Almond Vista Healthcare

CMS-10055 revealed the directions stated the facility was to complete the section titled, Care

may not or won't be covered by Medicare. In the Reason Medicare May Not Pay section stated the The SNF must give the applicable Medicare coverage guideline(s) and a brief explanation of why that beneficiary's medical needs or condition do not meet Medicare coverage guidelines . In the box labeled .Estimated Cost Section. the facility was supposed to document, . In this section, the SNF enters the estimated cost of the corresponding care that may not be covered Medicare.

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

During an interview on 08/02/24 at 3:35 PM, LVN5 stated she was R203's nurse on 07/30/24 during day shift. LVN5 stated she was notified by the day shift CNA around 6:30 AM on 07/30/24 that R203 had a sock on his left hand. LVN5 stated she had not been aware of the sock being there prior to that day. LVN5 stated there was nothing in report about the sock and she asked the night shift nurse about it and was told the night shift nurse did not know about it. LVN5 stated she meant to go and check on the application of the sock on R203's left hand but got busy, and when she went to give R203 medications, his arm was covered with the bedding and she forgot. LVN5 stated she was not aware of a reason for the application of the sock. LVN5 stated R203 was anxious at times and placed his hand in his incontinence brief and rubbed himself. LVN5 stated R203 was not able to put the sock on his hand and would not be able to remove it either.

During an interview on 08/02/24 at 3:32 PM, the hospice LVN stated she had never seen a sock on R203's hand and there were no directions from hospice that would warrant it.

The hospice LVN stated R203 would not have been able to put the sock on himself and did not think he could remove it.

The hospice LVN stated R203's sister stated he was putting his hand in his brief and was fidgeting in that area.

During an interview on 08/02/24 at 4:12 PM, the hospice Registered Nurse (RN) stated she saw R203 on 07/30/24 and noticed a sock on his left hand.

The hospice RN stated she did not know why it was there or if it was a facility intervention for something.

The hospice RN stated hospice would not order a sock to be applied.

During an interview on 08/02/24 at 4:43 PM, the DON stated she had heard about the sock that was applied on 07/30/24 to R203's hand.

The DON stated she did not know why it was there or who applied it.

The DON verified the bandage/sock combination could function as a restraint.

The DON stated for all restraints there should be a physician's order, assessment, and care plan in place.

Review of the facility's Use of Restraints policy dated April 2017 revealed, Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls .

The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e. side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint .

Examples of devices that are/may be considered physical restraints include . hand mitts .

Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted .

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

During an interview on 08/01/24 at 11:06 AM, the Social Service Director (SSD) stated the nurses issued discharge notices when residents were sent to the hospital in emergency situations (via 911 and an ambulance).

During an interview on 08/01/24 at 1:26 PM, Licensed Vocational Nurse (LVN) 3 stated nurses filled out the transfer/discharge notice with emergent transfers to the hospital. LVN3 stated the resident did not receive a copy of the notice; the notice went to the hospital and to the ombudsman.

During an interview on 08/02/24 at 4:35 PM, the Director of Nursing (DON) stated the discharge notice was not provided in writing to the resident or RP when a resident was transferred emergently to the hospital.

The DON stated a call would be placed to the RP; however, the notice was not provided in writing.

The DON stated there was no process in place for providing written transfer/discharge notices for emergent hospitalizations.

The DON stated R99's family member was notified via a phone call of R99's transfer to the hospital.

The DON verified R99 was her own RP.

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

Review of R102's ''admission Record,'' located in the EMR under the ''Profile'' tab, included an original admission date of 09/17/22 and most recent readmission on [DATE]. R102's primary diagnosis was myocardial infarction.

Review of R102's ''Clinical Census,'' located in the EMR under the ''Census'' tab, indicated on 03/08/24 a hospital leave with readmission on [DATE].

Review of R102's ''Progress Note'' located in the EMR under the ''Progress Note'' tab and dated 03/08/24 included transfer to the ED for diarrhea, coffee ground emesis, high blood pressure, and anxiety.

No documentation was located in the EMR indicating a bed hold notice was provided to the resident or representative.

During an interview on 08/01/24 at 3:15 PM, the DON confirmed that R102's hospitalization from 03/08/24-03/12/24 did not a include a bed hold notification but should have.

Review of the facility policy titled ''Bed-Holds and Returns'' revised 10/2022 indicated ''.

All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave).

Residents, regardless of payor source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer . and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours) .''

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

During an interview on 08/01/24 at 10:47 AM, the Social Services Director (SSD) confirmed R95 had a positive PASARR Level I screening dated 12/13/23.

The SSD stated the normal process was for the PASARR office to call the facility during the week, the determination letter was dated 12/17/23 which was a Sunday, and she felt that maybe the nurses on duty did not have access to the PASARR information.

During an interview on 08/01/24 at 11:28 AM, the Director of Nursing (DON) confirmed R95 had a positive PASARR Level I screening dated 12/13/23.

The DON stated the state of California contracted with a company of psychologists that followed-up with PASARR Level II's.

This process usually occurred during the week and the DON or Assistant DON would assist with the process.

The DON stated she was not employed at the facility in 12/2023 and was not sure why the PASARR Level II letter dated 12/17/23 indicated that the resident was ''unable to participate in the evaluation.'' The DON confirmed the facility did not have a process in place to ensure that follow-ups were completed but should have been.

During an interview on 08/01/24 at 1:26 PM, the PASRR Manager reviewed internal documentation that indicated the Level I screening was submitted by Registered Nurse (RN) 1 on 12/13/23.

The normal process was for the contracted PASRR staff to contact the individual that submitted the Level I screening and in this particular case, the available staff that answered the phone could not answer the questions to complete the PASRR II screening.

The expectation was for the facility to submit a new Level I PASRR screening so that the Level II could be completed for determination of services needed.

During an interview on 08/01/24 at 1:51 PM, the Admissions Director (AD) stated the PASARR office did not typically notify the facility of screening results unless they spoke directly with someone at the facility. A determination letter would be uploaded to the PASARR system.

The determination letter should be followed up by the person submitting the Level I screening.

The AD was not sure why the PASARR screening was not followed up but should have been.

The AD confirmed that the facility did not have a process in place to ensure that follow-ups were completed.

Review of the facility policy titled, ''admission Criteria'' revised 03/2019 ''.

All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a.

The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process .

The social worker is responsible for making referrals to the appropriate state-designated authority. c.

Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate .

The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation.''

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

During observation in R304's room and interview on 07/30/24 at 10:00 AM, bilateral 1/4 side rails observed in the up position. R304 said that she used them sometimes to reposition.

During observation of R304's room on 07/31/24 at 3:50 PM, bilateral 1/4 side rails were observed in the up position even though R304 was sitting at the end of her bed.

Again on 08/01/24 at 8:30 AM, observed R304 lying in her bed with bilateral 1/4 side rails in the up position.

Review of admission ''Minimum Data Set (MDS)'' assessment, located under the ''MDS'' tab in the EMR, with an Assessment Reference Date (ARD) of 07/27/24 indicated a ''Brief Interview of Mental Status (BIMS)'' score of 14 out of 15, indicating intact cognition.

Review of ''Side Rail Assessment,'' located under the EMR ''Evaluation'' tab and dated 07/22/24, revealed the side rails were used to promote independence.'' Review of ''Physician Order,'' dated 07/22/24, located under the EMR ''Orders'' tab, indicated ''Side rail 1/4 X 2 up in bed as enabler to assist with bed mobility- nonrestraint.'' Review of ''Baseline Care Plan,'' located under the ''Evaluation'' tab, dated 7/23/24 indicated no evidence of side rails being used for positioning.

During an interview on 08/02/24 at 10:00 AM, the Director of Nursing (DON) confirmed that the baseline care plan did not address side rails.

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

Review of R204's EMR revealed that neither the Baseline Care Plan dated 07/18/24 under the

constipation.

During an interview on 07/30/24 at 2:15 PM, R204 stated he had been extremely sick when he was admitted to the facility due to COVID 19 and had not felt like eating or drinking much. R204 stated he was tired and did not want to be interviewed further.

During an interview on 08/01/24 at 1:43 PM, Assistant Director of Nursing (ADON) 1 stated the bowel protocol called for MOM was to be administered after 72 hours (three days) if a resident failed to have a bowel movement. ADON1 stated if MOM did not result in a bowel movement, then the Dulcolax suppository was given the next shift, and then if that did not work a fleets enema was given the next shift. ADON1 reviewed R204's record and confirmed the bowel protocol was initiated on the fifth (07/22/24) day instead of on the third day without R204 having a bowel movement.

During an interview on 08/01/24 at 5:32 PM, the Director of Nursing (DON) stated MOM should be given if a resident went three days without a bowel movement.

The DON stated if MOM did not produce a bowel movement, the suppository should be given on the next shift and if that did not produce a bowel movement, the enema should be given on the next shift.

The DON stated the managed care provider had contacted the facility and requested they conduct an investigation into the failure to institute the bowel protocol timely.

The DON stated the investigation revealed that the bowel protocol was not initiated timely.

The DON stated there were alerts in the EMR that prompted nurses that R204 failed to have a bowel movement and was due for initiation of the bowel protocol.

The DON stated the EMR flagged R204's failure to have a bowel movement after three days.

The DON stated the floor nurses had not initiated MOM for two days (on 07/20/24 and 07/21/24) even though a failure to have a bowel movement was flagged in the EMR for R204.

During an interview on 08/02/24 at 5:05 PM, the DON verified there was no care plan initiated to address R204's constipation.

The DON stated nurses should add acute problems that arose prior to the due date for developing a comprehensive care plan of 21 days after admission.

The DON stated an episodic care plan should have been opened to address constipation for R204.

A constipation/bowel policy was requested on 08/01/24; no policy was provided as of the survey exit on 08/02/24.

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

of status.

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

not receive medications that are not clinically indicated to treat a specific condition .

Psychotropic

orders for psychotropic medications are limited to 14 days . If the prescriber or attending physician

rationale for extending the use and include the duration for the PRN order .

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

Based on interview and facility assessment reviews, the facility failed to create and implement a

of its residents which had the potential to affect 161 residents residing in the facility.

Findings include: Review of the ''SNF/NF [Skilled Nursing Facility/Nursing Facility] Capabilities List'' dated 07/2021 was not a comprehensive Facility Assessment.

Review of the ''Facility Assessment Tool'' provided by the facility and updated 07/30/24.

During an interview on 08/02/24 at 6:04 PM with the Administrator confirmed that the current ''Facility Assessment'' dated 07/30/24 was updated and created after the surveyors entered the facility on 07/30/24.

Additionally, the Administrator provided ''SNF/NF [Skilled Nursing Facility/Nursing Facility] Capabilities List,'' dated 07/2021, which he stated was a ''snapshot'' of what the facility was able to provide.

The Administrator was unable to provide annual ''Facility Assessments'' for 2020, 2021, 2022, and 2023.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

Findings included: Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program'' revised 04/2014 included, ''.

Establishing a QAPI Plan that guides quality efforts and serves as the main document that supports the QAPI implementation .

Providing frequent leadership and staff training on the QAPI plan and its underlying principles, including the concept that systems of care and business practices must support quality care or be changed .'' Review of facility documents revealed the facility did not have a QAPI Plan.

During an interview on 08/02/24 at 6:04 PM, the Administrator confirmed the facility did not have a QAPI Plan.

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

audits in May 2024, however confirmed that audits were incomplete.

bed hold audits had not been completed per the facility's current PIP but should have been.

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program'' revised 04/2014 and provided by the facility did not include QAPI attendance expectations.

Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program- Analysis and Action'' revised 03/2020 and provided by the facility did not include QAPI attendance expectations.

During an interview on 08/02/24 at 6:04 PM, the Administrator confirmed that QAPI meetings were held at a minimum every quarter and that all meetings should include an Administrator, DON, Infection Preventionist (IP), and Medical Director (MD).

The Administrator confirmed that for the third and fourth quarters of 2023 the MD did not attend QAPI meetings, and for the first quarter of 2024 neither the IP or MD were in attendance but should have been.

555118 08/02/2024

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

During an observation and interview on 08/02/24 at 3:24PM with LVN2, R79 was lying in bed with the

LVN2 confirmed the urinary collection bag was on the floor, should have been in a dignity bag, and off the floor due to risk for infection.

During an interview on 08/02/24 at 5:40 PM, DON stated it was her expectation that urinary collection bags be in a dignity bag and kept off the floor due to risk for infection.

Review of the facility's policy titled, ''Catheter Care, Urinary'' revised 08/2022 indicated ''The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections . Be sure the catheter tubing and drainage bag are kept off the floor .''

During an observation on 07/30/24 at 1:32 PM, the Restorative Nursing Assistant pulled back the covers in the bed over R203's left hand and the bandage/sock combination was in place.

The Restorative Nursing Assistant stated she did not know why R203 had the bandage/sock combination in place.

Review of the Care Plan, dated 07/26/24 and located in the EMR under the Care Plan tab, revealed a problem of ADL self-care performance deficit r/t [related to] weakness/decreased mobility, dx [diagnosis] of acute encephalopathy, DM [diabetes mellitus], dysphagia [swallowing disorder], hx [history] of CVA [cerebrovascular accident or stroke].

The Care Plan did include application of a sock to R203's hand and did not identify restraint use.

During an interview on 07/31/24 at 3:42 PM, CNA2 stated she had not applied a sock to R203's hand and had not seen this. CNA2 stated R203 had previously unfastened his incontinence brief on one side and then urinated in the bed, soiling the bedding and that was likely why he had something applied to his left his hand. CNA2 stated R203 was confused and dependent for care.

During an interview on 08/01/24 at 1:18 PM, LVN3 (the wound care nurse) stated she was not aware of R203 wearing a sock on his left hand and further stated he should not be wearing one. LVN3 stated R203 had one skin tear to his forearm that had a dry dressing applied; however, she was not aware of other skin issues to his arms or scratching. ADON1, who was present, stated the sock would prevent R203 from accessing his body and there should be a physician's order for something like that.

During an interview on 08/02/24 at 3:35 PM, LVN5 stated she was R203's nurse on 07/30/24 during day shift. LVN5 stated she was notified by the day shift CNA around 6:30 AM on 07/30/24 that R203 had a sock on his left hand. LVN5 stated she had not been aware of the sock being there prior to that day. LVN5 stated there was nothing in report about the sock and she asked the night shift nurse about it and was told the night shift nurse did not know about it. LVN5 stated she meant to go and check on the application of the sock on R203's left hand but got busy, and when she went to give R203 medications, his arm was covered with the bedding and she forgot. LVN5 stated she was not aware of a reason for the application of the sock. LVN5 stated R203 was anxious at times and placed his hand in his incontinence brief and rubbed himself. LVN5 stated R203 was not able to put the sock on his hand and would not be able to remove it either.

During an interview on 08/02/24 at 3:32 PM, the hospice LVN stated she had never seen a sock on R203's hand and there were no directions from hospice that would warrant it.

The hospice LVN stated R203 would not have been able to put the sock on himself and did not think he could remove it.

The hospice LVN stated R203's sister stated he was putting his hand in his brief and was fidgeting in that area.

555118

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555118 B.

Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

During an interview on 08/01/24 at 3:15 PM, the DON confirmed the facility had a PIP in place for ensuring Bed Hold notifications were provided to residents or their responsible parties.

The DON confirmed the PIP included conducting audits for bed hold notifications, which she was not able to provide.

During an interview on 08/02/24 at 3:01 PM, ADON1 stated she was aware of the PIP for bed holds but had not been conducting audits herself, because this was being done by Medical Records.

555118

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555118 B.

Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350