Other·September 13, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey regarding investigation of a complaint conducted on 8/23/17, 8/24/17, 8/28/17 to 8/30/17, and 9/8/17. For Complaint CA00549356 regarding Quality of Care/Treatment, a federal deficiency was identified (see F281) with a Scope and Severity of "G". In addition, a Class "B" Citation was identified. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 37409, Health Facilities Evaluator Nurse.

F281 SS=G SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 10/03/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow the physician's order to administer laxatives (substances designed to loosen stools and increase bowel movements) LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPHU11 Facility ID: CA070000064 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055211 (X3) DATE SURVEY COMPLETED 09/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IDYLWOOD CARE CENTER 1002 W Fremont Ave Sunnyvale, CA 94087 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and to notify the physician for one of three sampled residents (1) when Resident 1 did not have a bowel movement for six consecutive days. These failures resulted in sending Resident 1 to an acute care with a fecal impaction incident with fecal disimpaction (manually removal of feces). Findings: Review of Resident 1's admission record indicated Resident 1 was admitted on 3/11/16 with diagnoses including dementia (a chronic or persistent disorder of the mental processes marked by memory disorders, personality changes, and impaired reasoning), chronic kidney disease, schizoaffective disorder (a chronic mental health condition characterized primarily by hallucinations or delusions, mania and depression) and depressive disorder (a mental disorder characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities). Review of the Minimum Data Set (MDS, an assessment tool), dated 7/25/17, indicated Resident 1 was not ambulatory, and was incontinent of urine and bowel. Review of Resident 1's physician orders, dated 8/2017, indicated Resident 1 had orders dated 3/11/16 for mirtazapine (a medication used to treat depression) 15 milligrams (mg, a metric unit of mass) at bedtime, clozapine (a medication used to treat schizoaffective disorder) 100 mg at bedtime, dated 9/27/16, olanzapine (a medication used to treat schizoaffective disorder) 10 mg at bedtime, dated 5/1/17, and olanzapine 2.5 mg every day, dated 6/22/17. Resident 1 also had orders for monitoring side effects of these three medications, such as constipation, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPHU11 Facility ID: CA070000064 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055211 (X3) DATE SURVEY COMPLETED 09/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IDYLWOOD CARE CENTER 1002 W Fremont Ave Sunnyvale, CA 94087 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3/11/16. Review of Resident 1's care plan, dated 3/30/17, indicated Resident 1 had the potential/risk for constipation due to dementia, limited physical mobility, and use of psychotropic medications (medication capable of affecting the mind, emotions, and behavior). During an interview with the Registered Dietitian (RD) on 8/24/17 at 2 p.m., she stated Resident 1 had poor bowel movement, so she recommended adding fiber blend (a dietary supplement that helps with the regularity of bowel movements) and Hyfiber (a medical food that provides the nutrients for the dietary management of constipation, hard stools, and irregularity) to his diet for bowel regularity. Review of Resident 1's physician orders, dated 8/2017, indicated Resident 1 had an order for fiber blend, 2 ounces (oz, a unit of weight), three times a day, dated 7/10/16, and Hyfiber, 1 oz ,three times a day, dated 7/26/17. Resident 1 also had an order for Milk of Magnesia (MOM, a medication used to treat constipation) 30 milliliters (ml, a metric unit of volume) every 24 hours as needed for constipation; Dulcolax suppository (a medication used to treat constipation), 10 mg as needed if MOM was ineffective, and Fleet Enema (a medication used to relieve constipation) 7-19 grams (g, a metric unit of mass)/118 ml every 24 hours as needed if the Dulcolax suppository was ineffective. Review of Resident 1's Transfer Discharge Notice, dated 8/14/17, indicated Resident 1 was sent to the hospital for difficulty breathing at 3:46 p.m. Review of Resident 1's Emergency Department (ED) Provider Notes, dated 8/14/17, at 4:13 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPHU11 Facility ID: CA070000064 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055211 (X3) DATE SURVEY COMPLETED 09/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IDYLWOOD CARE CENTER 1002 W Fremont Ave Sunnyvale, CA 94087 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE p.m., indicated Resident 1 had a markedly distended abdomen. Resident 1's computed tomography (CT, the use of computerprocessed combinations of many X-ray measurements taken from different angles to produce cross-sectional images of specific areas, allowing the user to see inside the object without cutting) of the abdomen and pelvis indicated Resident 1 had diffuse colonic distention without volvulus and with prominent fecal retention in the distal colon and rectum. The ED physician recommend and the resident was sent to surgery on 8/14/17 for severe dilation and bowel ischemia (a restriction in blood supply to tissues in the bowels) due to chronic constipation. Review of Resident 1's Full Operative Report, created on 8/15/17 at 7:29 a.m., indicated Resident 1 went through an exploratory laparotomy (a surgical operation where the abdomen is opened and the abdominal organs examined for injury or disease), sigmoid colectomy with end colostomy and fecal disimpaction. According to the Full Operative Report, "The most remarkable finding was a massively distended left colon...with the colon packed completely full of stool." The facility policy and procedure titled, "Bowel Care, Managing constipation", revision dated 9/1/13, indicated "Residents/clients are assisted to prevent and relieve bowel constipation or impaction. Upon written order from the physician, the following protocol shall be followed to provide adequate elimination of the bowels for residents/clients who require assistance ... Licensed nurses monitor resident/client bowel movements daily with assistance of certified nursing assistants. Bowel care protocol will be indicated for those who have not had a bowel movement in the past three days as follows (per physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPHU11 Facility ID: CA070000064 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055211 (X3) DATE SURVEY COMPLETED 09/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IDYLWOOD CARE CENTER 1002 W Fremont Ave Sunnyvale, CA 94087 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE order): A. The licensed nurse will administer 30 ml of MOM per physician order (recommend evening shift). B. If no results from MOM by the end of the subsequent shift (i.e., night shift), the licensed nurse will administer a Dulcolax suppository per physician order. C. If no results from a suppository by subsequent shift (i.e., morning shift), the licensed nurse will give resident a Fleet Enema per physician order. If no results from Fleet Enema by the end of the same shift, the licensed nurse will check for a possible fecal impaction. If the current bowel care orders are not sufficient to maintain regular evacuation of the bowels, contact the physician to discuss further interventions that may be needed ..." Review of Resident 1's Bowel Elimination Report for 7/2017 and 8/2017 indicated from 7/31/17 to 8/14/17, within those 15 days, there were 10 days Resident 1 did not have a bowel movement. In addition, Resident 1 did not have a bowel movement for six consecutive days from 7/31/17 to 8/5/17. Review of Resident 1's Medication Administration Record (MAR) for 8/2017 indicated from 7/31/17 to 8/5/17, MOM was given to Resident 1 on 8/3/17 at 6 p.m. by licensed vocational nurse A (LVN A) which was ineffective. The Dulcolax suppository was not given until 8/5/17 at 9:30 a.m. by a morning nurse, which was ineffective. MOM, rather than a Fleet Enema was given on 8/5/17 at 6:57 p.m. by registered nurse B (RN B), and it was ineffective. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPHU11 Facility ID: CA070000064 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055211 (X3) DATE SURVEY COMPLETED 09/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IDYLWOOD CARE CENTER 1002 W Fremont Ave Sunnyvale, CA 94087 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with LVN A on 8/28/17 at 3:40 p.m., he stated he should have given Resident 1 MOM on 8/2/17 instead of 8/3/17 since Resident 1 did not have a bowel movement since 7/31/17. On 8/29/17 at 12:20 p.m., LVN A stated after he gave Resident 1 MOM on 8/3/17 which was ineffective, and if the subsequent shifts did not give Resident 1 a Dulcolax suppository, he should have given it to him on 8/4/17. LVN A stated he did not inform the physician about Resident 1's constipation. During an interview with LVN C on 8/29/17 at 11:50 p.m., she stated after LVN A gave Resident 1 MOM on 8/3/17 at 6 p.m., which was ineffective, she did not give Resident 1 Dulcolax suppository because she did not know LVN A gave him MOM. LVN C stated she did not give Resident 1 the Dulcolax suppository on 8/4/17 either because she did not know the previous shifts did not give it to him. LVN C stated she did not check for a fecal compaction in Resident 1 and did not call the physician because she did not know Resident 1 was constipated. During an interview with LVN D on 8/29/17 at 11:05 a.m., she stated after LVN A gave Resident 1 MOM on 8/3/17 at 6 p.m., which was ineffective and LVN C did not give him the Dulcolax suppository on the night shift, she should have followed up and given Resident 1 the Dulcolax suppository on 8/4/17. LVN D stated she did not check Resident 1's Bowel Elimination Report and did not call the physician. During an interview with RN B on 8/29/17 at 3:10 p.m., she stated after a morning nurse gave Resident 1 a Dulcolax suppository on 8/5/17 at 9:30 a.m. which was ineffective, she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPHU11 Facility ID: CA070000064 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055211 (X3) DATE SURVEY COMPLETED 09/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IDYLWOOD CARE CENTER 1002 W Fremont Ave Sunnyvale, CA 94087 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE should have given Resident 1 a Fleet Enema instead of MOM. RN B stated she did not know Resident 1 did not have a bowel movement for six consecutive days, so she did not check for a fecal compaction for Resident 1 and did not notify the physician. During an interview with Resident 1's physician on 8/30/17 at 2:20 p.m., she stated she came to the facility to visit Resident 1 on 8/9/17, but she was not notified about Resident 1's constipation. Resident 1's physician stated the licensed nurses should have informed her about this issue, and if she knew she would have examined Resident 1 and ordered lab tests. During an interview with the director of nursing (DON) on 8/30/17 at 2:50 p.m., she reviewed Resident 1's MAR for 8/2017 and Bowel Elimination Report for 7/2017 and 8/2017, and she stated the licensed nurses did not follow the facility's policy on bowel management. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YPHU11 Facility ID: CA070000064 If continuation sheet 7 of 7