Health inspection·July 24, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record review, the facility did not meet this requirement when it failed to provide evidence of incontinent (no ability to control one's bowels or bladder and requires staff to clean), care for two of 17 sampled residents (Resident 1 and 2). Residents Affected - Few This resulted in the potential for skin breakdown and a loss of dignity for both residents, who were dependent on staff for care. Findings: Resident 1 was admitted to the facility on [DATE] for conditions that included rhabdomyolysis (a breakdown of muscle), spondylosis (abnormal wear of the spinal cartilage), history of stroke and difficulty walking. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment tool that measures health and mental status in nursing home patients), dated 6/4/24 indicated that her ability to use the restroom, Toilet Hygiene, was rated at 2 or Substantial/Maximal Assist. During an interview and observation on 7/24/24 at 11:20 AM, Resident 1 ' s room smelled strongly of stale urine. Resident 1 was observed seated at the edge of her bed and in an interview, concurrently stated that she was waiting for assistance because she was wet. Resident 1 stated that she had pressed the call light at 11:00 AM and had been at the edge of the bed waiting for an unidentified CNA (Certified Nursing Assistant) who said they would return, I ' ve been waiting 20 minutes here, I looked at the clock. Resident 1 stated that she had also been left wet the night before: a CNA changed her at 10:10 PM, the next shift took over, and Resident 1 stated that the CNA from registry (a temporary help agency) who did not check on her the entire shift until it was time for the next shift to come on and changed her at 5:25 AM. She stated this happens all the time, and that it also happened on 7/15/24 when she was left wet for at least six hours. Resident 1 stated that on 7/22/24 and 7/23/24, her sheets were wet and she was not changed which made her uncomfortable. Resident 2 was admitted to the facility on [DATE] for conditions that included leg cellulitis (inflammation of the leg), diabetes, congestive heart failure, legal blindness, muscle weakness and unsteadiness on her feet. A review of Resident 2 ' s MDS dated [DATE], indicated that her ability to use the restroom, Toilet Hygiene, was rated at 1 or Dependent, Helper does all the work. In an interview and observation on 7/24/24 at 11:42 AM, Resident 2 stated, I'm getting left wet all night long. I can't tell you which CNA was here because I never saw her. I get changed before the evening shift leaves, and I don't see anyone until morning. Resident 2 had a large cast on her right foot and stated that she previously had a boot with bolts in it that seemed to intimidate the newer or registry CNAs who were not sure how to handle her. She stated, I think they avoided changing me Page 1 of 3 555682 555682 07/24/2024 Marysville Post-Acute 1617 Ramirez Street Marysville, CA 95901

F 0677 because they didn't know how to handle me at night. Level of Harm - Minimal harm or potential for actual harm In an interview on 7/24/24 at 11:48 AM, CNA C acknowledged that CNA D was a registry staff member and that her shift followed CNA D ' s coming off of the night shift of 7/23/24 and she had been assigned to Residents 1 and 2 and began doing resident care at 6:45 AM. CNA C stated that she arrived on shift to find Resident 1's bed saturated by urine. CNA C stated that she had arrived at 6:15 am and began her shift at 6:45 following report. CNA C stated that CNA D reported to her that she had taken Resident 1 to the restroom at 5:30 AM, and that CNA D, was supposed to do a time stamp on her work if she had done it. CNA C stated that residents are to be rounded on every two hours or more frequently as needed, per policy. Residents Affected - Few In an interview on 7/24/24 at 11:50 AM, Licensed Vocational Nurse (LVN) A stated that she had been assigned as Unit Manager on the night shift. LVN A stated, I can tell if a CNA is rounding every two hours. If they're not, the bed will soak through, that ' s how I can tell if they ' re changing residents. Residents don't usually urinate enough every two hours to soak the bed. LVN A stated that she was familiar with Resident 1, whom she stated was alert, oriented, and credible. She keeps track of things. If she said it happened, it happened. LVN A stated that CNAs are trained to round every two hours, standard care, and that CNAs are also supposed to do walking rounds to check on residents being taken over by next shift, when a wet resident would be evident. In an interview and record review on 7/24/24 at 12:15 PM, Director of Staff Development (DSD) B confirmed that registry CNA D had been assigned to Resident 1 on 7/23/24, and that had been CNA D ' s first assignment at the facility. DSD B further stated that she received a text at 6:52 AM from unit manager LVN A on the morning of 7/24/24 regarding CNA D, Came in early, left at 6:50 [am], didn't give report and Nothing's done. In a concurrent record review of the facility ' s document titled, Point of Care Audit Report dated 7/24/24, reflected that CNA D had not charted that she gave any care to residents or indicated in any way that care had been done. DSD B also stated that she had received a report from staff on 7/15/24, the night that Resident 1 stated she had been left wet. DSD B provided the text for review, Whoever worked last night didn't give me a report. Some residents weren't changed. DSD B stated that registry CNAs come and go, they don't have a boss so it's hard to supervise them. They work for themselves. A review of the facility ' s policy titled, Activities of Daily Living, Supporting, (undated), provided by DSD B, indicated as follows: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including support and assistance with Elimination (toileting) q 2 hours and prn. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Total Dependence requires full staff performance of an activity with no participation of the resident for any aspect of the ADL activity. Finally, the policy indicated, The resident's response to interventions will be monitored, 555682 Page 2 of 3 555682 07/24/2024 Marysville Post-Acute 1617 Ramirez Street Marysville, CA 95901

F 0677 evaluated, and revised as appropriate. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555682 Page 3 of 3