Health inspection·August 30, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 2 residents (Resident 1) reviewed for 1:1 feeding assistance (staff member present to watch/help resident to eat during meals), was supervised during a meal. This failure placed Resident 1 at risk for aspiration (inhaling food particles into the lungs), choking, and weight loss. Findings: According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), cognitive communication deficit, and pneumonia (an infection in the lungs). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/22/24, indicated the resident had severely impaired cognitive skills (problems with person's ability to think, learn, remember, use judgement, and make decisions). On 8/29/24 at 12:16 P.M., an observation was conducted inside Resident 1 ' s room. Resident 1 was sitting in his wheelchair with his lunch tray in front of him. There was no staff member present in the room. Resident 1 was observed taking a bite of fish. After taking a bite of fish, Resident 1 picked up a napkin covered his mouth and began to cough. A sign posted above Resident 1 ' s bed dated 8/14/24, indicated Swallowing Guidelines with the following instructions checked: small bites/sips, 1 bite at a time, alternate liquids/solids, upright at 90 degrees for all intake, cues to swallow, assistance cutting food into small bites, 1:1 assistance during meals, sit up for 1 hour after meals, check mouth for pocketed food after meals, Meds 1 at a time with liquid, and tongue sweep. On 8/29/24 at 12:54 P.M., Certified Nursing Assistant (CNA) 1 was observed carrying a tall stool chair into Resident 1 ' s room. CNA 1 sat on the stool and gave Resident 1 a bite of fish. CNA 1 was observed positioned higher than Resident 1 ' s eye level, and looking down at the resident. On 8/29/24 at 12:56 P.M., a joint observation and interview was conducted with CNA 1. CNA 1 was observed walking out of Resident 1 ' s room with the resident ' s lunch tray. CNA 1 stated (Resident 1) only took 3 bites of fish . CNA 1 lifted the lid from Resident 1 ' s plate. There was a small piece of fish left on the plate. Resident 1 ' s plate had vegetables, French fries, and a roll which appeared untouched. CNA 1 stated Resident 1 was on 1:1 feeding during meals. CNA 1 stated 1:1 feeding assistance meant that either a nurse or a member of the therapy team had to sit with the resident Page 1 of 2 555804 555804 08/30/2024 Victoria Post Acute Care 654 S. Anza El Cajon, CA 92020

F 0689 during all meals. CNA 1 stated Resident 1 needs assistance with feeding. Level of Harm - Minimal harm or potential for actual harm On 8/29/24 at 1:05 P.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 1 was on 1:1 for staff supervision. LN 1 stated (Resident 1) can feed himself, but he needs supervision and cueing for aspiration precautions. If he is by himself he is at risk for aspiration . LN 1 further stated Resident 1 should not eat without supervision because .that could contribute to decline of health. He had Covid recently. We wanted to prevent further lung infection . Residents Affected - Few A review of Resident 1 ' s care plan dated 8/19/24 indicated, a focus for Swallowing problem r/t (related to) (mild oropharyngeal dysphagia) with the intervention for speech and oral function therapy as indicated for cognitive-communication deficit and oral-pharyngeal . A review of Resident 1 ' s [NAME] (a written guide for resident care) dated 8/29/24, indicated, 1:1 swallow supervision, small sips, slow rate, alternate bites/sips for liquids wash to clear oral cavity . and Special Instructions: .1:1 swallow/meal supervision; ASPIRATION PRECAUTION . On 8/29/24 at 3:15 PM., an interview was conducted with the Speech Therapist (ST). The ST stated 1:1 supervision .Helps with initiating meal tasks. Sometimes the food just sits there, and they ' re at risk for weight loss, especially with cognitive decline . The ST further stated 1:1 feeding assistance was beneficial for Resident 1, who was at risk for aspiration or choking hazards. On 8/29/24 at 3:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 should not have been served lunch without a staff member present. The DON stated Staff needs to be there for 1:1 feedings .especially if they ' re (alone) in the room .the resident could aspirate . The DON stated it was important for staff to assist Resident 1 during meals so the resident does not lose weight. On 8/30/24 at 10:03 A.M., an interview was conducted with the ST. The ST stated Resident 1 needed 1:1 supervision during feeding .because of his impaired cognitive status and poor meal intake In addition, the ST stated (Resident 1) coughs immediately when taking sips of liquid .He hasn ' t been eating much, he cannot really initiate feeding himself . The ST stated it was important for CNA 1 to sit at eye level with Resident 1 during 1:1 feeding supervision, to ensure that Resident 1 is swallowing properly and not pocketing foods. A review of the facility ' s policy titled Meal Services and Assist indicated, It is the policy of this facility to ensure that residents receive their meals and snacks as ordered and residents will be assisted by qualified staff as appropriate and necessary .Report signs of food intolerance (i.e., coughing, vomiting, spitting out, pocketing) . 555804 Page 2 of 2