Other·August 26, 2022

§483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). §483.35(a) Sufficient Staff. §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. 22 CCR §72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/14/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about quality of care/treatment and facility staffing. The facility failed the following: 1. Failed to treat with respect and dignity, provide care and assistance for activities of daily living (ADLs), and provide sufficient staffing for Resident 2 and Resident 6. Resident 2 was not provided with showers per a predetermined shower schedule or upon request, was not dressed in a manner based on her preference, and was not given prompt assistance with incontinence care. Resident 6 was not promptly assisted with incontinence care. As a result, these placed Residents 2 and 6 at risk for decline in health status due to delay in receiving the necessary services to maintain grooming and personal hygiene. Also, these placed Residents 2 and 6 at risk for not receiving necessary assistance to promote dignity and can affect Residents 2 and 6's sense of self-worth and self-esteem. 2. Failed to provide Restorative Nursing Assistance (RNA, a program designed to ensure each resident maintains their physical and functional abilities) services and sufficient staffing for Residents 1, 2, 3, 4, 5, and 6 while Restorative Nursing Assistant 1 (RNA 1) was on vacation. As a result, this placed Residents 1, 2, 3, 4, 5, and 6 at risk for decline in mobility and range of motion. 1. a. A review of Resident 2's Admission Record indicated the facility admitted the 68-year-old female resident on 8/24/2021 with diagnoses that included spinal stenosis (narrowing of the spaces in the spine), abnormal posture, and low back pain. A review of Resident 2's History and Physical (H&P), dated 8/26/2021, indicated the resident had the capacity to understand and make decisions. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/24/2022, indicated Resident 2 had the ability to make self-understood and had the ability to understand others. The MDS further indicated Resident 2 required extensive assistance with bed mobility, transfer, dressing, personal hygiene, and was totally dependent on staff for toilet use. A review of Resident 2's Care Plan (CP) titled, "Resident has daily preferences and/or activities," undated, indicated a goal that the resident would express satisfaction with their type of daily preferences and/or activities when asked. The CP further indicated Resident 2 preferred to choose between a tub bath, shower, bed bath, or sponge bath and the resident preferred to choose what clothes to wear. During an observation and interview on 6/14/2022 at 10:40 a.m. with Resident 2, Resident 2 was lying in bed in a room located in Nursing Station One. Resident 2 wore a stained hospital gown and stated the staffing shortage was getting worse at the facility. Resident 2 stated not having a shower in ten days and had been in a hospital gown for six of the last ten days. Resident 2 stated preference to be dressed in own clothes, but needed assistance getting dressed. Resident 2 stated requesting a shower on 6/11/2022 but did not receive one. Resident 2 stated not receiving a bed bath or shower because staff was so busy, they did not have time. Resident 2 stated feeling more depressed. During an interview on 6/14/2022 at 12:52 p.m., CNA 5 stated being Resident 2's CNA on 6/11/2022 and 6/14/2022. CNA 5 stated on 6/11/2022 Resident 2 requested a shower after stating not receiving one in over a week. CNA 5 stated not able to give Resident 2 a shower on 6/11/2022 and Resident 2 had still not received one. CNA 5 stated the facility was very short staffed and they didn't take breaks because they would get behind (on their work). CNA 5 stated on 6/14/2022 there were two CNAs in Nursing Station One with 37 residents, 15 of whom were scheduled for a shower during the day shift. CNA 5 stated Resident 2 was still in a hospital gown because CNA 5 had not been able to go into Resident 2's room yet. During an interview on 6/14/2022 at 3:15 p.m., and concurrent record review of Resident 2's Documentation Survey Report for ADLs form for the month of June, the Director of Nursing (DON) stated there was no documented evidence that Resident 2 had received a shower between 6/11/2022 and 6/14/2022. The DON stated showers should be given per resident ' s preferences and rights and Resident 2 should have received a shower when requested. The DON stated Resident 2 had previously expressed concerns regarding staffing. The DON stated staffing was an issue in the facility. During an interview on 6/21/2022 at 4 p.m., the Administrator (Adm) stated the facility was not able to consistently provide staffing to meet the required hours. The Adm stated residents were at risk for decline due to short staffing. 1. b. A review of Resident 2's care plan initiated on 9/21/2021, indicated the resident was frequently incontinent with bowel and bladder and that the resident was at risk for skin impairment and urinary tract infection (UTI-an infection in any part of the urinary system). The goal of the care plan indicated that the resident would remain free from skin breakdown and brief use. A review of Resident 2's care plan initiated on 9/10/2021, indicated the resident had an ADL related to impaired balance, complex medical conditions with comorbidities including end stage renal disease (occurs when the kidneys do not work effectively enough to keep someone alive without treatment), diverticulitis (infection in one or more small pouches in the digestive tract, and diabetes mellitus (a condition that affects the way the body processes sugar) with neuropathy (weakness, numbness and pain from nerve damage). The interventions included encouraging the resident to use call light for assistance and to encourage resident to discuss feelings of self-care deficit. During an interview on 6/15/2022 at 3 p.m., Resident 2 stated the facility had an on-going staffing issue every shift. Resident 2 stated that on 6/14/2022, she waited for two hours before staff came in and provided her incontinence care. Resident 2 stated she had a bowel movement at 10 a.m. and she did not get changed until 12 p.m. Resident 2 stated she felt "awful" and did not want to eat lunch sitting in her soiled briefs. Resident 2 stated LVN 2 came and changed her incontinence briefs at 12 p.m. During an interview on 6/14/2022 at 12:52 p.m., Certified Nursing Assistant 5 (CNA 5), when asked why Resident 2 was still wearing a gown at 10:40 a.m., stated she had not been to Resident 2's room because there were only 2 CNAs working in Station 1 for the 7 a.m. to 3 p.m. shift. During an interview on 6/15/2021at 4:55 p.m., LVN 2 stated there were two CNAs working in Station 2 on 6/14/2022 during the 7 a.m. to 3 p.m. shift. LVN 2 stated she was aware residents have concerns about staffing issues in the facility. LVN 2, when asked what her response was to residents voicing concerns on lack of staffing, stated she told the residents to bear with the facility while facility was looking for more nurses. A review of the Nursing Staffing Assignment and Sign-In Sheet, dated 6/14/2022, indicated two CNAs signed the sheet for the 7 a.m. to 3 p.m. shift for Station 1. A review of the facility's daily census report, dated 6/14/2022, indicated there were thirty-three residents in Station 1. During an interview on 6/16/2022 at 10:50 a.m., the Director of Staff Development (DSD) stated she was aware the facility was not meeting the state staffing requirements. During an interview on 6/16/2022 at 3:45 p.m., the Director of Nursing (DON) stated the facility's staffing issues placed the residents at risk for falls, skin breakdown, weight loss, and changes in mood behavior. 1. c. A review of Resident 6's Admission Record indicated the facility admitted the 76-year-old female resident initially on 12/24/2020, and was last readmitted on 2/7/2021, with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (a condition that affects the way the body processes sugar) with neuropathy (weakness, numbness and pain from nerve damage), and heart failure. A review of Resident 6's MDS, 5/24/2022, indicated the resident had the ability to understand and make self understood. The MDS indicated Resident 6 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS indicated Resident 6 was frequently incontinent of bowel and bladder. A review of Resident 6's H&P, dated 2/24/2022, indicated the resident had the capacity to understand and make decisions. A review of Resident 6's care plan, initiated on 4/8/2021, indicated the following focuses: i. The resident has bladder incontinence related to impaired cognition and mobility with goals including the resident remain free from skin breakdown due to incontinence and brief use and the resident ' s risk for septicemia (life threatening complication of an infection) will be minimized/prevented via prompt recognition and treatment of symptoms of urinary tract infection. The interventions included checking for incontinence, wash rinse and dry perineum, change clothing as needed after incontinence episodes. ii. The resident has bowel incontinence related to impaired cognition and mobility with interventions including checking resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode, take resident to toilet at same time each day resident usually has a bowel movement. A review of Resident 6's Medication Administration Record (MAR) for June 2022, indicated, the resident received Cefdinir (medication used to treat bacterial infections) capsule 300 milligrams (mg) by mouth two times a day for urinary tract infection (UTI) for seven days. The MAR indicated the medication was ordered on 6/3/2022. During an interview on 6/15/2022 at 12:58 p.m., Resident 6, who was in the room sitting in a wheelchair, stated she was incontinent of bowel and bladder and needed help with brief change and she had to wait for an hour and half for staff on multiple occasions. Resident 6 stated she kept track of how long she waited for help by watching the clock on the wall and by checking her cell phone. The resident stated she felt pain and burning sensation in her skin half an hour after sitting in urine and feces. The resident stated she felt frustrated, and it took her the whole night to get over it because it was uncomfortable for her to be left unchanged. The resident stated the Certified Nursing Assistants (CNAs) were doing their best, but the lack of staffing affected the care of the residents. Resident 6 stated, "I feel bad for them, but I feel bad for myself too." Resident 6 also stated she just had a bladder infection and just finished her antibiotic treatment. Resident 6 stated she had been attending the Resident Council meeting and that the members had voiced their concerns to Administration about staffing shortage, but it had not been solved. A review of the Resident Council Meeting minutes, dated 3/29/2022, indicated the residents had concerns about not being able to find a nurse when needed and that the CNAs were rushing residents, or the residents cannot find them when needed. A review of Resident Council Meeting minutes, dated 5/31/2022, indicated the residents had issues with short staffing (CNAs and Licensed Vocational Nurses [LVNs]). During an interview on 6/16/2022 at 3:20 p.m., CNA 6 stated she gets the job done but she felt like she is rushing during care and not spending enough time with the residents. During an interview on 6/16/2022 at 10:50 a.m., DSD stated she was aware the facility was not meeting the state staffing requirements. During an interview on 6/16/2022 at 3:45 p.m., the DON stated the facility's staffing issues placed the residents at risk for falls, skin breakdown, weight loss, changes in mood behavior. 2. a. A review of Resident 1's Admission Record indicated the facility admitted the 36-year-old male resident on 5/28/2019, and readmitted on 5/9/2022, with diagnoses that included hemiplegia (mild to severe loss of strength on one side of the body) affecting the left side and par