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Department of Veterans Affairs Community Living Center Survey Report

This document or report and the information contained herein, which resulted from the Community Living Center Unannounced Survey, hasbeen de-identified to remove individually identifiable health information (also known as protected health information) in accordance with theHealth Insurance Portability and Accountability Act (HIPAA) Privacy Rule and other federal and state laws. De-Identification was completed inaccordance with guidance published by the Office for Civil Rights to protect the privacy of the Community Living Center's residents.

General Information:

CLC: VA Palo Alto Health Care System - Menlo Park (Menlo Park, CA)

Dates of Survey: 11/6/2018 to 11/8/2018

Total Available Beds: 151

Census on First Day of Survey: 138

F-Tag Findings

F241

483.15(a) Dignity. The facility mustpromote care for residents in amanner and in an environment thatmaintains or enhances each resident’sdignity and respect in full recognitionof his or her individuality.

Level of Harm - No actual harmwith potential for more thanminimal harm that is not immediatejeopardy

Residents Affected - Some

Based on observation, interview and record review, the CLC did not promote care forresidents in a manner and in an environment that maintained or enhanced each resident’sdignity and respect in full recognition of the resident’s individuality. Findings include: Staff Communication with ResidentsResident #401, [LOCATION]

Resident #401 was admitted to the CLC with diagnoses that included chronic paranoidschizophrenia. The resident’s most comprehensive Minimum Data Set (MDS)assessment dated 02/28/18 was coded to indicate Resident #401 had a Brief Interviewfor Mental Status (BIMS) score of 15 suggesting intact cognition.During observations of the evening meal in the [LOCATION] neighborhood on 11/07/18at approximately 5:05 p.m., a nursing assistant (NA) and a registered nurse (RN) wereoverheard talking in the dining room about their schedule and personal activities in theevening. Both the NA and the RN were speaking in a foreign language and withinhearing distance of five residents in the dining room. One of the residents, Resident#401, stated, “What are you guys [referring to the NA and the RN] fussing about?”When asked about his comment and if he had concerns with staff using a language theresident could not understand, the resident said, “It’s just common sense. When youwork in a setting such as this and you can be heard, you speak in a way that theVeterans would understand.” During the interview, the resident indicated that it“bothered” him when the staff spoke in a language the resident could not understand;the resident’s facial expressions suggested displeasure. The resident stated thatleadership staff “knew about the concern because it was not something new.”

Resident #403, [LOCATION]

Resident #403 was readmitted to the CLC with diagnoses that included a spinal cordinjury. The resident’s most recent comprehensive MDS dated 11/01/18 was coded toindicate Resident #403 had a Brief Interview for Mental Status (BIMS) score of 15suggesting intact cognition.During an interview in the resident’s room on 11/07/18 at approximately 8:15 a.m.,Resident #403 expressed concerns about direct care staff that spoke in a language hecould not understand. The resident stated, “They [staff] do it all the time, whether inhere when they provide me with care or in the dining room or TV hall [shared gatheringarea]. They [staff] talk to each other as though nobody’s around and no one could hearthem. I don’t like it at all. I’d like to understand what they are talking about. Are theytalking about me that’s why they speak in their own language?” The resident indicatedhe had informed the clinical nurse specialist and RN charge nurse about his concerns.

[LOCATION]

On 11/06/18 at 4:40 p.m. during the evening meal, 9 residents were observed in the[LOCATION] dining room with a visitor. During the meal, two NAs were observedspeaking to each other in a foreign language; the staff were not conversing with theresidents.

of 17 -- VA Palo Alto Health Care System - Menlo Park -- 11/6/2018 to 11/8/2018

During the daily meeting with leadership staff, the staff were informed about andacknowledged the concerns with staff speaking in a foreign language; the medical directorasked if the concern was more prevalent on the night shift. [LOCATION]

On 11/07/18 at 8:50 a.m., residents were observed in the [LOCATION] living room. Oneresident was seated at a desk reading a newspaper. Without saying anything to theresident, an RN passing medications took the resident’s arm to scan the resident’sidentification wristband; the resident appeared startled by the RN’s actions. The RNreturned with the resident’s medication and without saying anything to the resident,nudged the resident’s arm two times to get the resident’s attention. The resident wasobserved interacting with other staff members during the survey and did not appear tohave a hearing deficit.

Posting of Personal InformationResident #103, [LOCATION]

Resident #103 was admitted to the CLC with diagnoses including [DIAGNOSIS]. Theresident’s quarterly MDS dated 10/19/18 indicated the resident had a BIMS score of 5suggesting severely impaired cognition. Section G of the MDS (Functional Status)indicated the resident required total assistance of one to two staff for most ADLs.During the initial tour on 11/06/18 at 10:40 a.m., a charge nurse indicated the residenthad a limited ability to communicate, and could respond to yes and no questions.A nutrition note dated 10/30/18 indicated the resident received a pureed honey-thickened liquid diet. A speech pathology report dated 01/12/18 recommendedaspiration precautions. A nurse evaluation note dated 01/05/18 indicated aspirationprecautions were to be implemented by staff.During observations on 11/06/18 at 12:41 p.m. in the resident’s room, an 8-inch by11-inch poster was on the wall at the head of the resident’s bed; the sign was visiblefrom the hallway. The poster stated, “ASPIRATION PRECAUTIONS [emphasis notadded].”On 11/07/18 at 2:10 p.m., a clinical nurse specialist was asked about the signage. Theclinical nurse specialist stated the sign was used to notify staff of the resident’s needfor aspiration precautions. On 11/08/18 at 9:00 a.m. after discussions with the surveyor,the clinical nurse specialist stated the CLC planned to implement a process to keepinformation related to the care and services provided for a resident in a private location.

F248

483.15(f)(1) Activities. The facilitymust provide for an ongoing programof activities designed to meet, inaccordance with the comprehensiveassessment, the interests and thephysical, mental, and psychosocialwell-being of each resident.



Based on observation, interview and record review, the CLC did not provide an ongoingprogram of activities for residents who resided in the [LOCATION] neighborhood. Findingsinclude: Resident #202

Resident #202 was admitted to the CLC with diagnoses that included schizoaffectivedisorder.The resident’s comprehensive MDS dated 04/07/18 indicated the resident had a BriefInterview for Mental Status (BIMS) score of 10 suggesting moderately impairedcognition; the resident had no signs of delirium, experienced delusions and verbal andother behavioral symptoms directed toward others, and did not reject care. Accordingto the MDS, the resident required extensive assistance of two staff for bed mobility andtransfers, and used a wheelchair for locomotion in the neighborhood. The MDSindicated staff determined the resident preferred music, favorite activities, and spendingtime outdoors and away from the CLC. The most recent quarterly MDS dated 10/02/18was essentially the same except the MDS indicated Resident #202 had a BIMS scoreof 14 suggesting intact cognition, rejected care 4 to 6 days during the assessmentperiod, and experienced hallucinations.The resident’s recreational therapy/creative arts annual assessment dated 04/13/18indicated, “Social support: Enjoys 1:1 [one-to-one] social interaction, small group,prefers passive activities, will engage if others initiate interaction…going out withcompanion, sitting on the patio.” The treatment plan included, “group activities forsocial interaction and peer support…social gatherings/adapted games…limit femalevisits, especially students and volunteers.”Resident #202’s care plan dated 04/17/18 stated, “Reason for admission:Schizoaffective disorder…various symptoms including mania manifested by singing,being loud, decreased sleeping…and being agitated….” The care plan indicated theresident’s preferences included, “Likes to joke and laugh, prefers to stay in the diningroom at daytime…favorite thing to do is watch football games or listen to music.”Approaches specific to the preferences included, “Encourage veteran to participate inward [neighborhood] activities. Encourage veteran to participate in activities in small,


quiet settings, avoiding any large groups of people that can agitate him and psychosis.Veteran using iPad…He has his own iPod and enjoys listening to it.”On 11/06/18 at approximately 10:30 a.m. during the initial tour of the [LOCATION]neighborhood, Resident #202 was observed in bed wearing head phones that wereconnected to an iPod. At 1:45 p.m., the resident was observed seated in a wheelchairin the dining room wearing headphones. An RN was interviewed and indicated theresident had a paid companion who was very familiar with the resident and was(currently) doing the resident’s laundry. The RN indicated the companion would assistthe resident with laundry and music selection, and was onsite one or two days a weekfor approximately 4 hours each day.On 11/07/18 at 9:10 a.m., Resident #202 was observed lying in bed, awake and waswearing head phones. The resident was interviewed and stated he had not been up toeat breakfast and would get up around 9:30 a.m. and eat. When asked about theresident’s plans for the day, Resident #202 stated, “The same thing as I alwaysdo…nothing....I’d like to get out and go do something else.” The resident’s room wasnot observed with personal items. On 11/07/18 at approximately 5:25 p.m., Resident #202 was observed sitting in thedining room eating the evening meal; another resident was sitting in a chair in the dayroom. There was no music playing on the stereo. An RN standing at a medication cartnear the nursing station was interviewed and indicated, “Most of the residents areeating in their rooms…they [residents] usually stay in their rooms.” Resident #202 wasnot observed during the survey engaged in recreational therapy activities as indicatedin the resident's plan of care and recreational therapy assessment other than listeningto music (e.g., activities in small quiet setting, social gatherings).

Resident #207

Resident #207’s comprehensive MDS dated 06/14/18 indicated the resident had aBIMS score of 7 suggesting severely impaired cognition. The MDS indicated theresident’s activity preferences included music, being around animals, favorite activities,and going outdoors. The care plan approaches to address activity preferencesincluded, “prefers solitude, invite to activities, and [assist] outdoors.” Resident #207’scare plan with a revision date of 06/15/18 indicated, “Resident is a night owl, staying uplate at night (early hours of the morning) and he is a later riser (about noon)…not ableto participate in special events or musical performances.” The resident’s care planincluded approaches dated 02/09/15 to address the resident’s behavioral symptomsthat included, “The unit [[LOCATION] neighborhood] Mr. [Resident #207] is on hasbeen undecorated to reduce items available to hoard.” There were no care planapproaches to address the resident’s preference to listen to music as indicated in theMDS.

[LOCATION] Neighborhood

On 11/06/18 at 10:25 a.m., a charge RN and assistant nurse manager wereinterviewed during the initial tour of the [LOCATION] neighborhood. The RN indicatedthat staff assigned to the neighborhood cared for residents with primarily behavioralhealth and/or dementia-related diagnoses who required supervision in a securedenvironment. The RN indicated residents in the neighborhood had the potential for“aggression” toward staff and other residents, and required close supervision. Duringthe tour of the neighborhood, resident rooms at the end of two hallways were observedwith the doors closed; there were a total of 10 residents residing in the rooms. Anursing assistant (NA) was seated on a chair at the end of each hallway. One of theNAs indicated the reason the NAs sat in the chairs was because “if they [residents]stay in their rooms with the doors closed…I sit here to listen to see if they needanything.” When asked if the residents preferred to remain in their rooms, the NAstated, “Yes.” The resident rooms had a clear glass window in each door and the NAsreportedly used the windows to check on the residents in their rooms. The NAindicated the resident rooms could be locked from the hallway and a resident couldopen the door from inside to exit. There were no activities occurring in the day room inthe neighborhood during the observations; the lights, television and stereo in the roomwere turned off.On 11/07/18 at 9:15 a.m., when asked why the 10 residents were in their rooms, thecharge RN stated, “They [the residents] get up and eat breakfast then go back to bed.They like to stay in their rooms.”On 11/07/18 at approximately 9:35 a.m. an activity calendar titled, “[LOCATION] –November 2018” was reviewed; the calendar indicated that on 11/07/18 a coffee breakwas scheduled for 9:30 a.m. No residents were observed in the dining room or “dayroom” participating in a coffee break. There were no other activities listed on thecalendar for the neighborhood and no indication residents from [LOCATION]participated in activities outside the neighborhood.On 11/07/18 at 10:00 a.m., the charge nurse was interviewed and stated, “We goaround to their [resident] rooms and ask them to come out for coffee…a lot of them go


back to bed after breakfast.” During observations, staff was not observed visitingresidents in their rooms to offer coffee and residents were not participating in activitiesin their rooms. When asked if there were other activities provided for residents, thecharge RN stated, “We don’t really have time. Some of these guys need to be watchedpretty close.” The assistant nurse manager (ANM) stated, “People [residents] stay intheir rooms.” When asked why there were no more than two chairs in the day room, theANM indicated that one resident would move from chair to chair almost constantlyduring certain periods of time and staff were afraid the resident would fall. When askedhow many nursing staff were available for the 10 residents, the ANM stated, “We have4 staff for the day shift.” The ANM indicated staff would “offer activities” to residents,but most residents remained in their rooms; the ANM did not specify the types ofactivities provided.On 11/07/18 at approximately 10:45 a.m. during observations in the [LOCATION]neighborhood, all resident room doors were closed; no staff were observed seated inthe hallways. It was indicated some of the residents were watching television; norecreational therapy activities were observed occurring. The ANM was present andindicated the residents “don’t like to come out of their rooms.” When asked aboutactivities planned for the neighborhood, the ANM stated, “We don’t have any dedicatedrecreation therapist. It has to be quiet here for the type of patients [residents] we have;”the ANM added staff were to “keep [resident] stimulation down.”On 11/07/18 at approximately 11:30 a.m., the psychologist was interviewed aboutresidents who resided in the [LOCATION] neighborhood. The psychologist stated,“Generally speaking, they [residents] have serious mental illnesses, their symptomsvacillate…they cannot have over-stimulating activities. A lot of [residents] have theirown companions” that can “take them out of the neighborhood sometimes.” Thepsychologist indicated that some residents could go to other neighborhoods to enjoyactivities. It was later indicated that two residents had companions during the survey.On 11/07/18, one of the companions assisted a resident to the canteen. The October 2018 and November 2018 activity calendars were reviewed and indicatedthat each Tuesday the recreational therapist and/or recreational therapy assistantprovided a structured activity at 10:00 a.m. in the [LOCATION] neighborhood; thecalendar did not specify what type of activity would be offered. There were no otheractivities listed on the calendars for residents in the [LOCATION] neighborhood. Duringobservations during the survey, group activities were not occurring.In addition to Resident #202 and Resident #207 (as above), medical records for 8residents living in the neighborhood were reviewed to determine activity preferencesand care plan approaches for the residents. A summary in each resident’s medicalrecord related to care plan information for the residents indicated that activity careplanning did not consistently address the resident’s preferred activities. Examplesincluded (but were not limited to) the following:

Resident #204’s annual MDS dated 01/22/18 indicated the resident had a BriefInterview for Mental Status (BIMS) score of 5 suggesting severely impairedcognition. The MDS indicated music was very important for the resident andactivities with groups of people were not very important. The care planapproaches to address activity preferences included, “Invite…to groupprogramming on both [LOCATION] [neighborhood] and [LOCATION]. Encourageto leave unit [neighborhood], walks with staff.” There were no care planapproaches to address providing the resident with preferred music.Resident #205’s comprehensive MDS dated 08/18/18 indicated the resident’scognition was severely impaired based on staff assessment. The MDS activitypreferences indicated the resident enjoyed animals and going outdoors. Thecare plan approaches to address activity preferences stated, “Works best with1:1 [one-to-one staff support], reduce noise stimuli, encourage unit[neighborhood] activities.” There were no care plan approaches to addressproviding the resident with activities related to animals (e.g., television programsor videos related to animals) or to assist the resident to go outdoors. Duringobservations during the survey, the resident was not observed participating inpreferred activities.Resident #208’s comprehensive MDS dated 03/26/18 indicated the resident hada BIMS score of 6 suggesting severely impaired cognition. The activitypreferences on the MDS included music and favorite activities; the care plan didnot address the resident’s preferred activities.Resident #209’s comprehensive MDS dated 12/21/17 indicated the resident hada BIMS score of 14 suggesting intact cognition. The MDS preferences includedbooks, going outdoors, and religious activities; the care plan did not address theresident’s preferences. During observations of the resident’s room during thesurvey, there were no books or other reading materials in the room.

Systems-level Review


On 11/07/18 at 5:00 p.m., the recreational therapy (RT) supervisor and recreationaltherapist responsible for the [LOCATION] neighborhood were asked about the level ofsupport for activities for residents in the [LOCATION] neighborhood. The RT supervisorindicated the CLC had 3.5 full-time RT staff including 2 full-time RT’s, one part-time RT,and one part-time RT assistant; one full-time RT position was vacant and there were nocurrent plans to fill the position. The RT responsible for the [LOCATION] neighborhoodstated she was responsible for the [LOCATION] and [LOCATION] neighborhoods and“covers two other neighborhoods” due to RT staff vacancy. The RT for the [LOCATION]neighborhood indicated she organized supplies for the neighborhood but staff “took thesupplies away a few years ago…I added more and those were removed too. I was toldI could not have recreation supplies [in the [LOCATION] neighborhood].” The RTindicated the activity calendar for [LOCATION] was essentially the same each monthand she relied on nursing staff to facilitate resident small group activities most of thetime. The RT stated one part-time RT assistant visited the [LOCATION] neighborhoodeach Monday to facilitate a group activity. When asked what “group activity” referred toon the activity calendar, the treating RT stated, “It can be any activity such as bagtoss…;” the RT acknowledged residents would not know what group activity was to beprovided by review of the calendar, since it could vary. The RT supervisor stated herecognized that “more can be done” in the [LOCATION] neighborhood and was“surprised” that there were no activity materials available (including in a secure area) inthe neighborhood.On 11/08/18 at approximately 8:30 a.m., the charge nurse was asked if nursing staffwas able to provide both structured and unstructured recreational activities and shestated, “It’s not realistic. We have to supervise the residents and redirect them…it’shard to do an activity.” When asked about the lack of available activity supplies such asmagazines, game boards, and cards, the charge nurse stated, “We can’t keep anythingout…[Resident #207] will come out of his room and take things…he…takeseverything.” During the survey, there were no activity supplies available in theneighborhood including in a secured area and no group activities occurring.

F278

483.20(g) Accuracy of Assessment.The assessment must accuratelyreflect the resident’s status.


Residents Affected - Few

Based on observation, interview and record review, the CLC did not ensure assessmentsaccurately reflected a resident’s status. Findings include: Resident #304, [LOCATION]

Resident #304 was admitted to the CLC with diagnoses including diabetes mellitus,and liver cell carcinoma. The resident’s significant change in status Minimum Data Set(MDS) dated 08/24/18 indicated the resident scored 2 on the Brief Interview for MentalStatus (BIMS) suggesting severely impaired cognition; the resident had unclearspeech, and was usually understood by and understood others. According to the MDS,the resident required extensive assistance with activities of daily living, including bedmobility, eating and transfers. The MDS indicated an indwelling urinary catheter wasused and the resident was frequently incontinent of bowel; the resident was at risk ofpressure ulcer development and had no pressure ulcers. Skin and ulcer treatmentscoded on the MDS included a pressure reducing device in the chair and bed, andapplication of ointment/medication other than to the resident’s feet. The resident’s current care plan did not address pressure ulcer prevention or identifyskin care concerns.The most recent skin assessment dated 11/02/18 at 9:33 p.m. stated, “The patient’s[resident’s] Braden Scale Score is 21. The patient is considered not at risk fordevelopment of pressure ulcers.” The assessment indicated the resident had nosensory perception impairment, walked frequently, had no mobility limitations, and noproblem with friction and sheer.On 11/06/18 at 12:40 p.m., the resident was observed in bed. The resident’scompanion was at the bedside and stated he just finished assisting the resident to eatthe noon meal. The companion said, “Some days are better than others” and somedays the resident “stays in bed.” The resident’s feet were observed beneath the sheet.The resident was wearing a gown without socks, and the resident’s bare heels wereresting directly on the mattress. The resident’s heels appeared dry and cracked asconfirmed by the assistant nurse manager.During an interview on 11/06/18 at 4:40 p.m., an RN stated, “After his fall in lateOctober [2018] he is refusing to walk. He also refused an x-ray of his knee.” The RNsaid the resident required extensive assistance to reposition in bed.During an interview on 11/07/18 at 8:15 a.m., the social worker stated, “The resident isno longer ambulating with a walker” and indicated the resident used a wheelchair formobility.On 11/07/18 at 12:02 p.m., a skin assessment was completed by the charge RNfollowing inquiry by the surveyor. The resident had a score of 14 (as compared to ascore of 21 suggesting no risk on 11/02/18) on the Braden Scale for Predicting


Pressure Ulcer risk suggesting the resident was at moderate risk for development ofpressure ulcers. The assessment indicated the resident had slightly limited sensoryperception impairment (3), had occasionally moist skin (3), was chairfast (2), had verylimited mobility (2), had adequate nutrition (3), and had a problem with friction andsheer (1). As a result of the Braden Scale assessment completed on 11/07/18, thepressure ulcer prevention protocol was implemented. (See Pressure Ulcers)

F309

483.25 Quality of Care. Each residentmust receive and the facility mustprovide the necessary care andservices to attain or maintain thehighest practicable physical, mental,and psychosocial well-being, inaccordance with the comprehensiveassessment and plan of care. UseF309 for quality of care deficienciesnot covered by §483.25(a)-(m).

Level of Harm - Actual harm that isnot immediate jeopardy


Based on observation, interview and record review, the CLC did not provide the necessarycare and services to attain or maintain the highest practicable physical, mental andpsychosocial well-being of each resident. Findings include: Pain ManagementThe CLC “Pain Management Policy,” dated January 31, 2016, was provided by the actingnurse manager on 11/07/18 at 5:25 p.m. According to the policy, “In those situations wherepain is anticipated, clinicians are to treat pain before the pain becomes severe…interventionswill be used to prevent pain or to treat pain before it recurs whenever possible.” Resident #304, [LOCATION]

Resident #304 was admitted to the CLC with diagnoses including diabetes mellitus,chronic low back pain and liver cell carcinoma. A significant change in status MDSdated 08/24/18 indicated the resident scored 2 on the Brief Interview for Mental Status(BIMS) suggesting severely impaired cognition; the resident had unclear speech, andwas usually understood by and usually understood others. The MDS indicated theresident required extensive assistance with activities of daily living, including bedmobility and transfers. According to the MDS, the resident received scheduled painmedication and received or was offered and declined PRN (as needed) painmedication; the resident did not receive non-medication interventions for pain. TheMDS indicated that the resident had no pain in the last 5 days based on an interviewwith the resident.The resident’s care plan dated 08/27/18 included a statement related to activities ofdaily living (ADLs) that read, “Bed mobility- extensive to total [assistance]. Transfers -extensive [assistance], unable [to transfer without] sara lift….” According to the nursingmonthly summary dated 10/06/18, the resident’s current weight was 264 pounds. The care plan dated 11/02/18 stated, “Complaint of left knee pain-refused knee x-ray”following a 10/25/18 fall with injury; there were no approaches identified on the careplan for pain management. The care plan also indicated the resident was receiving“comfort care at end of life” with “generalized pain” but did not include specificapproaches for pain management.Provider orders for pain management included:

10/30/18: “Oxycodone (Immediate Release) tab 5 MG [milligrams] PO [orally]Q6H [every 6 hours] PRN [as needed] for pain (1-10) [on a scale of 0-10 with 10being the worst pain imaginable].”10/30/18: “Renew Oxycodone (Immediate Release) Tab 5 MG PO Q12H [every12 hours] for chronic pain (HOLD [emphasis not added] for oversedation).”

The Bar Code Medication Administration (BCMA) record for the months of October2018 and November 2018 indicated the resident received one 5 mg dose of oxycodonePRN for left leg pain at an intensity rating of 8/10 on 10/09/18, 10/10/18, 10/12/18,10/15/18, 10/16/18, 10/18/18, 10/20/18, 10/21/18, 10/23/18, 10/24/18, 10/25/18,11/01/18 through 11/03/18, 11/06/18, and 11/07/18.On 11/07/18 at 4:35 p.m., the resident was observed seated in his wheelchair in theliving room. When asked by the ANM if he would like to lay down, the resident said, “Ithurts really bad;” the resident was not able to state where the pain was located or whatwas hurting. Two NAs assisted the resident to his room. The NAs pushed the resident’swheelchair to the edge of the bed and transferred the resident by lifting him under hisarms with one NA holding the back of the resident’s pants; the NAs did not use a saralift to transfer the resident as indicated in the resident’s plan of care. (See Accidents)Once on the bed, the resident struggled to get to the center of the bed by pushingagainst the mattress with his feet. With each push the resident loudly stated, “Ow! Ah!”while grimacing and gasping for breath. When the resident reached the center of thebed, the NAs asked him to push upward using his heels to push into the mattress. Theresident pushed up in the bed by bending his knees and pushing his heels into themattress; the resident verbalized loudly and grimaced during the movement. After threeattempts, the resident reached the head of the bed. The NA asked the resident whathis pain level was on a scale of 0-10 and the resident said, “10, my knees and all over.I don’t want any dinner I just want to go to sleep. I hurt so bad.” When asked whatincreased his pain, the resident said, “It’s my bones; moving around.” According to the


BCMA record, the resident last received a scheduled dose of oxycodone at 8:25 a.m.On 11/07/18, PRN oxycodone was administered at 4:42 p.m.; comments in the BCMAstated, “10/10 [resident pain rating] repositioning done but ineffective…complaint ofbilateral knee pain.”The nursing pain management note dated 11/07/18 at 5:47 p.m. stated, “At around1630 [4:30 p.m.] while resident was repositioning himself in bed he was verbalizingpain [stating] ‘au au’ with facial grimacing. When asked if he has had pain heresponded, yes my both [sic] knees. Pain level 10/10.”In summary, during observations on 11/07/18 at 4:35 p.m., Resident #304 was askedby the ANM if he would like to lay down; the resident said, “It hurts really bad;” theresident was not able to state where the pain was located or what was hurting. Aftertaking the resident to his room, two NAs transferred the resident to bed by lifting himunder his arms with one NA holding the back of the resident’s pants; the NAs did notuse a sara lift to transfer the resident as indicated in the resident’s plan of care. As theresident attempted to reposition onto and in bed, the resident loudly stated, “Ow! Ah!”while grimacing and/or gasping for breath. When asked about experiencing pain, theresident said, “10, my knees and all over. I don’t want any dinner I just want to go tosleep. I hurt so bad.” A sara lift was not used to transfer the resident to bed; instead,the resident was asked to reposition in bed without staff assistance. According to theBCMA record, the resident last received a scheduled dose of oxycodone at 8:25 a.m.

F314

483.25(c) Pressure Sores. Based onthe comprehensive Assessment of aresident, the facility must ensure that(1) A resident who enters the facilitywithout pressure sores does notdevelop pressure sores unless theindividual’s clinical conditiondemonstrates that they wereunavoidable; and (2) A residenthaving pressure sores receivesnecessary treatment and services topromote healing, prevent infectionand prevent new sores fromdeveloping.



Based on observation, interview and record review, the CLC did not ensure residents receivednecessary treatment and services to promote healing, prevent infection and prevent newpressure ulcers from developing. Findings include: On 11/06/18 at approximately 5:15 p.m., the acting quality management (QM) managerprovided a copy of the Veterans Affairs Palo Alto Health Care System Memorandum No.1-18-31 dated January 17, 2007, and titled, “Pressure Ulcer Prediction, Assessment andPrevention.” Pertinent information from the memorandum stated, “The RN is responsible for(1) collaborating with the patient [resident]/caregiver and interdisciplinary team to develop anindividualized plan of care for prevention and management interventions for patients at riskand/or with pressure ulcers….(3) Promoting safety, wound healing, to include….(7)Assessment: An assessment using the Braden scale will be completed by an RN uponadmission to the…CLCs, and upon non-emergent inter or intra-facility transfer….(b) CLC/LongTerm Care patients are risk assessed using the Braden scale, on admission. As part of thereview of systems, it is important to note whether there is a history of prior pressureulcers….(f) Formulation of Plan of Care: Patients designated as ‘at risk’ on the Braden Scalewill have interventions implemented as appropriate.” Resident #401, [LOCATION]

According to the medical quarterly summary notes dated 08/14/18, Resident #401 haddiagnoses including chronic obstructive pulmonary disease (COPD), diabetes, anddegenerative joint disease of the spine.The resident’s most recent comprehensive MDS dated 02/28/18 was coded to indicateResident #401 scored 15 on the Brief Interview for Mental Status (BIMS) suggestingintact cognition; the resident had physical behavioral symptoms directed toward others1 to 3 days during the review period and did not reject care. The MDS indicated therequired extensive to total assistance of two or more staff with most activities of dailyliving (ADLs) including bed mobility, transfers and toileting; the resident had functionallimitations in range of motion of the bilateral lower extremities. The resident used anindwelling urinary catheter and was always incontinent of bowel. Section M (SkinConditions) of the comprehensive MDS assessment indicated the resident was at riskfor pressure ulcer development and had a Stage 4 pressure ulcer that was presentupon admission/entry or reentry; dimensions of the pressure ulcer were documented as1.7 centimeters (cm) in length, 0.8 cm in width and 2.5 cm in depth; the most severetissue type was described as granulation tissue. Section M of the MDS alsodocumented the resident had moisture associated skin damage (MASD). Skin andulcer treatments coded on the MDS included pressure reducing devices for the bedand chair, nutrition or hydration interventions, pressure ulcer care, applications ofnonsurgical dressings and applications of ointments/medications other than to the feet.The quarterly MDS assessment dated 08/24/18 documented Resident #401 scored 13on the BIMS suggesting intact cognition; the resident did not experience behavioralsymptoms of potential distress or reject care. The quarterly MDS indicated the residentrequired extensive to total assistance with most ADLs including bed mobility, transfers,and toileting; had functional limitations in range of motion of the lower extremities; usedan indwelling urinary catheter and was always incontinent of bowel. Section M (SkinConditions) of the quarterly MDS assessment indicated the resident was at risk for


pressure ulcer development and had a Stage 4 pressure ulcer that was present onadmission/entry or reentry; dimensions of the pressure ulcer were documented as 1.0cm in length, 0.5 cm in width and 4.1 cm in depth; the most severe tissue type wasgranulation tissue. Skin and ulcer treatments coded on the MDS included pressurereducing devices for the bed and chair, and applications of ointments/medications otherthan to the feet.On 08/24/18, the nursing wound and ostomy care specialist documented the resident’s“sacral wound opening measures about 0.5 cm x 0.5 cm and it tunnels 5.5 [cm] deepwith large amount of yellow drainage.”During an initial interview with the RN charge nurse on 11/06/18 beginning at 10:12a.m., the RN charge nurse stated Resident #401 “was transferred from [anotherneighborhood in the CLC] and has a stable Stage 4 pressure ulcer on the sacrum.” TheRN charge nurse stated, “The opening [pressure ulcer] is very tiny and it is draining,but it is stable.”The prosthetics request dated 02/13/18 indicated the resident was provided with a“new” power wheelchair with a wheelchair cushion (Invacare® Matrix®). Resident #401was observed during the initial tour of the neighborhood on 11/06/18 seated in aregular wheelchair; a wheelchair cushion was in place in the wheelchair.The Braden Scale for Predicting Pressure Ulcer Risk documented on [DATE] in thenursing admission note to [LOCATION] indicated Resident #401 scored 14 suggestingthe resident was at moderate risk for pressure ulcer development; risk factors includedvery limited sensory perception, rarely moist skin, chairfast, very limited mobility and aproblem with friction. The nursing RN wound note dated [DATE] (following theresident’s transfer to [LOCATION]) described the resident’s coccyx wound as follows,“Dimensions: L [length] 0.6 cm, W [width] 0.6 cm, D [depth] 4 cm. Undermining: Yes,2.8 cm at 11 o’clock and 2.8 cm at 12 o’clock. Wound bed: visible area is noted to bebeefy red, granulation 100%. Drainage: moderate, yellowish discharge, could bedisintegrated Aquacel packing. Edges: rolled, macerated. Peri-wound skin:intact…factors impairing healing: neurogenic bladder, BPH [benign prostatichyperplasia], urinary retention. Has foley catheter, DM [diabetes mellitus] II, activechronic smoker and bowel incontinence (neurogenic bowel). Veteran prefers to be up inhis wheelchair before 10 am [10:00 a.m.] and he prefers to get back to bed at 10 pm.Staff had emphasized the importance of offloading and going back to bed between 10[a.m.] and 10 pm but veteran insisted that he prefers to be up…protective devices:specialty mattress – Immerse. Other: wheelchair cushion. Limit sitting out of bed to lessthan two hours at a time.”The medical quarterly summary notes dated 08/14/18 documented the following aboutthe resident’s skin/coccyx wound: “patient with recurrent stage IV coccyx wound –wound healed 03/01/17 but recurred 10/20/17….Continue Vitamin A/Vitamin D OINT[ointment], TOP [topical] small amount TOP daily PRN [as needed] to use as neededfor prevention of maceration around periwound of sacral wound…limited time up in w/c[wheelchair] to facilitate wound healing, offload/shift wt [weight] from 1 side to the otherQ1H [every hour] while in w/c. Continue to offload with Prevalon boots when in bed.”The 11/06/18 history & physical documented the same information about the resident’spressure ulcer including use of Vitamin A&D ointment and a recommendation to “stressimportance of limited time up in wheelchair to facilitate wound healing with the residentand to offload/shift weight from one side to the other Q1hr [every hour] while up in w/c[wheelchair].” The most recent Braden scale documented within the nursing RN wound note dated11/01/18 indicated Resident #401 scored 15 on the Braden suggesting the residentwas at moderate risk for pressure ulcer development. The nursing RN wound noteindicated the resident had a “chronic stage IV pressure ulcer on the coccyx,dimensions: L 1.0 cm, W 1.0 cm, D 4.3 cm. Undermining: Yes, 2.1 cm at 1 o’clock, 2.1cm at 2 o’clock, 4.1 cm at 8 o’clock, 4.8 cm at 9 o’clock, 5.0 cm at 10 o’clock, 3.4 cm at11 o’clock and 2.1 cm at 12 o’clock. Wound bed: wound has narrow opening, woundbed not visible. Drainage: copious serosanguineous; mixed with disintegrated AquacelAG strip. Edges: macerated; peri-wound skin: intact…factors impairing healing:anemia, diabetes, smoking, neurogenic bowel and bladder and non-adherence to planof care such as veteran refusing to offload and prefers to sit on his wheelchair forseveral hours…protective devices: specialty mattress – Immerse; use wheelchaircushion while in wheelchair. Limit sitting out of bed to less than two hours at a time.”Current provider orders included the following:

“11/20/17 Out of Bed with assistance.”“11/20/17 Please have resident take Juven 1 packet PO [orally] BID [twice daily](to help with wound healing). NOW [emphasis not added].”“10/16/18 Renew Sodium Hypochlorite 0.125% (1/4 Strength) SOLN [solution],TOP 0.125% small amount TOP daily as per wound RN recommendation: cleanwound with Dakin’s 0.125% daily. Soak for 15 minutes then dry and continuewith same treatment.”“10/16/18 Renew Vitamin A/Vitamin D OINT, TOP 5 GM [gram] pack small


amount TOP daily PRN to use as needed for prevention of maceration aroundperiwound of sacral wound.”“10/25/18 For Coccyx Wound: perform QAM [every morning] and PRN ifsoiled/not-intact. Cleanse with wound cleanser and pat dry. Cavilon to woundedges. Cut a rope of Aquacel AG and LIGHTLY [emphasis not added] packwound bed. Cover with OptiLock and secure with protective foam dressing.”

A statement in the resident’s care plan dated 08/22/18 stated Resident #401 “haschronic stage 4 pressure injury on his coccyx, chronic but stable dry callus formationon bilateral plantar aspect of feet, chronic right plantar diabetic foot ulcer and chronicdry skin on bilateral upper and lower extremities.” The care plan goal stated theresident’s “ulcer will remain free of infection and be free of further skin breakdown inthe next quarter.” The care approaches related to the Stage 4 pressure ulcer includedthe following:

“Wheelchair cushion in use (when up OOB [out of bed]) in manual wheelchair.Entered 09/05/18.”“Render coccyx wound treatment as ordered. Monitor for any worsening in sizeand notify WCC [wound care certified nurse]. Entered 09/05/18.”

The resident’s pressure ulcer care plan did not include individualized approaches toaddress the RN wound note dated 07/06/18 that stated, “Staff had emphasized theimportance of offloading and going back to bed between 10 [a.m.] and 10 pm butveteran insisted that he prefers to be up.” The resident’s medical record was reviewed with the clinical nurse specialist for[LOCATION] on 11/07/18 at approximately 9:15 a.m. The Bar Code MedicationAdministration (BCMA) record from 10/08/18 through 11/07/18 indicated Vitamin A&Dwas not used including on 10/11/18, 10/16/18, 10/25/18 and 11/01/18 when weeklynursing RN wound notes stated, “macerated wound edges.”During an interview with Resident #401 in the resident’s room on 11/08/18 atapproximately 8:00 a.m., the resident indicated that he “did not want to go back to bedafter rising in the morning because it takes so long before [I] can get anyone to help[me] back to [my] chair.” The resident added, “I’m very active and if they will keep theirword of helping me out of bed, I may be more inclined to sit less in my chair.” Theresident indicated needing to be reminded to shift his weight and reposition while in thewheelchair.Resident #401 was observed seated in his wheelchair in his room or in the main diningroom intermittently on 11/06/18 from 12:30 p.m. to 1:10 p.m. and from 4:45 p.m. to 5:30p.m.; on 11/07/18 from 8:00 a.m. to 8:15 a.m., at 9:15 a.m., from 10:00 a.m. to 10:15a.m., from 2:00 p.m. to 2:30 p.m., and from 4:50 p.m. to 5:15 p.m.; and on 11/08/18 at8:00 a.m. During the observations, staff were not observed encouraging the resident toshift weight or reposition. The seat of the wheelchair was not visible during theobservations to determine if there was a cushion in the chair.On 11/07/18 at approximately 8:45 a.m., the RN charge nurse was observed, with theresident’s permission, providing wound care for the resident. At the beginning of theobservation, the resident was lying on his right side, facing the window. The residentwas lying on a pressure redistribution mattress (Immerse™) in bed and the head ofbed was elevated at 30-degrees. The resident had a wound dressing over the coccyxthat was dated 11/06/18; the wound dressing was visibly soiled as confirmed by the RNcharge nurse who stated (after removing the dressing), “It’s probably a mixture of thewound draining and the disintegrated Aquacel AG.” The RN charge nurse cleansed thewound bed consistent with the provider’s order; the RN charge nurse remarked, “Thewound has a very small opening and it’s hard to visualize the wound bed…there’sundermining. I don’t detect any odor. The wound edges are calloused…there are dayswhen it is macerated.” When asked what caused the maceration of the wound edges,the RN charge nurse said, “Probably because of the exudate [drainage]…exposure ofthe wound to the exudate. We’ve offered to get him back to bed but he always sayshe’s busy.” When asked how often the resident’s dressing was checked and if PRNdressing changes were conducted, the RN charge nurse said, “I’m not quite sure howoften, but the only time we’ve been successful in checking if he [the dressing] wassoiled was when we had to change his catheter. He had a previously healed ulcer onthe [left] ischium and that was due to pressure from sitting in his wheelchair. They toldus it was the resident’s right [to sit in the wheelchair] and what he prefers and we canonly encourage him.” When asked how long the resident had a wheelchair cushion(Invacare® Matrx®) and if the CLC had a process in place to check the wheelchaircushion, the RN charge nurse said, “He’s had it [wheelchair cushion] for a while now.We don’t really have a process for checking wheelchair cushions but we can alwaysrefer him to OT [occupational therapy].” The resident’s wheelchair cushion waschecked following the dressing change; the wheelchair cushion was noted to be firm onthe end near the front of the wheelchair and boggy/soft on the end near the back of thewheelchair. The RN charge nurse indicated the cushion needed to be replaced andstated, “We can ask for a referral to check his cushion.”In summary, Resident #401 had a “...recurrent stage IV coccyx wound – wound healed


03/01/17 but recurred 10/20/17.” During the survey, the resident was observed seatedin his wheelchair intermittently on 11/06/18, 11/07/18, and 11/08/18. During theobservations, staff were not observed encouraging the resident to shift weight orreposition while in the wheelchair, although the resident indicated during interview heneeded reminders to shift weight. On 11/07/18 at approximately 8:45 a.m. duringobservations of wound care, the resident had a visibly soiled wound dressing over thecoccyx that was dated 11/06/18; the RN charge nurse stated, “It’s [the soiled area is]probably a mixture of the wound draining and the disintegrated Aquacel AG….Thewound has a very small opening…there’s undermining. I don’t detect any odor. Thewound edges are calloused…there are days when it is macerated;” the wound edgeswere not macerated during the observation. Vitamin A&D had been ordered formaceration of the wound edges and when asked what caused the maceration, the RNcharge nurse said, “Probably…exposure of the wound to the exudate. We’ve offered toget him back to bed but he always says he’s busy.” The Bar Code MedicationAdministration (BCMA) record from 10/08/18 through 11/07/18 indicated Vitamin A&Dwas not used including on 10/11/18, 10/16/18, 10/25/18 and 11/01/18 when weeklynursing RN wound notes stated, “macerated wound edges.” The nursing RN woundnote dated 07/06/18 described the resident’s coccyx wound as follows, “Dimensions: L[length] 0.6 cm, W [width] 0.6 cm, D [depth] 4 cm. Undermining: Yes, 2.8 cm at 11o’clock and 2.8 cm at 12 o’clock. Wound bed: visible area is noted to be beefy red,granulation 100%. Drainage: moderate, yellowish discharge, could be disintegratedAquacel packing. Edges: rolled, macerated. Peri-wound skin: intact….” The nursing RNwound note dated 11/01/18 indicated the coccyx wound "dimensions: L 1.0 cm, W 1.0cm, D 4.3 cm. Undermining: Yes, 2.1 cm at 1 o’clock, 2.1 cm at 2 o’clock, 4.1 cm at 8o’clock, 4.8 cm at 9 o’clock, 5.0 cm at 10 o’clock, 3.4 cm at 11 o’clock and 2.1 cm at 12o’clock. Wound bed: wound has narrow opening, wound bed not visible. Drainage:copious serosanguineous; mixed with disintegrated Aquacel AG strip. Edges:macerated; peri-wound skin: intact….” The resident’s pressure ulcer care plan did notinclude individualized approaches to address the resident wanting to remain in thechair from 10:00 a.m. to 10:00 p.m. The care plan approaches did not includeencouraging the resident to shift weight and approaches to address the resident’sconcern that he “did not want to go back to bed after rising in the morning because ittakes so long before [I] can get anyone to help [me] back to [my] chair.” The residentadded, “I’m very active and if they will keep their word of helping me out of bed, I maybe more inclined to sit less in my chair.”

Resident #304, [LOCATION]

Resident #304 was admitted to the CLC with diagnoses including diabetes mellitus,chronic low back pain and liver cell carcinoma. A significant change in status MDSdated 08/24/18 indicated the resident scored 2 on the Brief Interview for Mental Status(BIMS) suggesting severely impaired cognition; the resident had unclear speech, andwas usually understood by and usually understood others. The MDS indicated theresident required extensive assistance with activities of daily living, including bedmobility and transfers.The most recent skin assessment dated 11/02/18 at 9:33 p.m. stated, “The patient’s[resident’s] Braden Scale Score is 21. The patient is considered not at risk fordevelopment of pressure ulcers.” The assessment indicated the resident had nosensory perception impairment, walked frequently, had no mobility limitations, and hadno problem with friction and sheer.On 11/07/18 at 12:02 p.m., a skin assessment was completed by the charge RNfollowing inquiry by the surveyor. The resident had a score of 14 on the Braden Scalefor Predicting Pressure Ulcer risk suggesting the resident was at moderate risk fordevelopment of pressure ulcers. The assessment indicated the resident had slightlylimited sensory perception impairment (3), had occasionally moist skin (3), waschairfast (2), had very limited mobility (2), had adequate nutrition (3), and had aproblem with friction and sheer (1). The skin assessment also stated, “Intact blister onscrotal area and superficial abrasion, redness on penile area.”A nurse practitioner (NP) observed the blister area with a surveyor on 11/07/18 at 4:45p.m.; the resident had a urinary catheter in place. The NP said to the resident, “I’mhere to look at the new blister.” The NP examined the area and stated, “It doesn’t looklike pressure but moisture related. You need to secure the [urinary catheter] tube so itdoesn’t rub [create friction].” The indwelling catheter tubing was not secured to thestatlock that was in place.The NP report dated 11/07/18 at 5:17 p.m. stated, “In to see resident for evaluation ofblister noted on scrotum where staff currently applying skin barrier topical forprotection….Left side of scrotum with open blister area (loose skin/epidermis noted)underlying skin pinkish in color…staff to ensure foley catheter not rubbing on affectedskin areas as they are already doing (e.g., with 'stat lock' in place).”


F318

483.25(e)(2) Range of Motion. Basedon the comprehensive assessment ofa resident, the facility must ensurethat: A resident with a limited range ofmotion receives appropriatetreatment and services to increaserange of motion and/or to preventfurther decrease in range of motion.



Based on observation, interview and record review, the CLC did not ensure a resident with alimited range of motion received appropriate treatment and services to increase range ofmotion and/or to prevent further decrease in range of motion. Findings include: On 11/08/18 at approximately 9:30 a.m., the clinical nurse specialist (CNS) for [LOCATION]provided a copy of the Veterans Affairs Palo Alto Health Care System Memorandum No.171-18-03 titled, “Restorative Nursing Care Program;” the CNS stated the memorandum wasin “draft form and has not been approved.” Pertinent information in the memorandum stated,“Residents in a Functional Maintenance Program at a minimum must have daily ADL[activities of daily living] documentation in the ADL software and captured in the ECS [notfurther clarified] Monthly Nursing Summary.” “The Restorative Nurse Champion or designeewill complete the due assessments and reassessment and any changes in goals with neworders on admission, quarterly, annual and significant change in Restorative Assessmenttemplates and assure the interdisciplinary care plan is updated to reflect the Resident’s needsin real time.” “LVNs and RNs will include the restorative goals, interventions and progress and[sic] in the ECS Monthly Nursing Summary.” Resident #404, [LOCATION]

Resident #404 was admitted to the CLC with diagnoses that included vasculardementia.The annual history and physical (H&P) dated 02/02/18 read, “Functional Status:Baseline, [Resident #404] is wheelchair bound, requires a ceiling lift for transfers,needs set up [assistance] from staff with personal care for grooming (brushinghair/teeth); extensive assistance with full bathing/showers/dressing due to weaknessand functional limitations. He can feed himself with set-up of meal tray. He can makehis needs known, but occasionally gets frustrated/impatient.…BLE [bilateral lowerextremities] with muscle atrophy and moderate spasticity…stable LE [lower extremity]weakness. Wheelchair is primary mobility method…continue restorative nursing.”The resident’s most recent comprehensive Minimum Data Set (MDS) assessmentdated 02/12/18 indicated Resident #404 scored 11 on the Brief Interview for MentalStatus (BIMS) suggesting moderately impaired cognition. According to the MDS, theresident had no behavioral symptoms of potential distress and did not reject care. TheMDS indicated the resident required extensive assistance with most activities of dailyliving including bed mobility, transfers, dressing, toilet use, and personal hygiene; wasable to eat independently with set-up assistance; and had functional limitations in rangeof motion of both lower extremities. The most recent quarterly MDS assessment dated07/26/18 indicated Resident #404 scored 12 on the BIMS suggesting moderatelyimpaired cognition; the resident had no behavioral symptoms of potential distressincluding rejection of care. According to the MDS, the resident required extensiveassistance with most activities of daily living including bed mobility, transfers, dressing,toilet use, and personal hygiene; was able to eat independently with set-up assistance;and had functional limitations in range of motion of both upper and lower extremities.During the initial tour of the neighborhood with the RN charge nurse on 11/06/18 atapproximately 10:55 a.m., the RN charge nurse reported the resident “had dementiaand verbally aggressive behavior.” Resident #404 was observed lying supine in bed;the head of the bed was elevated to a 30-degree angle and the resident appeared tobe watching television.The 10/23/18 medical quarterly summary notes included the same information aboutthe resident’s functional status as the 02/02/18 annual H&P (as above). In addition, thenotes indicated the same plan of “continuing supportive treatment and restorativenursing care” to address lower extremity weakness.The provider order sheet included an order dated 11/01/18 that read, “FunctionalMaintenance – Resident to perform range of motion exercises: extension, flexion,adduction and abduction of upper extremities during ADL [activities of daily living] careto maintain upper body strength.”Resident #404 did not have a comprehensive care plan addressing functionallimitations in range of motion of the upper and lower extremities (the most recent careplan review was dated 07/25/18).On 11/06/18 at approximately 5:30 p.m., the resident was observed in bed in his roomwith the evening meal on an overbed table in front of the resident; the RN charge nurseaccompanied the surveyor during the observation. The resident was observed eatingindependently with predominate use of the right hand. The RN charge nurse stated theresident’s left arm and shoulder “gets stiff.” When asked if the resident receivedrestorative nursing exercises for the upper extremities, the RN charge nurse said, “Theaides [nursing assistants] try to exercise him every shift when they do the ADL care.He does not move his legs. He used to stay in his wheelchair and propel himself to thevending machine. I have not seen him do that in awhile, probably because he was toldnot to go to the vending machine.”On 11/07/18 at 2:10 p.m., Resident #404 was observed with the clinical nurse specialist


for [LOCATION]; the resident was in his room seated in a wheelchair and appeared tobe watching television. A nursing assistant (NA) who was consistently assigned to theresident indicated the resident “did not want to participate in range of motion (ROM)exercises [of the upper extremities].” The NA did not provide further explanation as towhy the resident did not participate in ROM; the resident did not respond appropriatelywhen asked about ROM exercises.On 11/07/18 at 5:15 p.m., the resident was observed in his room seated in hiswheelchair; a meal tray was on the overbed table in front of the resident and theresident asked the CNS to open sugar packets that were on the meal tray. The eveningshift NA who was assigned to the resident indicated the resident did not participate inROM exercises during ADL care.On 11/07/18 at 5:20 p.m., the resident’s clinical records were reviewed with the CNSand it was determined there was no documentation to indicate the resident receivedrange of motion exercises. The CNS stated, “If the aides [nursing assistants] do theROM with the resident’s ADLs, it should appear in the CareTracker [documentation]. Idon’t see the ROM [icon] lit which means the aides cannot access that section of theCare Tracker for the resident. I cannot see any documentation [last 90 days] of anyrange of motion exercises.”On 11/08/18 at approximately 7:50 a.m., Resident #404 was observed eating breakfastin bed. The same evening shift NA who was interviewed on 11/07/18 at 5:15 p.m. wasat the resident’s bedside setting up the resident’s meal tray. The NA said the residentdid not participate in ROM exercises during ADL care; the NA did not provide furtherinformation as to why the resident did not participate in ROM exercises. The NA stated,“I will try later after he’s done with breakfast. He is usually more alert after breakfast.”At approximately 8:50 a.m., the surveyor and CNS for [LOCATION] observed the sameNA providing ROM exercises for Resident #404. The resident was able to raise hisright arm only to chest level with active assistance from the NA; the resident repeatedthe exercise four times. The resident appeared tired and sleepy (the resident’s eyeswere closed). The NA remarked, “He’s usually more alert at this time of the day. I don’tknow why he’s so sleepy.”On 11/08/18 at 9:00 a.m., during an interview with the restorative RN assigned to[LOCATION], the restorative RN stated she was assigned to the neighborhood in April2018 and “started reviewing residents.” The restorative RN said, “I just heard about him[Resident #404] last month in the [restorative] meeting. I assessed him for restorativecare needs on 10/31/18 and recommended range of motion exercises to his upperextremities during ADL care to maintain upper body strength.” The restorative RNadded, “An order was written on 11/01/18 for functional maintenance.” When askedabout developing a comprehensive plan of care to monitor the effectiveness of theROM exercises and address the resident’s functional limitations in range of motion ofthe lower extremities, the restorative RN said, “We are still in the process ofreorganizing the [restorative] program. We plan on having regular meetings and weeklysummaries [to document the resident’s progress with restorative nursing care].”On 11/08/18 at 9:25 a.m., the CNS for [LOCATION] provided a copy of the restorativenotes dated 02/19/18 that indicated the resident “participated in a group exercise usingthe theraband for 20 minutes without any complaints of pain to his upper extremities.”A restorative nursing program assessment/reassessment dated 05/10/18 was reviewedwith the CNS; the document indicated Resident #404 had “impairment of both lowerlegs, required extensive assistance with bed mobility, dressing; total assistance withtransfers, bathing, toilet use; was non-ambulatory and direct care staff believe residentis not capable of maintaining or increasing independence.” There was no restorativenursing care plan in the restorative nursing program assessment note. When askedabout documentation regarding ROM following the provider order dated 11/01/18, theCNS provided reports from CareTracker for the period of time from 11/01/18 through11/06/18. Care Tracker documentation for that time period indicated the residentparticipated in ROM on 11/05/18 and 11/06/18; the resident refused to participate on11/02/18, 11/03/18, and 11/04/18. CareTracker documentation indicated the residentdid not participate in active ROM on 11/01/18. The CNS confirmed there was nothingdocumented in the resident’s clinical record about potential causes (e.g., timing of theROM) for the resident’s “refusal” to participate.In summary, during observations with the RN charge nurse on 11/06/18 atapproximately 5:30 p.m., Resident #404 was eating independently using primarily hisright hand. The RN charge nurse stated the resident’s left arm and shoulder “getsstiff....The resident does not move his legs. He used to stay in his wheelchair andpropel himself to the vending machine….” The resident’s comprehensive MDS dated02/12/18 indicated the resident had functional limitations in range of motion of bothlower extremities and no limitations in range of motion of the upper extremities. Themost recent quarterly MDS dated 07/26/18 indicated the resident had functionallimitations in range of motion of both upper and lower extremities. Medical quarterlysummary notes dated 02/02/18 and 10/23/18 indicated the resident was to be providedwith “restorative nursing care.” Based on staff interview and record review, the CLC did


not provide the resident with restorative nursing care; documentation indicated ROMwas provided or offered and refused following a provider’s order dated 11/01/18. Theresident’s care plan did not address the resident’s limitations in range of motion.

F323

483.25(h)(1) Accidents. The facilitymust ensure that: The residentenvironment remains as free ofaccident hazards as is possible;



Based on observation, interview and record review, the CLC did not ensure the residentenvironment remained free of accident hazards and that each resident received supervision toprevent accidents. Findings include: Accident Prevention Related to FallsThe CLC policy dated December 31, 2016, and titled, “Fall Prevention Program,” wasprovided by the acting quality manager (QM) on 10/06/18 at 5:15 p.m. According to thepolicy, “Patients, their families, and health care providers are integrally involved in all aspectsof their care planning and will be involved in determining factors for risk of fall or injury from afall, and designing fall prevention strategies in collaboration with the patient’s health careteam….Document the evaluation of risk factors, the interventions, and the evaluation of theinterventions on the care plan….A Post Fall Huddle should be done as soon as possible aftera fall and be summarized in an addendum note to the Fall Note in CPRS [computerizedpatient record system].” The CLC policy dated February 6, 2016, and titled, “Safe Patient Handling and MovementProgram” was provided by the ANM on 11/07/18 at 5:30 p.m. According to the policy, “Thereis no safe way to manually lift, reposition, push or pull a HCR [health care recipient].” Resident #304, [LOCATION]

Resident # 304 was admitted to the CLC with diagnoses including schizoaffectivedisorder, diabetes mellitus and chronic low back pain. The resident’s significant changeMDS dated 08/24/18 indicated the resident had a Brief Interview for Mental Status(BIMS) score of 2 suggesting severely impaired cognition, had unclear speech, andusually understood and was understood by others. According to the MDS, the residentrequired extensive assistance with activities of daily living (ADLs) including eating andtransfers; the resident had not any falls in the last 2 to 6 months, had unsteady balancebut was able to stabilize with assistance, and had no swallowing difficulties.During the initial tour on 11/06/18 at 10:00 a.m., the charge RN indicated the resident“is receiving palliative-comfort care…. He has had a recent decline in functioning and isdisoriented and restless. He is a high fall risk with a fall on Friday [11/02/18] and onethis morning [11/06/18]. He has had an assigned sitter but none since last week. Healso has a companion that is with him from 12:00 p.m. to 4:00 p.m. The companion ishired by the family and will do his laundry, take him outside, and assist with ADLs. Asitter is VA staff that is built into our staffing methodology. We can request a sitter fromdifferent neighborhoods to stay with the resident.” The assistant nurse manager (ANM)stated the companion’s hours were determined by the time of day the resident mostfrequently fell. During an interview on 11/07/18 at 11:00 a.m., the charge RN clarifiedthat the resident had the one-to-one (1:1) sitter on 11/01/18 starting on the night shiftand through 11/02/18 at 2:00 p.m. when the resident was reportedly less restless andthe close observation [sitter] was discontinued. According to the charge RN, the falloccurred at 6:50 p.m. on 11/02/18 after the 1:1 was discontinued. The charge RNstated, “It is up to the charge nurses’ discretion when a 1:1 is needed. He [Resident#304] has not had a sitter since 11/02/18 at 2 p.m.” The charge RN confirmed that newapproaches were not implemented following each fall; the charge RN stated, “Wecontinue with the standard fall precautions.”Resident #304’s care plan dated 08/20/18 addressed comfort care at end of life andstated, “Resident will benefit from End of Life Symptoms Management. Symptoms…r/t[related to] resident’s terminal diagnosis…which may include fatigue, generalizedpain…restlessness, ascites causing resident discomfort when in recline[d] position,fluctuating mental alertness and others.” A goal related to the statement read,“Resident will have no fall while he has delirium” with approaches that included, “Staffwill monitor resident’s condition closely to offer help as needed, staff will assist residentwhile getting out of bed to prevent a fall.” The resident’s care plan dated 08/27/18 addressed the resident’s psychosocialwell-being and included an approach that read, “Close observation related toconfusion, unsafe behavior/fall risk related to encephalopathy.” The care plan includeda statement related to ADL function that read, “Bed mobility - extensive to total[assistance]. Transfers - extensive [assistance], unable [to transfer without] sara lift….”A provider’s order dated 10/03/18 stated, “Change fall risk precautions to Fall Risk(implement nec [necessary] fall injury prevention measures per nursing judgement).”According to the nursing monthly summary dated 10/06/18, Resident #304 weighed


264 pounds.The pharmacy monthly review dated 10/17/18 stated, “There does not appear to be acorrelation between specific fall events and the medications the veteran is receiving.”According to a fall note dated 10/18/18 at 1:15 a.m., Resident #304 fell whileambulating to the dining room. The note stated, “Observed resident walking with hiswalker towards the dining room, he then attempted to sit on a chair but missed it andstarted to lost [lose] his balance with his left buttock landing on the floor; his head didnot hit the floor….The Morse Fall scale was performed and score was 80. This isindicative of high risk for falls.” “Fall Prevention Interventions for all Patients/Residentswere already in place and included: Use of non-skid slippers or gripper socks, requestassistance for daily activities, reinforce need for assist[ance]/supervised transfers(Education), complete surveillance rounds every 1 hour, use alarm as reminder to callfor assistance, re-educate/reminders regarding safety.” A post fall huddle note dated10/25/18 stated, “This fall is anticipated r/t hx [history of] falls in the past, poor safetyawareness, and unsteady gait. Observed resident walking towards the dining room withhis walker in a hurry. As he reach [reached] the table by the sink, he attempted toreach over to one of the chair [chairs] then tried to sit, however missed the chair andstarted to loss [lose] his balance and fell on his left buttock.” There was no indicationstaff provided supervision and assistance for the resident while the resident waswalking.A fall note dated 10/25/18 indicated Resident #304 experienced a fall at 11:00 a.m.According to the note, “Veteran has inconsistent statements, at first he stated, ‘I usedthe bathroom and fell and crawled all the way here.’ His second statement was, ‘I usedthe bathroom and was on my way to my walker and fell on my knees and hit my head.’Writer noted veteran lying on his right side, yelling and creaming [screaming] ‘I fell, Ifell.’ He was lying on the floor near the bed, his walker on his far left side and thebathroom door was close [closed].” The Morse Fall Scale score was 80, suggesting ahigh risk for falls. According to the note, “The resident was able to stand with 2 personassist[ance]. He complained of 10/10 [10 out of 10 on a scale of 0 to 10 with 10 beingthe worst pain possible] pain in his left knee. He was offered pain medication butrefused. He [is] guarding and rubbing his left knee when writer asked veteran to movetowards the head of the bed, He stated, ‘I can’t my knee is in so much pain.’ An x-raywas ordered, but the resident refused.” There was no indication the bed alarm soundedor that staff were monitoring the resident’s condition closely to offer help as neededand assisted the resident while getting out of bed to prevent a fall, as indicated in theresident’s plan of care dated 08/20/18.The resident’s care plan dated 10/26/18 related to falls stated, “At risk for additionalfalls related to high Morse Fall scale, use of psychotropic & [and] diuretic medication,unsteady gait & balance and poor safety awareness. More confused and restless -attempts to get out/climb out/slide out of bed unassisted, getting out of chair wanting towalk without help. Forgets to use 4WW [four wheeled walker] at times. Two falls thismonth, complaint of left knee pain-refused knee x-ray. 11/02/18 Fall without injury.”Approaches stated, “Frequently remind of staff’s availability to assist him during hismobility and location….Use w/c [wheelchair] for mobility when he is out of bed(8/27/18). Provide assistance as he sit [sits] on a chair. Reinforce anticipation of needsthat might trigger veteran’s [resident’s] sudden onset of getting up from bed or suddenambulation to prevent future falls (10/11/18). Assist and supervise veteran duringambulation secondary to unsteady gait and weakness (10/11/18). Resident needs abed/chair alarm at this time related to confusion and unsteadiness (8/16/18).” The careplan did not address use of a paid companion to assist with fall prevention.A fall note dated 11/02/18 indicated Resident #304 fell at 6:50 p.m. According to thenote, “Staff found him lying on the floor mat on his right side. It appeared that he puthimself to the floor from bed. He was fighting and screaming. When asked what heneeds, no responded [response] back…denied pain or discomfort.” There was noindication the resident’s bed alarm had sounded. A post fall huddle note dated 11/02/18stated, “Vet [Veteran] is a very high risk for fall mostly r/t to his behavior. Last falls10/25/18 and 10/18/18. Very difficult to communicate with him as he [is] very resisted[resistant] fighting and screaming.” There were no changes or updates to the resident’scare plan.A fall note dated 11/06/18 was provided and indicated the resident had a fall at 4:30a.m. According to the fall note written on 11/07/18 at 12:10 p.m. following discussionswith a surveyor, “The NA reported to the charge nurse that the resident was insisting togo on the floor and he started dangling his legs out of the bed. The NA was not able tobreak the intent to go to the floor thus the resident was assisted by the NA to slide on[to] the floor.” The provider was notified on 11/07/18 at 12:05 p.m. about the resident’sfall according to the fall note. A post fall huddle was conducted on 11/07/18 at 4:37p.m. The post fall note stated, “Notify social services to extended [extend] companion’shours with the resident. Maintain on fall precaution such as bed alarm, wheelchairalarm, bed on low position, floor mat, call bell within reach.” No changes were made tothe resident’s plan of care. Staff did not provide information regarding the new hours for


the companion to address the times the resident was experiencing falls (1:15 a.m.,4:30 a.m., 11:00 a.m., 6:50 p.m.).On 11/07/18 at 4:35 p.m., the resident was observed seated in his wheelchair in theliving room. When asked by the assistant nurse manager (ANM) if he would like to laydown, the resident said, “It hurts really bad;” the resident was not able to state wherethe pain was located or what was hurting. Two NAs assisted the resident to his room.The NAs pushed the resident’s wheelchair to the edge of the bed and transferred theresident by lifting him under the arms with one NA holding the back of the resident’spants; the NAs did not use the sara lift as indicated in the resident’s plan of care. Asthe resident was assisted to pivot to sit to the edge of the bed, the resident attemptedto sit before he was positioned near the bed and the NA’s braced the resident byholding the resident with their bodies.In summary, Resident #304 had a fall on 10/18/18 at 1:15 a.m. while ambulating to thedining room. There was no indication that staff were monitoring the resident closely tooffer help as needed, as indicated in the resident’s plan of care dated 08/20/18. Theresident had a fall on 10/25/18 when the resident “complained of 10/10 pain in his leftknee.” There was no indication the bed alarm sounded or that staff were monitoring theresident’s condition closely to offer help as needed, and assisted the resident whilegetting out of bed to prevent a fall, as indicated in the resident’s plan of care dated08/20/18. A fall note dated 11/02/18 indicated the resident fell at 6:50 p.m. and “stafffound him lying on the floor mat on his right side. It appeared that he put himself to thefloor from bed. He was fighting and screaming. When asked what he needs, noresponded [response] back…denied pain or discomfort.” There was no indication theresident’s bed alarm sounded and there were no changes to the resident’s care plan.According to the charge RN, the fall occurred after a sitter was discontinued. A fall notedated 11/06/18 indicated the resident had a fall at 4:30 a.m. According to the post fallhuddle note that was written on 11/07/18 at 12:10 p.m., “…the resident was insisting togo on the floor and he started dangling his legs out of the bed. The NA was not able tobreak the intent to go to the floor thus the resident was assisted by the NA to slide on[to] the floor.” The charge RN confirmed that new approaches were not implementedfollowing each fall; the charge RN stated, “We continue with the standard fallprecautions.” It was not evident the CLC conducted a comprehensive assessment toidentify causal and contributing factors to the resident’s falls (e.g., bed/chair alarm notsounding, staff not providing close monitoring) to ensure care plan approaches wereimplemented and the care plan updated as needed.

Accident Prevention Related to Swallowing PrecautionsUndated CLC guidelines titled, “Companion Services,” were provided by the social worker on11/06/18 at 1:30 p.m. According to the guidelines, “Companions do not assist with toileting,personal hygiene, showering, feeding (they can do set up but not actual feeding), dressing(including incontinence briefs) and taking vital signs.” Resident #304, [LOCATION]

Resident # 304 was admitted to the CLC with diagnoses including schizoaffectivedisorder and diabetes mellitus. The resident’s significant change MDS dated 08/24/18indicated the resident had a Brief Interview for Mental Status (BIMS) score of 2suggesting severely impaired cognition, had unclear speech, usually understood andwas understood by others. According to the MDS, the resident required extensiveassistance with activities of daily living including eating and transfers; the resident didnot have swallowing difficulties.An occupational therapy consult dated 08/16/18 stated, “Resident with increasedconfusion and risk for aspiration.” The resident’s care plan dated 08/27/18 stated,“Veteran is having more difficulty with chewing and swallowing.” There was no followup consult with speech therapy and no care plan approaches related to chewing orswallowing difficulties. The assistant nurse manager (ANM) stated on 11/07/18 thatthere was no follow up related to the resident’s swallowing and chewing difficultiesbecause the resident experienced a change in condition and “we [CLC staff] reallydidn’t expect him to make it.” On 11/06/18 at 12:40 p.m., Resident #304 was observed in bed. The resident’scompanion at the bedside stated, “I just finished feeding him. Yes, I had to feed him.Some days are better than others.” I work with him 12:00 p.m. to 4:00 p.m. onMondays, Tuesdays, Thursdays, and Fridays. I feed him and do a bed bath on Fridays,and also take him to the store and clean the bathroom and do laundry.” The companiondid not provide information about education received related to feeding the resident orindicate if there were concerns when the companion fed the resident (e.g., choking,coughing).The social worker was interviewed on 11/07/18 at 8:15 a.m. regarding the role of acompanion hired by a family. The social worker stated, “They [companions] areprimarily for companionship but can do additional showers if the family requests. It isup to the nursing staff to ensure the companions are properly trained. If the companion


assists with ADLs it will be in the care plan.” When asked if companions should feedresidents, the social worker said, “No.” The social worker said, “I didn’t know that he[Resident #304] required assist [assistance] with feeding. He had a change in conditionand we were surprised at his comeback….” On 11/07/18 at approximately 10:23 a.m.,the social worker stated, “At this point, only NAs [nursing assistants] will feed;” thesocial worker acknowledged Resident #304’s companion had not been trained to feedresidents.The care plan did not include information regarding the use of the companion orspecific feeding guidelines.An RN familiar with the resident was interviewed on 11/06/18 at 4:40 p.m. The RNstated that the resident “can sometimes eat by himself but is at risk and needs to besupervised so he doesn’t choke.”

F441

483.65 Infection Control. The facilitymust establish and maintain aninfection control program designed toprovide a safe, sanitary, andcomfortable environment and to helpprevent the development andtransmission of disease and infection.



Based on observation, interview and record review, the CLC did not maintain an infection andprevention control program designed to help prevent the development and transmission ofdisease and infection. Findings include: On 11/07/18 at approximately 8:30 a.m., a CLC clinical nurse specialist provideddocumentation related to infection prevention and control practices. The document titled,“Addendum to: Health Care System Memorandum No. 11-14-65 July 31, 2014. MedicationProcedures for Residents on Enhanced Barrier Precautions (EBP). Addendum to AttachmentF: Medication Administration Procedures for Patients on Transmission Precautions.” Theprocedures included section C. that read, “For Enhanced Barrier Precautions (EBP) rooms:Assess personal protective equipment (PPE) needs. As appropriate, don gown and/or glovesfor resident isolation (i.e., use gown and gloves if physical contact with resident/environmentis likely).” Included with the above information was the “Healthcare System Memorandum No.OSV-15-86, dated December 31, 2015 Attachment 2. Sequence for putting on PersonalProtective Equipment (PPE).” The instructions to staff stated, “1. Gown-fully cover torso fromneck to knees, arms to end of wrists, and wrap around the back - Fasten in back of neck andwaist.” A third document was provided by the clinical nurse specialist and titled, “Veterans AffairsPalo Alto Health Care System, 3801 Miranda Avenue Palo Alto, CA 94304-1290. EffectiveDate: January 1, 2005. Issue Date: July 13, 2015. Health Care System Memorandum No.137-15-03. Subject: Guidelines for the cleaning and disinfection of non-critical reusablemedical equipment.” Section b of the policy stated, “Dedicated, disposable equipment shouldbe utilized whenever possible to decrease cross contamination (i.e., disposable bloodpressure cuffs for inpatients).” [LOCATION]Resident #104

During a medication administration observation on 11/06/18 at 4:30 p.m., an RN waspreparing medications for Resident #104 for whom staff were to implement EnhancedBarrier Precautions (EBP) for a positive methicillin-resistant Staphylococcus aureus(MRSA) culture of the nares. A sign posted at the door to the resident’s room indicatedEBPs were to be implemented. The resident was identified by the charge nurse duringthe initial tour as a resident with chronic heart and lung disease. The RN performedhand hygiene, donned gloves and a gown, and entered the resident’s room to obtain ablood pressure The RN placed her arms through the sleeves of the gown and tied thegown at the waist without tying the gown at the neck; this action prevented the gownfrom covering the RN’s back. During the observation, the back of the RN’s clothingcame into contact with the resident’s bedside table. The vital sign machine that wasbrought into the room had an attached blood pressure cuff that was used by the RN.After the resident’s blood pressure was obtained, the RN brought the vital sign machine(with cuff) into the hallway. The disposable cuff on the vital sign machine was notdisposed of and the machine was not cleaned. The RN doffed the gown and gloves,re-entered the resident’s room without donning a gown or gloves and moved theresident’s bedside table closer to the side of the bed. The RN exited the room, usedhand sanitizer and prepared the residents medications without additional concernsrelated to infection prevention and control.During an interview on the morning of 11/07/18, the clinical nurse stated all vital signmachines in the [LOCATION] were cleaned and new blood pressure cuffs were placed.

[LOCATION]


Resident #303

On 11/06/18 at 1:35 p.m., two NAs were observed providing hygiene care for Resident#303. The NAs performed hand hygiene, donned gloves, and assisted the resident to asara lift and into the bathroom. One NA removed the resident’s adult brief that wasvisibly soiled, and lowered the resident onto the commode. The NA cleansed theresident and without changing gloves, applied a clean brief and pulled up the resident’spants. The resident was assisted back into his wheelchair and the NA doffed anddisposed of the gloves. Without performing hand hygiene, the same NA tied theresident’s shoe, removed the lift sling, and assisted the resident to hand wash at thesink in the resident’s room. The second NA who did not assist with the hygiene care,doffed gloves and disposed of the gloves by lifting the lid of the trash receptacle withbare hands. Without performing hand hygiene, the second NA provided range ofmotion for the resident’s hands and assisted the resident to the living room.

[LOCATION] Neighborhood

On 11/07/18 at 9:25 a.m., an environmental management services (EMS) staff personwas observed wiping a resident’s room walls and bathroom door using disposablewipes while wearing gloves. It was not indicated staff were to implement ContactPrecautions for the resident. As the EMS staff person wiped the walls and door, hediscarded the soiled wipes onto the floor in a pile of discarded wipes, dust and paperdebris; a trash receptacle with a closed lid was observed near the pile of debris. Whenasked about discarding the soiled wipes on the floor and not in the trash receptacle,the EMS staff person stated, “I have to sweep the floors anyway. What does it matter ifI put it on the floor or in there? I have to clean the floors anyway.” The [LOCATION]neighborhood nurse manager was standing nearby and asked if it was appropriate todiscard soiled wipes on the floor. The nurse manager stated, “Absolutely not. I’ll talk tohim; he’s new.” The nurse manager spoke with the resident and then contacted theEMS supervisor about providing further guidance for the EMS staff person.

[LOCATION]Resident #304

On 11/06/18 at 2:10 p.m., Resident #304 was observed in his room with a companion.The companion was wearing gloves and disposed of an unknown item in the trashreceptacle by touching the receptacle with a gloved hand. The companion doffedgloves, placed the gloves in the trash receptacle and came into contact with the trashreceptacle with ungloved hands; without performing hand hygiene the companionassisted the resident out of the room. The companion stated, “We are going to thestore to buy snacks.”


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