Health inspection·July 3, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An admission Record revealed the facility admitted Resident #101 on 07/26/2022. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. Residents Affected - Few Resident #101's Care Plan included a focus area, initiated on 12/16/2022, that indicated the resident was at risk for falls. An intervention initiated on 05/19/2023 indicated the resident utilized a pad alarm in their bed. Another focus area, initiated on 02/07/2023, indicated Resident #101 was at risk for injury due to wandering. An intervention initiated on 03/30/2023 indicated the resident utilized a wanderguard (a type of wandering/elopement alarm) on their wheelchair. Resident #101's Progress Notes included a Health Status Note, dated 07/17/2023 at 5:08 AM, that indicated the resident's wanderguard was in place. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/2023, revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated that Resident #101 wandered during four to six days of the seven-day assessment look-back period. The MDS did not reflect the resident's use of a bed alarm or wander/elopement alarm during the seven-day look-back period. Resident #101's Progress Notes included the following entries: - a Health Status Note, dated 03/29/2024 at 6:05 AM, that indicated Resident #101's bed alarm was in place and working properly; and - an IDT [interdisciplinary team] Progress Notes- Behavior Management note, dated 04/01/2024 at 2:25 PM, that indicated Resident #101 utilized a wanderguard. A quarterly MDS, with an ARD of 04/02/2024, revealed Resident #101 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS did not reflect the resident's use of a bed alarm or wander/elopement alarm during the seven-day look-back period. During an interview on 07/03/2024 at 2:17 PM, the Director of Nursing (DON) stated MDS assessments needed to be accurate. Based on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of 1 (Resident #91) of 3 sampled residents reviewed for nutrition and 1 (Resident #101) of 1 sampled resident reviewed for dementia care. Specifically, the MDS assessments inaccurately indicated Resident #91's weight-loss was due to a Page 1 of 3 555915 555915 07/03/2024 The Springs Health and Rehabilitation Center 25924 Jackson Ave Murrieta, CA 92563

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician-prescribed weight-loss regimen and did not reflect Resident #101's use of bed and wander/elopement alarms. Findings included: A facility policy titled, Resident Assessment, revised in 03/2023, revealed, 1. The facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. 1. An admission Record revealed the facility admitted Resident #91 on 10/21/2021. According to the admission Record, the resident had a medical history that included diagnoses of liver cancer and encounter for palliative care. Resident #91's Care Plan included a focus area, revised on 10/31/2023, that indicated the resident had an unavoidable risk for weight loss due to poor intake and pressure injuries. A quarterly MDS, with an Assessment Reference Date (ARD) of 03/04/2024, revealed Resident #91 weighed 92 pounds at the time of the assessment, had lost five percent (%) or more in the last month or 10% or more in the last six months, and was not on a physician-prescribed weight-loss regimen. A quarterly MDS, with an ARD of 05/29/2024, revealed Resident #91 weighed 81 pounds, had lost 5% or more in the last month or 10% or more in the last six months, and was on a physician-prescribed weight-loss regimen. Resident #91's Order Summary Report, listing active orders as of 07/03/2024, revealed no evidence of orders for a physician-prescribed weight-loss regimen. During an interview on 07/02/2024 at 8:08 AM, MDS Coordinator #2 stated Resident #91 was on hospice and lost weight due to poor intake. During an interview on 07/02/2024 at 8:14 AM, MDS Assistant #3 stated that a prescribed weight-loss regimen required a physician's order and confirmed Resident #91 did not have a physician's order for a prescribed weight-loss regimen. MDS Assistant #3 stated Resident #91's MDS, dated [DATE], should have been coded, Yes [for weight loss] - not on prescribed weight loss regimen. During an interview on 07/02/2024 at 8:23 AM, the Director of Nursing (DON) stated Resident #91's MDS assessment should have reflected that the resident had lost weight but should not have indicated the resident was not on a prescribed weight-loss regimen. The Administrator (ADM) was interviewed on 07/02/2024 at 9:32 AM. The ADM stated Resident #91 did not have a prescribed weight-loss regimen, and the resident's weight loss was unplanned. The ADM stated Resident #91's MDS should have been coded for weight loss but should not have indicated the resident was not on a prescribed weight-loss regimen. 555915 Page 2 of 3 555915 07/03/2024 The Springs Health and Rehabilitation Center 25924 Jackson Ave Murrieta, CA 92563

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff properly donned personal protective equipment (PPE) prior to entering the room of 1 (Resident #268) of 4 residents reviewed for transmission-based precautions. Residents Affected - Few Findings included: A facility policy titled, Resident Isolation-Categories of Transmission-Based Precautions, revised on 09/01/2023, revealed, III. A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. i. Examples of infections requiring Contact Precautions include, but are not limited to: a. Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant organisms (e.g. [exempli gratia, for example], MRSA [Methicillin-Resistant Staphylococcus Aureus]. The policy further revealed, gloves (clean, nonsterile) are worn when entering the room, and gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. An Admit/Readmit Assessment revealed the facility admitted Resident #268 on 07/01/2024. The assessment revealed Resident #268 was admitted from a hospital with a diagnosis of right foot osteomyelitis. Resident #268's Order Summary Report, listing active orders as of 07/02/2024, contained an order, started on 07/02/2024 for, Contact isolation for diagnosis of: MRSA, every shift for Right foot wound. An observation on 07/02/2024 at 7:41 AM revealed a sign on Resident #268's door that specified, Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Certified Nursing Assistant (CNA) #1 entered Resident #268's room without donning any PPE. During an interview on 07/02/2024 at 8:10 AM, CNA #1 stated he had delivered Resident #268's breakfast tray. CNA #1 stated he was aware Resident #268 was on contact precautions, which required staff to put on gowns and gloves before entering the room. During an interview on 07/03/2024 at 2:30 PM, the Director of Nursing (DON) stated her expectation was that staff should wear the proper PPE before entering a resident's room. During an interview on 07/03/2024 at 2:49 PM, the Administrator stated staff should don PPE prior to entering the room of a resident on contact precautions. 555915 Page 3 of 3