Health inspection·October 10, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to provide care with dignity for one of two sampled residents (Resident 21) when a Certified Nurse Assistant (CNA) did not provide privacy for Resident 21 while delivering personal care and preparing the resident for a shower. This deficient practice had the potential to affect Resident 21's sense of self-worth and self-esteem. Findings: A review of Resident 21's Face Sheet indicated Resident 21 was admitted to the facility with multiple diagnoses, including Alzheimer's disease and age-related physical debility. A review of Resident 21's Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in the Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/13/19, indicated the resident's score was 08, meaning Resident 21's cognitive ability was mildly impaired. Resident 21's MDS also indicated Resident 21 required extensive assistance with bed mobility, moving from one surface to another, dressing, toilet use, and personal hygiene from one or more staff members and required physical help from staff when bathing. During a concurrent observation of Resident 21 and interview with CNA 1 on 10/7/19 at 9:50 a.m., Resident 21 was laying on the bed with her lower extremities fully exposed and the window blinds and privacy curtain fully opened. CNA 1 immediately closed the blinds and privacy curtain, then stated I'm sorry, it's not supposed to be open, I'm supposed to give privacy. A review of the facility's Resident Rights Guidelines for All Nursing Procedures policy, dated 9/08, indicated that staff should either close the entrance door to the room or draw privacy curtains during treatment and personal care to provide residents privacy and dignity. Page 1 of 4 555855 555855 10/10/2019 Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546

F 0558 Reasonably accommodate the needs and preferences of each resident. 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, for two of two sampled residents (Residents 29 and 10), the facility failed to place their call lights within reach. Residents Affected - Few This failure had the potential for Residents 29 and 10 to not receive urgently needed medical care or assistance with their activities of daily living (ADLs). Findings: 1. A review of Resident 29's Facesheet indicated Resident 29 was admitted with multiple diagnoses, including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one entire side of the body) affecting her right dominant side following a history of unspecified cerebrovascular disease (loss of blood flow to part of the brain). A review of Resident 29's Minimum Data Set (MDS, an assessment tool used to guide care) dated 9/16/19 indicated Resident 29 needed extensive assistance with bed mobility, moving between surfaces, dressing, toilet use, and hygiene from one or more staff members. During an observation and concurrent interview with Resident 29 on 10/7/19 at 9:08 a.m., Resident 29's call light was hanging on the left side of the bed, below the side rail. Resident 29 stated, I cannot reach my call light. I need someone to take away my tray. Resident 29 further indicated she knows how to use her call light with her right hand, but it is never in reach. During an interview with the Director of Staff Development (DSD) on 10/7/10 at 9:14 a.m. in Resident 29's room, DSD acknowledged Resident 29's call light was not in reach. A review of Resident 29's Urinary Incontinence care plan, dated 8/29/19, indicated the intervention, Call light in reach and answer promptly. A review of Resident 29's Safety care plan, dated 8/22/19, indicated the intervention, Place call light within easy reach. A review of Resident 29's Falls care plan, dated 8/20/19, indicated the intervention, Call light within reach and answer promptly. 2. A review of Resident 10's Facesheet indicated Resident 10 was admitted with multiple diagnoses, including Alzheimer's disease (a type of dementia that causes problems with memory, thinking, and behavior), history of falling, hypertension (high blood pressure), and a history of compression fracture (loss of bone mass that occurs a part of aging). A review of Resident 10's MDS dated [DATE] indicated Resident 10 needed extensive assistance with bed mobility, moving between surfaces, and toilet use from one or more staff members and was totally dependent on staff for personal hygiene activities, such as brushing her teeth and washing her face. During an observation on 10/10/19 at 8:53 a.m., Resident 10 was asleep in her wheelchair in her room. Resident 10's call light was on the floor, on the left side of her wheelchair. During an interview on 10/10/19 at 8:56 a.m., Licensed Vocational Nurse 1 (LVN 1) acknowledged the call light was not in reach and stated the call light should be on top of Resident 10's bedside 555855 Page 2 of 4 555855 10/10/2019 Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546

F 0558 table where she can press it with her palm. Level of Harm - Minimal harm or potential for actual harm A review of Resident 10's Falls care plan, dated 3/13/17, indicated Resident 10 was at risk for fall and injury related to: hypertension, a history of falls, severe dementia Alzheimer's, a history of compression fractures, incontinence, use of anti-hypertensives, use of narcotics (pain relievers), and use of cathartics (laxatives). The care plan indicated the intervention for the risk of falls was to keep the Call light within reach and answer promptly. Residents Affected - Few A review of the facility's Answering the Call Light policy, dated 9/08, indicated, All staff will maintain a call light within the resident's reach at all times and further indicated the purpose for this was, To respond to resident's request and needs promptly. The policy also stated, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 555855 Page 3 of 4 555855 10/10/2019 Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, for one of two sampled residents (Resident 35), the facility failed to develop an individualized comprehensive care plan for the use of an antidepressant (a psychotropic medication capable of affecting the mind, emotions, and behavior) to treat depression (a mood disorder characterized by a feeling of sadness and a general loss of interest in activities). This deficient practice had the potential to negatively affect the delivery of medical care and services to Resident 35. Findings: A review of Resident 35's Facesheet indicated Resident 35 was admitted to the facility with multiple diagnoses, including major depressive disorder. A review of Resident 35's Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in the Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/12/19, indicated the resident's score was 15, meaning Resident 35's cognitive ability was fully intact. A review of the progress notes in Resident 35's medical record showed a note written on 9/18/19 at 1:52 p.m. by Registered Nurse 1 (RN 1), indicating Resident 35 had spoken to her physician, requesting an order for Prozac (an antidepressant). A review of Resident 35's Physician's Order, dated 9/18/19 at 1:32 p.m., indicated a telephone order for Prozac, 40 milligrams (mg, a unit of measurement), to be administered once a day. A review of Resident 35's Medication Administration History (MAH), covering the period of 9/18/19 through 10/10/19 indicated Prozac, 40 mg, was administered to Resident 35 every morning starting on 9/19/19. A review of Resident 35's medical record showed no comprehensive care plan developed for Prozac, a psychotropic medication, ordered on 9/18/19. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 10/10/19 at 9:39 a.m., MDSC verified Resident 35 did not have care plan for psychotropic medication ordered on 9/18/19. During an interview with the Director Of Nursing (DON) on 10/10/19 at 10:22 a.m., DON stated the care plan should be done within 48 hours after receipt of the medication order from the doctor. DON further stated Resident 35 did not have a care plan for Prozac done within 48 hours per protocol. DON also stated RN 1 should have care planned the psychotropic medication ordered on 9/18/19 for Resident 35. During an interview with RN 1 on 10/10/19 at 10:36 a.m., RN 1 stated she received the telephone order for Prozac on 9/18/19 and did not know she was supposed to create a care plan for the psychotropic medication. 555855 Page 4 of 4