Health inspection·September 27, 2024

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a certified nursing assistant was able to demonstrate competency in skills and techniques for one of three sampled residents (Resident 1) when a Certified Nursing Assistant (CNA 1) did not report Resident 1's redness on the nose to a licensed nurse. This failure had the potential to result in delayed treatment and care for Resident 1, placing Resident 1 ' s health at risk. Findings: During a review of Resident 1 ' s admission Record (contains demographic and medical information), the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of malignant neoplasm of the stomach (stomach tumor), malignant neoplasm of unspecified kidney (kidney tumor) and repeated falls. During a concurrent observation and interview on September 5, 2024, at 9:58 AM, with Resident 1, in Resident 1 ' s room, Resident 1 was lying in bed. Resident 1 ' s bed was in the lowest position. Resident 1 had redness on her nose, appearing like flushing on her nose. Resident 1 stated she did not know how she got it. During an interview on September 11, 2024, at 1:47 PM, with CNA 1, CNA 1 stated she noticed the redness but did not report it to the licensed vocational nurse (LVN 1) or the registered nurse (RN). CNA 1 further stated she was busy and forgot to tell the licensed staff. During an interview on September 11, 2024, at 2:08 PM, with LVN 1, LVN 1 stated he saw the redness on Resident 1 ' s nose but stated he believed it had already been identified due to Resident 1 ' s behavior of hitting her face. LVN 1 further stated it was his expectation for the CNA ' s to report any skin changes. During an interview on September 11, 2024, at 2:16 PM, with RN, the RN stated he was not informed until later that Resident 1 had redness to her nose. The RN further stated Resident 1 when asked about her nose, Resident 1 could not state what happened to her nose. The RN stated it is his expectation for the staff to report any changes with the residents. During a concurrent interview and record review on September 26, 2024, at 12:01 PM with the Administrator (Admin) and Director of Nursing (DON), the facility ' s document titled Certified Nursing Page 1 of 2 555089 555089 09/27/2024 Meadows Ridge Care Center 1700 E Washington St Colton, CA 92324

F 0726 Level of Harm - Minimal harm or potential for actual harm Assistant (CNA) Job Description dated August 23, 2011, was reviewed. The Certified Nursing Assistant (CNA) Job Description indicated .Essential Duties and Responsibilities . observes resident ' s skin and documentations and reports skin conditions .Other Duties . Recognize and reports resident pain. Abnormal skin condition, incident, etc., to the charge nurse. The Admin stated the job description was not followed by CNA 1. Residents Affected - Few During a concurrent interview and record review on September 26, 2024, at 12:02 PM, with the Admin and DON, the facility ' s policy and procedure (P&P) titled, Change In A Resident ' s Condition or Status dated revised February 2021 was reviewed. The P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition .1. The nurse will notify the resident ' s attending physician . when there has been a(an ) a. accident or incident involving the resident; b. discovery of injuries of unknown source . The Admin stated CNA 1 did not follow the policy when CNA 1 did not report to the charge nurse the redness on Resident 1 ' s nose. The Admin further stated CNA 1 was terminated. 555089 Page 2 of 2