Health inspection·July 26, 2023

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident medical records were maintained, private and confidential for one out of three sampled residents (Resident 2) when the Medication Administration Record (MAR) was exposed and visible in the hallway. Residents Affected - Few This failure decreased the facility's potential to protect residents' personal information being accessible to unauthorized staff, residents, and visitors. Findings: During a concurrent observation and interview conducted on 7/25/23 at 11:39 a.m., Licensed Nurse 1 (LN 1) went into room [ROOM NUMBER] and left the computer 's screen open exposing the MAR outside the hallway. There were other staff in the hallway. During an interview with the Director of Nursing (DON) on 7/25/23 at 12:14 p.m., the DON confirmed the resident's medical record should have been lock and closed. The DON stated, It 's a HIPAA [Health Insurance Portability and Accountability Act] violation. Review of a facility policy titled, HIPPA: Privacy Policies and Procedure, dated 4/14/03, indicated, 'Protected health information' consists of health information about an individual that is in individually identifiable form. It includes all information, regardless of the format, whether in written, oral, or electronic form. Page 1 of 3 555555 555555 07/26/2023 Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide resident-centered care and services for one of three sample residents (Resident 2) when her call light was not within reach. Residents Affected - Few This failure decreased the potential for the resident to receive effective treatment and necessary personal care when needed. Findings: According to the resident 's face sheet, Resident 2 was admitted to the facility in mid-2017 with diagnoses including mild cognitive impairment, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and depression. A review of a Minimum Data Set (MDS, a comprehensive assessment tool), dated 6/14/23, indicated Resident 2 was totally dependent on assistancefrom one or two staff for transfering, bed mobility, getting dressed, toilet use and personal hygiene. During a concurrent observation and interview on 7/25/23 at 11:45 a.m., Resident 2 was in bed with nasal cannula in her nose delivery oxygen. Resident 2 stated she could not locate the call light and could not find it. The call light was clipped and hanging off the bed. Resident reported she wanted a shower. During an interview on 7/25/23 at 11:50 a.m. in the residents room, Certified Nursing Assistant 2 (CNA 2) stated, I don 't see the call light, and immediately put the call light cross the resident 's body when noticed. CNA 2 confirmed the purpose of having the call light was for the resident to use when needing assistance. During an interview on 7/25/23 at 12:14 p.m., the Director of Nursing (DON) confirmed the call light should be clipped to the resident, chair, or bed and should always be within reach of the resident. Review of a facility policy titled, Call Light System, revision date 3/5/02, indicated, Each resident will have their call light system within reach while in their room. 555555 Page 2 of 3 555555 07/26/2023 Eskaton Village Care Center 3939 Walnut Ave. Carmichael, CA 95608

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were stored securely for a census of 32, when a medication cart was left open and unattended. This failure had the potential for medication misuse and drug diversion. Findings: During a concurrent observation and interview conducted on 7/25/23 at 11:39 a.m., Licensed Nurse 1 (LN 1) went into room [ROOM NUMBER] and left the medication cart in the hallway unlocked and unattended. There were other staff in the hallway. LN 1 confirmed the medication cart should have been locked when left unattended. During an interview with the Director of Nursing (DON) on 7/25/23 at 12:14 p.m., the DON confirmed the medication cart should have been locked at all times. Review of a facility policy titled, Storage of Medications, dated 2007, indicated, Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. 555555 Page 3 of 3