Health inspection·May 31, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure a resident ' s right of being fully informed of care being furnished for one of three sampled residents (Resident 1), when the facility did not notify Resident 1 ' s representative party (RP) of an ophthalmology (branch of medicine concerned with the diagnosis and treatment of disorders of the eye) procedure that involved removing Resident 1 ' s eyelashes on 10/25/22. Residents Affected - Few This failure had the potential to result in Resident 1 having feelings of anguish and depression from moving eyelashes without her knowledge and consent from the RP. Findings: During a review of Resident 1 ' s admission Record (AR), dated 4/25/23, the AR indicated, .Original admission Date 3/12/2019 .Diagnosis Information .Chronic Obstructive Pulmonary Disease (refers to a group of diseases that cause airflow blockage and breathing-related problems) . During review of Resident 1 ' s Minimum Data Set Section C Cognitive Patterns (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs), dated 1/31/23, the MDS indicated, .BIMS (Brief Interview for Mental Status) Summary Score .7 (indicating impaired cognition) . During a review of Resident 1 ' s Progress Note (PN), dated 10/25/22, the PN indicated, Resident [1] was seen by Ophthalmologist (specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye) .Physician Notes: PCO trichiasis (Posterior capsule opacification, often referred to as secondary cataract, is the most common postoperative complication of cataract extraction resulting from eyelashes that are misdirected against the ocular surface) . During a review of Resident 1 ' s Ophthalmology Consultation (OC), dated 10/25/22, the OC indicated, .Procedure: Epilation Lashes (eyelash removal) .E1 left upper lid E2 left lower lid E3 right upper lid E4 right lower lid . During an interview on 5/17/23, at 10:20 a.m., with the Director of Nursing (DON), the DON stated on 10/25/22 Resident 1 had an Ophthalmologist appointment that included removal of eyelashes due to a condition where Resident 1 ' s eyelashes were growing inward. The DON stated she thought Resident 1 ' s RP knew of the need for follow up with the Ophthalmologist. The DON stated there was no indication in Resident 1 ' s records of notification of the ophthalmologist procedure to the RP. The DON stated she had spoken to the RP during a care conference meeting on 4/18/23, and RP stated she wanted to be notified of any procedure for Resident 1. The DON stated Resident 1 ' s ophthalmology procedures for removing eyelashes should have been discussed with the RP to give consent to treat. The DON Page 1 of 2 555347 555347 05/31/2023 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0552 stated the facility should have informed the RP of the eyelash removal for Resident 1. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/17/23, at 12:40 p.m., with the RP, the RP stated she had not approved the procedure to remove Resident 1 ' s eyelashes. The RP stated she did not know about the procedure until she was sent a Medicare Summary Notice EOB (explanation of benefits is statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf) that indicated an ophthalmology procedure had been done to remove Resident 1 ' s eyelashes. The RP stated because Resident 1 did not have the capacity to make those informed decisions, the facility should have communicated to consent to the procedure. Residents Affected - Few During a review of Resident 1 ' s admission Agreement (AA), dated 3/13/19, the AA indicated, .III. Consent to Treatment .you have the right, to the extent permitted by law, to refuse any treatment and the right to be informed of potential medical consequences should you refuse treatment. We will keep you informed about the routine nursing and emergency care we provide to you, and we will answer your questions about the care and services we provide you. If you are, or become, incapable of making your own medical decisions, we will follow the direction of a person with legal authority to make medical treatment on your behalf, such as a guardian, conservator, next of kin, or a person designated in an Advance Health Care Directive or Power of Attorney for Health Care . During a review of the facility policy and procedure (P&P) titled, Health, Medical Condition and Treatment Options, Informing Residents of, dated January 2018, the P&P indicated, .1. Every Resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance treatment and on an on-going basis. If a resident has an appointed representative, the representative is also informed . During a review of the facility P&P titled, Resident Rights, dated January 2018, the P&P indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to .o. be notified of his or her medical condition and of any changes in his or her condition: P. be informed of and participate in, his or her care planning and treatment . 555347 Page 2 of 2