Madera Rehabilitation & Nursing Center

F-F689)

Findings:

During a review of the facility ' s document titled Incidents By Incident Type, dated 1/1/25 to 3/4/25, the document indicated, . Total ' Fall ' Incidents: 64 . One fall was crossed out in error.

During an interview on 2/12/25 at 4:01 p.m. with the Director of Staff Development (DSD), the DSD stated

she was aware the facility had a high number of resident falls. The DSD stated she held a fall prevention in-service for the staff on 1/28/25 to address the high fall rate. The DSD stated she did not test the staff ' s competency after the in-service.

During a concurrent interview and record review on 2/12/25 at 4:17 p.m. with the ADM, the ADM stated the QAPI committee included himself, the department heads, the interdisciplinary team (IDT-involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident), and the medical director. The ADM stated the QAPI met on a monthly basis to discuss any issues happening within the facility. The facility ' s document titled Incidents By Incident Type, dated 1/1/25 to 2/12/25 was reviewed. The document indicated there were 31 falls in 1/2025 and 11 falls between 2/1/25-2/12/25. The ADM stated he was aware there were issues with the number of resident falls. The ADM stated the falls were a clinical issue and would fall under the Director of Nursing ' s (DON) responsibility. The ADM reviewed the QAPI document titled [name of facility] Performance Improvement Plan, the plan indicated, . 1. Resident Falls . 2. 4 P ' s [pain, position, placement and personal needs] Fall prevention program (May 2023) . 1. Initiate Safety Committee for Resident Falls which will include Admin [administrator], DON, DOR [Director of Rehabilitation], ACT [activities], RNA [Restorative Nursing Assistant], and DSD [Director of Staff Development] to review and assess resident falls. Committee will review conditions, medications, interventions, as well as hold weekly meetings to identify whether the interventions that have been implemented are affective [effective] and provide new recommendations to reduce resident falls .1. Our goal is to reduce falls to 15 or less per month for three months . There were 31 resident falls in January 2025, the ADM stated he could not answer if the QAPI was effective because he needed to review the month-to-month data. The ADM was unable to state how the data gathered as part of QAPI was used to decrease resident falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 055147 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055147 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 During a telephone interview on 2/19/25 at 3:57 p.m. with the ADM, the ADM stated the facility did not have integrated QAPI minutes because each department head took their own minutes and presented the previous Level of Harm - Minimal harm or months for review. The ADM was unable to provide documentation of the minutes related to the resident potential for actual harm falls. The ADM stated the clinical staff was responsible to review and evaluate the falls. The ADM stated he did not know how the clinical staff decided what interventions to put into place for fall prevention, but falls Residents Affected - Some were clinical issues, and it was ultimately the DON ' s responsibility to provide oversight. The ADM stated falls were reviewed during the daily stand-up meeting, but he did not attend it was for clinical staff. The ADM was unable to state what fall performance improvement plan was put into place by the QAPI committee.

During an interview on 3/5/25 at 2:37 p.m. with the ADM, the ADM stated resident falls were discussed between clinical staff in the IDT. The ADM stated, There is a lot that goes on in this building. The ADM stated

the Director of Nursing was in charge of resident falls and the IDT. The ADM stated, I am not a nurse, so I am not involved in that part, [the] clinical part of the meeting.

During a review of the facility ' s policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) Program, dated 2/2020, the P&P indicated, . facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents . objectives of QAPI program are to . provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators . establish systems through which to monitor and evaluate corrective actions . administrator is responsible for assuring that this facility ' s QAPI program complies with federal, state, and local regulatory agency requirements . QAPI committee reports directly to the administrator . QAPI plan describes the process for identifying and correcting quality deficiencies. Key components . tracking and measuring performance . identifying and prioritizing quality deficiencies . systematically analyzing underlying causes of systemic quality deficiencies . developing and implementing corrective action or performance improvement activities . committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 055147 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055147 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 44899 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective infection control Residents Affected - Few program when one of 12 sampled residents' (Resident 8) oxygen concentrator filter was found covered with dust and lint.

This failure placed Resident 8 at an increased risk to develop respiratory and healthcare-associated infections.

Findings:

During a review of Resident 8's Admission Record (AR, a document that

provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/7/25, the AR indicated, Resident 8 was admitted from an acute care hospital on 1/9/25 to the facility, with diagnoses that included Congestive Heart Failure (CHF- define), Type 2 Diabetes Mellitus (abnormal levels of blood sugar), Hypertension (high blood pressure), and Pleural Effusion (an abnormal accumulation of fluid

in the lungs and the chest wall).

During a review of Resident 8's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 1/15/25, the MDS indicated Resident 8's Brief Interview for Mental Status (BIMS) score was 5 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact).

During a review of Resident 8's Order Summary Report (OSR), dated 3/7/25, the OSR indicated, . Order Summary . Oxygen at 2-4 liter/minute (unit of measurement) via Nasal Cannula (a device used to deliver supplemental oxygen) related to CHF. May titrate (adjust) level every shift .

During a concurrent observation and interview, on 3/6/25, at 4:22 p.m., in Resident 8 ' s room, with the Assistant Director of Nursing (ADON), the ADON looked at Resident 8 ' s oxygen concentrator and stated

the oxygen concentrator filter was covered with dust and lint. The ADON stated using a dirty oxygen concentrator was not acceptable. RN 1 stated Resident 8's was not getting the full benefit of supplemental oxygen and her respiratory condition could worsen. The ADON stated maintaining the cleanliness of an oxygen concentrator was the responsibility of the licensed nurses.

During an interview on 3/7/25, at 3:21 p.m., with the Director of Nursing (DON), the DON stated using a dirty oxygen concentrator was not acceptable and could potentially cause residents to become ill. The DON stated the purpose of the oxygen concentrator was to improve resident's oxygen level. The DON stated residents using a dirty oxygen concentrator could have respiratory infection. The DON stated she expects

the oxygen concentrator to be cleaned weekly and as needed by the licensed nurses for the safety and well-being of all residents receiving oxygen.

During a review of the facility ' s document titled, Job Description: Floor Nurse, undated, the document indicated, . Essential Duties and Responsibilities . Ensuring equipment is in good operating order . Following Infection and Control policies .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 055147 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055147 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of the facility's P&P titled, Oxygen Administration, dated 2/24, the P&P stated, . Preparation . 3. Assemble the equipment and supplies as needed . Steps in the Procedure . Check the mask, tank, Level of Harm - Minimal harm or humidifier, etc., to be sure they are in good working order and are securely fastened . potential for actual harm

During a review of the facility's policy and procedure (P&P) titled, Assistive Device and Equipment, dated Residents Affected - Few 1/20, the P&P stated, . 6 . c. Device Condition - devices and equipment are maintained on schedule and according to manufacturer ' s instructions. Defective or worn devices are discarded or repaired .

During a review of the facility's policy and procedure (P&P) titled, Infection Control, dated 10/18, the P&P indicated, . 1. The facility ' s infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment . 4. All personnel will be trained on our infection control policies and practices .

During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2021, the manual indicated, . Frequency of inspection and cleaning of filter may be dependent upon environmental conditions like dust and lint . NOTE- The air filter should be monitored closely in environments with abnormal amounts of dust and lint .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 055147