Health inspection·May 19, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to offer and/or assist Resident 5 to formulate an advance directive (a written statement of a person's wishes regarding medical treatment) at the time of admission for one of one sampled resident (Resident 5). This deficient practice had the potential for the staff to violate Resident 5's right to refuse treatment and implement the resident's preferred medical interventions. Findings: A review of Resident 5's admission Record indicated the resident was admitted on [DATE], with diagnosis of sepsis (a life-threatening complication of an infection). A review of Resident 5's Minimum Data Set ([MDS] a standardized assessment and care planning tool) dated 4/12/23, indicated the resident was assessed with good short and long- term memory recall ability. The MDS also indicated Resident 5's hearing was adequate, speech was clear, able to make self-understood and understand others during communication with staff. During an observation and interview on 5/17/23 at 9:50 a.m., Resident 5 was lying on her back in bed. She stated she did not have an advance directive. Resident 5 stated upon admission staff did not offer or let her know that she could be assisted to formulate an advance directive. Resident 5 stated, I do not want any machine to keep me going when seriously ill. During an interview and concurrent record review of Resident 5's clinical record on 5/17/23 at 2:47 p.m., the Director of Nursing (DON) stated there was no documented evidence that an advance directive was offered to Resident 5. The DON stated advance directive would let the staff know the wishes of the resident regarding medical treatment. A review of the facility's Policy and Procedures titled, Advance Directive dated 03/2023, indicated an interim advance directive on admission will be given to the patient to complete if the patient does not have an advance directive and will be placed in the medical record. Page 1 of 8 555610 555610 05/19/2023 Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. Covina, CA 91723

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop an individualized person-centered care plan for two of two sampled residents (Residents 117 and 119). a. There was no care plan developed for Resident 117 who was observed with edema (excess fluid in tissues of the body) on bilateral (both) legs and feet. b. There was no care plan developed For Resident 119 for the use of side rails (a barrier attached to the side of a bed). These deficient practices had the potential to result in inconsistent implementation of care and services to Residents 117 and 119. Findings: a. During a review of Resident 117's Inpatient Face Sheet (admission record) indicated, Resident 117 was admitted to the facility on [DATE]. During a review of Resident 117's History and Physical (H&P), dated May 2023, the H&P indicated, Resident 117 was alert and oriented, and in no acute distress. During a review of Resident 117's Care Assessments (CA), dated from 5/12/2023, 5/13/2023, 5/14/2023 and 5/15/2023, the CA indicated, Resident 117 had pitting (when pressure is applied to the swollen area, a pit or indentation will remain) edema on both left and right legs and left and right feet. During a review of Resident 117's Nurse's Notes, (NN), dated 5/12/2023, the NN indicated, swelling was noted on Resident 117's both lower extremities (legs and ankles) and swelling on both feet. During an observation on 5/16/23 at 10:52 am, of Resident 117 in Resident 117's room and a concurrent interview with Resident 117, Resident 117 was alert and oriented and noted with swelling of both legs and ankles. Resident 117 stated I have had swollen ankles before I got here (the facility). During an interview on 5/16/23 at 11:47 am, with Registered Nurse 1 (RN 1) and concurrent record review of Resident 117's electronic chart (EC), RN 1 stated, there was no care plan developed to address Resident 117's swelling on both lower extremities and both feet. RN 1 stated, a care plan to address Resident 117's swelling of both lower extremities and both feet should have been developed that indicated interventions to help decrease the edema on Resident 117's legs and feet. b. During a review of Resident 119's Inpatient Face Sheet indicated, Resident 119 was admitted to the facility on [DATE]. During a review of Resident 119's H&P dated May 2023, the H&P indicated, Resident 119 was alert and 555610 Page 2 of 8 555610 05/19/2023 Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. Covina, CA 91723

F 0656 oriented, and in no acute distress. Level of Harm - Minimal harm or potential for actual harm During an observation on 5/16/23 at 10:45 am, in Resident 119's room, Resident 119 was asleep on her bed with bilateral (left and right) upper and lower side rails up, surrounding Resident 119. Residents Affected - Some During a concurrent interview on 5/17/23 at 2:32 pm, with RN1 and review of Resident 119's electronic chart (EC), RN 1 stated, a care plan was not created regarding Resident 119's use of bilateral upper and lower side rails. RN 1 stated, care plans were important to list the purpose and track interventions for the use of side rails. During a review of the facility's policy and procedure (P&P) titled, Multidisciplinary Plan of Care, reviewed on 12/2022, the P&P indicated, Planning for medical, nursing, and other clinical discipline care, treatment, and services is individualized to meet the patient's unique needs. The first step in the process includes creating an initial plan of care, treatment, and services that is appropriate to the patient's specific assessed needs. 555610 Page 3 of 8 555610 05/19/2023 Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. Covina, CA 91723

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow its Policy and Procedure, titled Equipment Change for three of three sampled residents (Residents 2, 8, and 167) who had orders for oxygen (air/gas needed for human life) administration, consistent with professional standards of practice, by failing to: Residents Affected - Some 1. Ensure the nasal cannula (tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) tubing for Resident 2 was changed every Wednesday of the week. 2. Ensure the nasal cannula tubing for Residents 8 and 167 was dated and labeled when it was changed. These deficient practices had the potential to expose Residents 2, 8 and 167 to infection. Findings: a. A review of Resident 2's admission Record, indicated the facility admitted Resident 2 on 4/11/2023, with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) exacerbation (increase in severity) and pneumonia (lung inflammation caused by infection). A review of Resident 2's Physician Order, dated 4/11/2023 at 9:12 p.m., indicated for Resident 2 to receive continuous oxygen administration of 0.5 liters per minute to 5 liters per minute (oxygen flow rate) via (through) nasal cannula, may titrate (adjust) to keep oxygen saturation (refer to the percentage of oxygen in the blood) greater than 88 percent (%). During an observation and interview on 5/16/2023 at 11:33 a.m., RN 5 stated Resident 2 was on two liters of oxygen via nasal cannula. Resident 2's nasal cannula tubing had a label and date of 5/4/2023. RN 5 stated the date (5/4/2023) indicated the nasal cannula tubing was changed on 5/4/2023. RN 5 stated the respiratory therapist should change the nasal cannula tubing every Wednesday of the week to decrease or prevent the risk of infection. b. A review of Resident 8's admission Record, indicated the facility admitted Resident 8 on 5/11/2023, with diagnoses including hemorrhage (blood loss) due to vascular prosthetic device (implanted device intended to repair, replace a missing part of the body or make a part of the body work better). A review of Resident 8's Physician Order, dated 5/11/2023 at 9:26 p.m., indicated for Resident 8 to receive PRN (as needed) oxygen administration of 0.5 liters per minute to 5 liters per minute via nasal cannula for shortness of breath/wheezing (high-pitched whistling sound during breathing), may titrate to keep oxygen saturation greater than 90%. During an observation and interview on 5/16/2023 at 11:48 a.m., RN 2 stated Resident 8 was on 2 liters of oxygen via nasal cannula. Resident 8's nasal cannula tubing was hanging on the side of Resident 8's bed with the tip of the tubing touching the floor. Resident 8's nasal cannula tubing was not dated and labeled. Resident 8 stated she used her nasal cannula occasionally (unspecified dates). 555610 Page 4 of 8 555610 05/19/2023 Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. Covina, CA 91723

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some c. A review of Resident 167's admission Record, indicated the facility admitted Resident 167 on 5/15/2023, with diagnoses including displaced (not aligned) comminuted fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of left femur (thigh bone). A review of Resident 167's Physician Order, dated 5/15/2023 at 8:34 p.m., indicated for Resident 167 to receive PRN oxygen administration of 2 liters per minute via nasal cannula to keep oxygen saturation greater than 92 %. During an observation and interview on 5/16/2023 at 11:03 a.m., Registered Nurse 4 (RN 4) stated Resident 167 was on 2 liters of oxygen via nasal cannula. Resident 167's nasal cannula tubing was not dated and labeled. During an interview on 5/17/2023 at 9:16 a.m., the facility's Infection Preventionist (IP- a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) stated, the nasal cannula tubing (in general) should be dated and labeled to keep track when it was changed. The IP stated, resident's nasal cannula should be changed every Wednesday because of the risk of infection. During an interview on 5/19/2023 at 10:12 a.m., the facility's Respiratory Therapist (RT) stated, she changed the resident's nasal cannula tubing every Wednesday of the week and whenever the tubing was dirty or dropped or touched the floor. RT stated, the resident's nasal cannula tubing should be dated and labeled to indicate who it belonged to, when it was changed and to prevent infection. During an interview on 5/19/2023 at 10:32 a.m., the facility's Director of Nursing (DON) stated, resident's nasal cannula tubing should be changed regularly because of the risk of infection. The DON stated, resident's nasal cannula tubing should be dated and labeled to indicate who it belonged to and when it was changed. A review of the facility's policy and procedure, titled Equipment Change, revised 9/2020, indicated O2 delivery devices were change every Wednesday by day shift and PRN; include patient label and ear/mask foam if needed. 555610 Page 5 of 8 555610 05/19/2023 Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. Covina, CA 91723

F 0700 Level of Harm - Minimal harm or potential for actual harm Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. Residents Affected - Some During a review of Resident 119's Inpatient Facesheet indicated, Resident 119 was admitted to the facility on [DATE] During a review of Resident 119's History and Physical (H&P), dated May 2023, indicated, Resident 119 was alert and oriented, and in no acute distress. During an observation in Resident 119's room, on 5/16/23, at 10:45 a.m., and on 5/17/23, at 10:28 a.m., Resident 119 was observed laying the bed and on her side, alert, and coherent, bilateral upper and lower side rails were up (total of 4). During a record review of Resident 119's Side Rail Assessment, (SRA) dated 5/11/23, the SRA indicated, one or two side rail(s) were indicated to assist Resident 119 with bed mobility. The SRA indicated three split side rails were used per Resident 119's preferences and the use of four split side rails was not indicated for Resident 119. The SRA did not indicate if appropriate alternatives were attempted prior to installation of the side rails. During an interview on 5/16/23, at 3:58 p.m., with the Corporate Director (CD), the CD stated, entrapment was a risk if all four side rails were up for residents (in general). The CD stated, Resident 119 would not be able to physically remove the bed rails and this posed a risk for entrapment. During an interview on 5/17/23, at 10:28 a.m., Resident 119 stated, the bed rails were attached to her bed when Resident 119 first arrived at her room. Resident 119 stated I did not ask for them [bed rails] to be up, it was that way when I got here. During an interview and concurrent record review on 5/17/23, at 2:32 p.m., with Registered Nurse 1 (RN 1), Resident 119's electronic chart (EC) was reviewed. RN 1 stated, there was no documented evidence that appropriate alternatives were attempted prior to the installation of Resident 119's bed rails. c.During a review of Resident 120's Inpatient Facesheet indicated, Resident 120 was admitted to the facility on [DATE]. During a review of Resident 120's Internal Medicine H&P (H&P), dated 5/9/23, indicated, Resident 120 was alert and in no acute distress. During an observation in Resident 120's room, on 5/16/23, at 11:46 a.m., and on 5/17/23, at 10:30 a.m., Resident 120 was observed laying on her bed, alert and coherent, bilateral upper and lower bed rails were up (total of 4). During a record review of Resident 120's Side Rail Assessment, (SRA), dated 5/1/23, the SRA indicated, one or two side rails were to be used to assists Resident 120 with bed mobility. The SRA also indicated three split side rails were used per resident preferences and the use of four split side rails was not indicated. The SRA did not indicate if appropriate alternatives were attempted prior to 555610 Page 6 of 8 555610 05/19/2023 Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. Covina, CA 91723

F 0700 installation of the side rails. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent record review on 5/17/23, at 2:32 p.m., to 2:43 pm, with Registered Nurse 1 (RN 1), Resident 120's electronic chart was reviewed. RN 1 stated there was no documented evidence that appropriate alternatives were attempted prior to the installation of Resident 120's bed rails. Residents Affected - Some During an interview on 5/16/23, at 3:58 p.m., the CD stated, entrapment was a risk if all four bed rails were up for Resident 120. The CD stated, Resident 120 would not be able to physically remove the bed rails and posed a risk for entrapment. During an interview on 5/17/23, at 3:07 p.m., the Director of Nursing (DON) stated, alternative measures should be attempted prior to the use of bed rails to prevent entrapment, injury, or even death. During a review of the facility's undated policy and procedure (P&P) titled, Side/Bed Rail Use Policy #S-101-a, indicated, This facility will ensure that the appropriate alternatives are attempted prior to use of side/bed rails. Based on observation, interview and record review, the facility failed to ensure appropriate alternatives were used before the installation of bed rails for three of three sampled residents (Residents 5, 119 and 120). This deficient practice placed Resident 5, 119 and 120 at risk for entrapment and injury from the use of bed rails. Findings: a. During a review of Resident 5's Inpatient Facesheet (admission record) indicated Resident 5 was admitted to the facility on [DATE] with diagnosis that included sepsis (a life-threatening complication of an infection). During a review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/12/23, indicated Resident 5 was assessed with good short and long- term memory recall ability. Resident 5 required extensive assistance (staff provide weight- bearing support) in most levels of activities of daily living with physical assistance from one-person. During observations on 5/16/23, at 10:12 a.m., and on 5/17/23, at 9:50 a.m., Resident 5 was lying on her back in bed. Resident 5's bilateral (both sides) full length bed rails were up. Resident 5 stated, upon admission her bed had bed rails and she did not know why the bed rails were always up. During an interview and concurrent record review on 5/17/23, at 2:32 p.m., the Director of Nursing (DON) stated, Resident 5's medical record did not contain information that indicated appropriate alternatives to bed rails were tried before installation on Resident 5'a bed. The DON stated, the facility's beds had attached bed rails when they were bought. The DON stated the use of appropriate alternatives to bed rails were necessary to prevent entrapment, injury and/or death of the residents. 555610 Page 7 of 8 555610 05/19/2023 Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. Covina, CA 91723

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure two of five Infection Prevention and Control Program (IPCP, a facility wide program to prevent, recognize, control the onset, and spread of infections to the extent possible) policy and procedures (Discontinuation of Transmission-Based Precautions and Disposition of Patient with COVID-19 and Covid-19: Monitoring of Employees) were reviewed annually. Residents Affected - Some This deficient practice had the potential to result in outdated IPCP policies, noncompliance with federal and state regulations, and lack of infection control guidance for the facility staff. Findings: A review of the facility's IPCP policy titled Discontinuation of Transmission-Based Precautions and Disposition of Patient with COVID-19 (A highly contagious respiratory disease caused by the coronavirus) #IC046, indicated a revision date of 8/2020, and the next review would be completed on 8/2023. A review of the facility's IPCP policy titled Covid-19: Monitoring of Employees, #IC049, indicated a revision date of 1/2021, and the next review would be completed on 1/2024. During an interview and concurrent review of the two IPCP policies IC046 and IC049 on 5/19/2023, at 10:04 AM, the Infection Preventionist (IP) stated she was the IP for the hospital including the Transitional Care Unit (TCU, is an important part of the medical center, a skilled nursing facility that assists patients as they transition from a stay in the hospital to home or another level of care). The IP stated IC046 and IC049 policies applied to all hospital sites including the TCU. The IP stated the hospital scheduled and reviewed all IPCP policies every three years. The IP stated she did not know that TCU IPCP policies needed to be reviewed annually. The IP stated a yearly review of policies could ensure the facility's program was up to date with State and Federal regulations. A review of the facility's policy and procedure titled Policy and Procedure Review, #P-111, effective 7/2022, indicated policies, procedures, and standards of care shall be reviewed annually and revised as necessary. 555610 Page 8 of 8