Health inspection·November 15, 2019

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview and record review, for one of 14 sampled residents (Resident 43) the facility failed to provide appropriate treatment and services to a resident with an indwelling catheter (a tube inserted into the body that drains the urine into an external bag) when facility staff failed to monitor the resident's intake (the measurement of fluids taken into the body) and the output (the measurement of fluids expelled from the body). This failure had the potential to negatively impact Resident 43's existing urinary conditions. FINDINGS: A review of Patient 43's admission Record indicated Resident 43 was admitted with multiple diagnoses, including Benign Prostatic Hyperplasia (an enlarged prostate gland that can cause urinary symptoms such as blocking the flow of urine out of the bladder) with lower urinary tract symptoms, a urinary tract infection, retention of urine (the inability to completely empty the bladder of urine), and a flaccid neuropathic bladder (impairment of the bladder function due to nerve damage). A review of Patient 43's Minimum Data Set (MDS, an assessment tool used to guide care), dated 10/26/19, indicated Resident 43 had a Brief Interview for Mental Status (BIMS, a tool used to assess mental function) score of 8, meaning Resident 43 had mild cognitive impairment. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 11/14/19 at 9:30 a.m., LVN 1 stated Patient 43 was admitted with an indwelling urinary catheter. LVN 1 indicated Patient 43's fluid intake and output were not being monitored nor recorded. During a concurrent interview and record review with the Director of Nursing (DON) on 11/14/19 at 12:35 p.m., DON was unable to show evidence Patient 43's fluid intake and output were being monitored. DON stated Resident 43's intake and output should have been monitored and documented in Patient 43's chart. A review of Patient 43's care plan, dated 10/24/19, indicated a nursing intervention for Resident 43's indwelling catheter was to observe and document intake and output as per facility policy. A review of the facility's Intake and Output Protocol policy, dated 9/17/19, indicated, Fluid intake and output is recorded for each patient .with an indwelling catheter. Page 1 of 3 555895 555895 11/15/2019 Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 144) received appropriate medical care when oxygen was administered to Resident 144 without a physician's order. Residents Affected - Few This failure placed Resident 144 at risk for a delay in identifying or treating any adverse effects from oxygen therapy. Findings: A review of Resident 144's admission Record indicated Resident 144 was admitted to the facility for hospice care with multiple diagnoses, including acute respiratory failure with hypoxia (a low oxygen level), acute respiratory distress, and lung cancer that had spread to the bone. During an observation and concurrent interview with Resident 144 on 11/12/19 at 11:50 a.m., Resident 144 was wearing a nasal cannula (tubing that fits in the nares) and receiving oxygen at 4 liters per minute. Resident 144 stated he had been receiving oxygen since he was admitted to the facility at the beginning of the month. A review of the Order Summary Report in Resident 144's medical record indicated there was no physician's order for oxygen administration. During an interview with the Director of Nursing (DON) on 11/13/19 at 9:00 a.m., DON stated she could not find an order for oxygen administration in Resident 144's medical record. A review of the facility's Oxygen Management policy, dated 10/28/19, indicated, Oxygen therapy is administered to the resident only upon the written order of a licensed physician or in the event of an emergency until a physician order can be received. 555895 Page 2 of 3 555895 11/15/2019 Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions when: Residents Affected - Some 1. Two male dietary staff did not cover their beards while working in the kitchen; and 2. Two ice machines (one in the kitchen and one in the front Nursing Station) had brownish/black substances in the ice bins. This failure resulted in all 54 residents of the facility receiving food prepared under conditions not meeting professional standards and had the potential to cause food-borne illnesses. Findings: 1. During a dietary observation with the Director of Dietary Services (DDS) and concurrent interviews with Kitchen Utility Staff 1 (KU 1) and [NAME] 3 on 11/13/19 at 11:20 a.m., KU 1 was in the kitchen with his hairnet on but his overgrown beard was uncovered. KU 1 indicated the DDS did not tell him to wear a beard guard, and stated, I don't cook, but I work inside the kitchen. I know I should cover my beard or just shave it. [NAME] 3 was observed walking around in the kitchen with his beard uncovered. [NAME] 3 indicated this was the first time he had grown a beard but stated, I understand it should be covered. The facility's Personal Hygiene/Safety/Food Handling policy, dated 3/5/19, indicated, Beards or any body hair that may be exposed (i.e., arms) must be covered. 2. During a dietary observation and concurrent interview with DDS, the Administrator-in-Training (AIT), and KU 1 on 11/13/19 at 11:25 a.m., the kitchen ice machine had a blackish substance in the ice bin. The DDS stated she had wiped the ice bin two days earlier (11/11/19), and it was clean. DDS and AIT agreed the black substance came from the ice machine. KU 1 indicated the ice machine was cleaned on 11/4/19. During an observation of the front Nursing Station ice machine and concurrent interview with the Director of Nursing (DON) on 11/13/19 at 12:30 p.m., there was brownish/black substance and reddish brown splatters in the ice bin and DON stated, That is dirty. A review of the facility's Ice Machine Cleaning Schedule policy, dated 1/10/19, instructed staff to, Wash inside of machine with approved detergent and hot water. Rinse with clean water. Then use sanitizing solution and clean cloth to sanitize. Make sure the door liner, door gasket and door frame are free of scale and/or mild .Allow to air dry. A review of the facility's Ice Machine & Filter Cleaning Log indicated both ice machines were cleaned on 11/4/19. A review of the facility's Ice Machine Service policy, dated 9/19/19, indicated it is the facility's policy, to maintain and service the ice machine and ice bin in a matter to obtain a clean and functioning system. 555895 Page 3 of 3