Health inspection·April 25, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 21) was referred for a Preadmission and Resident Review (PASRR-screening tool used to determine if placement in a nursing facility is appropriate for those with mental illness and makes recommendations for specialized services based on the Level II evaluation) after a change in psychological status. This failure resulted in Resident 21 not receiving recommendations for specialized services to best meet her needs. Residents Affected - Few Findings: During a concurrent interview and record review on 4/24/24 at 10:45 a.m. with the Social Worker (MSW) Resident 21's PASRR, dated 11/26/19 and Psychiatric Mental Health Progress Note (PMHPN), dated 8/22/23 were reviewed. The PASRR indicated, Generalized Anxiety Disorder [feelings of worry or restlessness that can interfere with daily activities]. The PMHPN indicated, Schizophrenia [mental disorder that affects a person's ability to think feel and behave clearly]. MSW stated the PASRR does not include diagnosis of schizophrenia. MSW stated Resident 21 received the new diagnosis in August 2023 and should have had a new PASRR Level 1 screening completed at that time. Page 1 of 10 555517 555517 04/25/2024 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to communicate the weightbearing status to the interdisciplinary team (IDT-group of healthcare professionals from different fields working together) for one of one sampled resident (Resident 13). This failure resulted in a delay of rehabilitative and restorative care to prevent further physical decline. Residents Affected - Few Findings: During a concurrent observation and interview on 4/22/24 at 10:07 a.m. in Resident 13's room, Resident 13 was in bed with a brace on her right leg. Resident 13 stated she wanted to have therapy, but had not received any since she broke her leg about six weeks ago. During an interview on 4/23/24 at 10:30 a.m. with Physical Therapist (PT), PT stated she discontinued Resident 13's RNA (Restorative Nursing Assistant - light stretching and range of motion) on 3/29/24 because she was unable to determine the weightbearing status. During an interview on 4/23/24 at 12:08 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 13 went to the orthopedic doctor on 3/18/24. No orders or follow up documentation was sent back to the facility regarding care or weightbearing status. During a concurrent interview and record review on 4/23/24 at 12:15 p.m. with Director of Nursing (DON), a letter from Resident 13's orthopedic clinic, dated 3/19/24 was reviewed. The letter indicated, Weightbearing is allowed with the knee brace on and the knee in full extension only. Patient instructed to be maintained in a knee immobilizer when she attempts to walk. DON stated weightbearing status should have been documented and communicated to all staff involved in Resident 13's care. During an interview on 4/25/24 at 10:41 a.m. with PT, PT stated if she had known Resident 13's weightbearing status she would not have discontinued the RNA, she would have revised it. 555517 Page 2 of 10 555517 04/25/2024 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to provide care for the Foley catheter (tube placed into the bladder to drain urine) to prevent infections and other complications for one of four sampled residents (Resident 33). This failure had the potential to result in infections and injury to the penis or bladder. Findings: During an observation on 4/24/24 at 7:23 a.m. outside Resident 33's room, Resident 33's Foley catheter tubing was on the floor under the wheelchair. Licensed Vocational Nurse (LVN) 1 stated Resident 33 is currently being treated for a urinary tract infection (UTI-bladder infection) and his catheter tubing should not be on floor because of the risk for infection or getting pulled out. During an interview on 4/24/24 at 11:22 a.m. with Infection Preventionist (IP), IP stated Resident 33's catheter tubing should not have been touching the floor. IP stated Resident 33 is already at a high risk for infection. During a review of the facility's policy and procedure (P&P) titled, Indwelling Foley Catheter Care, dated 11/6/13, the P&P indicated, Drainage bags are. kept off the floor. 555517 Page 3 of 10 555517 04/25/2024 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to provide sufficient Certified Nursing Assistants (CNA) and Restorative Nursing Assistant's (RNA) to meet the needs for 20 of 31 sampled residents (Resident 3, Resident 4, Resident 5, Resident 6, Resident 8, Resident 10, Resident 11, Resident 13, Resident 15, Resident 16, Resident 17, Resident 19, Resident 21, Resident 22, Resident 23, Resident 26, Resident 29, Resident 30, Resident 40, and Resident 42). This failure had the potential for a decline in residents Range of Motion (ROM) and mobility. Findings: During an interview on 4/22/24 at 2:19 p.m. with Resident 17, Resident 17 stated the CNAs are always short staffed and it takes 45 minutes to answer the call lights. Resident 17 stated it mostly happens at night, but it also happens during the day. Resident 17 stated she has not gotten her exercises for several days or maybe weeks. During a review of Resident 17's BIMS, dated 4/25/24 the BIMS indicated, Resident 17 had BIMS score of 15 [Intact cognitive response]. During a concurrent interview and record review on 4/22/24 at 2:20 p.m. with Staffing Coordinator (SC), the NOC [Night] Shift Assignment (NSA), dated 4/20/24 was reviewed. The NSA indicated, three CNAs were scheduled for the night shift on 4/20/24. One CNA called off and the other CNA worked from 11-4 a.m. and two other CNAs from the Emergency Department (ED) were scheduled to come to the Skilled Nursing Facility (SNF) to cover for two hours. SC stated the two ED CNAs worked in the facility for a few minutes before they returned to the ED. SC stated the facility census for 4/20/24 was 43 and they were short staffed that day. SC stated they only had one CNA covering for most of the night. During an interview on 4/22/24 at 2:26 p.m. with Resident 13, Resident 13 stated the facility is short staffed and sometimes only has one CNA for everyone at night. Resident 13 stated she has waited five hours for a CNA to answer the call light. Resident 13 stated she has not received RNA since last month and stated she is ready to start moving again. During a review of Resident 13's BIMS indicated, Resident 13 had a BIMS score of 14 [Intact cognitive response]. During an interview on 4/22/24 at 2:43 p.m. with Resident 8, Resident 8 stated they are short staffed and take a long time to answer the call lights. During an interview on 4/22/24 at 3:04 p.m. with CNA 5, CNA 5 stated she worked by herself on Saturday night 4/20/24. CNA 5 stated two other CNAs from the ED came to the SNF to cover, but they only stayed for a few minutes, and they did not help with the residents. CNA 5 stated their census was 43 on 4/20/24 and she had to answer call lights and change residents by herself. During an interview on 4/24/24 at 2:51 p.m. with CNA 2, CNA 2 stated she worked day shift on 4/20/24. CNA 2 stated she gave report to the two CNAs covering from the ED since they were going to help cover in the SNF. CNA 2 stated she left at 7:19 p.m. and the CNAs from the ED had already returned to the ED leaving CNA 5 to work alone. 555517 Page 4 of 10 555517 04/25/2024 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/24/24 at 2:18 p.m. with SC, SC stated for day shift they schedule four CNAs and for nights they typically schedule three CNAs. SC stated they schedule according to Census and Direct Care Service Hours per Patient Day (DHPPD) SC stated they are not always able to get 2.4 hours of DHPPD to meet the requirements. During an interview on 4/25/24 at 10:51 a.m. with CNA 6, CNA 6 stated she is a CNA/RNA. CNA 6 stated she gets pulled when she is scheduled as an RNA to do CNA work when CNAs call out. CNA 6 stated residents needing RNA do not receive RNA consistently. During an interview on 4/25/24 at 11:01 a.m. with Resident 5, Resident 5 stated he was supposed to have RNA and it has not been done for the last couple of weeks. During a review of Resident 5's Minimum Data Set [MDS-assessment tool] Section C Cognitive Patterns/Brief Interview for Mental Status (BIMS), dated 4/25/24 the BIMS indicated, Resident 5 had a BIMS score of 14 [Intact cognitive response]. During an interview on 4/25/24 at 11:06 a.m. with Resident 10, Resident 10 stated she had not received RNA in the last week. During a review of Resident 10's BIMS, dated 4/25/24 the BIMS indicated, Resident 10 had BIMS score of 15 [Intact cognitive response]. During an interview on 4/25/24 at 11:22 a.m. with Resident 29, Resident 29 stated he had not received RNA in the last week. During a review of Resident 29's BIMS, dated 4/25/24 the BIMS indicated, Resident 29 had BIMS score of 13 [Intact cognitive response]. During a concurrent interview and record review on 4/25/24 at 2:02 p.m. with Licensed Vocational Nurse (LVN) 2, RNA Weekly Schedule (RNAWS), dated 4/14/24 was reviewed. The RNAWS indicated, NO RNA services were provided on 4/14/24, 4/15/24, 4/16/24, 4/17/24, 4/18/24, 4/19/24, and 4/20/24 for Resident 3, Resident 4, Resident 5, Resident 6, Resident 8, Resident 10, Resident 11, Resident 13, Resident 15, Resident 16, Resident 17, Resident 19, Resident 21, Resident 22, Resident 23, Resident 26, Resident 29, Resident 30, Resident 40, and Resident 42. LVN 2 stated the residents did not receive RNA for the week of 4/14/24-4/20/24. LVN 2 stated they did not have enough staff to cover RNA services. During a review of Resident 3's Physician Orders List (PO) dated 3/7/23, the PO indicated, RNA to perform active/passive range of motion exercises to upper and lower extremities 3 times a week to tolerance. During a review of Resident 4's PO dated 4/10/23, the PO indicated, RNA to ambulate with front wheeled walker, ROM to right upper extremities, cup stacking, 3x's (times) weekly. During a review of Resident 5's PO dated 3/12/24, the PO indicated, RNA to active & passive range of motion exercises to upper and lower extremities to tolerance three times weekly. During a review of Resident 6's PO dated 10/8/23, the PO indicated, RNA to perform PROM [Passive range of motion] 3x weekly. 555517 Page 5 of 10 555517 04/25/2024 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0725 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 8's PO dated 9/27/23, the PO indicated, RNA to perform active range of motion leg exercises and standing balance exercises two times per week. Priority one. During a review of Resident 10's PO dated 3/7/23, the PO indicated, RNA to perform heel cord stretching and foot massage 2 times weekly to tolerance. Residents Affected - Some During a review of Resident 11's PO dated 3/7/23, the PO indicated, RNA to provide active range of motion exercises to upper extremities, ROM to right heel. Sit-to-stand exercises, 3 times a week to tolerance. During a review of Resident 13's PO dated 4/23/24, the PO indicated, RNA to perform minimal weight bearing and transfer 2-3 times per week as tolerated. During a review of Resident 15's PO dated 4/9/23, the PO indicated, RNA to perform passive range of motion to left shoulder, heel cord stretching, pillow under elbow, open to air three times a week to tolerance. During a review of Resident 16's PO dated 3/12/23, the PO indicated, RNA to perform range of motion exercises to right hand once weekly to tolerance. During a review of Resident 17's PO dated 3/7/23, the PO indicated, RNA to perform assisted active range of motion exercises to upper and lower extremities 3 times a week. During a review of Resident 19's PO dated 5/24/23, the PO indicated, RNA to Ambulate Resident 100 feet 3 times weekly with front wheeled walker, gait belt and close guard. Priority 1. During a review of Resident 21's PO dated 3/7/23, the PO indicated, RNA to provide neck massage, standing exercises using SA400 mechanical lift 3 times a week to tolerance. During a review of Resident 22's PO dated 3/29/24, the PO indicated, RNA/CNA to AMB 3X WKLY [Weekly] W/FWW [With front wheel walker] (WC [wheelchair] Behind for O2 [oxygen]). During a review of Resident 23's PO dated 3/7/23, the PO indicated, RNA to perform active range of motion to upper & lower extremities 3 times weekly; RNA to encourage to mobilize to tolerance in wheelchair 3 times weekly. During a review of Resident 26's PO dated 3/12/23, the PO indicated, RNA to perform range of motion exercises to right shoulder, table slides three times weekly. During a review of Resident 29's PO dated 3/12/23, the PO indicated, RNA to perform massage to right hip 2-3 times per week. During a review of Resident 30's PO dated 3/7/23, the PO indicated, RNA to ambulate 3x weekly to tolerance with 4-wheeled walker. During a review of Resident 40's PO dated 3/29/24, the PO indicated, RNA/CNA LUE [Left upper extremity] PROM X3 weekly. AMB [Ambulate] 3 X weekly. During a review of Resident 42's PO dated 3/29/24, the PO indicated, RNA to perform STS [Sit to 555517 Page 6 of 10 555517 04/25/2024 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0725 stand] W/FWW or SA400 [Mechanical lift] 5-10 times and stand until fatigue 3 times weekly. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL'S), dated 6/6/18, the P&P indicated, All nursing service personnel shall follow daily work assignments and perform assigned duties in accordance with professional standards of practice and facility policy. Daily personal duties. Answer call lights as quickly as feasible. Provide daily range of motion. Turn bed-ridden residents every 2 hours and as needed. Perform all assigned tasks. Residents Affected - Some 555517 Page 7 of 10 555517 04/25/2024 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Change a physician order, and 2. Communicate the change in the dietary order to provide the dietary preferences for one of three sampled residents (Resident 33). This failure resulted in Resident 33's preferences to not be honored and had the potential to result in further weight loss. Findings: 1. During a concurrent interview and observation on 4/22/24 at 12:44 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 33's room, Resident 33's meal tray contained a glass of milk that had been thickened (for those with swallowing difficulty) and a carton of reduced fat milk that had not been thickened. CNA 1 stated Resident 33 was served thickened milk by the kitchen, but Licensed Vocational Nurse (LVN) 3 told her Resident 33 was supposed to have gotten thin liquids. CNA 1 stated she went to the kitchen and got the carton of reduced fat milk. CNA 1 stated Resident 33's tray ticket indicated Resident 33's preference was for whole milk. CNA 1 stated she did not honor Resident 33's preference. During a concurrent interview and record review on 4/22/24 at 12:46 p.m. with LVN 3, Resident 33's Physician Order List (POL), dated 4/22/24 was reviewed. The POL indicated, NECTAR THICK LIQUIDS. LVN 3 stated she got in report Resident 33 is no longer on thickened liquids. LVN 3 stated she should have checked the order. LVN 3 stated the physicians order did not get updated to thin liquids but should have been. During an interview on 4/22/24 at 1:59 p.m. with Physician Assistant (PA), PA stated he came to the facility to speak with Resident 33 and his family on Friday morning around 11 a.m. to discuss comfort care options. Resident 33 had expressed that he was not happy with the thickened liquids, so he ordered the change back to thin liquids per Resident 33's request. 2. During an interview on 4/25/24 10:12 a.m. with Registered Dietician (RD), RD stated the kitchen did not get notification of PA's recommendation to change Resident 33's meal tray to thin liquids. RD stated the order had not been changed so that's why kitchen still sent out thickened liquids on Monday. RD stated the order was updated Monday, but the kitchen wasn't notified until Tuesday at lunch. RD stated on Friday she had received an email that Resident 33 wants to die eating whole food. RD stated nursing staff is supposed to notify the kitchen by submitting a dietary service request when an order has been changed and they did not. RD stated she told Registered Nurse (RN) 1 the reason the thickened milk was sent was because the kitchen was not notified of the new order. During an interview on 4/22/24 at 2:02 p.m. with Director of Nursing (DON), DON stated the change in Resident 33's diet order was not entered into the computer or communicated to dietary staff. 555517 Page 8 of 10 555517 04/25/2024 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one refrigerator and one freezer were monitored for temperature control. This failure had the potential for foodborne illnesses to be spread to residents. Findings: During a concurrent observation and interview on 4/23/24 at 9:32 a.m. with Director of Nursing (DON) and Activities Director (AD) in the Day room, the Day room refrigerator nor freezer had a thermometer inside. There were drinks in the refrigerator and ice cream in the freezer. DON stated this is where food brought in from the outside would be stored. DON and AD confirmed there were no thermometers. During a concurrent interview and record review on 4/23/24 at 10:29 a.m. with Plant Operations Manager (POM), the SNF Activities Refrigerator [Day room] report ([NAME]), dated 4/23/24, was reviewed. The [NAME] indicated, There are no data to be displayed. POM stated the [NAME] indicated there was no data because the sensor had been installed that same day. POM stated food should not have been placed in the refrigerator/freezer until the sensor was placed to monitor the temperatures. During a concurrent interview and record review on 4/23/24 at 10:56 a.m. with Registered Dietician (RD), Work Order 005907 (WO), dated 2/22/24 was reviewed. The WO indicated, In the SNF dayroom there is a fridge/freezer. This unit needs to be temperature monitored in both the fridge unit and freezer unit. If resident's family bring food in from outside, this is the fridge/freezer food would be stored in. Please check the unit and if needed order and install temp monitoring system. RD confirmed she sent the WO. 555517 Page 9 of 10 555517 04/25/2024 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to store oxygen tubing per policy for two of four sampled residents (Resident 13 and Resident 31). This failure had the potential to result in respiratory infections. Residents Affected - Few Findings: During a concurrent observation and interview on 4/22/24 at 11:30 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 13's room, Resident 13's oxygen tubing was laying on the handrail of the bed. CNA 1 stated it is supposed to go in the plastic bag. During a concurrent observation and interview on 4/22/24 at 2:56 p.m. with Registered Nurse (RN) 1 in Resident 31's room, Resident 31's oxygen tubing was on the handrail of the bed. RN 1 stated if the tubing is not in use, it should have been placed in the plastic bag to avoid contamination. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy Supplies, dated 12/1/10, the P&P indicated, Purpose: To ensure residents receiving oxygen therapy. have clean equipment to decrease the risk of infection. All tubing will be placed in a plastic bag. 555517 Page 10 of 10