Health inspection·October 26, 2023

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to evaluate the status and to document weekly assessments for one of three sampled residents' (Resident 1) right big toe discoloration, in accordance with the facility's policy and procedures. Residents Affected - Few This failure led to facility staff being unaware of the changes in the condition of Resident 1's right big toe, which could delay the provision of the appropriate treatment resulting in worsening of the resident's wound. Findings: On September 21, 2023, 10:42 a.m., an unannounced visit was made to the facility to investigate a quality care issue. A review of Resident 1's medical records was conducted, and indicated the resident was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (disease which causes elevated blood sugar levels, which can result in circulatory problems). A review of Resident 1's admission Skin Assessment, by the admission Nurse dated December 31, 2022, indicated, R (Right) Greater Toe Discoloration. A review of admission Skin Assessment, dated January 2, 2023, by the Treatment (Tx) Nurse, indicated (Right) Great Toe Discoloration. A review of Resident 1's weekly skin evaluation indicated no weekly skin assessments of Resident 1's right big toe discoloration was documented between his admission date of December 31, 2022, and discharge date of January 26, 2023. A review of Resident 1's physician order dated January 2, 2023, indicated, . (Right) GREAT TOE DISCOLORATION: MONITOR FOR SKIN INTEGRITY FOR ANY BREAKDOWN REPORT TO MD (Medical Doctor) every day shift for 21 days . A review of Resident 1's Treatment Administration Record (TAR), for the month of January 2023, indicated, Resident 1's right great toe was being monitored for discoloration daily between the dates of January 3, 2023, to January 23, 2023. The TAR indicated initials were entered by the Tx nurse. A review of the Interdisciplinary Team's (IDT) Meeting notes dated January 5, 2023, at 2:08 p.m., was conducted, and indicated, . 7c. Special Treatments, Procedures and Devices . MONITOR FOR SKIN Page 1 of 3 555613 555613 10/26/2023 The Grove Care and Wellness 3401 Lemon Street Riverside, CA 92501

F 0684 INTEGRITY FOR ANY BREAKDOWN REPORT TO MD every day shift for 21 day (Right) GREAT TOE . Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's care plans indicated there was no care plan initiated for Discoloration of right great toe, after being identified during the admission process on December 31, 2022, and January 2, 2023, when the new orders to monitor Resident 1's right great toe skin issue. Residents Affected - Few A review of Resident 1's Change of Condition (COC), dated, January 22, 2023, at 7:00 p.m., was conducted, and the COC indicated, Resident 1's .Right Big Toe (had) discoloration and bleeding to toenail bed . started January 22, 2023. A review of Resident 1's progress notes, indicated resident was being monitored for a COC . Right Big Toe discoloration and bleeding to toenail bed . identified on January 22, 2023, at 7:00 p.m. Further review indicated the following: - January 23, 2023, at 02:35 a.m., . Resident (1) continues to have no new changes noted with (Right) Big Toe necrosis . · January 23, 2023, at 6:05 p.m., . (Continued) (sic) to be monitor for Right Big Toe necrosis . · January 23, 2023, at 10:04 a.m., .being monitored for right big toe discoloration . · January 23, 2023, at 10:35 p.m., . being monitored for RIGHT BIG TOE NECROSIS . · January 24, 2023, at 01:00 a.m., . being monitored for (Right) 1st (Big) TOE NECROSIS . · January 24, 2023, at 10:39 a.m., . being monitored for (Right) 1st (Big) TOE NECROSIS . · January 24, 2023, at 2:57 p.m., . being monitored for right big toe necrosis . · January 24, 2023, at 7:05 p.m., . on monitoring for (right) big toe necrosis . · January 25, 2023, at 2:13 a.m., . Resident continues to have no new complications from (Right) toe necrosis . · January 25, 2023, at 8:52 a.m., . being monitored for right big toe discoloration . The review of the progress notes from January 23, 2023, to January 25, 2023, did not clearly indicate whether there was necrosis or just discoloration on the right big toe. On September 21, 2023, at 11:13 a.m., during an interview with the Tx Nurse, the Tx Nurse stated the process for admitting a new resident with impaired skin integrity included completing a head-to-toe assessment by the admission nurse to identify any type of skin impairments, discolorations, or wounds. The admission nurse would then report the assessment findings to the physician for wound care orders, then document their assessment in the resident's medical records. The Tx Nurse stated the next day the Tx nurse would conduct a head-to-toe assessment to further identify any skin impairments, and notify the physician of new findings, if any, and obtain orders for wound care. The Tx Nurse further stated it is the facility's policy to perform weekly skin assessments on all 555613 Page 2 of 3 555613 10/26/2023 The Grove Care and Wellness 3401 Lemon Street Riverside, CA 92501

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents with identified skin impairments, and she is responsible for documenting the skin assessments in the resident's medical records. She stated the assessment would be documented under Skin Evaluation PRN/Weekly (Skin evaluation), on Tuesdays. On September 21, 2023, at 3:35 p.m., a concurrent interview with the Tx Nurse, and record review of Resident 1's Skin evaluation, was conducted, and the Tx Nurse verified, her weekly assessments of Resident 1's right big toe discoloration was not documented between the dates of December 31, 2023, and January 26, 2023. She stated, The weekly assessments should be there, and she stated she not sure why she did not document her weekly assessments. On September 21, 2023, at 3:45 pm, a concurrent interview was conducted with the Director of Nursing (DON), and record review of Resident 1's Skin evaluations was conducted. The DON verified Resident 1's right big toe weekly assessments were not documented on Tuesdays by the tx nurse. She stated, The assessments should have been documented weekly, per facility's policy. On October 25, 2023, at 11:01 a.m., a concurrent interview with the DON, and record review of Resident 1's nursing progress notes was conducted. The DON verified, There is a discrepancy in the documentation on right big toe on whether it is necrotic or just discolored. The DON stated Resident 1's right great toe was documented on separated occasions by several different nursing staff. The DON further stated if the resident's toe was truly necrotic, her expectation would be for the staff to notify the physician. The DON stated, she believed the toe was not necrotic but could be just a discrepancy in documentation. A review of the facility's P&P, titled, Significant Change in Conditions, monitoring for, reviewed, June 2019, indicated, . Procedures: 1. If, at any time, it is recognized by any one of the team members that the care needs of the resident have changed, the Nurse Supervisor should be made aware of, and he/she will monitor. 2. An attempt to identify the cause for decline, when it occurs . will be monitored . A review of the facility policy and procedure (P&P) Wound Care & Treatment Guidelines, dated January 2023, was conducted. P&P stated, . Procedures: 1. A weekly assessment should be done on all wounds requiring treatment. This should include measurement and a description .14. The care plan should reflect the current status of the wound and appropriate goals . A review of the facility P&P, Wound Management, dated November 2021, was conducted. The P&P indicated, . Procedures: 1. A weekly wound assessment will be completed on all residents and documented in the nurse's notes . 555613 Page 3 of 3