Health inspection·June 21, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a staff member promoted dignity and respect by maintaining an eye to eye level during meal assistance for one of one resident (Resident 1) reviewed for dignity. As a result, this failure had the potential to negatively impact Resident 1's self-esteem and self-worth. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), per the facility's admission Record. On 6/19/23 Resident 1's clinical record was reviewed: The quarterly Minimum Data Set (a clinical assessment tool), dated 6/6/23, listed a cognitive score of 7, indicating moderately impaired cognition. The Functional Status indicated one person staff assist was required during meals. The care plan, titled ADL (Activities of Daily Living) self-care deficit, revised 5/3/23, listed an intervention, .totally dependent on (1) staff for eating . On 6/19/23 at 11:54 A.M., an observation and interview was conducted with LN 1, as he was assisting Resident 1 with a lunch meal inside his room. Resident 1 was seated upright in bed, with the bed in the lowest position. LN 1 was standing on the right side of the bed and assisting with feeding. Resident 1's head aligned with LN 1's abdomen. LN 1 stated he should not be standing while feeding the resident and should be at an eye-to-eye level. LN 1 stated when sitting at eye level, it promoted socialization and respect. LN 1 left the area to retrieve a chair. On 6/19/23 at 11:57 A.M. an observation and interview was conducted with CNA 1 inside Resident 3's room. CNA 1 was sitting in a chair on the right side of the bed, with Resident 3 seated upright in bed. CNA 1 was feeding Resident 3 and stated staff should always be at an eye-to-eye level with residents during feeding, in order to promote dignity and to connect socially with the resident. On 6/20/23 at 12:21 P.M., an interview was conducted with the DON. The DON stated he expected all staff to sit with the resident's during feeding assistance. The DON stated sitting at an eye-to-eye level was less intimidating, promoted socialization, and displayed dignity. Page 1 of 7 555928 555928 06/21/2023 Ridgeview Skilled Nursing Facility 9825 Glen Center Drive San Diego, CA 92131

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few According to the facility's policy, titled Assistance with Meals, dated January 2022, .c. Resident who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: (1) Not standing over residents while assisting them with meals; . According to the facility's policy titled Quality of Life-Dignity, dated January 2021, .2: Treated with Dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . 555928 Page 2 of 7 555928 06/21/2023 Ridgeview Skilled Nursing Facility 9825 Glen Center Drive San Diego, CA 92131

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and collaborate on unintended weight loss and the the decline in oral (by mouth) food intake for one of one resident (Resident 2) reviewed for care plan. This failure had a potential for Resident 2's weight loss to go unaddressed, leading to weakness, fatigue, and increasing dependency on others. Findings: Resident 2 was admitted to the facility on [DATE], with diagnoses which included post surgical repair of compression fractures (when one or more bones of the spine collapses), per facility's admission Record. On 6/19/23 at 8:40 A.M., an observation was conducted of Resident 2 in her room. Resident 2 was sitting up in her wheelchair, dressed, and appropriately groomed, with a breakfast tray in front of her. The food tray remained untouched. On 6/19/23 at 11 A.M. Resident 2's clinical record was reviewed: The 14 day admission MDS (a clinical assessment tool), Functional Status indicated the resident was dependent for transfers, but able to eat on her own. The admission weight, dated 3/24/23, listed a weight of 214 pounds (lbs). There was two out of four weekly weights documented after admission. On 6/4/23, Resident 2's weight was documented as 192 lbs. (loss of 22 lbs in three months. The Physician Progress note, dated 3/31/23, listed a cognition as moderate impairment of thinking and reasoning skills. On 6/19/23 at 12 P.M., Resident 2 was observed and interviewed in her room while eating lunch. The lunch plate was full and remained untouched. Resident 2 stated she is aware of her weight loss, but she does not know why she is losing weight. On 6/19/23 at 12:15 P.M., an interview was conducted with CNA 2. CNA 2 stated that Resident 2 average meal intake was 25% for breakfast and lunch, and sometimes 50% for dinner. Resident 2's husband would come to the facility to encouraged her to eat. CNA 2 stated she was aware of Resident 2's limited food intake and had informed the licensed nurses several times of less then 50% intake. On 6/19/23 at 2:30 P.M., an additional interview was conducted with CNA 2. CNA 2 stated Resident 2's did not eat any of her lunch today and decline staff assistance. CNA 2 offered Resident 2 an alternative meal, but she declined, however she accepted her afternoon protein shake to drink. On 6/20/23 at 8:30 A.M., an observation of Resident 2 was conducted. Resident 2 was up in her wheelchair, well groomed with her breakfast tray in front of her, untouched. On 6/20/23 at 1 P.M. Resident 2's clinical record was reviewed: 555928 Page 3 of 7 555928 06/21/2023 Ridgeview Skilled Nursing Facility 9825 Glen Center Drive San Diego, CA 92131

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's ADL (activities of daily living) eating task was reviewed from 5/22/23 through 6/20/23. The flowsheet contained 88 opportunities with six meals refused, 38 meals charted at. uneaten, 30 meals had 25% consumed, six meals with 50% consumed, only two meals 100% consumed and six meals list as, resident not available. The Physician Progress note, dated 5/5/23, contained no reference to recent eight loss of poor nutritional intake. The physician referenced Resident 1's edema (fluid accumulates in the soft tissue) with no current edema noted. There was no documented evidence of a Team meeting (IDT- when department heads meet to discuss residents current condition changes) related to Resident 2's weight loss. RD 1's (currently on vacation) note dated 5/3/23, documented significant 14 pound weight loss, in one month for Resident 2. RD 1 listed a reasonable weight for Resident 2's was 190-205 lbs. RD 1 documented an observation of Resident 2's in her room with her tray untouched. The RD 1 note indicated no edema was detected with a summary of, inadequate to meet nutritional needs .will monitor intake and weekly weight. There was not documented evidence weekly weights were conducted after 5/3/23. There was no documented evidence Resident 2's Nutritional care plan had been updated or revised. RD 1's summary, dated 6/7/23, documented an, additional weight loss of 5.2 pounds (2.6%) in one month. Resident 2 continued with 25% food intake, protein shakes added in May 2023, following a significant weight loss last month. Will monitor oral intake and weight trend. There was no documented evidence of an IDT meeting being conducted or Resident 2's Nutritional care plan had been updated or revised to reflect the unattended weight loss. On 6/20/23 at 3:01 P.M., an interview and record review was conducted with RD 2, (covering for RD 1). RD 2 confirmed she had reviewed Resident 2' chart, and weights. RD 2 stated the admission assessment indicated Resident 2 had edema (swelling from fluid) to both lower legs, which would account for most of the weight loss). RD 2 stated Resident 2's food preferences were noted in the kitchen, but were not listed on the resident's care plan. RD 2 stated before an IDT weight loss meeting was conducted, the RD would print a variation in weight form, so it could be discussed in the IDT. RD 2 stated there was no no documented evidence an IDT weight committee meeting was held for Resident 2 or a variation of weight form had been printed. RD 2 stated Resident 1's weight loss was not harmful, due to Resident 2's overweight status. On 6/20/23 at 4:05 P.M., a concurrent record review and interview was conducted with the DON. The DON stated the physician ordered protein shakes twice daily for Resident 2 on 5/3/23, but did not address the weight loss in the physician note. The DON could not locate an IDT meeting for Resident 2's weight loss and stated the DON was never informed of the weight loss. The DON stated a care plan would have been update after a weight loss IDT meeting for additional interventions such as; assistance or supervision with meals, adaptive equipment, additional supplements or even a depression evaluation. The meal intake record for 5/22/23 - 6/20/23 was reviewed by the DON. The DON stated, I would have expected this to be escalated for identification and proper monitoring. The DON states that the policy and procedures for monitoring intake and resident weights were not being followed. The DON stated 555928 Page 4 of 7 555928 06/21/2023 Ridgeview Skilled Nursing Facility 9825 Glen Center Drive San Diego, CA 92131

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there were no additional weights in the chart We missed April's (weight) for Resident 2. The DON stated if a weight loss was not identified timely, it could lead to a low energy and an overall decline in their condition. According to the facility's policy, titled Comprehensive Care Plans, dated November 2017, The Interdisciplinary Team shall develop and implement a comprehensive person-centered care plan when .d. Problem Identification: problem, related to (etiology, contributing factors) .The IDT with the participant of the resident and/or the resident representative is to develop objectives for the highest level of functioning .This is to be documented in the clinical record .The interventions must be related back to the goals . 555928 Page 5 of 7 555928 06/21/2023 Ridgeview Skilled Nursing Facility 9825 Glen Center Drive San Diego, CA 92131

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure assessments, non-pharmological interventions, and evaluation of medications use were conducted for one of three residents (Resident 5), reviewed for psychotropic use when: 1. Resident 5 had an assessment and evaluation for continued use of a PRN (as needed) psychoactive (alters the mind) hypnotic medication prescribed for sleeplessness. 2.Non- Pharmacological interventions (any intervention intended to improve the health or the well-being of individuals that does not involve the use of any drugs or medicine) were not attempted prior to medicating for sleeplessness. 3. Resident 5 had an assessment and evaluation for the use of a psychoactive antidepressant (for depression) medication that increased the effect of the hypnotic medication. As a result, Resident 5 was at risk for increased sedation, decreased mental clarity, and decreased coordination. Findings: Per the facility's admission Record, dated 5/11/23, Resident 5 was admitted on [DATE] for physical therapy post-surgery for a left hip fracture, per the facility's admission Record. On 6/19/23 at 10:31 A.M., an observation and interview with Resident 5 was conducted. Resident 5 was sitting up in bed, eyelids drooping, and struggling to lift his head. Resident 5 stated he had been on Ambien for over 25 years. Resident 5 stated that he was on Elavil for indigestion. Resident 5 also stated he did not seem to be able to stand and walk like he used to. Resident 5 stated he felt unstable and uncoordinated. On 6/19/23 at 10:50 A.M., an interview with CNA 2 was conducted. CNA 2 stated that Resident 5 needed extensive assistance with things like dressing, standing, and transfers. CNA 2 stated extensive assistance meant two nursing assistants were required to help Resident 5 most of the time, when he was transferring or standing. On 6/20/23 Resident 5's clinical record was reviewed: 1. The physician's orders, dated 5/11/23, listed Ambien (a hypnotic medication for sleeplessness) was prescribed every night as needed. An additional physician's orders, dated 6/12/23, indicated Resident 5 was to continue to receive Ambien for sleeplessness every night as needed. The Physician Progress Notes, dated 5/11/23 through 6/21/23, there was no documented evidence an assessment or evaluation was conducted for the continued use of Ambien. was absent. The Medication Regimen Review (MRR-pharmacist review each resident's medications on a monthly basis), there was no recommendation for an evaluation or assessment of continued Ambien use. 555928 Page 6 of 7 555928 06/21/2023 Ridgeview Skilled Nursing Facility 9825 Glen Center Drive San Diego, CA 92131

F 0758 Level of Harm - Minimal harm or potential for actual harm According to the facility's Behavioral Monitoring Record for sedation for the month of June 2023, Resident 5 was sleeping from 3-5 hours on the day shift and 0-2 hours on the evening shift. 2. The physicians' orders, dated 5/11/23 and 6/12/23, listed no non-pharmacological interventions for sleeplessness. Residents Affected - Few The Physician Progress Notes, dated 5/11/23 through 6/21/23, there were no commended non-pharmacological interventions. The MRR listed no recommendations of implementing non-pharmacological interventions for sleeplessness. 3. The physicians' orders, dated 5/11/23, listed Elavil (an antidepressant medication) for indigestion every night. An additional physician's orders, dated 6/12/23, indicated Resident 5 was to continue to receive Elavil for indigestion every night. The physician had no orders for staff to monitor the combined effect of Elavil and Ambien on Resident 5's mental clarity, sedation, and coordination. The Physician Progress Notes, dated 5/11/23 through 6/21/23, had no documented evidence an assessment or evaluation of Resident 5's need for Elavil, along with the combined effects of Elavil and Ambien on Resident 5's mental clarity, sedation, and coordination functional level. The MRR listed no recommendations that addressed the risk of combining Elavil and Ambien. On 6/20/23 at 9:10 A.M., an interview was conducted with the DOR. The DOR stated Resident 5's responses to exercise and participate in therapy were delayed. The DOR stated Resident 5 is sleeping during the day and has had a hard time remembering what he did during the day. On 6/20/23 at 10:11 A.M., an interview with was conducted with PT. PT stated Resident 5 was confused at times during the therapy sessions and his gait was unstable. On 6/20/23 at 10:11 A.M., an interview with was conducted with the PC. The PC stated drugs like Ambien and Elavil were not recommended for use in older adults. The PC stated older adults like Resident 5 might experience confusion and increased sedation, because the drugs stayed in Resident 5's system longer. The PC confirmed that Elavil enhanced the sedation effects of Ambien. The PC stated the facility needed to provide nonpharmacological interventions for Resident 5's sleeplessness. On 6/20/23 at interview was conducted with the DON. The DON stated the staff should have offered Resident 5 non-pharmacological interventions for his sleeplessness. The DON stated Resident 5 should be evaluated for continuing to use Ambien for sleep and Elavil for indigestion. The DON stated these drugs increased Resident 5's risk for increased sedation, mental confusion, and loss of coordination. Per the facility policy, titled Psychotropic Drug Use, revised 10/2018, . each resident shall receive the necessary care and service to attain and maintain the highest practicable level of physical, mental and psychosocial well-being .all PRN psychoactive medications should not be used beyond 14 days .the IDT team with the assistance of the pharmacy consultant will review the resident's status and symptoms for dose reduction or discontinuance of the medication according to established guidelines . 555928 Page 7 of 7