position at least every two hours or more frequently if needed...If a special mattress is needed, use one that contains foam, air, or gel as indicated...Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medical necessity...For a person in a chair...Change position at least every hour...Routinely assess and document the condition of the resident's skin per facility wound and skin care program for signs and symptoms of irritation or breakdown...Immediately report any sign of a developing pressure ulcer [injury] to the supervisor...Administer vitamins, minerals and 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE protein supplements in accordance with physician orders and dietitian recommendations."

F689 SS=E Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 01/14/2020 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure adequate supervision or a clutter-free environment for two of 16 sampled residents (Resident 26 and Resident 196) when: 1. The facility failed to identify the location of Resident 26; and 2. The facility placed long electrical wires and oxygen tubing on the ground next to Resident 196. These failures increased the risk for residents to sustain falls and injuries. Findings: 1. Resident 26 was admitted to the facility the summer of 2019 with diagnoses which included stroke and muscle weakness. A review of Resident 26's Minimum Data Set 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE (MDS, an assessment tool) dated 8/17/19, indicated Resident 26 had impairment to one side of his lower extremities. A review of Resident 26's Physical Therapy Progress notes dated 10/20/19, indicated, "Precautions Patient is a fall risk from CVA [cerebrovascular accident, stroke] leaving [Resident 26] with right sided weakness." On 10/22/19 at 1:08 p.m., Resident 26 was not in his bedroom nor the dining room. During a concurrent observation and interview with Licensed Nurse 1 (LN 1) on 10/22/19 at 1:10 p.m., LN 1 confirmed Resident 26 was not in the bedroom, dining room, nor the therapy room. During an interview with the Social Services Director (SSD) on 10/22/19 at 1:15 p.m., the SSD confirmed Resident 26 was not in the facility nor was he signed out of the facility. The SSD was unable to confirm whether Resident 26 left the facility alone or with another individual. The SSD stated she was unable to reach Resident 26 by telephone and was able to leave Resident 26 a voice message. A review of the facility document titled, "RELEASE FOR TEMPORARY ABSENCE," on 10/22/19 at 1:15 p.m., indicated Resident 26 was not signed out of the facility on 10/22/19. During an interview with LN 5 on 10/22/19 at 3:10 p.m., LN 5 stated she did not observe Resident 26 leave the facility. LN 5 stated she last observed Resident 26 at 7:30 a.m. A review of Resident 26's Nurses Notes dated 10/22/19, indicated, "Resident went LOA [leave of absence] ...without informing staff." 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During an interview with the Director of Nursing (DON) on 10/23/19 at 1:30 p.m., the DON stated she could not confirm whether the staff observed Resident 26 leave the facility. The DON stated she expected the nursing staff to inform her of when a resident left the facility. The DON confirmed the nursing staff did not notify her Resident 26 had left the facility. The DON stated the purpose of a LOA sign-in and sign-out sheet was for the facility to know where residents were and to ensure residents had proper supervision. The DON confirmed Resident 26 was not signed out. A review of the facility policy titled, "Therapeutic Leave/Out on Pass," revised 11/16, indicated, "Each resident leaving the premises (excluding transfers/discharges) must be signed out ...Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once." 2. Resident 196 was admitted to the facility in fall of 2019 with diagnoses, which included lung and heart disease causing shortness of breath, and difficulty walking. Review of Resident 196's medical record revealed the following: A Fall Risk Assessment, dated 10/11/19, indicated the facility considered Resident 196 at moderate risk for falls. A Physical Therapy Plan of Care, dated 10/12/19, indicated Resident 196 completed the FRT (forward reach test, fall risk assessment) and was found to be a fall risk. During observation of Resident 196's room on 10/21/19, at 8:36 a.m., Resident 196 was in bed, and was wearing a yellow plastic bracelet with the words, "fall risk." A walker was up 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE against the wall, and between the walker and the bed lay several electrical wires. Resident 196 was wearing a nasal cannula (plastic tubing delivering oxygen through the nostrils), which was attached to a long tubing extension. The tube lay coiled up in piles under the resident's bed. Pictures of the resident's environment were taken. During an interview with the DON on 10/23/19, at 1:54 p.m., the DON looked at the pictures, and stated Resident 196's immediate environment contained accident hazards. During a concurrent observation and interview with Resident 196 on 10/24/19, at 3:21 p.m., Resident 196 was in bed wearing his nasal cannula. The cannula was connected to the long extension tube, which lay coiled up on the ground next to his bed. Resident 196 agreed the electrical wires and oxygen tubing posed a trip hazard for him. A facility policy and procedure titled, "ACCIDENT AND INCIDENT PREVENTION," dated 8/18, indicated, "It is the policy of this facility...to prevent accidents and incidents and eliminate preventable occurrences, practices, or systems, which negatively impact residents and/or resident care and environmental hazards whenever possible."

F692 SS=D Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 01/14/2020 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to prevent a significant weight loss in one of 16 sampled residents (Resident 42). This failure increased the risk of Resident 42 not obtaining the required nutrition to maintain a healthy body weight. Findings: Resident 42 was admitted to the facility in the summer of 2019 with diagnoses, which included heart disease, kidney disease, dementia (progressive memory loss), and a surgical wound to her right lower leg. Review of Resident 42's medical record revealed the following: A Weekly Weight Log for 8/19, indicated Resident 42 weighed 101 pounds on 8/26/19. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Nurses notes from 8/25/19 to 10/5/19, contained no documented evidence of Resident 42's continued weight loss. A nutrition care plan, dated 8/29/19, indicated Resident 42 had, "Actual Nutrition alteration LESS than body requirements...Manifested by...Reported food intake of less than 75 [percent]." The care plan indicated Resident 42 was to receive house supplements, which included "[brand name of nutrition shake] TID [three times daily]." A Weekly Weight Log for 9/19, indicated Resident 42 weighed 96 pounds on 9/30/19. A nutritional progress note by the Registered Dietician (RD), dated 9/19/19, indicated Resident 42 had increased calorie and protein needs for wound healing. The RD made recommendations, which included changing Resident 42's current nutrition shake at 6 grams of protein per serving to a nutrition shake with 9 grams of protein per serving, at each meal. A physician order, dated 9/23/19, indicated, "[Brand name for nutrition shake] GIVE 1 CAN Oral With Bkfst [breakfast], Lun [lunch], and Din [dinner] AS SUPPLEMENT." A Weekly Weight Log for 10/19, indicated Resident 42 weighed 90 pounds on 10/21/19, which signified a 10 percent loss of body weight in less than two months. A history and physical note by the nurse practitioner, dated 10/21/19, contained no documented evidence of Resident 42's significant weight loss. During an observation on 10/23/19 at 7:55 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE a.m., Resident 42 was observed eating her breakfast in bed. Her breakfast items included a nutrition shake with 6 grams of protein, instead of the nutrition shake with 9 grams of protein, as ordered. During observations of Resident 42's breakfast and lunch meals on 10/24/19 at 7:49 a.m., and 12:36 p.m., Resident 42 drank nutrition shakes with 6 grams of protein per serving, instead of the nutrition shake with 9 grams of protein, as ordered. During an observation of Resident 42's breakfast meal on 10/28/19 at 7:30 a.m., Resident 42's breakfast tray included a nutrition shake with 6 grams of protein, instead of the nutrition shake with 9 grams of protein, as ordered. During an interview with the RD on 10/28/19, at 8:45 a.m., the RD confirmed she recommended Resident 42 switch to a different nutrition shake for her weight loss and wound care needs. The RD stated the nutrition shakes differed in volume, calories, and amount of protein. The RD stated she participated in the Interdisciplinary Team weekly weight meetings, and was not aware Resident 42 was not receiving the nutrition shakes with 9 grams of protein as ordered. The "California Nursing Practice Act" enacted on 1/1/13, indicated, "...The practice of nursing within the meaning of this chapter means those functions including...Direct and indirect patient care services...necessary to implement a treatment...or rehabilitative regimen ordered by and within the scope of licensure of a physician..." 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG

F711 Physician Visits - Review Care/Notes/Order CFR(s): 483.30(b)(1)-(3)

F711 SS=C DEFICIENCY) COMPLETE DATE 01/14/2020 §483.30(b) Physician Visits The physician must§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure a physician oversaw residents' care when the orders written by the nurse practitioner were not cosigned by a physician for a census of 43. This failure had the potential to negatively impact the residents' program of care. Findings: Review of the medical records for Resident 12, Resident 20 and Resident 42, for the month of August contained no documented evidence of a physician's signature. Review of the medical records for Residents 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 12, 17, 20, 42, and 147, for the month of September contained no documented evidence of a physician's signature. Review of the medical records for Residents 3, 12, 17, 20, 39, 44, and 298, for the month of October contained no documented evidence of a physician's signature. In an interview on 10/28/19 at 12:52 p.m., the Director of Nurses (DON) stated, "The Nurse Practitioner (NP) signs the orders. The MD [Medical Doctor] does not co-sign the orders. The MD is not co-signing the recap [recapitulation, summary] orders." In an interview on 10/28/19 at 1:10 p.m., the MD stated, "I was not aware I was to co-sign the recap orders...I do not co-sign all orders the NP writes...If they [orders] are not given to me by Medical Records to sign, then I am not signing...it is the medical record's responsibility to give me the paperwork to sign." Review of a facility policy titled "Medication Orders," revised 11/14, indicated, "Physician Orders/Progress Notes must be signed and dated every thirty (30) days." Review of a facility policy titled "Physician Services," revised 4/01, indicated, "The...physician is responsible for...supervising follow-up visits from nurse practitioners...to ensure that the resident receives quality care and medical treatments...Physician orders and progress notes shall be maintained in accordance with current regulations and facility policy."

F727 SS=C RN 8 Hrs/7 days/Wk, Full Time DON CFR(s): 483.35(b)(1)-(3)

F727 01/14/2020 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.35(b) Registered nurse §483.35(b)(1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. §483.35(b)(2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. §483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for 8 consecutive hours seven days a week for a census of 43. This failure increased the potential risk for residents' unmet healthcare needs. Findings: During an interview with the Director of Nursing (DON) on 10/24/19 at 3:37 p.m., the DON stated she was the only RN who worked at the facility. The DON stated she worked 8 consecutive hours on weekdays and was oncall on weekends. Review of the licensed nurse (LN) schedules for 8/19, 9/19, and 10/19, indicated there was no RN working on the weekends. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG

F755 Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 SS=E DEFICIENCY) COMPLETE DATE 01/14/2020 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE pharmaceutical policies and procedures for a census of 43 and for 1 of 16 sampled residents (Resident 21) when: 1. The facility staff did not follow the facility's Emergency Medication Supplies policy when the E-Kit (storage box containing emergency supplies of medication) and the "Emergency Kit Log" did not contain documented evidence indicating when the E-Kit had been accessed by facility licensed nursing staff for removal of controlled medication (narcotics and other medications with a high potential for abuse and diversion). 2. The refrigerator, injectable and oral medication E-Kits had not been replaced within 72 hours after being first accessed. 3. For Resident 21, licensed nursing staff did not document administration of six doses of PRN (administered as needed) oxycodone (potent narcotic controlled medication indicated for moderate to severe pain) in accordance with facility policy. These failures increased the potential risk for medication errors, narcotic diversion and unaccounted for emergency medications. Findings: 1. During a medication storage inspection in the facility's medication room on 10/22/19 at 10:30 a.m. with Licensed Nurse 1 (LN 1), an Emergency Kit box (E-Kit, storage box containing emergency supplies of medication) containing controlled medications was observed secured with regular plastic zip ties (indicating the E-Kit had been opened by the facility) instead of numbered zip ties with unique codes as issued by the provider pharmacy. In a concurrent interview and record 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE review, LN 1 confirmed the E-Kit and the "Emergency Kit Log" did not contain documented evidence indicating when the E-Kit had been accessed by facility licensed nursing staff for removal of controlled medication. 2. During a continued inspection of the injectable, refrigerator and oral medication Ekits, the Emergency Kit Log did not contain documented evidence indicating that the E-Kits had been replaced within 72 hours after being used. During a concurrent interview, LN 1 confirmed the observations. Per a review of the Refrigerator E-Kit log, a sealed unopened E-kit was received from the pharmacy provider and documented by facility staff on 10/5/19. The use of E-Kit was documented on 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12, 10/13, 10/14, 10/15, 10/16, 10/17, 10/18, 10/19, 10/20, 10/21, and 10/22. There was no documentation indicating the used E-Kit was replaced by a new sealed E-Kit after the Refrigerator E-Kit was originally accessed on 10/6/19. During an interview with the Director Of Nursing (DON) on 10/24/19 at 1 p.m., the DON acknowledged the E-Kit Log was not filled out by licensed nursing staff for the open Narcotic E-Kit, and the refrigerator, injectable and oral medication E-Kits were not being replaced within 72 hours according to the E-Kit logs per facility policy. A review of the facility policy titled, "Emergency Medication Supplies," last revised 3/4/14, indicated, "If the emergency medication supply is an emergency kit, the nurse records the medication use on the E-BOX SIGN-OUT RECORD and faxes the reorder sticker to the pharmacy as soon as possible after the medication has been administered ...If 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE exchanging kits, opened kits are replaced with newly sealed kits from the pharmacy within 72 hours of opening." 3. Resident 21 was admitted in early March 2019 with diagnoses including low back pain. Resident 21's current Physician Orders included an order (dated 3/13/19) for oxycodone 10 mg (milligrams, a unit of measure) every 4 hours as needed for moderate pain and 20 mg every 4 hours as needed for severe pain. Reconciliation of Resident 21's oxycodone controlled drug sign-out record (CDR) for the supply dispensed 10/2/19; and Medication Administration Record (MAR); and PRN documentation record (Nurses Medication Notes) for the time period 10/1/19 through 10/6/19 indicated the following licensed nursing staff documentation omissions: a. For the oxycodone 20 mg dose signed out of the CDR 10/1/19 at 10:30 a.m., licensed nursing staff did not document Resident 21's administration on the front of the MAR or the pre and post pain level on the PRN documentation record. b. For the oxycodone 20 mg dose signed out of the CDR on 10/2/19 at 11:10 p.m., licensed nursing staff did not document Resident 21's administration on the front of the MAR or the pre and post pain level on the PRN documentation record. c. For the oxycodone 20 mg dose signed out of the CDR on 10/4/19 at 8:30 p.m., licensed nursing staff did not document Resident 21's administration on the front of the MAR or the pre and post pain level on the PRN documentation record. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE d. For the oxycodone 20 mg dose signed out of the CDR on 10/6/19 at 12 midnight, licensed nursing staff did not document Resident 21's administration on the front of the MAR. e. For the oxycodone 20 mg dose signed out of the CDR on 10/6/19 at 10:30 a.m., licensed nursing staff did not document Resident 21's administration on the front of the MAR or the pre and post pain level on the PRN documentation record. f. For the oxycodone 20 mg dose signed out of the CDR on 10/6/19 at 4 p.m., licensed nursing staff did not document Resident 21's pre and post pain level on the PRN documentation record. Review of the facility policy "Administering Medications," revised 4/08, indicated under item 13: "When medications are administered, the individual administering the medication must record in the resident's medical record...a. the date and time the medication was administered...f. Any results achieved and the time such results were observed..." Review of the facility policy "Narcotic Reconciliation," revised 3/4/14, indicated under item A: "Records of receipt, usage and disposition must be maintained and stored for all controlled medications and have sufficient details to allow for reconciliation..." During an interview on 10/24/19 at 1:21 p.m. the DON confirmed Resident 21's oxycodone licensed nursing documentation omissions for the time period 10/1/19 to 10/6/19; and further confirmed licensed nursing staff should document administration of controlled medications on the front of the MAR and PRN documentation record after documenting 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE removal from the resident's supply on the CDR.

F756 SS=E Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 01/14/2020 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview, record review and facility document review, the Consultant Pharmacist (CP), did not identify MRR (Medication Regimen Review) irregularities for 3 of 16 sampled residents (Resident 5, Resident 13, and Resident 29) and the facility failed to act on MRR irregularities when: 1. Resident 13 was receiving duplicate antidepressants, fluoxetine (a medication indicated for depression) and mirtazapine (a medication indicated for depression) since admission to the facility in late January 2019 (almost 9 months) and no mirtazapine gradual dosage reduction (GDR) had been attempted; with the potential for adverse medication effects such as weight gain, sedation, falls, and arrhythmias (abnormal heart rhythm). 2. Resident 29 was receiving lactulose (used to lower high levels of ammonia, a waste product in the blood) since 10/30/18 (approximately one year) for inadequate indication and without adequate monitoring. This failure had the potential to contribute to Resident 29 experiencing adverse lactulose effects such as diarrhea, stomach pain and discomfort. 3. For Resident 5, the facility failed to act on the pharmacist's new admission MRR related to two potentially interacting medications. Findings: 1. Clinical record review indicated Resident 13 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE was a 67 year-old admitted to the facility in January 2019 with diagnoses including insulindependent diabetes mellitus and depression. Resident 13's facility admission orders (dated 1/31/19) included Physician Orders for fluoxetine 20 mg (milligram, unit of measure) in the morning for depression and mirtazapine 15 mg at bedtime for depression. Further clinical record review indicated a Physician's Order (dated 6/11/19) to increase Resident 13's fluoxetine to 40 mg daily for depression. Review of the facility policy, "General Guidelines for the Use of Psychoactive Medications," revised 10/17, indicated under item 11: "Designated facility staff will monitor for side effects, reduce dosage to the minimum required and, when possible, discontinue the use of such medications when medically and pharmacologically appropriate." Under item 14, the policy indicated: "Duplicate therapy for psychopharmacological [psychoactive] medications is generally not indicated. Documentation by the physician is necessary to clarify the rationale for and benefits of duplicate therapy and the approach to monitoring for benefits and consequences." According to DailyMed, a nationally recognized official provider of current FDA (Food and Drug Administration, a federal regulatory agency) medication manufacturer label information (package inserts), last updated 8/19, increased appetite and weight gain were common adverse events associated with mirtazapine. Review of Resident 13's consolidated behavioral summaries (completed by licensed nursing staff) for the months of February, March, April, May and July 2019 indicated 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE mirtazapine was administered for appetite loss; the behavior summary document for September 2019 indicated the behavioral indication had been changed to "sadness." Further review of Resident 13's consolidated behavior summaries indicated no depressionrelated behaviors (isolation or sadness) had been documented by licensed nursing staff from 2/1/19 through 7/31/19 and 9/1/19 through 9/31/19. In addition, no documented episodes of sadness had been documented on Resident 13's Medication Administration Record by licensed nursing staff 10/1/19 through 10/22/19. Review of Resident 13's Weight Flow Sheet indicated he weighed 216 pounds on 2/9/19 and 244 pounds on 10/1/19. This represented a 28 pound weight gain in approximately 8 months. A review of the consultant dietitian's nutritional progress note, dated 9/26/19, indicated Resident 13's 9/19 weight was 229 lb (pounds). The consultant dietitian's noted indicated, "Resident noted [with] significant weight gain in the last 3 + 6 months ...Weight gain d/t [due to] 100 % intake of large portions ..." Review of Resident 13's clinical record IDT (interdisciplinary team) notes did not indicate any documentation regarding Resident 13's duplicate antidepressant therapy or consideration to attempt a mirtazapine gradual dosage taper related to Resident 13's significant weight gain. A review of facility policy titled, "Provider Pharmacy Requirement," last revised 3/3/14, indicated, "The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to: 7) Screening each 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE new medication order for an appropriate indication or diagnosis; for medication interactions; for duplication on therapy with other drugs in the same therapeutic class ordered for the resident." Review of the facility policy titled, "General Guidelines for the Use of Psychoactive Medications," revised 10/17, indicated under item 16: "The Pharmacy consultant will review resident medication records on a monthly basis for documentation/justification for drug use and will recommend dosage reductions or modification." During a phone interview on 10/24/19 at 11:10 a.m., the CP confirmed he had reviewed Resident 13's medical record during his MRR visit earlier in October but had not identified Resident 13's duplicate antidepressant therapy or recommended a mirtazapine GDR. 2. Clinical record review indicated Resident 29 was admitted to the facility from an acute care hospital in mid-May 2013 with diagnoses which included feeding difficulties, muscle weakness, dementia and Parkinson's Disease. Resident 29's admission Physician Orders included an order, dated 10/30/18, for lactulose 45 ml (milliliter, unit of measure for volume) by mouth three times a day for "increase ammonia." Review of Resident 29's current care plans indicated the IDT had not developed a plan of care for lactulose. During a phone interview on 10/24/19 at 11:10 a.m. with the CP, when asked what should be monitored for a resident receiving lactulose for increased serum ammonia, the CP stated he would review laboratory assessments for evidence of a serum ammonia level. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During a continued phone interview, the CP confirmed he had reviewed Resident 29's medical record in October 2019 and had not recommended a serum ammonia level to monitor Resident 29's lactulose. 3. Resident 5 was admitted to the facility in 2015 and readmitted in the fall of 2019, with diagnoses which included heart failure and anxiety disorder. The Minimum Data Set (MDS, an assessment tool) dated 6/17/19, indicated Resident 5's memory was intact. Review of a facility document for Resident 5 titled "New Admission Medication Regimen Review," dated 10/11/19, indicated, "The resident is taking donepezil [a drug used to treat memory disorders] and sertraline [a drug to treat depression]. This combination increases the risk of QT prolongation [a cardiac rhythm irregularity]. Please monitor for and report to the provider if the resident experiences changes in heart rate." There was no notation on the document or in Resident 5's medical record to indicate any follow up was done or that the recommendation had been seen by the medical provider. In an interview on 10/24/19 at 10:11 a.m., the Director of Nurses (DON) stated, "The desk nurse should have given a copy to the physician and noted it on the document. It appears the recommendation was filed and not done anything with." The DON verified there was no documentation of a response by the nurse practitioner or doctor. The DON stated, "If the medical provider saw the recommendation there would be a notation in the chart and a care plan to address the issue." She verified there was no care plan or follow 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE up. Review of a facility document titled "MEDICATION REGIMEN REVIEW [MRR, a pharmacist generated recommendation regarding potential risks of drug therapy]," revised 3/4/14 indicated, "Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented...and reported to the Director of Nursing, and/or prescriber as appropriate. The MRR comments will be delivered to the DNS [Director of Nursing Services] for timely follow through with the prescriber and/or nursing staff...Recommendations are acted upon and documented by the facility staff and or the prescriber."

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 01/14/2020 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure Residents were from unnecessary drugs when 1 of 42 sampled residents (Resident 29) was receiving lactulose (used to lower high levels of ammonia, a waste product, in the blood) since 10/30/18 (approximately one year) for inadequate indication and without adequate monitoring in accordance with facility policy. This failure had the potential to contribute to Resident 29 experiencing adverse lactulose effects such as diarrhea, stomach pain and discomfort. Findings: Clinical record review indicated Resident 29 was admitted to the facility from an acute care hospital in mid-May 2013 with diagnoses which included feeding difficulties, muscle weakness, dementia and Parkinson's Disease. Resident 29's current Physician's Orders included an order, dated 10/30/18, for lactulose 45 ml (milliliter, unit of measure for volume) by mouth three times a day for "increase ammonia." Review of Resident 29's laboratory assessments since 10/18 did not indicate a serum ammonia assessment. A review of Resident 29's quarterly Minimum Data Set (MDS, a comprehensive federallymandated assessment tool), indicated Resident 29 did not have any Care Area Assessment (CAA) Summary specifically related to elevated 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE ammonia in Section V. During an interview on 10/24/19 at 3:21 p.m., the Director of Nursing (DON) confirmed facility licensed staff had not developed a care plan for Resident 29's lactulose, which would have included monitoring parameters for resident's diagnosis of elevated ammonia.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 01/14/2020 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview, record review and facility document review, 1 of 16 sampled residents (Resident 13) failed to be free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when Resident 13 had been receiving duplicate antidepressants fluoxetine (a medication indicated for depression) and mirtazapine (a medication indicated for depression) since admission to the facility in January 2019 (almost 9 months); and no mirtazapine gradual dosage reduction (GDR) had been attempted; with the potential for adverse medication effects such as weight gain, sedation, falls, and arrhythmias (abnormal heart rhythm). Findings: Clinical record review indicated Resident 13 was admitted to the facility in late January 2019 with diagnoses including insulin-dependent diabetes mellitus and depression. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident 13's facility admission orders (dated 1/31/19) included Physician Orders for fluoxetine 20 mg (milligram, unit of measure) in the morning for depression and mirtazapine 15 mg at bedtime for depression. Further clinical record review indicated a Physician's Order (dated 6/11/19) to increase Resident 13's fluoxetine to 40 mg daily for depression. Review of the facility policy, "General Guidelines for the Use of Psychoactive Medications," revised 10/17, indicated under item 11: "Designated facility staff will monitor for side effects, reduce dosage to the minimum required and, when possible, discontinue the use of such medications when medically and pharmacologically appropriate, Under item 14, the policy indicated: "Duplicate therapy for psychopharmacological [psychoactive] medications is generally not indicated. Documentation by the physician is necessary to clarify the rationale for and benefits of duplicate therapy and the approach to monitoring for benefits and consequences." According to DailyMed, a nationally recognized official provider of current FDA (Food and Drug Administration, a federal regulatory agency) medication manufacturer label information (package inserts), last updated 8/19, increased appetite and weight gain were common adverse events associated with mirtazapine. Review of Resident 13's consolidated behavioral summaries (completed by licensed nursing staff) for the months of February, March, April, May and July 2019 indicated mirtazapine was administered for appetite loss; the behavior summary document for September 2019 indicated the behavioral 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE indication had been changed to "sadness." Further review of Resident 13's consolidated behavior summaries indicated no depressionrelated behaviors (isolation or sadness) had been documented by licensed nursing staff from 2/1/19 through 7/31/19 and 9/1/19 through 9/31/19. In addition, no documented episodes of sadness had been documented on Resident 13's Medication Administration Record by licensed nursing staff 10/1/19 through 10/22/19. Review of Resident 13's Weight Flow Sheet indicated he weighed 216 pounds on 2/9/19 and 244 pounds on 10/1/19. This represented a 28 pound weight gain in approximately 8 months. A review of the consultant dietitian's nutritional progress note, dated 9/26/19, indicated Resident 13's 9/19 weight was 229 lb (pounds, unit of measure for weight). The consultant dietitian's noted indicated, "Resident noted [with] significant weight gain in the last 3 + 6 months ...Weight gain d/t [due to] 100 % intake of large portions ..." Review of Resident 13's clinical record physician/IDT (interdisciplinary team) notes did not indicate any documentation regarding Resident 13's duplicate antidepressant therapy or consideration to attempt a mirtazapine gradual dosage taper related to Resident 13's significant weight gain. During an interview on 10/24/19 at 3:21 p.m., the Director of Nursing (DON) confirmed Resident 13's medical record contained no physician/IDT documentation regarding Resident 13's duplicate antidepressant medications or consideration to attempt a mirtazapine gradual dosage taper related to 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident 13's significant weight gain.

F759 SS=E Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 01/14/2020 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% (percent) for 3 of 16 sampled residents (Resident 295, Resident 21, and Resident 197) when: 1. For Resident 295, a licensed nurse administered Resident's insulin aspart (rapid acting injectable blood sugar lowering medication), not in accordance with Physician Orders; 2a. For Resident 21, a licensed nurse did not administer Resident 21's vitamin C (a type of vitamin prescribed to speed the wound healing process), as ordered by the physician; 2b. For Resident 21, a licensed nurse administered ferrous sulfate 325 mg (milligram, a unit of measure), a type of mineral also known as iron, prescribed for anemia, not in accordance with the Physician Orders for ferrous sulfate 324 mg; and 3. For Resident 197, a licensed nurse administered five medications via Resident 197's G-tube (Gastrostomy tube, a tube inserted through the abdomen that delivered fluids and nutrition directly to the stomach) without flushing the tube with water in 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE accordance with the Physician Orders. These failures resulted in four errors identified out of 26 opportunities during the observation of medication administration; the facility medication error rate was 15.38 %. Findings: 1. During an observation of medication administration on 10/21/19 at 11:48 a.m., Licensed Nurse 5 (LN 5) was observed to prepare and administer Resident 295's before lunch insulin aspart after assessing Resident 295's fingerstick Blood Sugar (BS). On 10/21/19 at 11:50 a.m., LN 5 administered 4 units of insulin aspart subcutaneously (under the skin) to Resident 295. During an interview on 10/21/19 at 11:55 a.m. with LN 5, LN 5 confirmed Resident 295's before lunch blood sugar level was 193 mg/dl (milligram per deciliter, unit of measure for weight/volume). During a continued interview with LN 5, when asked how the dose of insulin for the administration was calculated, LN 5 responded based on Resident 295's blood sugar level of 193 mg/dl, the sliding scale insulin order (various units of insulin based on blood sugar levels) was used to calculate the dose. Reconciliation of the observation of medication administration with Resident 295's current Physician Orders indicated orders for, "Novolog insulin [insulin aspart] 100 u/ml [units/milliliter, unit of measure] give 4 units for DM2 [Diabetes Mellitus 2, a condition whereby the body ineffectively metabolizes sugar] 5-10 minutes before meals subcutaneous with Bkfst [breakfast], Lun [lunch] and Din [dinner]." Resident 295 had an additional order for 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE "Novolog insulin 100 u/ml give 2-20 units with SS [Sliding Scale] for DM2 subcutaneous insulin before Bkfst, Lun, Din FSBG [Finger Stick Blood Glucose] 70-130=0, 131-150=2U, 151-180=3U, 181-210=4U, 211-240=6U, 241270=8U, 271-300=10U, 301-330=12U, 331360=15U, 361-400=18U, 400&> [greater than]= 20U and Notify MD [Medical Doctor]. Give 5-10 min [minutes] before meals." Resident 295 should have received a total of 8 units of insulin aspart before lunch on 10/21/19 in accordance with the physician orders which represented a combination of the routine and sliding scale doses. During a later observation of medication administration on 10/21/19 at 4:51 p.m., LN 6 was observed to prepare and administer Resident 295's before dinner insulin after assessing Resident 295's fingerstick BS. On 10/21/19 at 4:55 p.m., LN 6 administered 19 units of insulin aspart subcutaneously to Resident 295. During an interview on 10/21/19 at 4:58 p.m. with LN 6, LN 6 stated Resident 295's blood sugar level was 346 mg/dl prior to administration of insulin aspart. During a continued interview with LN 6 when asked how the dose of insulin was calculated, LN 6 responded based on Resident 295's blood sugar level of 346 mg/dl, both insulin orders (routine and sliding scale) were combined together. During an interview on 10/22/19 at 11:10 a.m. with LN 5, when asked about the proper way of calculating Resident 295's insulin, LN 5 stated the routine and sliding scale insulin orders were not clear to licensed nursing staff. Review of Resident 295's October MAR, the section for 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 10/21/19 indicated LN 5 had not documented Resident 295's pre-lunch routine dose of insulin. A review of facility policy titled, "Administering Medications," revised 04/08, indicated, "Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders ...When medications are administered, the individual administering the medication must record in the resident's medical record: a. The date and time the medication was administered; b. The dosage." During a phone interview on 10/28/19 at 1:12 p.m. with the medical director regarding Resident 295's insulin orders, the medical director indicated he expected nurses to follow prescribed orders. If orders were not clear, nurses should have contacted the prescriber. 2a. During an observation of medication administration on 10/21/19 at 4:24 p.m., LN 4 was observed to prepare and administer Resident 21's two evening medications, which did not include vitamin C. Reconciliation of the observation of medication administration with Resident 21's current Physician Orders indicated an order dated 3/22/19 for vitamin C 500 mg. A review of Resident 21's October 2019 MAR for Vitamin C indicated the administration documentation area was blocked out with ** (double asterisks). During an interview on 10/21/19 at 5:51 p.m., LN 4 stated he did not administer Resident 21's vitamin C dose. 2b. During a continued observation of 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE medication administration on 10/21/19 at 4:24 p.m., LN 4 was observed to prepare and administer Resident 21's two evening medications which included an order for ferrous sulfate 324 mg. On 10/21/19 at 4:25 p.m., LN 4 was observed to administer a ferrous sulfate 325 mg tablet (not 324 mg) to Resident 21. Reconciliation of the observation of medication administration with Resident 21's current Physician Orders indicated an order dated 3/11/19 for ferrous sulfate 324 mg. A review of Resident 21's October 2019 MAR indicated LN 4 documented ferrous sulfate 324 mg was administered during the evening medication administration observation on 10/21/19. During an interview on 10/21/19 at 5:51 p.m., LN 4 confirmed he had administered ferrous sulfate 325 mg, not 324 mg as ordered by Resident 21's physician. 3. During an observation of medication administration on 10/21/19 at 8:43 a.m., LN 3 was observed to prepare and administer Resident 197's five morning medications for Gtube administration. LN 3 crushed each medication separately and diluted each medication with approximately 10 ml (milliliter, unit of measure for volume) of water. LN 3 measured an additional 30 ml of water into a small disposable cup and brought it into Resident 197's room with the five medications. On 10/21/19 at 8:45 a.m., LN 3 was observed to administer Resident 197's five crushed and diluted medications through a syringe attached to the G-tube extension tubing, using fractions 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE tube before, between each medication, and after the last medication. During an interview on 10/21/19 at 9:10 a.m., LN 3 confirmed a total of 30 ml of water was used to flush Resident 197's G-tube during medication administration observation. Reconciliation of the observation of medication administration with Resident 197's current MAR (Medication Administration Record) indicated an order to flush the G-tube with 30 ml of water before and after medication administration every shift. According to American Society for Parenteral and Enteral Nutrition guidelines (ASPEN), a professional organization involved in injectable and tube feeding nutrition, published 1/17, indicated, "Consistent and scheduled flushing of all types of tubes during feeding medication administration is the best way to decrease the incidence of tube occlusion." During a concurrent interview on 10/24/19 at 1:29 p.m. with the DON and Minimum Data Set coordinator (MDSC), the MDSC stated the facility did not have a specific policy for flushing G-tubes. The DON confirmed nurses should follow physician orders for flushing G-tubes. A review of facility policy titled, "Administering Medications," revised 4/08, indicated, "The individual administering the medication must ensure that the right medications, right dosage, right time and right method of administration are verified before the medication is administered (e.g., review of drug label, physician's order, etc.)."

F760 SS=E Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 01/14/2020 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure 6 residents in a census of 43 (Residents 295, 26, 247, 298, 44, and 21) were free from significant medication errors when: 1a. For Resident 295, a licensed nurse administered resident's insulin aspart, medication used to lower blood sugar level, not in accordance with the physician's orders. This failure resulted in hyperglycemia (elevated blood sugar level). 1b. For Resident 26, a licensed nurse did not administer a scheduled dose of insulin aspart in accordance with the physician's orders. This failure resulted in hyperglycemia. 1c. For Residents 6, 14, 23, 247, 30, discharged Resident A, 298 and 44, licensed nurses administered residents' insulin not in accordance with the physician orders. This failure had the potential to result in hyperglycemia and hypoglycemia (low blood sugar level). 2. For Resident 21, a licensed nurse did not administer Resident 21's vitamin C, a type of vitamin that could help speed the healing process of wounds, in June, August, September, and October of 2019 as ordered by the physician. This failure had the potential to result in prolonged wound healing. Findings: 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 1a. According to American Diabetes Association guidelines, the preprandial, measured before dinner or lunch, sugar target level is 80-130 mg/dl (milligram per deciliter, unit of measure for weigh/volume). Long term complications of untreated hyperglycemia can include: nerve damage, kidney damage, and damage to the blood vessels of the retina, the tissue that lines the back of the eye on the inside, leading to blindness. According to Institute for Safe Medication Practices (ISMP), updated in 2017, indicated "Insulins, all formulations and strengths are considered to be high-alert medications [dangerous medication when used in error]." Resident 295 was admitted to the facility in October 2019 with diagnosis which included DM2 (Diabetes Mellitus 2, a condition whereby the body ineffectively metabolizes sugar). During an observation of medication administration on 10/21/19 at 11:48 a.m., Licensed Nurse 5 (LN 5) was observed to prepare and administer Resident 295's before lunch insulin aspart after assessing Resident 295's fingerstick Blood Sugar (BS, the amount of sugar in the blood). On 10/21/19 at 11:50 a.m., LN 5 administered 4 units of insulin aspart subcutaneously (under the skin) to Resident 295. During an interview on 10/21/19 at 11:55 a.m. with LN 5, LN 5 confirmed Resident 295's before lunch blood sugar level was 193 mg/dl (milligram per deciliter, unit of measure for weight/volume). During a continued interview with LN 5, when asked how the dose of insulin for the administration was calculated, LN 5 responded based on Resident 295's blood sugar level of 193 mg/dl, the sliding scale 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE insulin order (various units of insulin based on blood sugar levels) was used to calculate the dose. Reconciliation of the observation of medication administration with Resident 295's current Physician Orders indicated orders for "Novolog insulin [insulin aspart] 100 u/ml [units/milliliter, unit of measure] give 4 units for DM2 5-10 minutes before meals subcutaneous with Bkfst [breakfast], Lun [lunch] and Din [dinner]." Resident 295 had an additional order for "Novolog insulin 100 u/ml give 2-20 units with SS [Sliding Scale] for DM2 subcutaneous insulin before Bkfst, Lun, Din FSBG [Finger Stick Blood Glucose] 70-130=0, 131-150=2U, 151-180=3U, 181-210=4U, 211-240=6U, 241270=8U, 271-300=10U, 301-330=12U, 331360=15U, 361-400=18U, 400&> [greater than]= 20U and Notify MD [Medical Doctor]. Give 5-10 min [minutes] before meals." Resident 295 should have received a total of 8 units of insulin aspart before lunch on 10/21/19 in accordance with the Physician Orders which represented a combination of the routine and sliding scale doses. During a later observation of medication administration on 10/21/19 at 4:51 p.m., LN 6 was observed to prepare and administer Resident 295's before dinner insulin after assessing Resident 295's fingerstick BS. On 10/21/19 at 4:55 p.m., LN 6 administered 19 units of insulin aspart subcutaneously to Resident 295. During an interview on 10/21/19 at 4:58 p.m. with LN 6, LN 6 stated Resident 295's blood sugar level was 346 mg/dl prior to administration of insulin aspart. During a continued interview with LN 6 when asked how 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE the dose of insulin was calculated, LN 6 responded based on Resident 295's blood sugar level of 346 mg/dl, both insulin orders (routine and sliding scale) were combined together. During an interview on 10/22/19 at 11:10 a.m. with LN 5, when asked about the proper way of calculating Resident 295's insulin, LN 5 stated the routine and sliding scale insulin orders were not clear to licensed nursing staff. Review of Resident 295's October Medication Administration Record (MAR), the section for 10/21/19 indicated LN 5 had not documented Resident 295's pre-lunch routine dose of insulin. During a phone interview on 10/28/19 at 1:12 p.m. with the medical director regarding Resident 295's insulin orders, the medical director indicated he expected nurses to follow prescribed orders. If orders were not clear, nurses should have contacted the prescriber. A review of facility policy titled, "Administering Medications," revised 04/08, indicated "Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders ...When medications are administered, the individual administering the medication must record in the resident's medical record: a. The date and time the medication was administered; b. The dosage." 1b. Resident 26 was admitted to the facility the summer of 2019 with diagnoses which included DM2. A review of Resident 26's Minimum Data Set (an assessment tool) dated 8/17/19, indicated Resident 26 had no cognitive impairments. A review of Resident 26's Physician's Orders 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE with a start date of 9/30/19, indicated, "[brand name for insulin aspart, a rapid-acting insulin used to quickly lower blood sugar] ...INJECT 6 UNITS WITH MEALS for DM2 Subcutaneous With Bkfst, Lun, and Din." During a concurrent interview and Dining Room Observation on 10/21/19 at 11:54 a.m., Resident 26 stated he was diabetic and had not had his blood glucose (BG, sugar in the blood) checked nor had he received insulin injection. At 12:05 p.m., Resident 26's meal tray arrived and Resident 26 was observed eating the lunch meal. During an interview with LN 5 on 10/21/19 at 12:36 p.m., LN 5 confirmed she had not checked Resident 26's BG nor administered Resident 26 his insulin. LN 5 stated she did not offer to check the BG and administer insulin because she would have had to remove Resident 26 from the dining room. LN 5 confirmed the BG check and insulin should have been administered prior to lunch. During a follow-up interview with Resident 26 on 10/21/19 at 3:50 p.m., Resident 26 stated the nurse offered to check his BG after he had already eaten. Resident 26 stated he declined the offer because he had already finished eating. A review of Resident 26's Medication Administration Record dated 10/21/19, indicated at 6 p.m., Resident 26's blood sugar was 320. According to the National Center for Biotechnology Information, a nationally recognized medical reference indicated, "The aim of the treatment is to protect the quality of life, prevent hypoglycemia and related complications. Eight point five percent for A1C 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE value and 200 mg/dL for average glucose ...should be targeted." (https://www.ncbi.nlm.nih.gov/pmc/articles/PM C5483426/) During a follow-up interview and record review with LN 5 on 10/22/19 a 3:10 p.m., LN 5 confirmed she had signed and circled her initials on Resident 26's MAR for the 10/21/19 lunchtime insulin. LN 5 stated circled initials on the MAR indicated the resident refused the medication. LN 5 stated Resident 26 declined her offer to check the BG and administer insulin because Resident 26 had already eaten. During an interview with the Director of Nursing (DON) on 10/23/19 at 1:30 p.m., when asked if Resident 26 should have been administered (brand name for insulin aspart) prior to lunch, the DON stated insulin is scheduled at specific times and should be administered prior to meals. A review of the facility policy titled, "Administering Medications," revised 4/08 indicated, "Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders." 1c. Resident 247 was admitted to the facility in fall of 2019 with diagnoses which included DM2. A review of Resident 247's Physician's Orders with a start date of 10/4/19, stipulated, "[name brand for insulin aspart] ...INJECT 1-12 UNITS FOR DM2 Subcutaneous Insulin before Bkfst, Lun, Din. PER SLIDING SCALE 151-200= 2 UNITS, 201-250=4 UNITS, 251-300=6 UNITS, 301-350=8 UNITS, 351-400= 10 UNITS, 401 < [401 and greater] 12 UNITS AND NOTIFY MD [physician]." 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Review of Resident 247's MAR from 10/4/19 to 10/23/19, indicated the following for the slidingscale insulin aspart: On 10/13/19 at 5:30 p.m., the documented BG was 334, and the documented units of slidingscale insulin administered was 6 (the order indicated 8 units for BGs of 301-350). On 10/14/19 at 5:30 p.m., the documented BG was 238, and the documented units of slidingscale insulin administered was 6 (the order indicated 4 units for BGs of 201-250). On 10/19/19 at 5:30 p.m., the documented BG was 433, and the documented units of slidingscale insulin administered was 10 (the order indicated 12 units for BGs of 401 and higher). On 10/20/19 at 6:30 a.m., the documented BG was 197, and the documented units of slidingscale insulin administered was 5 (the order indicated 2 units for BGs 151-200). During an interview with the DON on 10/28/19 at 7:12 a.m., the DON confirmed the insulin aspart was administered incorrectly on 10/20/19. The DON stated the nurse should have given 2 units instead of 5 units. A review of Resident 247's Physician Orders with a start date of 10/4/19, stipulated, "[name brand for insulin glargine, a long-acting insulin which works evenly for 24 hours] ...INJECT 35 UNITS FOR DM2 Subcutaneous at Bedtime." Review of Resident 247's MAR from 10/4/19 to 10/23/19 indicated the following for insulin glargine: On 10/8/19 at 8 p.m., the administration time, BG, and injection site boxes were blank. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE On 10/17/19 at 8 p.m., the administration time, BG, and injection site boxes were blank.Resident 298 was admitted to the facility in early 2019 with diagnoses which included diabetes. Residnt 298's MDS, dated 7/6/19, indicated Resident 298 needed insulin injections. Review of a physician order for Resident 298 dated 9/29/19, indicated "INSULIN GLARGINE 100 UNITS/ML SOLUTION INJECT 30 UNITS Subcutaneous at Bedtime FOR DM2. A review of Resident 298's Medication Record for insulin glargine dated 9/1/19 to 9/30/19 indicated on 9/3/19 at 8 p.m., the initial box was blank. Review of the physician order for Resident 298 dated 9/29/19, indicated "insulin lispro 100units/3 ml, inject 8 units Subcutaneous Insulin before Bkfst, Lun, Din FOR DM2. A review of Resident 298's Medication Record for insulin lispro 9/1/19 to 9/30/19 indicated the following: On: 9/2/19 at 11:30 a.m., 9/3/19 at 5:30 p.m., 9/6/19 at 6:30 a.m., 9/7/19 at 11:30 a.m., 9/10/19 at 6:30 a.m., 9/14/19 at 11:30 a.m., 9/15/19 at 6:30 a.m. and 11:30 a.m., 9/17/19 at 6:30 a.m., and 11:30 a.m. 9/20/19 at 6:30 a.m., and 11:30 a.m., and 9/23/19 at 6:30 a.m. and 11:30 a.m., the initial, BG, and site boxes were blank, and on 9/26/19 at 5:30 p.m. the BG and site boxes were blank. Review of a physician order for Resident 298 dated 6/28/19, indicated "INSULIN LISPRO 100U/ML TAKE 3 ML PER SLIDING SCALE Subcutaneous With Bkfst, Lun, and Din BG 70150=NONE BG 151-200= 1U, BG 201-250= 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 2U, BG 251-300=3U, BG 301-350= 4 U, BG 351-400 6U, BG >400= 8U. A review of Resident 298's Medication Record for Insulin Lispro sliding scale dated 9/1/19 to 9/30/19 indicated the following: On: 9/1/19 at 8 a.m., 9/2/19 at 1 p.m., 9/3/19 at 6 p.m., 9/6/19 at 8 a.m. and 1 p.m., 9/8/19 and 9/10/19 at 8 a.m., 9/17/19 and 9/20/19 at 8 a.m. and 1 p.m., the initial, BG, site and units boxes were blank. On: 9/2/19 at 8 a.m., 9/4/19 at 6 p.m., and 9/26/19 at 6 p.m., the BG, site, and units boxes were blank. On 9/4/419 at 1 p.m., the BG box indicated 188 and the units box indicated 3 units of insulin were given (the order indicated one unit of insulin should have been given. On 9/5/19 at 1 p.m., the BG box indicated 271 and the site and units boxes had a line through them (the order indicated three units should have been given). On 9/23/19 at 6 p.m., the BG box indicated 248 and the units box was blank (the order indicated 2 units should have been given). On 9/24/19 at 6 p.m., the BG box indicated 198 and the units box was blank (the order indicated 1 unit should have been given). On 9/25/19 at 6 p.m., the BG box indicated 313 and the units box was blank (the order indicated 4 units should have been given). On 9/26/19 at 1 p.m., the BG box indicated 158 and the units box was blank (the order indicated 1 unit should have been given). On 9/27/19 at 1 p.m., the units box was blank (the order indicated 4 units should have been 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE given). On 9/27/19 at 6 p.m., the BG box indicated 280 and the units box was blank (the order indicated 3 units should have been given). On 9/29/19 at 6 p.m., the BG box indicated 381 and the units box was blank (the order indicated 6 units should have been given). Resident 44 was admitted to the facility in summer of 2019 with diagnoses which included sepsis [a potentially life threatening infection] and Diabetes. A review of a facility document for Resident 44 titled "Physician Orders," dated 10/25/19, indicated "INSULIN LISPRO...INJECT WITH SS 0-8, FOR DM2 Subcutaneously With BKFST, Lun, and Din 151-2--=1U 201-260=2U, 251-300=3U, 301-350=4U, 351-400=6U, 351400=8U AND NOTIFY MD." Review of Resident 44's Medication Record for insulin lispro dated 10/23/19 at 1 p.m., the BG box indicated 155 and the units box was blank (the order indicated 1 unit should have been given). 2. Resident 21 was admitted to the facility in March 2019 with diagnoses which included disorder of iron metabolism and malignant neoplasm of skin (a new and abnormal growth of tissue in some part of the body). In a review of Resident 21's wound care plan dated: 3/10/19, vitamin C was selected to be "an approach plan" for Resident 21's "skin breakdown problem/need". During an observation of medication administration on 10/21/19 at 4:24 p.m. LN 4 was observed to prepare and administer 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident 21's two evening medications, which did not include vitamin C. Reconciliation of the observation of medication administration with Resident 21's current Physician Orders indicated an order dated 3/22/19 for vitamin C 500 mg. A review of Resident 21's MAR from May 2019 to October 2019 indicated the vitamin C was only administered in the months of May and July. The Vitamin C order was blocked out with ** (double asterisks) on the MAR for the months of June, August, September, and October, 2019. During an interview on 10/21/19 at 5:51 p.m., LN 4 was unable to explain why Resident 21's vitamin order was blocked out on Resident 21's MAR. During an interview on 10/24/19 at 1:52 p.m. the DON was unable to explain why Resident 21's vitamin C order was not administered during the late afternoon observation of medication administration 10/21/19. A review of facility policy titled, "Administering Medication," last revised April 2008, indicated "The individual administering the medication must ensure that the right medications, right dosage, right time, and right method of administration are verified before the medication is administered (e.g., review of drug label, physician's order, etc.)"

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 01/14/2020 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement their medication storage and labeling and pharmaceutical policies and procedures when: 1. Licensed staff did not secure the bottles of Rx Destroyer, a charcoal-based chemical for destruction of wasted or refused medication, and were accessible to facility residents; 2. Prescription medications were stored in medication carts without resident prescription label, with the potential for errors in medication administration; 3. A licensed nurse returned a used inhaler back to the medication cart without entering the 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE date opened and the new expiration date, with the potential for administration of an expired medication; 4. A licensed nurse left a medication cart unlocked and unattended, with the potential for access by unlicensed staff or facility residents; 5. Medications requiring storage at room temperature were kept at temperatures higher than the recommended range, with the potential for negative impact on potency of those medications; and 6. Expired and discontinued medication were not removed and destroyed according to facility policy, with the potential for administration of an expired medication; or an error in medication administration. Findings: 1. Inspection of medication carts A and B with Licensed Nurse 1 (LN 1) on 10/21/19 at 2:17 p.m., revealed the open top storage shelf of the carts contained 16 oz. (Ounce: unit of measure) bottles of Rx Destroyer, a charcoalbased chemical for destruction of wasted or refused medication; the bottles were unsecured and accessible to the facility residents. During a concurrent interview, LN 1 confirmed the observation. During an interview on 10/24/19 at 12:52 p.m., the Director of Nursing (DON) acknowledged contents of the bottles of Rx Destroyer were subject to potential accidental or intentional ingestion by facility residents; and therefore secure storage inside the locked medication cart would be more appropriate. A review of the facility policy titled, "Medication Destruction," revised 3/4/14, indicated "unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed ...medication 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE destruction occurs only in the presence of at least two licensed healthcare professionals or according to regulation and applicable law." 2. Inspection of treatment Cart B with LN 1 on 10/21/19 at 2:15 p.m., revealed the bottom drawer of the cart contained used prescription medications with no pharmacy labeling indicating resident names. These medications included: a 100 g (gram, unit of measure for weight) tube of diclofenac gel 1% for treatment of pain, a 30 g tube of nystatin cream for treatment of fungal infection, a 60 g tube of permethrin cream 5% for treatment of lice or scabies, and a 30 ml (milliliter, unit of measure) syringe with unknown clear liquid. During a concurrent interview, LN 1 confirmed he had not prepared the 30 ml syringe containing clear liquid; and that none of the medications were labeled with resident names in accordance with facility policy. A review of the facility policy titled, "Medication Labels," revised 3/4/14, indicated "Medications are labeled in accordance with facility requirements and state and federal laws ...Labels are permanently affixed to the outside of the prescription container ...Each prescription medication label includes: resident's name ...Specific directions for use ...Medication name ...Strength of medication...Expiration date of medication ...Accessory labels indicating storage requirements and special procedures ..." 3. Resident 12 was admitted in 2013 with diagnoses which included chronic obstructive pulmonary disease (COPD: a long-term lung disease). During a Medication Pass Observation on 10/21/19 at 4:13 p.m., LN 4 administered a dose of Advair Diskus 250/50 mcg/dose 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE (microgram, unit of measure) to Resident 12 after removing the device from the manufacturer's overwrap foil pouch. Advair Diskus was an oral inhaler with two medications combined together to help with COPD symptoms. According to the manufacturer's labeling information (package insert), the device should be used within 30 days of removal from the overwrap foil pouch. LN 4 returned the used inhaler back to the medication cart without entering the date opened and the new expiration date. During a concurrent observation and interview with LN 1 on 10/22/19 at 10:07 a.m., Resident 12's supply of Advair Diskus inhaler was still in medication cart B with no open date and no new expiration date. LN 1 acknowledged and confirmed that the inhaler belonged to Resident 12, had been used, had no open date and no new expiration date. A review of the facility policy titled, "Medication Storage in The Facility," revised 3/4/14, indicated, "When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a "date opened" sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating." A review of the facility policy titled, "Specific Medication Administration Procedures," revised 3/4/14, indicated, "Check expiration date on package/container before administering any medication. When opening a multi-dose container, place the open date and expiration date on the container." 4. During a medication cart inspection on 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 10/21/19 at 5:45 p.m., medication cart B was observed to be unlocked and unattended. During an interview with LN 4 on 10/21/19 at 5:50 p.m., LN 4 acknowledged the medication cart was unlocked and unattended, and that LN 4 had been out of the facility for a short time. During an interview with the DON on 10/24/19 at 12:59 p.m., the DON confirmed the medication cart should have been locked when nursing staff were not present. Review of the facility policy "Medication Administration-General Guidelines," revised 3/4/14, indicated, "During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide." 5. During a concurrent observation and interview with LN 1 on 10/22/19 at 10:30 a.m. in the Medication Room, the room temperature was 80 degrees F (Fahrenheit, unit of measure for temperature) per the wall thermometer. According to the temperature log for the medication room, the temperature had been logged as 79 degrees F for 21 consecutive days. The temperature log indicated, "Medication requiring storage at "Room Temperature" are kept at temperatures ranging from 68 [degrees] to 77 [degrees]." LN 1 confirmed the room temperature and log documentation. During an interview with the DON on 10/24/19 at 12:45 p.m., the DON reviewed the medication room's temperature log and acknowledged that the temperature was out of range. She also confirmed facility policy stipulated that the upper range could not exceed 77 degrees F for medications stored at room temperature. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of the facility policy titled, "Medication Storage in The Facility," revised 3/4/14, indicated, "Medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines [pharmacy standards of practice] for temperature ranges ...Medications requiring storage at "room temperature" are kept at temperatures ranging from 68 [degrees] F to 77 [degrees] F." 6a. Resident 6 was admitted in 2018 with diagnoses which included iron deficiency anemia (low blood cell count). During a concurrent observation and interview with LN 1 on 10/22/19 at 10:45 a.m., a vial of Resident 6's Procrit (medication used to treat low red blood cell level) was available with an expiration date of 6/2019 (approximately 4 months prior to the inspection) in the medication refrigerator. LN 1 confirmed the expired Procrit. A review of the facility policy titled, "Medication Storage in The Facility," revised 3/4/14, indicated, "All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining." 6b. Resident 296 was admitted in 2019 with bacterial bowel infection. Resident 296's physician orders dated 10/7/19 included an order for Firvanq (an antibiotic used to treat bowel-related bacterial infections) oral solution, to be administered until 10/17/19. During a concurrent observation and interview with LN 1 on 10/22/19 at 10:50 a.m., Resident 296's discontinued supply of Firvanq was observed stored in the medication refrigerator 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE in the medication room. The direction on the pharmacy label indicated to use the medication until 10/17/19 (5 days prior to the inspection). LN 1 confirmed the observation and stated Resident 296's medication should have been removed from the refrigerator. During an interview with the DON on 10/24/19 at 1:15 p.m., the DON acknowledged that Resident 6's expired medication had not been removed from the medication refrigerator by licensed nursing staff in accordance with facility policy; and Resident 296's discontinued supply of Firvanq had not been removed from the refrigerator by licensed nursing staff after the order had been discontinued and the medication was available for use.

F803 SS=D Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 01/14/2020 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a controlled carbohydrate (CCHO, a low-sugar and lowstarch) diet for 1 of 16 sampled residents (Resident 26). This failure increased the potential for Resident 26 to experience large elevations and drops in blood glucose (BG, the amount of sugar in the blood). Findings: Resident 26 was admitted to the facility in the summer of 2019 with diagnoses which included diabetes mellitus II (DM2, whereby the body ineffectively metabolizes sugar). A review of Resident 26's Physician Orders with a start date of 8/13/19, indicated, "Diet: CCHO, NAS [no added salt], REGULAR TEXTURE, THIN LIQUIDS With Bkfst [breakfast], Lun [lunch], and Din [dinner]." A review of Resident 26's Minimum Data Set (an assessment tool), dated 8/17/19, indicated Resident 26 had no cognitive impairments. A review of Resident 26's meal tray ticket indicated Resident 26 was on a CCHO diet. During an interview with the Food Service Director (FSD) on 10/21/19 at 7:47 a.m., FSD stated he had worked at the facility as a FSD for about 4 months. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During an interview with Resident 26 on 10/21/19, at 10:45 a.m., Resident 26 stated he was diabetic. He stated despite having spoken to the Registered Dietitian (RD), the meals were not proper for his diabetes. Resident 26 stated his glucose was very high due to the high carbohydrate diet. During an interview with the FSD on 10/21/19 at 1:47 p.m., when asked to describe the difference between a regular diet and a CCHO diet, the FSD responded the CCHO diet contained no salt packet. During an interview with the RD on 10/22/19 at 9:59 a.m., the RD stated CCHO diets were typically for residents with DM. The RD stated the CCHO diet was about 200 calories less than a regular diet. The RD stated differences between the regular and CCHO diets were specified on the cook's spreadsheet. A review of the facility menu from 10/21/19 to 10/27/19, indicated the lunch menu for 10/24/19 included mashed yams and a wheat roll. During an interview with the FSD on 10/24/19 at 11:45 a.m., when asked to described the difference between a regular diet and a CCHO diet, the FSD continued to respond the CCHO diet residents did not get a salt packet. A review of the facility's Cooks Spreadsheet for lunch on 10/24/19, indicated: Regular and CCHO diets were to be served 1 wheat roll; Regular diets were to be served 1/3 cup of mashed yams; and CCHO diets were to be served ¼ cup of mashed yams. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During a tray-line observation on 10/24/19 at 11:50 a.m., the FSD was observed plating all mashed yams with the same scooper. No wheat rolls were observed on any tray. During an interview with the FSD on 10/24/19 at 12:20 p.m., the FSD confirmed he did not know the difference between a CCHO diet and a regular diet. The FSD confirmed he used the same 1/3 cup scooper size for both regular and CCHO diets when he served the mashed yams. He confirmed no wheat rolls were served. During a follow-up interview with the RD on 10/28/19 at 8:21 a.m., the RD stated she expected the dining staff to follow the directions on the cook's spreadsheet. During an interview with the Medical Director (MD) on 10/28/19 at 1:10 p.m., the MD stated he expected the staff to understand what a diabetic (CCHO) diet was and to follow the diet orders. A review of the facility policy titled, "FOOD PREPARATION," dated 2018, indicated, "Food shall be prepared by methods that conserve nutritive value, flavor and appearance ...Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide." A review of the facility policy titled, "MENU PLANNING," dated 2018, indicated, "The facilities' diet manual and diets ordered by the physician should mirror the nutritional care provided by the facility."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary

F812 01/14/2020 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure food safety practices were maintained during food preparation, food handling, and food storage for residents who ate food prepared by the kitchen in a census of 43, when: 1. Food thermometers were not calibrated; 2. Germicidal wipes were used on the bare hands of two residents (Resident 11 and Resident 20); and 3. Hamburger buns and supplemental milkshakes were not labeled with pull dates (dates of when the item was pulled from the freezer) or use-by dates. These failures increased the potential for foodborne illnesses in a vulnerable population. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Findings: 1. During an interview with the Food Service Director (FSD) on 10/21/19 at 7:47 a.m., the FSD stated he had been working as the FSD at the facility for about four months. During an interview with the Cook (CK) on 10/22/19 at 8:57 a.m., when asked to demonstrate how thermometers were calibrated, she stated she did not know how to calibrate the thermometers. The CK stated the FSD calibrated the thermometers. During a concurrent observation and interview with the FSD on 10/22/19 at 9:10 a.m., when asked to demonstrate how thermometers were calibrated, the FSD placed two dial thermometers in a cup of ice water. One dial thermometer read 38 degrees Fahrenheit (a temperature scale) and a second dial thermometer read 42 degrees Fahrenheit. The FSD placed one digital thermometer inside the cup of ice water. The digital thermometer read 38.5 degrees Fahrenheit. The FSD stated Dining Services also had a thermometer gun. He confirmed none of the thermometers read 0 degrees Celsius (a temperature scale) or 32 degrees Fahrenheit (0 degrees Celsius and 32 degrees Fahrenheit are both the freezing temperature of water). The FSD stated the dial thermometers were missing the wrench used to calibrate the thermometers and could not be calibrated. The FSD stated none of the dial or digital thermometers could be calibrated. During a follow-up interview with the FSD on 10/22/19 at 9:55 a.m., when asked for documented evidence of the last 4 month's thermometer calibrations, the FSD was unable to provide documented evidence the thermometers had been calibrated. The FSD 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE stated he never calibrated the thermometers while working at the facility. He stated he had been using the digital thermometers and assumed the digital thermometers were calibrated. He confirmed the digital thermometers in the kitchen could not be calibrated. During an interview with Registered Dietitian (RD) on 10/22/19 at 9:59 a.m., the RD stated she expected thermometers to work. The RD stated, you cannot tell if food is adequately cooked if the thermometer does not work. The facility policy titled, "THERMOMETER USE AND CALIBRATION," dated 2018, indicated, "Food thermometers are to be used properly and calibrated to ensure accurate temperature reading." 2. Resident 11 was admitted to the facility in the fall of 2015 with diagnoses which included epilepsy (a seizure disorder). Resident 20 was admitted to the facility in the fall of 2015 with diagnoses which included stroke and glaucoma (an eye condition which can cause blindness). During a concurrent dining room observation and interview with Certified Nursing Assistant 2 (CNA 2) on 10/21/19 at 11:54 a.m., CNA 2 was observed handing germicidal (capable of killing blood borne pathogens) disposable cloths to Resident 11 and Resident 20. The residents were observed wiping their hands with the germicidal wipes. CNA 2 confirmed she was using the germicidal wipes instead of hand sanitizing wipes on Resident 11 and Resident 20. CNA 2 confirmed the germicidal wipes container indicated, "PRECAUTIONARY STATEMENTS: Hazard to humans and domestic animals," "NOT A BABY WIPE," and 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE "NOT FOR USE ON SKIN." During an interview with the FSD on 10/23/19 at 7 a.m., the FSD stated residents should not use germicidal wipes to clean their hands. The FSD confirmed using the germicidal wipes during meal service had the potential for the chemical contamination of food. During a concurrent observation and interview with the Director of Laundry and Housekeeping (DLH) on 10/23/19 at 1:16 p.m., the DLH confirmed the germicidal wipes container label indicated the wipes were EPA (Environmental Protection Agency, an agency which maintains and enforces standards under environmental laws) hospital grade. The DLH stated gloves should be worn when handling the product and [it] should not have been handled with bare hands. During an interview with the Director of Nursing (DON) on 10/23/19 at 1:30 p.m., the DON stated the germicidal wipes should not have been used to clean the hands of residents. The DON confirmed the germicidal wipes had the potential to cause chemical contamination to the food. During an interview with the Administrator (ADM) on 10/24/19 at 10 a.m., the ADM confirmed he was the Safety Committee Chair Person. He stated based on the label of the germicidal wipes, the staff should not have used germicidal wipes on the bare hands of residents. A review of an undated facility policy titled, "Housekeeping and Pest Control," indicated "EPA-registered hospital grade disinfectants must be used according to manufacturer's specifications." 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of the facility policy titled, "FOOD PREPARATION," dated 2018, indicated, "Do not use cleaning products or sanitizer in the food preparation or food storage areas in a way that could result in contamination of exposed food items." 3. During a concurrent observation and interview with the FSD on 10/21/19 at 7:47 a.m., milkshake supplements were observed without a thaw date (date of when the item was pulled from the freezer) and stored in the refrigerator. The FSD confirmed the supplements were not labeled with a thaw date. During a continued kitchen observation and interview with the FSD on 10/21/19 at 8:01 a.m., three bags of hamburger buns were stored in the pantry. Each bag contained 12 pairs of hamburger buns. One of the three bags contained the handwritten date of 10/4/19. The FSD stated bread is frozen, defrosted, and placed in the pantry for use. The FSD confirmed none of the three bags containing hamburger buns were labeled with a thaw date or use-by (expiration) date. During an interview with the RD on 10/22/19 at 9:59 a.m., the RD stated the supplemental milkshakes are placed in the freezer unless needed right away. The RD stated the supplemental milkshake lasts for 14 days after it is thawed. She stated the milkshakes, "should have some indication of when it is pulled." During a concurrent observation and interview with the RD and the FSD on 10/22/19 at 1:10 p.m., a supplemental milkshake box indicated, "STORE FROZEN THAW AT OR BELOW 40 [degrees] F [Fahrenheit] USE THAWED PRODUCT WITHIN 14 DAYS." The RD confirmed the supplemental milkshakes should 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE have been labeled with a pull date to determine when to discard the product. The RD confirmed bread should be labeled with a pull date. She stated bread is good on the shelf for five to seven days. A review of the facility document titled, "DRY GOODS STORAGE GUIDELINES," dated 2018, indicated bread can be kept frozen for 3 months and has a shelf life of five to seven days. A review of the facility policy titled, "PROCEDURE FOR REFRIGERATED STORAGE," dated 2018 indicated, "Supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator. Follow the manufacturer's recommendation (specifications) for shelf life."

F814 SS=D Dispose Garbage and Refuse Properly CFR(s): 483.60(i)(4)

F814 01/14/2020 §483.60(i)(4)- Dispose of garbage and refuse properly. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility policy review, the facility failed to cover outdoor dumpsters for a census of 43. This failure increased the potential for pest infestation and the transmission of infection to a vulnerable population. Findings: During a concurrent observation and interview with the Food Service Director (FSD) on 10/21/19 at 8:01 a.m., the recycling dumpster was observed uncovered. The trash dumpster 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE was observed overflowing and not completely covered. The FSD confirmed the observations. The FSD stated, "It's supposed to be covered." During an interview with the Registered Dietitian (RD) on 10/22/19 at 9:59 a.m., the RD stated, "The trash and recycling should be covered if it is outside and not actively in use." During an interview with the Director of Laundry and Housekeeping (DLH) on 10/23/19 at 2:14 p.m., the DLH stated the lid should have covered the dumpster and no trash should have been overflowing. During a concurrent observation and interview with the FSD on 10/24/19 at 7:50 a.m., the FSD confirmed the recycling dumpster remained uncovered. The FSD confirmed a bag of trash hung out from the trash dumpster. The FSD stated the dumpsters should have been covered with nothing hanging out. A review of an undated facility policy titled, "CODE OF SAFE WORK PRACTICES DIETARY," indicated, "Keep lid on trash dumpster closed at all times."

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 01/14/2020 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to maintain a complete, accurate medical record for 1 of 16 sampled residents (Resident 246) when there was no documented evidence of pre and post dialysis (the removal of water, salt, and waste from the blood) assessments, and dialysis communication log. This failure increased the potential for oversight in resident assessment, care, and treatment. Findings: Resident 246 was admitted in fall of 2019 with diagnoses which included dependence on renal dialysis. A review of Resident 246's physician orders titled, "CLARIFICATION OF DIALYSIS ORDERS. [sic]," dated 10/1/19, indicated, "Dialysis ...Every: M,W,F [Monday, Wednesday, Friday] At: 1415 : 1745 [2:15 p.m. to 5:45 p.m.] ...After Dialysis: Monitor shunt for signs of bleeding, bruit [blood flow by sound], thrill [blood flow by touch], infection and pain ...Pre Dialysis weight (Done at Dialysis Center) 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE ...Post Dialysis Weight (Done at Dialysis Center) ....Check Pre- Dialysis Vital Signs (T-PR-B-P-Pain) [temperature, pulse, respirations, blood pressure, pain] ...Check Post Dialysis Vital Signs (T-P-R-B-P-Pain)." A review of Resident 246's care plan titled, "Dialysis Care Plan," dated 10/1/19, indicated, "PRE & POST DIALYSIS V/S [vital signs] CHECK." During an interview with the Director of Nursing (DON) on 10/22/19 at 7:35 a.m., when asked for evidence of Resident 246's dialysis communication logs, the DON stated Resident 246's logs were placed in a binder and sent with the resident to the dialysis center. The DON stated, Resident 246 was discharged to the acute care hospital from the dialysis center. The DON confirmed the facility did not have possession of Resident 246's dialysis communication logs. During an interview with the DON on 10/23/19 at 1:30 p.m., the DON confirmed the facility did not have documented evidence of the assessments completed and of the communication between the facility and the dialysis center. The DON stated she expected the nursing staff to maintain documentation of the resident's dialysis assessments and the facilities communication with the dialysis center. During a follow-up interview with the DON on 10/23/19 at 2:20 p.m., the DON stated Resident 246 had been discharged from the facility. During an interview with the Desk Nurse (DN) on 10/24/19 at 4:30 p.m., when asked if pre and post dialysis assessments were documented anywhere other than in the 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Dialysis Communication Record, the DN stated the Dialysis Communication Record contained the pre and post dialysis assessments. A review of a facility template titled, "DIALYSIS COMMUNICATION RECORD," indicated, "Skilled Nursing Facility: Prior to sending resident to dialysis center, the Licensed Nurse completes the top portion of this form and sends a copy with the resident to the Dialysis Center. The Licensed Nurse completes lower portion of form when the resident returns from dialysis. Dialysis Unit: Complete middle portion of the form at end of treatment. Keep a copy for your records and send the original back to SNF [Skilled Nursing Facility]." The Dialysis Communication Record contained three sections titled, "SNF: PRE DIALYSIS ASSESSMENT AND COMMUNICATION," "DIALYSIS CENTER ASSESSMENT/COMMUNICATION," and "SNF: POST DIALYSIS ASSESSMENT." A review of the facility policy titled, "Renal Dialysis, Care of Residents," dated 11/17, indicated, "Record date, time, access site condition, patency after dialysis and access site care in the Dialysis Communication Form." A review of the facility contract with the dialysis center titled, "NURSING HOME DIALYSIS TRANSFER AGREEMENT," dated 3/20/19, indicated, "Facility will provide for the interchange of information useful or necessary for the care of the Designated Resident ..."

F867 SS=D QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii)

F867 01/14/2020 §483.75(g) Quality assessment and assurance. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to address, develop, and implement an appropriate written plan of action in its Quality Assessment Assurance (QAA) and Performance Improvement (QAPI) program to correct their Minimum Data Set (MDS, a resident assessment instrument) deficiencies for a census of 43. This failure had the potential to contribute to the ongoing delayed completion and transmission of MDS assessments which had the potential to affect quality of care and services delivered, identification of problems and opportunities for improvement, and progress towards correction of issues to meet the residents' needs. Findings: A review of the facility's QAA QAPI Plan was conducted on 10/28/19. The review revealed the facility neither addressed in the minutes, nor specified in a written plan in detail the scope of the QAA committee's responsibilities, or their process for addressing MDS deficiencies. There was no documented evidence of a written QAPI plan for correcting MDS issues to reflect the specifics of the facility's population as identified in it's facility assessment. In an interview on 10/28/19 at 10:23 a.m., the Director of Nursing (DON) stated, "The MDS issue had not been specifically addressed in 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE QAA...Most of the assessments are not [completed with-] in the time frame that they are needed to be completed or transmitted [in]." An interview was conducted with the Administrator (ADM) on 10/28/19 at 1:48 p.m. The ADM did not mention the issue for MDS and confirmed the facility had not developed a written QAPI plan for the MDS. In an interview on 10/28/19 at 2:18 p.m., the ADM stated, "I have not attended any QAA/QAPI meeting since the last administrator was still at the facility...I am not sure of the issue on the MDS. I know the last MDS Coordinator left and we have a new one on board and I brought in a new MDS Resource Nurse who helps in correcting the issue about MDS."

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 01/14/2020 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility policy review, the facility failed to maintain an infection prevention and control program for a census of 43 when: 1. Treatment Nurse (TN) did not sanitize scissors between residents or follow hand hygiene procedures during dressing changes; 2. A Licensed Nurse (LN) did not sanitize a blood glucose monitor per manufacturers' guidelines; and 3. Resident 22's urinary catheter (a tube inserted into the bladder to drain urine) and oxygen tubing were not labeled or dated. This failure increased the potential risk for the spread of infection. Findings: 1. During a concurrent interview and wound care observation on 10/21/19 at 9:35 a.m., the TN used bandage scissors to remove soiled rolled gauze dressing from a resident's leg wound and replaced the scissors in his scrub pants pocket without cleaning them. The TN did not change gloves after removing soiled dressings from the resident's foot before applying clean dressing. The TN did not wash or sanitize his hands after removing his gloves. When asked when he should have changed his gloves, the TN stated, "I should remove gloves when I throw away the dirty dressing, I didn't." When asked when he should have cleaned his 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE scissors and what he should have used to clean them with he stated, "I should clean them after I use them, and I use alcohol wipes." During a concurrent interview and wound care observation on 10/21/19 at 10:15 a.m., the TN was observed touching the bed rails and call light of Resident 42's roommate, and then proceeded to change Resident 42's dressing without changing his gloves. When asked if he should have changed his gloves before continuing care he stated, "I didn't touch her [meaning the other resident's body]." The TN then continued with the care without changing gloves. In an interview on 10/22/19 at 1:30 p.m., the Wound Care Physician (WCP) stated, "I would expect him to change gloves between wounds and from dirty to clean [areas]." In an interview with the Director of Nurses (DON) on 10/22/19 at 4 p.m., the DON stated her expectations were that the TN would follow standard precautions (a set of standard infection control practices used to prevent transmission of diseases) and the facility policy. In an interview with the DON and Director of Staff Development (DSD) on 10/23/19 at 4 p.m., the DON stated she expected staff to wash their hands after removing gloves and between resident care. The DSD stated staff should have used germicidal disinfectant wipes per manufacturer guidelines to clean direct care equipment between residents. Review of a facility policy titled, "Infection Control, Standard Precautions," dated 2001, indicated, "Hand hygiene [should be performed] immediately after gloves are removed and between resident contacts...Change gloves between tasks and procedures on the same 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE resident after contact with material that may contain a high concentration of microorganisms [germs]...Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of microorganisms to other residents or environments...Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed..." 2. During an observation of medication administration on 10/21/19 at 11:22 a.m., LN 5 measured Resident 295's blood sugar level using a blood glucose meter, a device used to measure blood sugar level. LN 5 then cleaned the device with an alcohol wipe for approximately three seconds. During an interview on 10/21/19 at 11:25 a.m., when asked about the proper way of disinfecting the blood glucose meter, LN 5 pulled a container of bleach germicidal wipes from the medication cart and used a wipe to clean the glucometer device for approximately five seconds; wrapped the device in several facial tissues; and placed it in a resealable plastic bag. During an interview on 10/23/19 at 3:55 p.m. with the DON and DSD, the DSD stated, "[Brand name] Wipes [germicidal disposable cloth capable of killing blood borne pathogens such as AIDS, Hepatitis B & C viruses] should have been used to clean the blood glucose meter. Licensed nursing staff should have wiped the meter for one full minute and dried it for three minutes without fanning it." According to the [Brand name] Wipes product labeling guidelines, "treated surface must remain visibly wet for a full three (3) minutes. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Use additional wipe(s) if needed to assure continuous three (3) minute wet contact time." 3. Resident 22 was admitted to the facility in the middle of 2016 with diagnoses which included retaining urine and urinary tract infection. In a concurrent observation and interview on 10/21/19 at 9:25 a.m., nebulizer (a breathing treatment equipment), a nasal tubing attached to an oxygen concentrator, and a urinary catheter bag, uncovered and hung at the bedside, were found with no labels and no dates. Resident 22 stated, "The doctor put me on this catheter for a long time and I wanted it to be removed. The staff don't even take care of it. They don't even cover it." In an interview on 10/21/19 at 9:28 a.m., LN 3 verified there were no labels or dates on the oxygen tubing or cover for the catheter bag. In an interview on 10/21/19 at 9:35 a.m., LN 1 verified the catheter bag had no cover and stated, "We are supposed to label it every time we change. It should have been labeled, dated." In an interview on 10/23/19 at 1:48 p.m., the DON stated, "On tubes, lines, catheters and personal equipment, I expect the staff to label with the names of residents and to put dates when they are using them." In an interview on 10/24/19 at 1:24 p.m., LN 2 stated, "When we receive a resident with a catheter...cover with a dignity bag and assess for signs and symptoms of infection." In an interview on 10/24/19 at 1:32 p.m., the Minimum Data Set Coordinator stated, "We would follow the standard procedure, label with 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE name and date when the catheter was inserted, cover the catheter with a clothing bag."

F921 SS=E Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 01/14/2020 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment for potentially 9 residents in a census of 43 residents when walls, doors, and dressers where in disrepair in rooms 107, 108, and 109. This failure had the potential to negatively affect the residents' safety and well-being. Findings: A concurrent interview and observation of room 109 with Certified Nursing Assistant 2 (CNA 2) was conducted on 10/21/19 at 8:37 a.m. The room had a built-in wardrobe system which included six drawers. Two drawers did not fully close, and four drawers were off their tracks and dropped down when opened. The door leading to the bathroom had scratches, scraped off paint, and no door knob. The bottom of the bathroom door frame had deeply gouged out wood, indentations, and peeled paint. CNA 2 agreed with the observations, and stated residents would need to reach to the top of the bathroom door to open it. CNA 2 stated one of the three residents in room 109 was able to use the bathroom independently. 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A concurrent interview and observation of the resident bathroom for rooms 107 and 108 was conducted with CNA 1 on 10/21/19 at 9:47 a.m. The bathroom was shared by six residents, two of which used the bathroom independently (Resident 195 and Resident 198). The paint had bubbled and peeled off the wall behind the toilet, the tiled flooring was chipped, and sections of grout were darkened and had a white chalky-crystalline substance, the walls had cracks, sections of the coving were detached from the wall, the caulk between the sink and the wall was cracked and dirty, the bathroom doors were scratched and had peeled off paint, and there were three large buckets stacked on top of each other stored next to the toilet. The top bucket contained a substance that resembled vomit. CNA 1 agreed with the observations made of the bathroom. When asked about the buckets, CNA 1 stated a resident in room 108 was always nauseated. CNA 1 covered the inside of the bucket with paper towel and stated he would tell janitor to clean it up. During an interview with Resident 195 on 10/21/19 at 11:39 a.m., Resident 195 confirmed it was her vomit in the buckets in the bathroom. Resident 195 stated she thought the facility was in a state of disrepair. The resident stated, when she was leaning up against the bathroom sink, it pulled away from the wall. Resident 195 stated she thought it would rip completely away from the wall. Resident 195 stated she notified someone in the maintenance department, who reassured her the sink would get fixed. An observation of room 107 on 10/21/19 at 4:47 p.m., revealed the wall at the head of bed B had deep gouges into the drywall, and large sections of peeled paint. Two bedside dressers had table tops with no plastic edges; which left 131 055956 10/28/2019 BRIDGEWOOD POST ACUTE 5901 Lemon Hill Avenue Sacramento, CA 95824 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE exposed rough particle board and chunks of hardened adhesive. The window sill had long cracks, chipped paint, and appeared water damaged. The bathroom door had black scuff marks, scratches, chipped paint, and no door knob. During an interview with the Administrator (ADM) on 10/23/19 at 8:17 a.m., the ADM reviewed the pictures taken of the resident rooms described above, and agreed the the rooms were in disrepair, and that the residents deserved a better living environment. 131