Health inspection·September 20, 2019

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food, in accordance with professional standards for food service safety when: Residents Affected - Few 1. An employee's large beverage container, half consumed, was stored on the shelf in the freezer with residents' food. 2. A baking pan full of green Jell-O was stored in the refrigerator uncovered and available for resident consumption. These deficient practices had the potential for food to become contaminated with harmful microorganisms causing foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins), placing residents at an increased risk of being exposed to infectious agents. Findings: 1. During a concurrent observation of the kitchen freezer and interview with the Director of Dietary Services (DDS), on 9/17/19, at 9:38 a.m., a large plastic beverage container with a half consumed drink was stored on the shelf in the freezer with residents' food. The DDS stated, It [large beverage container] should not be here. Employee personal items of any kind were not allowed to be stored in this [resident] freezer, they [dietary staff] know better. The DDS disposed the container into the garbage. During an interview with Dietary Aide (DA) 1, on 9/17/19, at 10:13 a.m., she stated employee personal food and drinks items were not allowed to be stored in the kitchen refrigerator and freezer because those food items could contaminate resident food stored and served to residents. DA 1 stated employee should use the refrigerator in the employee lounge to store their personal food items and never in the kitchen because of the risk of contaminating resident food items. During an interview with [NAME] 1, on 9/18/19, at 9:10 a.m., she stated staff should not store personal item, drink or food in the kitchen freezer and refrigerator because of the risk of contaminating resident food stored in the refrigerator. [NAME] 1 stated the facility had an employee refrigerator with a freezer that was available and designated for staff use to store their food and drinks. 2. During a concurrent observation in the kitchen refrigerator and interview with the DDS, on 9/17/19, at 9:42 a.m., a large baking pan full of green Jell-O was stored on the shelf in the refrigerator uncovered. The DDS stated, It [pan of green Jell-O] should be covered . it should still have a cover. Page 1 of 9 055028 055028 09/20/2019 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with [NAME] 1, on 9/18/19, at 9:10 a.m., [NAME] 1 stated the pan of green Jell-O should have been covered to avoid food contamination and food borne illness. [NAME] 1 stated all food and drinks stored in the freezer and refrigerator for resident should be covered and dated. The facility policy and procedure titled, Preventing Foodborne Illness - Food Handling dated 7/14, indicated, Policy Statement Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized . 055028 Page 2 of 9 055028 09/20/2019 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to conduct a facility wide risk assessment specific to the needs of the facility and resident population for 39 of 39 residents when the facility assessment did not include a water management plan. This deficient practice failed to establish an individualized facility assessment to meet the requirement for a water management plan which had the potential for waterborne bacteria exposure to the residents including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by bacterium known as legionella, most people get legionnaires' disease from inhaling the bacteria in showers, water faucets, water fountain) in an event of an outbreak. Findings: During an interview with the Maintenance Supervisor (MS), on 9/20/19, at 8:49 a.m., he stated the facility did not have a water management program in place. The MS stated he only checked the water temperature weekly. During an interview with the Administrator (ADM), on 9/20/19, at 9:02 a.m., the ADM stated she was not aware of the AFL (all facilities letter -is a letter from the Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C. The information contained in the AFL include changes in licensing requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the healthcare facility) 18-39 regarding, Reducing Legionella Risks in Health Care Facility Water System. The ADM stated she was not aware of the requirement to have a water management program and did not include a water management program in the facility assessment. During a review of the professional reference, CMS Quality, Safety & Oversight (QSO) letter dated and revised 7/6/18, indicated, Expectations for Healthcare Facilities: CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1) Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens .could grow and spread in the facility water system. 2) Develops and implements a water management program that considers the [American Society of Heating, Refrigeration and Air-Conditioning] ASHRAE industry standard and the [Centers for Disease Control] CDC tool kit. 3) Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are maintained. 4) Maintains compliance with other applicable Federal, State and local requirements . The facility policy and procedure titled, Facility Assessment for [name of facility] dated 7/30/19, indicated .Services Waste management, hazardous waste management, telephone, HVAC, dental, barber/beauty, pharmacy, laboratory, radiology, occupational, physical, respiratory, and speech therapy, religious, exercise . The facility assessment did not have information regarding the facility's need for a water management program. The facility policy and procedure titled, Facility Assessment dated 7/17, indicated . 4. The 055028 Page 3 of 9 055028 09/20/2019 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0838 facility assessment also includes a detailed review of the resources available to meet the needs of the resident population . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 055028 Page 4 of 9 055028 09/20/2019 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have an effective infection control and prevention program for three of six sampled residents (Resident 25, Resident 32 and Resident 35 when: Residents Affected - Many 1. Certified Nursing Assistant (CNA) 2 did not perform hand hygiene for three of six sampled residents (Resident 25, Resident 32, and Resident 35) after touching Resident's wheelchair, her clothing, and food containers and proceeded with providing feeding assistance to Resident 32, Resident 35 and Resident 25. This failure had the potential to cross contaminate (the process by which bacteria or other microorganisms [bacterium, virus, or fungus] are unintentionally transferred from one substance or object to another) residents' food and cause infections to residents. 2. The facility did not develop and implement a water management program to monitor for bacterial organisms in the water system used for 39 of 39 facility residents population. This failure had the potential risk for residents to become infected with legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by bacterium known as legionella, most people get legionnaires' disease from inhaling the bacteria in showers, water faucets, water fountain) or other water borne bacteria. Findings: 1. During an observation in the dining room on 9/17/19, at 11:37 a.m., CNA 2 was feeding Residents 25, 32, and 35 their lunch. CNA 2 used her ungloved hands and adjusted her clothing multiple times, touched the table, touched residents' trays, and touched residents' food containers while feeding Residents 32, Resident 35 and Resident 25 without washing her hands in between actions. During an interview with CNA 2, on 9/18/19, at 11:38 a.m., CNA 2 stated, I am not supposed to get up when I start feeding these residents . I am supposed to only touch the spoons. I didn't realize that I was touching other things . CNA 2 stated she should have wash her hands when she touched more than the residents' spoons. CNA 2 stated, I know that. I should be more conscious, I guess. During an interview with the Registered Dietitian (RD), on 9/17/19, at 11:53 a.m., she stated the dining room had a sanitizer dispenser. The RD stated CNA 2 should have washed her hands before feeding Resident 32 and Resident 25 and in-between tasks in the dining room. The RD stated staff who assist with feeding should only be handling the spoon to feed the residents. The RD stated, If touching more than that, I expect them to wash or sanitized their hands. During an interview with the Director of Nursing (DON), on 9/17/19, at 11:55 a.m., she stated staff who assisted with feeding more than one resident in a table were not supposed to get up until after the staff were finished with feeding the residents. The DON stated the staff were supposed to only touch the spoon. The DON stated if the CNA was touching other things besides the spoon then she needed to repeat her hand sanitation. The facility policy and procedure titled, Hand Washing/Hand Hygiene during feeding in the Dining Room dated 2018, indicated, .Procedure . CNA may touch feeding utensils ONLY while assisting residents with eating. If contact is made with the table, wheelchair, resident body, or any other object, CNA must sanitize/wash their hand . 055028 Page 5 of 9 055028 09/20/2019 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0880 Level of Harm - Minimal harm or potential for actual harm 2. During an interview with the Maintenance Supervisor (MS), on 9/20/19, at 8:49 a.m., he stated the facility did not have a water management program in place. The MS stated he only checked the water temperature weekly. The MS stated the facility did not have a system to detect the potential for legionella (bacterium found in both potable and non-potable water systems [showers, sinks and water fountains]) outbreak or other waterborne bacteria. Residents Affected - Many During an interview with the Administrator (ADM), on 9/20/19, at 9:02 a.m., the ADM stated she was not aware of the AFL (all facilities letter - is a letter from the Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C. The information contained in the AFL include changes in licensing requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the healthcare facility) 8-39 regarding, Reducing Legionella Risks in Health Care Facility Water System. The ADM stated she was not aware of the requirement to have a water management program and did not include a water management program in the facility wide risk assessment. During a review of the professional references, CMS Quality, Safety & Oversight (QSO) letter, dated and revised 7/6/18, indicated, Expectations for Healthcare Facilities: CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1) Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens .could grow and spread in the facility water system. 2) Develops and implements a water management program that considers the [American Society of Heating, Refrigeration and Air-Conditioning] ASHRAE industry standard and the [Centers for Disease Control] CDC tool kit. 3) Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are maintained. 4) Maintains compliance with other applicable Federal, State and local requirements . 055028 Page 6 of 9 055028 09/20/2019 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide and maintain a minimum of at least 80 square feet (Sq. Ft) per resident in eleven resident rooms (Room - Rm. # 1, 2, 3, 4, 6, 7, 8, 9, 10, 14 and 15). This failure resulted in inadequate space for staff to deliver care, insufficient space for resident's personal belongings, wheelchairs and could impact the residents' quality of life or quality of care. Findings: During an observation between 9/17/19 through 9/20/19, the following rooms did not provide the minimum square footage in Rm # 1, 2, 3, 4, 6, 7, 8, 9, 10, 14 and 15. During an interview with Resident 14, on 9/17/19, at 10:02 a.m., she stated she had enough space in her room area and the staff helped her in bed and transferring to her wheelchair. During an interview with Resident 31, on 9/17/19, at 1:47 p.m., she stated her room felt crowded for her. Resident 31 stated she had a difficult time getting to her belongings in the nightstand that were between her bed and the bed next to her. Resident 31 stated she was unable to have her wheelchair next to her bed because it blocked the pathway to the bathroom. Resident 31 stated staff moved the wheelchair against the sliding glass door when she was in bed in order to open the pathway to the bathroom. Resident 31 stated when staff removed her wheelchair from her bedside she was unable get out of bed unassisted and had to wait for staff to get her wheelchair for her from in front of the sliding glass door. Resident 31 stated the limited space made her feel crammed in the room. During a concurrent observation in room [ROOM NUMBER] and interview with Certified Nursing Assistant (CNA) 5, on 9/17/19, at 2:37 p.m., CNA 5 stated rooms with four beds, Get challenging to move around to do my work and give care to the residents in those room . [the room space] is worse when we have to use the (mechanical lift - device used to move those who were unable to stand on their own or whose weight made it unsafe to move or be lifted manually) or the shower chair that was bulky enough that we need to move furniture around in the room to make more space. [The room space] is tight with [the resident] wheelchairs . CNA 5 stated when CNAs were providing care they had to move the room furniture from one side of the room to have sufficient space to provide safe care to that resident. CNA 5 stated when CNAs finished providing care to one resident they moved to the other and again had to move all of the furniture to the other side of the room. CNA 5 stated, Meaning one side [of the room] we make wider so we move the furniture closer on one side of the room so that on that side of the bed there is a wider space and we tell the resident to use that side of the bed [where the furniture was removed] to be able to maneuver around to and from their wheelchair. During a concurrent observation in room [ROOM NUMBER] and interview with CNA 3, on 9/17/19, at 2:52 p.m., she stated rooms with four beds did not have enough space to complete resident care. CNA 3 stated Resident 32 used a mechanical lift for transfers and she had to resort to moving Resident 32's bed out of its position to fit the mechanical lift in the room. CNA 3 stated Resident 19 also used a mechanical lift for transfers on shower days and she would have to move the bed out of its position to safely fit the mechanical lift inside the room. 055028 Page 7 of 9 055028 09/20/2019 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation in room [ROOM NUMBER] and interview with CNA 3, on 9/17/19, at 2:55 p.m., she stated room [ROOM NUMBER] did not have enough space to safely accomodate and use the mechanical transfer lift inside the room for Resident 2 and Resident 25. CNA 3 stated she had to move Resident 2's bed to the side of the room in order to fit the mechanical lift in the room when transferring Resident 25. CNA 3 stated CNAs moved the bed next to Resident 34 blocking Resident 34's path to make the space needed between the beds to fit the wheelchair close enough to assist residents safely into the wheelchair. During an interview with Resident 33, on 9/17/19, at 3:32 p.m., she stated, It is a little tight with four beds in the room. I have to ask somebody to give me more space, move the other bed over to get my wheelchair close to where I want it to be. It's hard to get to my bedside cabinet . I can't get to it . my wheelchair won't fit in the room. Resident 33 stated her wheelchair was taken away from her and placed in an area she was unable to access and had to wait for staff to bring her the wheelchair when she needed to get out of bed. During a concurrent observation in room [ROOM NUMBER] and interview with the Director of Nursing (DON), on 9/19/19, at 4:15 p.m., the DON stated the room was a little bit crowded. The DON stated Resident 31's wheelchair could be moved closer to her, but the wheelchair would block the pathway to the bathroom for all residents in the room. The DON stated the wheelchair should not be out of Resident 31's reach. The DON stated the room space was not sufficient to accommodate having Resident 31's wheelchair accessible to her. During a concurrent observation in room [ROOM NUMBER] and interview with the DON, on 9/19/19, at 4:20 p.m., she stated the room was a little crowded. The DON stated Resident 9's bathroom access was blocked by the floor mat in front of the bathroom pathway used for Resident 32. The DON stated the room did not have sufficient space to accommodate the residents' needs. During a concurrent observation of room [ROOM NUMBER] and interview with CNA 8, on 9/20/19, at 9:15 a.m., a folded wheelchair was observed leaning against the sliding glass door. CNA 8 stated she had assisted Resident 31 to the bathroom. CNA 8 stated Resident 31's wheelchair was removed from her [resident] and was placed against the sliding glass door because if the wheelchair remained close to Resident 31 the wheelchair blocked access to the bathroom. During an interview with CNA 8, on 9/20/19, at 11:02 a.m., she stated Resident 31's wheelchair was normally placed on the side of the closet space next to the sliding glass door. CNA 8 stated the wheelchair was far from Resident 31 when placed next to the closet space and Resident 31 would not have access to the wheelchair. CNA 8 stated Resident 31 was able to transfer from bed to wheelchair on her own without staff assistance and would have to ask staff for assistance when the wheelchair was taken away from her. The residents' bedroom measurements were as follows: Rm. # Bed Capacity Sq. Ft. Per Resident 1 4 73.62 2 4 73.62 3 4 73.62 055028 Page 8 of 9 055028 09/20/2019 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0912 4 4 73.62 Level of Harm - Minimal harm or potential for actual harm 6 4 73.62 7 4 73.62 Residents Affected - Some 8 4 73.62 9 4 73.62 10 4 73.62 14 4 73.62 15 4 73.62 Recommend, room waiver for rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 14 and 15. __________________________________ Health Facilities Evaluator Supervisor Signature & Date Request waiver. ________________________________ Administrator Signature & Date 055028 Page 9 of 9