PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT O F HEALTH AN D HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-039 1 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MU LTIPLE CONSTRUCTION NAME OF PROVIDER OR SUPPLI ER STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF (X4) ID CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FU LL REGULATORY OR LSC IDENTIFYING INFORMATION) 1 I R-C 11/14/2017 B. WING _ __ _ _ _ _ _ __ 555221 PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ _ __ I ID PREFIX TAG I I I I I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I {F 000} I INITIAL COMMENTS r I COMPLETION (XS) DATE I I {F 000} I 1 I The following reflects the findings of the California Department of Public Health during a recertification revisit survey conducted from 11/13/17 to 11/14/17. I Representing the Department: 22705, Health I Faciliti es Evaluator Nurse (HFEN ); 38368, HFEN ; 29582, Health Facilities Evaluator Supervisor (HFES), and 31709, HFES. 1 I Entity reported incidents (ERi ) 553969, 555678 , I1 557894, 557085, 559492, and complaint 559265 were investigated during the revisit survey. Deficiencies were written for ERi 553969 and 555678 at F 226. Deficiencies were written for ERi 559492 at F 226 and F 431. I Deficiencies were written for ERi 557085 and complaint 559265 at F 334 and F 44 1. 1 I There were no deficiencies written for ERi 557894. : Census: 17 Sample: 6 {F 157} NOTIFY OF CHANGES SS=D (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.1 0(g)(14) { F 157} I i (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify , consistent with his or her authority, the resident representative(s) when there is- I I 1 (A) An accident involving the resident which l results in injury and has the potential for requiring I ~ I LABOflATOR.)" DIRECTO~'S OR PROVIDI RISUPPLIER REPRESENTATIVE'S SIGNATURE Ji ( L TITLE (X6) DATE I >'F ._}Ji/\__ \/v.. d. fl i A frV 0 Any de~ciency statem1 ,~t ending Wifn a asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that othe afeguards provi vi sufficie nt prate ion to the patients. (See instructions.) Except for nursing homes .. the findings stated above are disclosable 90 days follo wing the date of survey whether or not a plan of correction is provided . For nursing homes, the above findings and plans of correction are d1sclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited , an approved plan of correction is requ isite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete II /-z-ci I I/ Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 1 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECT ION OM8 NO 0938-0391 (X1) PROVIDER/SUPPLI ER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION R-C 11/14/2017 B. WING _ _ _ _ _ _ _ _ __ 555221 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL DIP SNF (X4) ID I PREFIX TAG I (X3} DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {F 157} Continued From page 1 I (XS) 'I COMPLETION DATE {F 157} physician intervention; \ (8) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); I (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1 )(ii). I (ii) When making notification under paragraph (g) (14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. ' (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (8) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. 1 (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 I Facility ID: CA230000144 If continuation sheet Page 2 of 36 PRI NTED: 11 /20/2017 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEA LTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICA ID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BU ILDING - - - - -- - - STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLI ER 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF TAG I CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENC IES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REG ULATORY O R LSC IDENTIFYING INFORMATION) I I R-C 11/14/2017 B. WING _ _ _ _ _ _ _ _ __ 555221 ( X4) ID PREFIX (X3) DAT E SURVEY COMPLETED I I {F 157} Continued From page 2 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO T HE APPROPRIATE DEFICIENCY) ID PREFIX TAG 1 (X5) COMPLETION DATE I {F 157} 1 Based on observation, interview, and record I review, the facility failed to inform the physician of the need for a podiatry (foot doctor) referral for 1 one of six sampled residents (Resident 1) when I her toenails were thick, long, and ragged. I , This fa ilure had the potential to cause Resident 1 ' I discomfort during ambulation. I I Findings: I A review of Resident 1's record indicated that she was admitted to the facility on 11/2/15 with diagnoses that included dementia with behaviors and chro nic hip pain. A review of the Minimum Data Set (MOS, a standardized reside nt I1assessment), dated 8/11/17, ind icated that Resident 1 was cognitively impaired and required supervision with her Activities of Daily Living (daily self-care activities). 1 I During an observation on 11/14/17 at 4 pm, Resident 1 wore open-toed shoes and the res ident's toenails were thick, long, and ragged. On 11 /14/17 at 4 pm, during a concurrent 1 interview and record review, Licensed Nurse (LN) F acknowledged Resident 1's toenails had not ! been trimmed and that several of her toenails were thick and long. LN F stated Resident 1's I toenails requ ired trimming by a pod iatrist due to 1 possible fungus . After review of the record, LN F stated Resident 1 had not been seen by a podiatrist in the past two months and acknowledged that there were no referrals or recent orders for her to be seen. {F 226} DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC SS=E POLICIES i I FORM CMS-2567(02-99) Previous Versions Obsolete {F 226) 1 Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 3 of 36 PRINTED: 11 /20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT O F DEFICIENCIES A ND PLAN OF CORRECT ION OMB NO 0938-0391 (X 1) PROVIDER/SUPPLI ER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ __ __ R-C 11/14/2017 B. WI NG _ _ _ _ _ __ _ __ 555221 NA ME OF PROV IDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CO DE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF CEDARVILLE, CA 96104 SUMMA RY STAT EMENT O F DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFY ING INFORMATION) (X4) ID PRE FIX TAG (X3) DATE SURVEY COMPLETED _ PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIAT E DEFICIENCY) ID PREFIX TAG {F 226} Continued From page 3 CFR(s): 483.12(b)( 1)-(3), 483.95(c)(1 )-(3) (X5) COMP LETION DATE {F 226} 1483.12 I (b) The facility must develop and implement ! written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neg lect, and exploitation . In add ition to ! the freedom from abuse, neglect, and exploitation requirements in§ 483.12 , facilities must also provide training to their staff that at a min imum educates staff on- I (c)( 1) Activities that constitute abuse, neg lect, exploitation, and misappropriation of resident property as set forth at§ 483. 12. (c)(2) Procedu res for reporting incidents of abuse, neglect, exploitation , or the misappropriation of resident property I I (c)( 3) Dementia management and resident abuse prevention. I , This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement its abuse policy when: ' 1. Two resident to resident altercations were not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 4 of 36 PRINTED : 11 /20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STAT EMENT OF DEFICIENCIES A ND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVID ER/SUPPLIER/CUA IDENTIFICAT ION NUMBER: (X2) MULTIPLE CO NSTRUCTION NA ME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CO DE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATO RY OR LSC IDENTIFYING INFORMATION) I CEDARVILLE, CA 96104 I I {F 226} Continued From page 4 1 R-C 11/14/2017 B. W ING _ _ _ __ _ _ _ __ 555221 (X4) ID I PREFIX TAG ' (X3) DAT E SURVEY CO MPLETED A. BUILDING _ _ _ __ _ __ PROVI DER'S PLAN OF CORRECT ION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE A PPROPRIATE DEFICIENCY) ID PREFIX TA G (X S) COMPLETION DATE {F 226} thoroughly investigated for four of six sampled residents (Residents 2 and 4, and Residents 5 and 7). 2. An injury of un known origin was not thoroughly investigated for one resident outside the sample (Resident 9) when Resident 12 sustained skin tears and bruises to her right arm. 3. Prior employment was not verified for two of five newly hired staff, and licenses were not verified for two of five newly hired staff. I 4. An unusual occurrence involving an employee's job performance was not thoroughly investigated . , These failures had the potential to result in recurring injuries and to expose the residents to abuse. Findings: , The facility's "Elder Abu se" policy and procedure, dated 6/4/14, was reviewed. The policy read, " Investigation: Initiate steps to protect the 1 resident, ensuring safety and comfort, document ' time this was implemented on the Investigation Statement form . 1. When abuse, m istreatment, neg lect, or injuries of unknown origin of a resident is observed by, reported to, or suspected of any employee at this facility , staff immediately notifies their supervisor on duty. The supervisor assumes responsibi lity for taking the following steps during the investigation .... A. Immediately notify the Director of Nurses and/or Administration/HR in person or by telephone. B. Immediately investigate alleged incident during ' the shift on which the alleged abuse occurred . FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA2300001 44 If continuation sheet Page 5 of 36 PRINTED: 11/20/2017 FORM APPROV ED DEPARTM ENT OF HEALT H AND HUMAN SERVICES C ENTERS FOR MEDI CARE & MEDICAID SERVIC ES STATEMENT OF DEFICI ENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1} PROVIDER/SUPPLI ER/CUA IDENTIFICATION NUMBER: (X2} MULTIPLE CONSTRUCTION 555221 STREET ADDR ESS , CITY, STATE, ZIP CO DE 741 N. MAIN STREET S URPRISE VALLEY COMMU NITY HOSPITAL D/ P SNF (X4) ID PREFIX TAG CEDARVILLE, CA 961 04 SU MMARY STAT EMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PREC EDED BY FULL R EGULATORY OR LSC IDENTIFYI NG IN FORMATION) I R-C 11 /14/201 7 B. W ING NAME OF PROVI DER OR SUPPLIER I (X3) DATE SURVEY COMPLETED A. BUILDING PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENC ED TO THE A PPRO PRIATE DEFICIENCY) ID PREFIX TAG I (XS) COMPLETION DATE I {F 226} Continued From page 5 { F 226} Obtain written statements from all employees present, any parties involved and have them sign and date. Written statements should include facts , conversations and observations... 2. I Interview the resident or other witnesses. T his interview is to be dated, documented and signed by the witness and/or victim if able and the supervisor. 3. G ive all completed forms to the Director of Nursing who then reports to the adm inistrator .... " I 1a. On 9/20/17 , the faci lity reported to the California Department of Public Health (CDPH) ' , that a resident to resident altercation had taken place on 9/20/17. The report ind icated Resident 4 had wandered into Resident 2's room and that I Resident 2 threw a glass of water on Resident 4. I ' i I I I Resident 4's reco rd was review ed and indicated I she was adm itted to the facility on 8/21 / 15 with diagnoses that included Alzheimer's disease (memory loss). A review of a nurse's note , dated 9/20/17 at 10 am , ind icated Resid ent 2 threw a glass of w ater on Resident 4 when she wandered , in her merry walker (ambulation device), into his room. IA review of a nurse's note, dated 9/26/ 17, I ind icated that on 9/2 5/17 at 11 am , Resident 4 ' was cornered by Residents 2 and 7 and that kept Resident 4 from moving her merry w alker. T he note indicated Resident 7 kic ked Resident 4's merry walker while Resident 2 blocked her. II II A review of the record revealed no further documentation regard ing the incidents or that a thorough investigation had taken place in order to I prevent recu rrence and ensure Resident 4's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 I 1 I Facility ID: CA230000144 If continuation sheet Page 6 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STAT EMENT OF DEFICIENCIES AND PLAN O F CO RRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CU A IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDI NG _ _ _ _ _ _ __ B. W ING _ _ _ __ _ _ __ 555221 NA ME OF PROVIDER OR SUPPLIER I R-C 11/14/2017 _ STREET ADDRESS, CITY, STAT E, Z IP CO DE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF (X4) ID PREFIX TAG (X3) DAT E SURV EY COM PLET ED CEDARVILLE, CA 96104 SUMMARY STATEMENT O F DEFICIENCI ES (EACH DEFICIENCY M UST BE PRECEDED BY FULL REGULATORY O R LSC IDENTI FYING INFORMATION) I ID PREFIX TAG {F 226} Continued From page 6 {F 226} PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE A PPROPRIATE DEFICI ENCY) (XS) COMPLETION DATE I safety when she wandered into other residents' Irooms, placing her at risk for harm. , 1b. On 10/4/17, the facility reported to the CDPH that a resident to resident altercation had taken place on 10/3/17. The report indicated Resident 7 would not let Resident 5 get by in the hallway. I A review of a nurse's note, dated 10/4/17 (no time), indicated Resident 5 was being physically harassed by Resident 7. I ! . A review of the record revealed no further 1 , documentation regarding the incident or that a thorough investigation had taken place in order to I prevent recurrence and protect Resident 5 from I 1 abuse. I Du ring an interview on 11 /13/17 at 2 pm , the 1 I Nu rse Manager (NM) was asked about the resident to resident altercations that had taken place on 9/20/17 and 10/3/17, and for documentation related to the facility's investigations of the incidents. The NM was unable to provide the requested documentation and stated there was none. The NM confirmed no investigations had been conducted . 2. Resident 12's record was reviewed and ind icated she was admitted to the faci lity on j 1/17/08 with diagnoses that included dementia (a ' ~ decline in mental ability severe enough to I interfere with daily life) , osteoarthritis (joint pain J and stiffness), chronic pain , and depression . 1 A review of a nurse's note, dated 9/26/17 at 7:15 ' am, indicated Resident 12 sustained a skin tear to her right upper arm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 7 of 36 PRINTED: 11/20/2017 FORM APPROVED D EPARTMENT OF HEALTH AND HUMAN SERVICES C ENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICI ENCIES A ND PLAN OF CORRECT ION OMB NO 0938-039 1 (X1 ) PROVIDER/SUPPLIER/CUA IDENT IFICATION NUMBER: (X2) MULTIPLE CONSTRUCT ION 555221 R-C 11/1 4/2017 B. WING NAME OF PROVIDER OR SUPPLIER STREET A DDRESS, CITY, STATE, ZIP CODE 741 N . MAIN STR EET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYI NG INFORMAT ION) (X4) ID P REFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING l I { F 226} 1 Continued From page 7 I , A review of a nurse's note, dated 9/30/17 at 10:30 pm , ind icated Resident 12 sustained a skin tear to her right forearm . PROVIDER'S PLAN O F COR RECTION (EACH CORRECTIVE ACT ION SHOULD BE CROSS-REFERENC ED TO THE A PPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE {F 226} I 1 A review of a Skin Problem Assessment Form (Skin Tear), dated 9/3 0/17, indicated Resident 12 had a 24 millimeter skin tear and three bruises on her right forearm . I Fu rther review of the record revealed no documented evidence that an investigation into the cause of Resident 12's skin tears had taken place to ensure abuse was not occurring. I During an interview on 11/14/17 at 12:45 pm , the Director of Nursing (DON) acknowledged there I was a lack of documentation related to the I investigations of injuries. I I During an interview on 11 /14/17 at approximately 3 pm , the ~urse Manager (NM ) stated there was 1 no system in place to ensure follow up : investigations had taken place and no j Interdisciplinary Team meetings were being held. The NM acknowledged this had the potential to result in further injury and abuse. I 1 I 3. The faci lity's "Elder Abuse" policy and procedure read , "Screening Procedures: [The faci lity] will follow the screening policy process for all potential hires to ensure the new employee is j appropriate for employment. The Human Resources Manager will attempt to contact I current employers and/or previous employers on all applications considered for hiring. Notations regarding information received wil l be made on the application next to the appropriate employer listing ." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 I !I Facility ID: CA230000144 If continuation sheet Page 8 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION R-C 11/14/2017 B. WING _ _ _ _ _ _ _ _ __ 555221 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING - - - - - - - - ID PREFIX TAG I I I {F 226} I I {F 226} Continued From page 8 Additionally, the Elder Abuse policy read , "All applicants for positions requiring licensure will be subjected to clearance with the appropriate State I Agency to ensure freedom from criminal conduct." 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE On 11/13/17 at4 :30 pm, during a concurrent interview and review of employee files, the Human Resources Manager (HRM) stated criminal background checks included verification of prior employment and licensure. The HRM , confirmed that prior employment was not verified I for one of five employees who had been hired within the past four months, and that another employee's prior employment was not verified until nine days after her date of hire. The HRM stated that the license for one of five newly hired employees was verified but not documented, and that another employee's license had not been verified since 10/14/15, when she was previously employed. The HRM stated the facility had 30 I days from the date of hire to obtain the verifications and acknowledged that this could result in a new employee working with residents prior to having a completed criminal background I check. I 4. On 11/2/2017 at 1:30 pm, the facility reported to CDPH (California Department of Public Health) that Licensed Vocational Nurse (LVN) 0 had been terminated due to two incidents of coming to work under the influence/altered and they suspected that she may have taken some narcotics. ! I I 1 I 1 The 1 facility's "Employee Handbook," revised 10/25/17, Section 701 titled "Employee Conduct and Work Rules," The following are examples of infractions of rules of conduct which violates our FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 9 of 36 PRINTED : 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STAT EMENT OF DEFICIENCI ES AND PLAN O F CORRECTION OMB NO 0938-0391 (X1) PROVIDERISU PPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING - - - - - - - B. W ING _ __ 555221 NAME OF PROVIDER OR SU PPLIER _ _ _ _ __ R-C 11/14/2017 _ STREET ADDRESS, CITY, STAT E, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF SUMMARY STATEMENT OF DEFICI ENCI ES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY O R LSC IDENTIFYING INFO RMATIO N) (X4) ID I PREFIX TAG (X3) DATE SURVEY COMPLETED CEDARVILLE, CA 96104 II I I ID PREFIX TAG I 1 I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOU LD BE CROSS-REFERENCED TO T HE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE I I {F 226} Continued From page 9 policy and will not be tolerated: Working under the influence of alcohol or illegal drugs, I unsatisfactory performance or conduct. LVN O's employee file was reviewed , it contained a note dated 11 /3/17, referencing an incident that occurred on 9/14/ 17 written by another LVN . The note described that LVN 0 came into work an hour late, had her scrub top on inside out which she took off and put on correctly in a public room . The note described that LVN 0 had a blank look on her face and took a long time to respond when spoken too. LVN 0 was sent home by the Director of Nurses. {F 226} i I ' i There was no other documentation in the Iemployee file about the 9/14/17 incident. LVN O's employee file contained a typed note dated 10/30/17 that referenced an incident that occurred on 10/26/17. The note documented that various members of the staff had thought that LVN 0 was impaired physically and mentally, ; when asked questions her answers did not logically correspond with the question , that her balance was contorted, and that she had severely movements when attempting to completing slow I task. I 1 1 I I LVN O's file containe d one "Written Counseling Memo," dated 10/30/17. T he Memo described an incident that had occurred on 10/26/17. The Memo stated that the LVN O had appeared incoherent, possibly under the influence , wh ich I impaired you r ability to perform your duties. The memo noted "This kind of behavior jeopardizes the health and safety of our residents." The Memo was completed by the Nurse Manager (NM). I I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 10 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STAT EMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING - - - - - - - - R-C 11/14/2017 B. WING _ _ _ _ _ _ _ _ __ 555221 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 741 N . MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCI ES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIAT E DEFICIENCY) ID PREFIX TAG { F 226} Continued From page 10 (X5) COMPLETION DATE {F 226} On 11 /13/17 at 1:45pm, during an interview the Administrative Assistant (AA) confirmed that she had sent the report to CDPH office. AA stated that she had reported both incidents. The AA confirmed that LVN 0 had been sent home after ' the 9/14/17 incident. The AA confirmed that the facility suspected that LVN 0 may have taken 1 resident narcotic medication that was discovered , missing on 10/5/17. The AA confirmed that there was no other investigation, counseling notes or interventions put into place after the 9/14/17 incident. The AA confirmed that the investigation 1 : for the missing narcotic was incomplete and 1 I stated that they do not drug test staff. The AA confirmed that LVN 0 was terminated after the 10/26/17 incident. On 11 /14/17 at 10:10 am, during an interview the Nurse Manager (NM) confirmed that LVN 0 . worked seven days in 9/17 and 11 days in 10/17. The NM confirmed that normally, that there is one registered nurse taking care of acute patients at one station and one nu rse on the other station 1 providing care for the skilled nursing residents. 1 1 The NM confirmed that LVN 0 did not have direct oversite while providing care to the skilled nursing residents . The NM confi rmed that LVN 0 was I terminated on 10/3 1/17 because they were concerned about the health and safety of the resident. {F 281} SERVICES PROVIDED MEET PROFESSIONAL SS=D STANDARDS CFR(s): 483.21 (b)(3)(i) J I I {F281} 1 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA 230000144 If continuation sheet Page 11 of 36 PRINTED: 11 /20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES C ENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MU LTIPLE CONSTRUCTION B. WING _ _ __ 555221 NAME OF PROVIDER OR SUPPLIER R-C 11/14/2017 _ _ _ _ __ STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUN ITY HOSPITAL D/P SNF CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BU ILDING - - - - - - - - PROVIDER'S PLAN OF CORRECTION (EAC H CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {F 281} Continued From page 11 (XS) COMPLETION DATE {F281} as outlined by the comprehensive care plan, . must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide services that meet professional standards for one of 8 sampled 1 residents (Resident 3), when bowel care was not 1 provided to the resident when clin ically indicated. I Th is had the potential to result in severe pain and medical complications . Findings: i A review of Resident 3's record indicated that she was admitted to the facility on 4/21/14 with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life), diabetes, and high blood pressure. The most recent Min imum Data SET (MOS, a standardized comprehensive assessment of each resident's functional capabilities that helps nursing staff identify health problems) dated 11 /3/17, was reviewed and indicated that Resident 3 was cognitively (the mental process of th inking , understanding , reasoning , and decision making) impaired and required maximum assistance with Activities of Daily Living (AOL's , self-care activities). I A review of the facility documentation of Resident I. 3's bowel movements, on 11 /14/17 at 9:30 am , : indicated that Resident 3 had last had a bowel movement (BM) on 11 /9/17. A review of the facility policy titled Bowel Care, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJ IP12 Facility ID: CA230000144 If continuation sheet Page 12 of 36 PRINTED: 11 /20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-039 1 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _ B. W ING _ 555221 NA ME OF PROVIDER OR SUPPLIER I (X3) DATE SURVEY COMPLETED _ _ _ _ __ R-C 11/14/2017 _ _ _ _ _ _ _ __ STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF (X4) ID P REFIX TAG _ CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENC IES (EACH DEFICIENCY M UST BE PRECEDED BY FU LL REGULATORY O R LSC IDENTIFYING INFORMATIO N) I ID PREFIX TAG I {F281} Continued From page 12 revised 7/26/17, indicated, "If no BM in 3 days give Milk of Magnesia [medication used to treat constipation] 30 cc at AM [morning)." Any bowel movement greater than 3 days shall be reported to the Director of Nursing (DON) and the bowel protocol shall be implemented ." PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION S HOU LD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIC IENCY) {XS) COMPLETION DATE {F281} 1 i A review of Resident 3's Med ication [ Admin istration Record (MAR) for 11 /2017, indicated that Resident 3 had not received any bowel care medication, per the facility protocol II and Physician order. I During an interview, on 11/14/17 at 3:30 pm, the Director of Nursing (DON) confirmed that Resident 3 should have been given medication •. for bowel care per the facility protocol. {F 333} 1 RESIDENTS FREE OF SIGNIFICANT MED SS=D ERRORS CFR(s): 483.45(f)(2) {F 333} I 483.45(f) Medication Errors. 1 The facility must ensure that its- I (f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced I by: Based on interview and record review, the facility failed to prevent a significant medication error for one of eight sampled residents (Resident 3). The physician ordered antibiotics to treat an infection and the medication was not given in a timely manner. 1 This had the potential to lead to life threatening infection and a decline in health of Resident 3. FORM CMS-2567(02-99) Previous Vers ions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 13 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STAT EMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILD I N G - - - - - - - B. WING _ _ _ _ _ _ _ __ 555221 NAME OF PROVIDER OR SUPPLIER I TAG I R-C 11/14/2017 _ STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF (X4) ID : P REFIX (X3) DATE SURVEY COMPLETED CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE I {F 333} Continued From page 13 {F 333} Findings: A review of Resident 3's record indicated she had been admitted to the facility on 4/21/14 with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily I life), diabetes and high blood pressure. I ' A review of the Medication Administration Record (MAR) and physician's orders indicated a physician's order at 6:55 pm on 9/22/17 for I Septra OS (an antibiotic typically used to treat 1 urinary tract infection) one time a day for seven , days. Resident 3 did not receive the first dose of medication until 9/23/17 at 8:00 am . A review of the facil ity's Policy and Procedure for Noting a Doctor's Order and Ordering of Med ication , indicated, "whenever a medication has been ordered by a physician and it will not be available within 2 hours form the time of the order 1 it is the nurse on duty responsibility to notify the ; ordering physician that the ordered medications J : are not available, obtain a new medication order that may be comparable and available or have the medication discontinued by the physician." 1 1 During an interview on 11 /14/17 at 3:30 pm, the Director of Nurses (DON) confirmed Resident 3's antibiotics were delayed because of pharmacy delivery issues. The DON implemented a new delivery system, but acknowledged that timely 1 medication administration was a problem at the facility. {F 334} INFLUENZAAND PNEUMOCOCCAL SS=D IMMUNIZATIONS CFR(s): 483.80(d)(1)(2) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP1 2 {F 334} Facility ID: CA230000144 If continuation sheet Page 14 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STAT EMENT OF DEFICIENCIES AN O PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION R-C 11/14/2017 B. WING _ _ _ _ _ _ _ _ __ 555221 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICI ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID P REFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ _ __ PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE {F 334} {F 334} Continued From page 14 i (d) Influenza and pneumococcal immunizations ' I ' (1) Influenza. The facility must develop policies and procedures to ensure thati I (i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each residen t is offered an influenza immunization October 1 throu gh March 31 annually, unless the immunization is medically 1 , contraindicated or the resident has already been immunized du ring this time period; · I 1 (iii) The resident or the resident's representative i has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicates , at a m inimum , the 1 following: I (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and I (B) That the resident either received the influenza immun ization or did not receive the influenza immun ization due to medical contra indications or refusal. (2) Pneumococcal disease . The facility must develop policies and procedures to ensure thatI (i) Before offering the pneumococcal I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJ IP12 Facility ID: CA230000144 If contin uation sheet Page 15 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AN D HU MAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1 ) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION NAME OF PROVI DER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUN ITY HOSPITAL D/P SNF (X4) ID I I R-C 11/14/2017 B. W ING _ _ _ __ _ _ _ __ 555221 PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUI LD I N G - - - - - - - - - CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {F 334} Continued From page 15 immunization , each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (X5) COMPLETION DATE {F 334} (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has . already been immunized; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicates, at a minimum , the following: 1 (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and ! (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. This REQUIREMENT is not met as evidenced by: I Based on interview and record review the facility ; failed to ensure that 4 of 4 residents (Resident 5 and out-of-sample Residents 9, 10, and 11 ) were 1 given or offered influenza (flu) vaccines when the ; vaccines were readily available in the facility and ' the facility policy incorrectly identified the start of [ flu season as November 1 instead of October 1. I This had the potential for the unvaccinated residents to develop influenza. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 16 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X 1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF (X4) ID PREFIX TAG I R-C 11/14/2017 B. W ING _ _ _ _ _ _ _ _ __ 555221 1 (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ __ _ __ CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REG ULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EAC H CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO TH E APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE I {F 334} ! Continued From page 16 {F 334} Findings: a. On 10/16/ 17, the California Department of Public Health (CDPH) received a letter, faxed from the facility, wh ich ind icated the facil ity had a respiratory outbreak, which started on 10/13 and 10/14/17, affecting five residents. On 10/17/17, CDPH received an updated list from the facility which indicated 12 residents were affected, three of which had tested positive for the flu . The facility policy titled "Immunizations", dated 5/31 /17, was reviewed and indicated, "all . residents (regardless of age) should receive influenza vaccine annually." Th is policy did not include a definition as to when flu season began or when vaccinations should occur. 1 1 \ The facility policy titled "Immunization Policy for Employees" , dated 8/4/17, was reviewed and indicated , "flu season shall mean the period of 1 time from November 1 each year through March I 31 ." During an interview on 11 /13/17 at 2:15 pm, the Licensed Vocational Nurse Manager (NM) said they did not have the flu vaccines available for residents before the outbreak. NM said the prior DON had called the company that supplies the medications for the hospital and was told they were out of flu vaccines. NM confirmed none of I the residents were vaccinated before the outbreak, except for one resident whose family 1 took her to a flu vaccination clinic where she : received the flu vaccine. This resident was not : on the list of residents who became ill. NM stated it was sometime during the outbreak before they FORM CMS-2567(02-99) Previous Versions Obsolete 1 Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 17 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES C ENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SU PPLIER/CUA IDENTIFICATION NUMBER: (X2) MULT IPLE CONST RUCTION A. BUILDING _ _ _ _ _ __ B. WING _ 555221 NAME OF PROVI DER OR SUPPLIER R-C 11/14/2017 _ _ _ _ __ _ __ STREET ADDRESS, CITY. STATE, Z IP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICI ENCIES (EAC H DEFICI EN CY MU ST BE PRECEDED BY FULL REG ULATORY O R LSC IDENTIFYING INFORMATIO N) (X4) ID P REFIX TAG (X3) DATE SURVEY COMPLETED _ I {F 334} Continued From page 17 got the flu vaccines from County Public Health. During interviews on 11 / 14/17 at 9:50 am and 10:20 am, the County Public Health Nurse (PHN ) said they were notified by the facility of several residents who had become ill with flu like symptoms who had not received the flu vaccine. She stated flu vaccines were delivered by County Public Health to the hospital on 10/19/17. PROVIDER'S PLAN O F CORRECTION (EACH CORRECT IVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIC IENCY) ID PREFIX TAG (XS) COMPLETION DATE {F 334} I I b. A list of resident names and the dates each Ireceived the flu vaccine was reviewed . There were four residents (Resident 5 and out-of-sample Residents 9, 10, and 11) who were I unaffected by the flu (it is recommended to not get a flu shot while you are ill with a fever) , but did not receive a flu vaccine until 11/1/17, even though the facil ity had received the vaccines by ! 10/ 19/17. 1 1 During an interview on 11/14/17 at 11 :10 am, NM was asked why there was a delay in giving the flu vaccine to the above referenced four residents. NM stated another nurse was supposed to give the vaccines, but vaccinated only two other residents on 10/20/17. The flu vaccines were then kept locked up by one of the night shift RN's in the pharmacy hospital medication room . Only , RN's can enter that room and the night shift RN I refused to give the vaccinations to the other residents and would not give the vaccines to other nurses so they could vaccinate the residents. { F 371} FOOD PROCUR E, STORE/PREPARE/SERVE SS=E SAN ITARY CFR(s): 483 .60( i)(1)-(3) I I I {F 371 } 1 (i)(1) - Procure food from sources approved or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJ IP12 Facility ID: CA230000144 If continuation sheet Page 18 of 36 PRINTED: 11 /20/2017 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ __ B. WING _ 555221 NAME OF PROVIDER OR SUPPLIER I R-C 11/14/2017 _ _ _ _ _ _ _ __ STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITA L D/P SNF (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED _ CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENC IES (EACH DEFICIE NCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {F 371} Continued From page 18 (XS) COMPLET ION DATE {F 371} considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or reg ulations. 1 (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the faci lity. 1 I 1 (i)(2) - Store, prepare, distribute and serve food in with professional standards for food ' service safety. 1 accordance (i)(3) Have a policy regard ing use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling , and consumption. I This REQU IREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow it's policy and procedures for food storage in the kitchen and in the resident nou rishment refrigerator when numerous food items were found to be expired or unlabelled . T his had the potential to negatively impact the health of the residents. Findings: 1. During a concurrent initial kitchen tour and interview with the Certified Dietary Manager (COM), on 11/13/17 at 1: 15 pm, a container of buttermilk with the expiration date 11/02/17, was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 19 of 36 PRINTED: 11 /20/2017 FORM APPROVED DEPARTMENT OF HEALTH AN D HUMAN SERVICES CENTERS FOR MEDICARE & MEDI CAID SERVICES STATEMENT OF DEFICIENCIES A ND PLAN OF CORRECT ION OMS NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICAT ION NUMBER: (X2) MULTIPLE CONSTRUCTION 555221 R-C 11/14/2017 B. WING NAME OF PROVI DER OR SUPPLI ER STREET ADDRESS, CITY, STATE, Z IP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/ P SNF SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FU LL REGULATO RY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DAT E SURVEY COMPLETED A. BUILDING CEDARVILLE, CA 96104 I I PROVIDER'S PLAN O F CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENC ED TO THE APPROPRIAT E DEFICIENCY) ID PREFIX TAG (XS ) COMPLETION DATE I {F 371} ] Continued From page 19 I in the walk-in refrigerator. The COM threw the , buttermilk away, confirming that it was beyond it's expiration date. ' I {F 371} 1 2. During an observation of the kitchen freezer on 11/13/17 at 1:25 pm, a bag of cooked sausage had visible ice build up inside the bag and a use-by date of 7/14/17. A bag that contained cooked roast beef was dated 6/20/ 17 and had no use-by date. The COM threw both items in the trash . The COM supplied a document, Storage of Frozen Foods from a Serving Safe Food ' Certification Coursebook. The document lists 2-3 months as a maximum storage period for leftover cooked meats. The COM stated that both meats were beyond their safe storage period and the roast beef should have had a use-by date written on the bag, per policy. 3. On 11/13/ 17 at 1:45 pm, during an observation of a kitchen refrigerator that con tained poured juices, milk and other items fo r immediate service, a staff ju ice bottle and a con tainer of 1 yogurt with an expiration date of 11/2/2017 were . noted . The C OM confirmed the yogurt had expired and that staff sometimes place their drin ks in the resi dent food areas. I I ' I ! 4. During a concurrent observation and interview on 11 / 13/ 17 at 2: 10 pm, while exam ining the contents of the resident nourishment refrigerator at the south nurses' station , outdated items were noted. A yogurt with an expiration date of 10/31 / 17, and slices of cheese and bread with the expiration date of 11 /08/17 were observed . An unlabelled bag of lettuce and a bag of lettuce with a resident's name, had no expiration date. All items were thrown away. The COM stated that it is the responsibility of the evening cook to I I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 I Facility ID: CA230000144 If continuation sheet Page 20 of 36 PRINTED: 11 /20/2017 FORM APPROVED DEPARTMENT OF HEALTH AN D HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STAT EM ENT O F DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-039 1 (X1 ) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION NAME OF PROVIDER OR SUPPLI ER ST REET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF TAG I I R-C 11/14/2017 B. W ING _ _ _ _ _ _ _ _ __ 555221 (X4) ID PREFIX (X3) DATE SU RVEY COMPLETED A. BUI LDING - - - - - - - - CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICI ENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I ID PREFIX TAG I PROVIDER'S PLAN OF CORR ECTION (EACH CORRECTIVE ACTION SHOU LD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE I I I I {F 371} ! Continued From page 20 exam ine the nourishment refrigerator and pull expired food items. She further reported that all staff knew to label all food before it went into the refrigerator and that it was to be thrown out after ' three days. I {F 37 1} I I 1 ' 1 A record review of the facility document, Policy and Procedure for Food fo r Residents from Outside of Facility, Board Approved 7/26/17 , indicates " perishable food from family members ... shall be labeled and dated when placed in the refrigerator. The item w il l be I discarded after three days." I i A facility document, Policy and Procedure for Food Storage, Board Approved 2/1 /17, indicated that all products shall be dated, labeled and rotated according to First In and First Out rule. F 431 1 DRUG RECORDS , LABEL/STORE DRUGS & SS=E BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h) F 431 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70 (g) of this part. The facility may permit I unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring , receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. {b) Service Consultation. The facility must employ or obtain the services of a licensed FORM CMS-2567(02-99) Previous Versions Obsolete I I Event ID: EJIP12 Facility ID: CA2300001 44 If continuation sheet Page 21 of 36 PRINTED : 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENC IES A ND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICAT ION NUMBER: (X2) MU LTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A BUI LDING R-C B. WING 555221 11 /1 4/2017 NAME OF PROVI DER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SURPRISE VALLEY COMMUNITY HOSPITAL D/ P SNF 741 N. MAIN STREET CEDARVILLE, CA 96104 SUMMARY STAT EMENT OF DEFICIEN CIES {EACH DEFICIENCY MUST BE PRECEDED BY FU LL REGULATORY OR LSC IDENTIFYING INFORMATION) ( X4) ID PREFIX TAG F 431 Continued From page 21 pharmacist who-1 PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE F 431 (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and I (3) Determines that drug records are in order and ' I · that an account of all controlled drugs is maintained and periodically reconciled . 1 (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when . applicable. I! I I (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature ' controls, and permit only authorized personnel to have access to the keys. I i (2) The facility must provide separately locked , permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the I quantity stored is minimal and a missing dose can ! be readily detected. This REQUI REMENT is not met as evidenced I I by: I ' Based on observation , interview, and record I review, the facility failed to ensure: I i I FORM CMS-2567(02-99) Previous Versions Obsolete I I Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 22 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION B. WING _ __ 555221 NAME OF PROVIDER OR SUPPLIER _ R-C 11/14/2017 _ _ _ _ __ STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. B U I L D I N G - - - - - - - - - CEDARVILLE, CA 96104 I I ID PREFIX I TAG I PROVI DER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE I F 431 Continued From page 22 1. An accurate process for reconciliation of controlled medications (a medications that have the potential for abuse and/or addiction, which are held under close government oversight) when an und isclosed amount of the medication Norco 1 (a narcotic, a combination of hydrocodone ' bitartrate and acetaminophen used to treat pain), was unaccounted for; I 1 2. They had a procedure for pharmaceutical services, which assure the accurate acquiring , and rece ivi ng of medications to meet the needs I of each resident when no delivery manifest was provided by the pharmacy. 1 IThese failures had the potential for medications including controlled drugs to be diverted (transfer of a legally prescribed controlled medication from the individual for whom it was prescribed to another person) for potential misuse or abuse. ! Findings: ' · 1. On 11/2/2017 at 1:30 pm, the facility reported ' to CDPH (California Department of Public Health) that an und isclosed amount of Norco was discovered missing from the medication cart on 10/5/17. On 11/13/17 at 2:10 pm, during an interview the Admin (Administrator) was asked for their report , or investigation regarding the missing Norco. The Admin stated that there was no documented investigation . The CEO stated that the facility was : plann ing to complete a root cause analysis on the missing Norco but had not started the process. I On 11/13/17 at 2:45 pm, during an interview and review of the facilities theft and loss report, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 23 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AN D HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION R-C 11/14/2017 B. WING _ _ _ _ _ _ _ _ __ 555221 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL DIP SNF CEDARVILLE, CA 96104 SUMMARY STATEMENT O F DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A BU ILDING _ _ _ _ __ __ PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I F 43 1 Continued From page 23 (XS) COMPLETION DATE F 431 10/6/17, the AA (Administrative Assistant) confirmed that of the six nurses listed on the report fou r continue to work at the facility and 1 have access to all the medications. The AA confirmed the report listed the missing item as "Medication card (a method of packing i medications, where each dose of medication is sealed individually in a plastic bubble on a card), , Norco 5/325 mg." The AA stated, the prior Director of Nurses (DON) indicated that he inteNiewed the nurses listed on the report. The AA stated she does not have documentation of ' the interviews o r any investigative notes regard ing the inc ident. The AA stated, it was reported to the police who had not yet completed their investigation . On 11/1 4/17 at 10:35 am , during an inteNiew and obseNation of the locked medication cart and the medication room Licensed Nurse (LN) F stated that there was one partial No rco card missing from the medication cart with the sign out sheet and one unused Norco card with the sign out sheet missing from the locked medication room. LN F showed that the Norco, which is a controlled medication, was double locked in the medication cart and in the medication room. I On 11/14/17 at 10:55 am, during an inteNiew the I current DON confirmed that there was one full I card and one partial card of No rco missing. The DON stated she did not know the total number of Norco missing was unable to find any information regarding an investigation of the missing Norco. I I On 11 / 15/ 17 at 1: 15 pm, during a phone inteNiew II the facility's Consulting Pharmacist (RPh .) 1 confirmed that he was notified about the missing 1 Norco. The RPh . stated he provided the prior FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 24 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STAT EMENT O F DEFICIENCIES AND PLAN O F CORRECTION OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION (X 1) PROVI DER/SUPPLIER/CUA ID ENTIFICATION NUMBER: STR EET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 741 N . MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF I R-C 11/14/2017 B. WING _ _ _ _ __ _ _ __ 555221 (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BU ILDING - - -- - - - - CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING IN FORMATION) ID PREFIX TAG I F 431 Continued From page 24 I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE F 431 1 DON ideas on how to investigate the missing ' medications. The RPh . stated that he visited the facility on 10/26/ 17. The RPh. stated that the DON was no longer there. The RPh stated that there was no record of an investigation and no one in the facility had information on the investigation. The RPh stated that he has not initiate an investigation of the missing Norco. The facility's "Pharmacy Service Agreement" signed by the pharmacist on 9/25/ 15, indicated 1 the Consultant Pharmacist responsibilities were a. Review and revise Medication Management Policies and Procedures ...j. Review and approve audit plans for control of narcotics ... and identify corrective actions as needed. 1 1 I I The facility's undated policy, titled, "Pharmacy Policy and Procedures," indicated all narcotics 1 . are accounted for ... if there is any discrepancy when reconciling narcotic the Director of Nursing Services must be notified before the second I licensed personnel doing the count leaves their shift. If the DNS is not able to resolve discrepancy, the Consulting Pharmacist and the Administrator must be notified as an unusual occurrence. I I ; The facility's policy, titled, "Unusual Occurrence Reporting," revised 7/2016, indicated the goal was to review unusual occurrences for performance improvement opportunities by the Quality Assurance Performance Improvement Program. 2. On 11 /14/17 at 10:35 am , during an interview and observation of the facili ty's medication room LN F described the medication ordering process. LN F stated that the nurses complete a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 25 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AN D HUMAN SERVICES C ENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1 ) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION B. WING _ _ _ _ _ _ _ __ 555221 NAME OF PROVIDER OR SUPPLIER R-C 11/14/2017 _ STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFIC IENCY MUST BE PRECEDED BY FU LL REGULATORY OR LSC IDENTI FYING INFORMATION ) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ F 431 Continued From page 25 medication order sheet and fax it to the pharmacy. The pharmacy delivers twice a week. If medications are needed before the regu lar delivery one of the licensed nurse will pick up the medication from the pharmacy. LN F reviewed the order sheets and explained that the pharmacy at times will send more or different medications then what is on the order sheet. LN F stated that they add the new medications to the bottom of order sheet. LN F stated that they do not I the receive a delivery list or manifest with the medications delivered. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOU LD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE I On 11/14/17 at 12:30 pm, during an interview the l Nurse Manager (NM) confirmed the nurses add 1 the extra med ication delivered to the order sheet. The NM was asked about a delivery list or a manifest to reconcile medications ordered with the medications delivered and confirmed that it is not routinely provided . The NM stated that they had received them in the past but they have a tendency to fade and become unreadable. On 11/15/17 at 1:15 pm , during a phone interview the facility's Consulting Pharmacist (RPh.) stated that he was unaware that the pharmacy was not providing a medication delivery list. {F 441 } INFECTION CONTROL, PREVENT SPREAD, SS=F LINENS CFR(s): 483.80(a)(1 )(2)(4)( e)(f) {F 441} (a) Infection prevention and control program . ' The facility must establish an infection prevention I and control program (IPCP) that must include, at a minimum , the following elements: I(1) A system for preventing , identifying, reporting, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJ IP12 Facility ID: CA230000144 If continuation sheet Page 26 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONST RUCTION A. BUILDING _ _ _ _ __ __ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 741 N . MAIN STREE T SU RPRISE VALLEY COMMUNITY HOSPITAL D/P SNF TAG I R-C 11/14/2017 B. WING _ _ _ _ _ _ _ _ __ 555221 (X4) ID PREFIX (X3) DATE SURV EY COMPLETED CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOU LD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {F 441} 1 Continued From page 26 investigating , and controlling infections and communicable diseases for all residents , staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.?0(e) and following 1 accepted national standards (facility assessment implementation is Phase 2); (XS) COMPLETION DATE {F 441 } I (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; I (iii) Sta ndard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a , resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. I (v) The circum stances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 27 of 36 PRINTED : 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING - B. W ING _ _ _ _ _ _ _ __ 555221 NAME OF PROVIDER OR SUPPLIER I R-C 11/14/2017 _ ST REET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING IN FORMATION) (X4) ID PREFIX TAG I (X3) DATE SURVEY COMPLETED - - -- -- - CEDARVILLE, CA 96 104 I I I {F 441} Continued From page 27 I contact with residents or their food , if direct contact will transmit the disease; and PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENC ED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I I (XS ) , COMPLETION DATE {F 441} (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must hand le, store, process , and transport linens so as to prevent the spread of infection. I I (f) Annual review. The facility will conduct an annual review of its IPCP and update their prog ram, as necessary. 1 This REQUIREMENT is not met as evidenced by: I Based on observation , interview, and record 1 review, the facility failed to implement an infection control program that was designed to provide a safe and sanitary environment to prevent the transmission of infection and disease when: I 1. The facility policy definition was inaccurate I when it incorrectly identified the start of influenza [ (flu) season as November 1 instead of October 1 1 as stated in fede ral regulations under F 334 and the infection control and isolation practices during 1 I I an influenza outbreak were inadequate when group activities were canceled for only 48 hours I and there was insufficient Personal Protective Equipment (PPE - masks, gowns, and gloves). 1 This resulted in the potential for resident not to have flu immunity during the flu season and the potential for flu or other communicable diseases to be spread to resident, staff, and visitors. I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP1 2 Facility ID: CA230000144 If continuation sheet Page 28 of 36 PRINTED: 11 /20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING _ _ __ __ __ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS , CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF 1 R-C 11/14/2017 B. WING _ _ __ __ _ _ __ 555221 (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I I {F 441} Continued From page 28 (XS) COMPLETION DATE {F 441} 2a. After the facility had available flu vaccines, ; there was a delay of 13 days before the flu 1 vaccinations were given to four of five residents (Resident 5 and out of sample Residents 9, 10, and 11) who were unaffected by the flu outbreak and 11 of 12 residents who were symptom free by 10/21. 2b. Several staff did not receive the flu vaccine and continued to care for or come into contact with residents, without wearing a mask, as required by facility policy and Department of Public Health mandates. I This had the potential to result in additional or prolonged flu outbreaks for all residents who reside in the facility as well as staff. 3. The facility failed to provide annual PPD tests (skin tests to check for Tuberculosis, an 1 I infections respiratory illness) for two of six sampled residents (Resident 2 and 3). This had the potential to result in infections for all residents who resided in the facility as well as staff. 1 I Findings: I 1. According to the Centers for Disease Control and Prevention (CDC), "the primary option for reducing the effect of influenza is immune-prophylaxis with vaccine. Inactivated (i.e., killed virus) influenza vaccine and live, attenuated influenza vaccine are available for use in the United States ... .Vaccinating persons at high risk for complications and their contacts each year before seasonal increases in influenza virus circulation is the most effective means of reducing the effect of influenza ... When vaccine FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 29 of 36 PRINTED: 11 /20/2017 FORM APPROVED OMB NO 0938-0391 DEPARTME NT OF HEALT H AND HUMAN SERVIC ES CENT ERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING - - -- - - - - STREET ADDRESS. CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF 1 I R-C 11/14/2017 B. WING _ __ _ __ _ _ __ 555221 (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I (XS) COMPLETION DATE I I {F 441} I Continued From page 29 : I and epidemic strains are well-matched , achieving I increased vaccination rates among persons living in closed settings (e.g., nursing homes and other I chronic care facilities) and among staff can I reduce the risk for outbreaks by inducing herd ' immunity. Vaccination of health-care workers and , other persons in close contact with persons at increased risk for severe influenza illness can 1 also reduce transmission of influenza and subsequent influenza-related complications. Antiviral d rugs used for chemoprophylaxis o r treatment of influenza are a key adjunct to vaccine ... However, antiviral medications are not a substitute for vaccination." During an interview on 11 /13/1 7 at 1 pm , the I Administrator stated she, the Director of Nurses (DON), who works night shift, and a Paramedic all been working on infection control , but the I facility had no designated Infection Control Nurse , at th is time. {F 441} 1 I I 1 had I I On 10/16/17, the Ca lifornia Department of Public 1 Health (CDPH) received a letter, faxed from the · faci lity, w hich ind icated the facility had a ; respiratory outbreak, which started on 10/13 and , 10/14/17, affecting five residents. This letter also I ind icated the facility had instigated CDPH "Recommendations fo r the Preven tion and Control of Influenza in California Long Term Care Facil ities." These recommendation s included: implement standa rd and droplet precautions (wearing a mask, gown, and gloves when caring for a resident, a mask when entering the room) for a resident with suspected or confirm ed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms , whichever is longer; confine first symptomatic resident and exposed roomm ate(s) FORM CMS-2567(02-99) Previous Versions Obsolete 1· I I 1 ' ! 1 j i I Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 30 of 36 PRINTED: 11 /20/2017 FORM APPROVED DEPARTMENT OF HEALTH AN D HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVIC ES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OM B NO. 0938-0391 {X2) MULTIPLE CONSTRUCTION A. BUILDING-- -- - - - - STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF II R-C 11/14/2017 B. WING _ _ _ _ _ _ _ _ __ 555221 {X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICI ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) CEDARVILLE, CA 96104 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I I (X5) COMPLETION DATE I ' { F 441} j Continued From page 30 {F 441} 1 to their room, restrict them from group activities, and serve meals in their room ; if other residents become symptomatic, cancel group activities and serve all meals in resident rooms; wear gown and gloves when providing direct care to a sym ptomatic res ident or in con tact with contaminate surfaces; change gowns and gloves after each encounter with symptomatic resid ent and perform hand hygiene. I IOn 10/ 17/17, C DPH received an updated list from • the facility which indicated 12 residents were ! I affected, three of which had tested positive for the I ; flu. The facility policy titled Immu nizations, dated 5/31/17, was reviewed and indicated, "all residents (regardless of age) should receive influenza vaccine annually." This policy did not include a definition as to when flu season is or when this should occur. The facility policy titled Immunization Policy for Employees, dated 8/4/17, was reviewed and indicated, "fl u season shall mean the period of time from November 1 each year through March 31." I During interview on 11/ 14/17 at 9:50 am and 10:20 am, the County Public Health Nurse (PHN) said they were notified by the faci lity of several residents and staff who had become ill with flu like symptoms who had not received the flu vaccine. She stated flu vaccines were delivered by Cou nty Public Health to the hospital on 10/19/17. PHN stated the faci lity initially said they had PPE, but she knew if the PPE was properly used, the facility would run out, so they also provided PPE to the facility on 10/19/17. I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 31 of 36 PRINTED: 11/20/201 7 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT O F DEFICIENCIES A ND PLAN OF CORRECTION (X 1) PROVIDER/SUPPLI ER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING - - - - - - - B. WING _ 555221 NA ME O F PROVIDER OR SUPPLI ER _ _ _ __ _ __ R-C 11/14/2017 _ STREET ADDR ESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PREC EDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURV EY COMPLETED ID PREFIX TAG I PROVI DER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO T HE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE I {F 441} Continued From page 31 {F 441} 1 On 11/14/17 at 7:50 am, Environmental Services Staff (EVS) was asked where gowns and masks were kept. She entered Room 4 (no residents) and opened the bedside table where there were 11 isolation gowns. I On 11 /14/17 at 8 am, NM opened an isolation cart that was in the hallway close to Room 14. This cart had 29 isolation gowns. NM stated that was probably not enough if they had another outbreak so they would have to get more from County Public Health . I 1 1 I On 11 /14/17 at 11 :40 am , the DON said they had ' PPE in the "warehouse". She went outside the hospital to a room connected to the back of the faci lity and unlocked the door. Inside was one I unopened box that contained 50 isolation gowns. J During an interview on 11 /14/17 at 12:50 pm , NM was unaware of the "warehouse" having extra gowns and stated it's kept locked and she was unaware of who had the keys when the central I supply staff were not working. During an interview on 11/14/17 at 2: 15 pm, Central Supply and Purchasing staff (CS) stated when she was not workin g, the Registered Nurse (RN) on duty would have access to the key. She supplied a copy of the last time isolation gowns were ordered, which was on 7/25/17, at which time one box with 50 gowns was ordered. I During an interview on 11/14/17 at 9 am , the Paramedic (PM) said he was the infection preven tionist and had received some train ing from the prior DON. He stated he was aware of the first three residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 1 Facility ID: CA230000144 If continuation sheet Page 32 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STAT EMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 741 N. MAIN STREET SURPRISE VALLEY COMMU NITY HOSPITAL D/P SNF (X4) ID I I R-C 11/14/2017 B. WING _ _ _ _ _ _ __ __ 555221 PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDI N G - -- -- - -- CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {F 441} Continued From page 32 who became ill, as reported to CDPH . He stated the residents just kept getting sick. PM provided J a list of actions taken for the flu outbreak starting 10/14/17, that included cancellation of all group activities for 48 hours. PM said he had been told to cancel group activities for 48 hours which : would have been over the weekend of 10/14 and 10/15/17. PM said group activities were canceled for only 48 hours after which affected residents weren't supposed to go to activities. PM said he doesn't work on the floor so he doesn't know if 1 staff wore masks and gowns when caring for ill I residents. I ID PREFIX I TAG I {F 441} PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE I 2a. During an interview on 11 /13/17 at 2: 15 pm , the Licensed Vocational Nurse Manager (NM) said they did not have the flu vaccines available 1 for residents before the outbreak. NM said the I prior DON had cal led the company that supplies 1 the medications for the hospital and was told they 1 were out of flu vaccines. NM confirmed none of the residents were vaccinated before the outbreak, except for one resident whose family 1 took her to a flu vaccination clinic where she I received the flu vaccine. This resident was not I on the list of residents who became ill. NM stated it was sometime during the outbreak before they 1 got the flu vaccines from County Public Health, as J well as PPE. She said, as far as she knew, they : I had run out of PPE during the outbreak. 1 I A review of the list of resident names and dates each received the flu vaccine was reviewed. There were four residents who were unaffected by the flu (it is recommended to not get a flu shot while you are ill with a fever), but did not receive a flu vaccine until 11/1/17, even though the facility I had received the vaccines on 10/19/17. The I symptoms of the 12 ill residents had subsided by FORM CMS-2567(02-99) Previous Versions Obsolete I Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 33 of 36 PRINTED: 11/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AN D PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555221 STREET ADDRESS, CITY, STATE, ZIP CODE 741 N . MAIN STREET SU RPRISE VALLEY COMM UNITY HOSPITAL D/P SNF CEDARVILLE, CA 961 04 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) During an interview on 11/14/17 at 11:10 am , NM was asked why the above four referenced residents were not given the flu vaccine as soon as the facility received it on 10/19/17. NM stated another nurse was supposed to give the vaccines, but vaccinated only two residents on 10/20/17. The flu vaccines were then kept locked j up by one of the night shift RN's in the pharmacy hospital medication room . Only RN's can enter that room and the night shift RN refused to give the vaccinations to the other residents and would not give the vaccines to other nurses so they could give vaccinate the residents. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {F 441} Continued From page 33 10/21 /17, and 11 of them also were not vaccinated until 11/1/17. 1 R-C 11 /14/2017 B. WING NAME OF PROVIDER OR SUPPLIER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING (XS) COMPLETION DATE { F 441} I I I I I I I I I 2b. On 11 /14/17 at 7:50 am , Environmental Services Staff (EVS) was observed not wearing a mask. On 11 /14/17 at 10:45 am , the Activities Staff I Certified Nursing Assistant (AS/CNA) was observed not wearing a mask. She was asked if she had received a flu shot and said no. AS/CNA said she has not been wearing a mask because she didn't th ink she needed to do so unless she had symptoms. I I I I I I i During numerous observations on 11/13/17, Medical Records Manager (MRM) and Medical Records Staff (MRS) were observed not wearing a mask while in resident hallways. On 11 /1 4/17 at 11 :30 am, they were observed wearing masks and MRM confirmed she had not received a flu shot. On 11/13/17, Certified Nursing Assistant (CNA) A was one of three CNAs who worked day shift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJIP12 Facility ID: CA230000144 If continuation sheet Page 34 of 36 PRINTED: 11 /20/2017 FORM APPROVED OM B NO 0938-0391 DEPARTMENT OF HEALTH AN D HU MAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STAT EMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVI DER/SUPPLIER/CUA IDENTIFICATION N UMBER: (X2) MULTIPLE CONSTRUCTION R-C 11 /14/2017 B. WING 555221 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF CEDARVILLE, CA 96104 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUI LDI NG {F 441} Continued From page 34 During an observation, CNAA did not wear a mask on 11/13/17, but wore one on 11/14/17. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I I (XS) COMPLETION DATE I {F 44 1} On 11 / 14/17 at 3 pm, Activities Aid (ACTA) was I sitting at a table with two residents in the activity I room and was observed not wearing a mask. I The Human Resources Director provided a list of employees who had not received the flu vaccine. This list was reviewed and included EVS, AS/CNA, MRM, MRS, CNAA, and ACTA I During an interview on 11/13/17 at 2:15 pm, NM said staff who did not receive the fl u vaccine needed to wear a mask while at work. She said she did not have a list of which staff have not received the flu vaccine , so she did not know if I this was being done. IThe facility policy titled Immunization Policy for I Employees , dated 8/4/17, was reviewed and indicated, "a mask will be worn in direct patient : care areas fo r those who refuse the vacci nation." : It also indicated the facility, "will provide influenza I vaccinations free of charge to all employees, J contract employees, and volunteers." I A letter to all hospitals and skilled nursing facilities, dated 10/1 /14, was reviewed and stated that County Public Health mandated all health care workers receive an annual flu vaccination, or if they decline, to wear a mask in patient care areas during the flu season. 3. Resident 2's record was reviewed and indicated he was admitted to the facility on 11/25/15 with diagnoses that included hemiparesis (paralysis of one side of the body), depression, Coumadin therapy (for prevention of FORM CMS-2567(02-99) Previous Versions Obsolete I i Event ID: EJIP12 I Facility ID: CA230000144 If continuation sheet Page 35 of 36 PRINTED: 11 /20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO 0938-0391 (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: A. BUILDING 555221 R-C 11 /1 4/201 7 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. M A IN ST REET SURPRI SE VALLEY COMM UNITY HOSPITAL D/P SNF SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLET ED (X2) MULTIPLE CONSTRUCTION CEDARVI LL E, CA 96104 I ' {F 441} , Continued From page 35 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOU LD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I (XS) COMPLETION DATE I {F 441} 1 blood clots), and seizure disorder. I A review of Resident 2's , lmmunizationNaccination record indicated Resident 2 was last given a PPD on 6/30/16. During a concurrent interview and record review, on 11 /1 4/17 at approximately 11 am, Licensed Nurse F reviewed the immunization record for Resident 2 and confirmed that the most recent PPD was completed 6/30/16, more than 16 months ago. I I I During an interview on 11/14/17 at 11: 15 am, the I Nu rse Manager (NM) stated all residents were to be screened for TB upon admission and annually. The NM stated all routine orders for TB screening had been discontinued by the former physician and that the facility was in the process of renewing those orders. I ' I I I I I I I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EJ IP12 Facility ID: CA230000144 If continuation sheet Page 36 of 36