Health inspection·February 14, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 928320. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for Complaint #928320 at F-tag 842/E. F842 Resident Records - Identifiable Information §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. §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. §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, nurse, and other licensed professionals progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50 On 11/12/24, an unannounced visit was conducted at the facility to investigate a complaint regarding resident provision of care. Based on observation, interview, and record review, the facility failed to accurately document services given for incentive spirometry (ISP - a breathing exercise that uses a device to help people inhale slowly and deeply to improve lung function) for one of four sampled residents (Resident 3). This failure resulted in falsification of documentation and had the potential for adverse health outcomes for Resident 3. Resident 3 is a 72-year-old male who was admitted to the facility on 11/1/2024 and has a diagnosis history of polyneuropathy (when nerves [a bundle of fibers that transmit messages to and from the brain] become damaged), dementia (a progressive state of decline in mental abilities), and need for assistance with personal care. During an interview on 11/12/24 at 11:50 a.m. with Registered Nurse (RN) 1, RN 1 stated ISP was ordered for all resident admissions as a set order (a set of instructions or directives from an MD to the facility about a resident's treatment). During a review of Resident 3's OS, dated 11/1/24, the OS indicated, Resident 3 had an MD order for ISP to be given every shift (morning, afternoon, night) with no end date indicated. During a concurrent interview and record review on 11/12/24 at 12:21 p.m. with Director of Nursing (DON), Resident 3's "Medication Administration Record (MAR)," dated 11/2024 was reviewed. DON stated Resident 3 had an order for ISP to be given 15 minutes during the day, evening, and night shift. DON stated Resident 3 was not getting ISP despite the MD order. DON stated any new resident admissions have an order for ISP because the digital system the facility was using to make MD orders was auto populating (to automatically fill in a digital document) that specific order. During a concurrent interview and record review on 12/2/24 at 12:32 p.m. with FN 2, Resident 3's MAR, dated November 2024 was reviewed. The MAR indicated FN 2 provided ISP at night to Resident 3 on 11/1/24, 11/8/24, 11/9/24, 11/10/24 and 11/11/24. FN 2 stated she did not provide ISP to Resident 3, and should not have documented on the MAR she provided the treatment. During an interview on 12/2/24 at 12:53 p.m. with FN 3, FN 3 stated ISP had not been available in the facility for about 3 months. During a concurrent interview and record review on 12/2/24 at 1:07 p.m. with FN 4, Resident 3's MAR, dated November 2024 was reviewed. The MAR indicated FN 4 provided ISP to Resident 3 in the night on 11/2/24 and 11/3/24. FN 4 stated she should not have documented ISP was provided to Resident 3 "as it was not given." During a concurrent interview and record review on 12/2/24 at 1:37 p.m. with FN 5, Resident 3's MAR, dated November 2024 was reviewed. The MAR indicated FN 5 provided Resident 3 ISP on 11/12/24 during the day but he had refused. FN 5 stated she should not have documented Resident 3 as refusing ISP as there was no ISP to give him. During a review of Resident 3's MAR, dated November 2024, the MAR indicated, Resident 3 was provided ISP by FN 12 during the day on 11/2/24, 11/3/24, 11/7/24, 11/8/24, 11/9/24, 11/10/24, and 11/13/24. During an interview on 12/2/23 at 4:03 and 4:07 p.m. with FN 12, FN 12 stated she did not provide ISP to Resident 3 on 11/2/24, 11/3/24, 11/7/24, 11/8/24, 11/9/24, 11/10/24, and 11/13/24. During a concurrent interview and record review on 12/5/24 at 11:37 a.m. with FN 7, Resident 3's MAR, dated November 2024 was reviewed. The MAR indicated Resident 3 was provided ISP to him on 11/6/24 in the night. FN 7 stated the facility did not have ISP and she should not have documented ISP being given because it was not. During a concurrent interview and record review on 12/5/24 at 2:06 p.m. with FN 8, Resident 3's MAR, dated November 2024 was reviewed. The MAR indicated Resident 3 had ISP provided to him on 11/5/24 during the night. FN 8 stated she did not recall documenting ISP given to Resident 3. During a concurrent interview and record review on 12/5/24 at 2:33 p.m. with FN 9, Resident 3's MAR, dated November 2024 was reviewed. The MAR indicated Resident 3 was given ISP during the evening on 11/4/24 and 11/5/24. FN 9 stated she did not remember signing off as giving ISP to Resident 3 despite the equipment not being available. FN 9 stated she remembered some residents (unable to identify) had ISP and others did not. During a concurrent interview and record review on 12/5/24 at 2:53 p.m. with FN 10, Resident 3's MAR, dated November 2024 was reviewed. The MAR indicated Resident 3 was given ISP on 11/4/24 during the day but had refused. FN 10 stated, "If I didn't do it (provide ISP to Resident 3) then I just put refused." During a concurrent interview and record review on 12/5/24 at 4:04 p.m. with DON, Resident 3's MAR, dated November 2024 was reviewed. DON stated despite nursing documentation stating otherwise Resident 3 was not provided ISP. DON stated, "I expect the nurses (FN) to be honest and document what they did and not document what they didn't, and it appears they documented providing care that they did not do." During an interview on 12/5/24 at 4:10 p.m. with DON, a request for the facility policy and procedure for nursing documentation and the job descriptions for nurses was requested but none was provided. During a concurrent interview and record review on 12/11/24 at 1:39 p.m. with FN 11, Resident 3's MAR, dated November 2024 was reviewed. The MAR indicated Resident 3 was provided ISP on 11/12/24 in the night but had refused. FN 11 stated the facility did not have ISP for Resident 3. FN 11 stated she should not have signed she provided ISP but instead put a note in the resident chart explaining the ISP was not available. In violation of the above cited standards, the facility failed to accurately document services given for incentive spirometry for one of four sampled residents (Resident 3). This violation had a direct or immediate relationship to the health, safety, or security of residents and represents a Class B citation.