Health inspection·May 14, 2024

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), mail was delivered unopened. This failure resulted in violation of Resident 1's resident rights and privacy. Residents Affected - Few Findings: During an interview on 5/14/24 at 10:24 a.m. with Resident 1, Resident 1 stated Administrative Service Manager in Training (ASM) handed her a letter from her insurance company and the letter was addressed to her, with her name on it. Resident 1 stated the letter was opened without an envelope. Resident 1 stated she asked ASM who opened her mail, she stated ASM did not respond. During a review of Resident 1's Interdisciplinary Progress Note, (IDTPN) dated 5/7/24 at 3:46 p.m. the IDTPN indicated, In the office this writer [ASM] had and [insurance] letter for [Resident 1] which was unopened. In order to assist, this writer [ASM] assumed this must be the letter [Resident 1] was talking about as the resident only showered [sic] an email version, and [ASM] opened the letter. During an interview on 5/14/24 at 1:11 p.m. with ASM, ASM stated Resident 1 asked him for assistance with some medication issues with her insurance company, but Resident 1 did not provide him with any documentation. ASM stated he saw the letter from Resident 1's insurance company and he assumed it was what Resident 1 was taking about so he opened it. ASM confirmed he did not have Resident 1's permission to open her mail. During a review of the facility's policy and procedure (P&P) titled, Mail and Electronic Communication, revised May 2017, the P&P indicated Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail, email, and other electronic forms of communication confidentially. 1. Mail will be delivered to the resident unopened. 2. Staff members of this facility will not open mail for the resident unless the resident requests them to do so. (Such request will be documented in the resident's plan of care.) Page 1 of 3 555877 555877 05/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) grievances were resolved. This failure had the potential for negative psychosocial outcomes. Residents Affected - Few Findings: During an interview on 5/14/24 at 10:24 a.m. with Resident 1, Resident 1 she stated she filed grievances, but the facility did not resolve her grievances. During a concurrent interview and record review on 5/14/24 at 3:13 p.m. with Administrative Service Manager in Training (ASM), ASM reviewed Resident 1's Resident/Family Concern/Grievance Report, (RFCGR) dated 4/22/24, 5/1/24. 5/4/24. ASM confirmed RFCGR were not completed (no follow up, no resolution, not signed off by administration, and the forms were not signed by Resident 1 concluding the grievances were resolved). ASM confirmed the findings and stated the resident did not sign the form to prove the grievances had been resolved. During a review of the facility's policy and procedure (P&P) titled, Grievances/Complaints, Filing, revised April 2017, the P&P indicated, The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. 8. Upon receipt of grievance and/or complaint, the grievance officer, will review and investigate the allegations and submit a written report of such findings to administrator within five (5) working days of receiving the grievance and or complaint.12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. a. The administrator, or his or her designee, will make such reports orally within [blank space] working days of the filing of the grievance or complaint with the facility. b. A written summary of the investigation will also be provided to the resident . 555877 Page 2 of 3 555877 05/14/2024 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure adequate supplies were available for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to have unmet care needs and discomfort. Residents Affected - Few Findings: During an interview on 5/14/24 at 10:24 a.m. with Resident 1, Resident 1 stated the facility runs out of chux (underpads) and wipes, she stated they (facility) ran out last night. Resident 1 stated it happens usually at night. During an interview on 5/14/24 at 11:13 a.m. with Resident 2, Resident 2 stated the facility run out of large briefs and chux about twice a month. Resident 2 stated when they run out the staff will put a larger brief or a smaller brief on him. Resident 2 stated When the staff puts a larger brief it was not tight enough to hold the liquid in and cause leaks and when the staff puts the smaller one on it is too tight and uncomfortable. Resident 2 stated the facility should not run out briefs are a predictable item, they (facility) should learn for their mistakes. During an interview on 5/14/4 at 12:04 p.m. with Unit Secretary (US), US stated she was responsible for placing supply orders. US stated she received training on how to place the order, not how to ensure we do not run out of items. During an interview on 5/14/24 at 12:27 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated the facility does run out of commode bags and briefs. CNA 1 stated she believes it is because of the facility's new admission, they are admitting new patient and not considering when ordering. During a review of the facility policy and procedure (P&P) titled, Covered Items and Services, revised April 2021, the P&P indicated, Residents are provided with information regarding covered and non-covered items and services provided by the facility. 1. During the course of covered Medicare/Medicaid stay, the following items and services are included: . e. Routine personal hygiene items and services as required to meet the resident's needs, including but not limited to: . (8) incontinence care supplies . 555877 Page 3 of 3