Health inspection·March 8, 2019

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and policy review, the facility failed to ensure personal privacy for three of 27 sampled residents (Resident 25, Resident 46, and Resident 142) when the privacy curtain or window curtain was not pulled while personal care was being provided. Residents Affected - Few This failure resulted in Resident 25, Residents 42, and Resident 142's privacy not being protected. Findings: a. Resident 142 was a long-term resident of the facility. During a concurrent interview and observation on 3/5/19, at 9:15 a.m., Resident 142 was observed lying in bed, naked, while certified nurse assistant (CNA) 1 provided incontinent care. Resident 142 resided in the B bed, next to the window. The privacy curtain between the A bed and B bed had been pulled, however, neither the privacy curtain on the other side of Resident 142's bed or the window curtain was pulled. While standing at the foot of Resident 142's bed, a car was observed driving past the unblocked window. CNA 1 stated she should have pulled the privacy curtain or pulled the window curtain. b. Resident 46 was admitted to the facility with a pressure ulcer on the tailbone. Resident 46 was dependent on staff for activities of daily living (ADL) care. During a concurrent interview and observation on 3/5/19, at 10:05 a.m., Resident 46 was observed, naked, in bed with feces all over her buttocks and an indwelling urinary catheter (tube that collects urine from the bladder and leads to a drainage bag). CNA 4 was at the bedside providing care to Resident 46. The privacy curtain was pulled, but was not wide enough to remove Resident 46 from public view during provision of care. The privacy curtain only covered the left side of Resident 46's bed and did not go all the way around the resident's bed. CNA 4 explained the resident should be covered during care, but the curtain is too short. On 3/7/19, at 11:50 a.m., Resident 46 was observed in bed turned to her right side with her briefs off, exposing a pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) on her tailbone. Licensed Nurse (LN 3) was at Resident 46's bedside to assist LN 5 with treating the pressure ulcer on Resident 46's tailbone. The privacy curtain was pulled but did not remove Resident 46 from public view during provision of wound care. In a concurrent interview with LN 3 and LN 5, they explained privacy curtains should be pulled during provision of care but Resident 46's privacy curtain was too short. Page 1 of 16 055039 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0583 c. Resident 25 was a long term resident of the facility. She was dependent on staff for ADL care. Level of Harm - Minimal harm or potential for actual harm On 3/7/19, at 9:15 a.m., Resident 25 was observed in bed with her gown up exposing her briefs and with her blankets pulled down to her feet. CNA 3 was at the bedside providing care to Resident 25. The privacy curtain was not pulled all the way around Resident 25's bed and not removing Resident 25 from public view during provision of wound care. Residents Affected - Few In a concurrent interview with CNA 3, she stated she should have pulled the privacy curtain around Resident 25. In an interview with the Director of Nurses (DON) on 3/7/19, at 5:30 p.m., she stated privacy curtains should be pulled to completely cover residents from view during provision of wound and ADL care. Review of an undated facility policy titled PROVIDING ASSISTANCE WITH ADL CARE included the following: Procedures. 15. Provide privacy at all times during ADL care, i.e. privacy curtain, shower curtain, closing of doors, etc. 055039 Page 2 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) and the Joint Mobility Assessment accurately reflected one of 27 sampled resident's (Resident 33) condition. Residents Affected - Few This failure had the potential for Resident 33 to receive inadequate care. Findings: Resident 33 was admitted to the facility with diagnoses which included Parkinson's disease (progressive nervous system disorder that affects movement). On 3/5/19, at 10:40 a.m., Resident 33 was observed in bed. Resident 33 had contractures (deformity and rigidity of joints) on both upper extremities and on her right lower extremity. Three splints were observed on Resident 33's wheelchair at the bedside. A review of an MDS and a joint mobility assessment dated [DATE] were not consistent. The MDS showed Section G (Functional Status assessment) G0400A Upper extremity (shoulder, elbow, wrist, hand) and Section G0400B Lower extremity (hip, knee, ankle, foot) were coded as 0, which indicated the resident had no functional limitation on BUE and BLE. The joint mobility assessment was marked M for both wrists which indicated the resident had minimal functional limitations on both wrists, MS for both shoulders which indicated moderate/severe functional limitations on both shoulders, and WFL for both knees and ankles which indicated within functional limits on both lower extremities. A review of an MDS and a joint mobility assessment, dated 10/1/18, were not consistent. The MDS Section G0400A was coded 1 which indicated impaired functional mobility on either of the upper extremities; Section G0400B was coded 2 which indicated impaired functional mobility on both lower extremities. The joint mobility assessment was marked M for both wrists which indicated minimal functional limitations on both wrists, MD which indicated moderate functional limitation on the left shoulder, MS for the right shoulder which indicated moderate/severe functional limitation on the right shoulder, and WFL for both knees and ankles which indicated within functional limits on both lower extremities. A review of Section G0400A and G0400B of the MDS, dated [DATE], were coded 2 which indicated impaired functional mobility on both upper and both lower extremities. This assessment was not consistent with the 11/2/18 physician's order and did not reflect the resident's current condition. A joint mobility assessment dated [DATE] was not consistent with the 11/2/18 physician's order and the MDS dated [DATE], and did not reflect the resident's current condition. The joint mobility assessment was marked M for both wrists which indicated the resident had minimal functional limitation on both wrists, MS for both shoulders which indicated moderate/severe functional limitations on both shoulders, and WFL for both knees and ankles which indicated within functional limits on both lower extremities. In an interview with the director of nursing on 3/8/19, at 1:03 p.m., she acknowledged, the MDS assessments and the joint mobility assessments did not accurately reflect Resident 33's condition. 055039 Page 3 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to develop a comprehensive smoking care plan (CSCP) for one of 27 sampled residents (Resident 53). Residents Affected - Few This failure had the potential to not provide a plan for safe and person centered care for Resident 53. Findings: Resident 53 was admitted with diagnoses which included altered mental status. In an interview on 03/05/19, at 10:21 a.m., Resident 53 stated, he was admitted to the facility as a smoker. When asked how often he smoked a day, Resident 53 stated, I smoke four times a day by myself. During an observation on 3/6/19, at 4:30 p.m., Resident 53 was seen sitting in a wheelchair smoking in the facility designated smoking area. Review of Resident 53's clinical record showed no evidence that a CSCP was developed. In an interview and concurrent record review on 3/7/19, at 7:41 a.m., licensed nurse (LN) 6 confirmed Resident 53 was a smoker and a CSCP was not developed. LN 6 stated she could not find a CSCP in Resident 53's clinical records. LN 6 added the CSCP should have been developed to ensure Resident 53 was provided with effective and person centered care. In an interview on 3/7/19, at 9:19 a.m., the director of nurses (DON) acknowledged Resident 53 was a smoker and a CSCP was not developed. The DON stated it was her expectation LNs develop a CSCP when a resident was admitted and identified as a smoker. A review of the undated facility document titled, Care plan indicated, .the facility's policy of providing appropriate care and services to residents admitted to the facility, the facility shall ensure development of a comprehensive care plan for each resident .Goals for plan of care should be measurable, achievable/attainable and resident-centered . 055039 Page 4 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide measures to prevent further decrease in joint mobility as ordered by the physician for one (Resident 33) of 27 sampled residents when splints were not applied per physician's order. Residents Affected - Few This failure had the potential to place Resident 33 at risk to develop further decrease in range of motion. Findings: Resident 33 was admitted to the facility with diagnoses which included Parkinson's disease (progressive nervous system disorder that affects movement). On 3/5/19, at 10:40 a.m., Resident 33 was observed in bed without a splint or a brace on. Resident 33 had contractures (deformity and rigidity of joints) on both upper extremities and on her right lower extremity. Three splints were observed on Resident 33's wheelchair at the bedside. In a subsequent observation on 3/5/19, at 2:34 p.m., Resident 33 remained in bed without a splint on. In a concurrent interview and record review on 3/5/19, at 2:43 p.m., restorative nurse assistant (RNA) 1 explained she applies Resident 33's right knee and bilateral arm splints five times a week except on Mondays and Tuesdays. She stated when splints are applied to Resident 33, they are left on for 4 to 6 hours and then removed. She reviewed Resident 33's RNA charting dated March 2019. Mondays and Tuesdays were marked by asterisks on the RNA charting, which according to RNA 1, indicated splints were not to be applied on those days. During a review of Resident 33's clinical record, the physician's order for March 2019 listed two different orders for splint application as follows: a. Static knee and arm orthosis [correction of disorder of the limbs by use of braces] on bilateral knees and BUE [bilateral upper extremities]: RNA to apply in bed after lunch. Keep for 8 hours as tolerated. Licensed nurse to check skin before and after removal. b. RNA to facilitate wearing of BUE elbow-hand orthosis and RLE [right lower extremity] splint for 4-6 hours. Check for skin integrity issues. In a concurrent interview and record review with the director of nurses (DON) on 3/6/19, at 4:21 p.m., she reviewed the physician's order for March 2019, and the RNA charting for February and March 2019. In February 2019, Resident 33's splints were documented by RNAs as applied every day. For March 2019, splints were documented by RNAs as applied every day except on Mondays and Tuesdays. The DON stated when the physician's orders do not specify how many days a week a splint should be applied to a resident, the splint should be applied seven days a week. The undated facility policy and procedure titled Policy and Procedure on Physician Orders indicated, It shall be this facility's policy to provide care and services to the resident in accordance with physician orders . 055039 Page 5 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0658 Level of Harm - Minimal harm or potential for actual harm The California Nursing Practice Act, enacted on 1/1/13, indicated, .The practice of nursing within the meaning of this chapter means .Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician . Residents Affected - Few 055039 Page 6 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards for two of 27 sampled residents (Resident 46 and Resident 53) when: Residents Affected - Few 1. Resident 46's care plan for padded siderails was not implemented. This failure had the potential for Resident 46 to sustain an injury during seizure activity. 2. Resident 53's Smoking Data Collection and Assessment (SDCA-an assessment tool) was not completed. The SDCA was used to determine the resident's ability to smoke safely. This failure had the potential for Resident 53 to receive inadequate supervision to smoke safely. Findings: 1. Resident 46 was admitted to the facility with diagnoses which included seizure disorder. Resident 46 used siderails in bed for bed mobility. On 3/7/19, at 9:15 a.m., Resident 46 was observed in bed with both siderails up and not padded. In a review of Resident 46's clinical record, a care plan for safety during seizure activity, dated 10/7/18, indicated Resident 46's siderails should be padded. In an interview with the director of staff development (DSD) on 3/7/19, at 9:59 a.m., the DSD reviewed the care plan for Resident 46 and stated Resident 46's siderails should be padded as stated in the care plan. 2. Resident 53 was admitted with diagnoses which included altered mental status. In an interview on 03/05/19, at 10:21 a.m., Resident 53 stated he was admitted to the facility as a smoker. When asked how often he smoked a day, Resident 53 stated, I smoke four times a day by myself. During an observation on 3/6/19, at 4:30 p.m., Resident 53 was, sitting in a wheelchair, smoking in the facility designated smoking area. Review of Resident 53's clinical record showed no evidence that an SDCA was completed. In an interview and concurrent record review on 3/7/19, at 7:41 a.m., licensed nurse (LN) 6 confirmed Resident 53 was a smoker and the SDCA was not completed. LN 6 stated she could not find a completed SDCA in Resident 53's clinical records. LN 6 added the SDCA should have been completed to assess the resident ability to smoke safely. In an interview on 3/7/19, at 9:19 a.m., the director of nurses (DON) acknowledged Resident 53 was a smoker and the SDCA was not completed. The DON stated it was her expectation LNs complete the SDCA 055039 Page 7 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when a resident was admitted and identified to be a smoker to determine the resident's ability to smoke safely. A review of the undated facility document titled, Nursing admission assessment indicated, .It shall be the facility's policy to initiate data collection and assessment of every resident admitted to the facility .Data collection and assessment shall include: .Safety concerns .Evaluate resident for any safety concerns including falls, smoking-related injury . 055039 Page 8 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to implement aspiration (breathing in food or liquid into the airway) precautions for one (Resident 46) of 27 sampled residents when Resident 46's bed was flat during tube feeding (nutrition administered through a tube inserted through the abdomen). This failure placed Resident 46 at risk for aspiration pneumonia (inflammation or infection of the lungs caused by aspiration). Findings: Resident 46 was admitted to the facility with dysphagia (difficulty swallowing). Resident 46 received tube feeding via a tube feeding pump. On 3/5/19, at 10:05 a.m., Resident 46 was observed in bed with the tube feeding infusing via pump at 75 milliliters (ml, unit of measure) per hour. Resident 46's head of bed (HOB) was flat. Certified nurse assistant (CNA) 4 was at the bedside providing care to Resident 46. In a concurrent interview with CNA 4, CNA 4 stated she just put Resident 46's HOB down to provide care. When asked if Resident 46's tube feeding was on, CNA 4 replied, Yes. I put her [HOB] up right away when I'm done [providing care]. In a concurrent observation and interview with licensed nurse (LN) 6 on 3/5/19, at 10:07 a.m., LN 6 was observed putting Resident 46's HOB up as soon as she saw the tube feeding was infusing. LN 6 stated It [HOB] should be up. In an interview with LN 3 on 3/5/19, at 10:25 a.m., LN 3 stated tube feeding is supposed to be turned off when a resident's HOB is flat. In an interview with CNA 4 on 3/5/19, at 11:44 a.m., she stated, Tube feeding should be [put] on hold before putting resident's head of bed down. The undated facility policy and procedure titled Policy and Procedure on Enteral Feeding Tube Care indicated, It is this facility's policy to provide services to a resident receiving nutrition via enteral feeding tube to prevent discomfort .Explain the adverse effects and/or complications of the procedure to the resident .Position resident in semi-Fowler's position [positioned on their back with the head and trunk raised to between 15 to 45 degrees] . 055039 Page 9 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure qualified staff provided oxygen (O2) therapy for one (Resident 55) of 27 sampled residents when certified nurse assistant (CNA) 8 turned on Resident 55's O2 concentrator (device that concentrates the oxygen from the air). Residents Affected - Few This failure placed Resident 55 at potential risk of receiving an incorrect amount of O2 which can lead to respiratory distress. Findings: Resident 55 was admitted with diagnoses which included chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe). During a concurrent interview and observation on 3/5/19, at 11:15 a.m., Resident 55 was seen lying in bed wearing a nasal cannula (NC-a tubing or device that is placed in the nostrils to deliver supplemental oxygen). The NC was attached to the O2 concentrator next to Resident 55's bed. The O2 concentrator was noted to be off and the O2 indicator gauge was at a 0. When asked if she could feel the air from the O2 concentrator, Resident 55 stated, No. During a continuous observation on 3/5/19, at 11:26 a.m., Resident 55 pressed her call light for assistance. CNA 8 acknowledged the call light; walked over to the O2 concentrator and turned it on. A review of a physician's order, dated 8/26/18, indicated Resident 55 was to receive continuous O2 to keep O2 level above 90 percent. In an interview on 3/5/19 at 11:51 a.m., CNA 8 confirmed he turned on the O2 concentrator. CNA 8 stated he turned on the O2 concentrator due to not being able to find a LN to turn on the O2 concentrator. In an interview on 3/5/19, at 11:30 a.m., licensed nurse (LN) 7 verified CNA 8 should not have turned on the O2 concentrator. LN 7 stated CNAs should have the LN turn the O2 concentrator on. In an interview on 3/6/19, at 1:20 p.m., the director of nurses (DON) acknowledged CNA 8 should not have turned on the O2 concentrator. The DON stated it was her expectation from CNAs to call or inform a LN to turn on the O2 concentrator. 055039 Page 10 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and medication warning label review, the facility failed to safely store medications for one resident (Resident 68) out of a census of 89 when Calmoseptine ointment (skin ointment used to prevent and heal skin irritation) was found on top of Resident 68's bedside table. This failure had the potential for accidental ingestion of a harmful substance by a resident. Findings: On 3/5/19, at 9:49 a.m., two clear, plastic 30 milliliters (ml, unit of measure) cups with light pinkish ointment in them were observed on top of Resident 68's bedside table. In a concurrent observation and interview on 3/5/19, at 9:51 a.m., licensed nurse (LN) 6 went inside Resident 68's room, picked up the two plastic cups of ointment, and brought them outside the room. LN 6 said, I'm not sure what it is. In a concurrent observation and interview with the director of staff development (DSD) on 3/5/19, at 9:53 a.m., LN 6 showed the DSD the two cups of ointment. The DSD said, I'm not sure if it's ok to be at bedside. In an interview with LN 3 on 3/5/19, at 9:55 a.m., she looked at the two cups of ointment and stated, That's Calmoseptine ointment. LN 3 said, It shouldn't be at the bedside. In an interview with certified nurse assistant (CNA) 4 on 3/5/19, at 11:44 a.m., CNA 4 stated, staff were not supposed to leave Calmoseptine ointment at the bedside, Because somebody can come and get a hold of it and eat it. In an interview with CNA 5 on 3/7/19, at 8:09 a.m., CNA 5 verified she was assigned to care for Resident 68 on the morning of 3/5/19. CNA 5 stated staff were, Not supposed to leave Calmoseptine ointment at the bedside. CNA 5 explained, on the morning of 3/5/19, she asked LN 3 to apply Calmoseptine ointment to Resident 68's reddened buttocks before she got the resident up out of bed. LN 3 came with two cups of Calmoseptine ointment, but CNA 5 left Resident 68's room to answer another resident's call light. In an interview with the director of nurses (DON) on 3/5/19, at 3:05 p.m., she said, Calmoseptine ointment is medicated and should not be left at the bedside. The warning label on the Calmoseptine ointment package indicated, In case of accidental ingestion contact a physician or Poison Control Center immediately. 055039 Page 11 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and document review, the facility failed to store food in a sanitary manner when containers of left over food in the refrigerator were found not fully covered, undated, and unidentified. These failures placed residents at risk of being served spoiled, outdated food and/or contribute to foodborne illness. Findings: During a concurrent observation and interview on 3/5/19, at 8:05 a.m., a walkthrough of the kitchen was conducted with the facility's cook. When the walk-in refrigerator was entered, a container of gravy, soup, and partly covered containers of prepared food were found to be undated and unidentified. When the cook was asked what the food was and how long it had been there, she said it was stewed pork with vegetables from yesterday. In a subsequent interview and review of the week's menu for the past 3 days, the facility's registered dietician (RD) verified, pork with vegetables was not found as a resident food item in the lunch or dinner menus. The cook was then asked further about the left over food; she declared the food had been prepared to be consumed by facility staff. The RD indicated that no personal food items should be stored in the facility's kitchen refrigerator. Review of the facility's policy titled, Procedure for Refrigerated Storage, dated 2018, indicated that leftover foods should, .be covered, labeled and dated . 055039 Page 12 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

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 implement their infection prevention program for 5 residents (Resident 38, Resident 71, Resident 46, and 2 unknown residents) out of a census of 89 when: Residents Affected - Some 1. Certified nurse assistant (CNA) 4 did not perform hand hygiene after contact with Resident 5 before she picked up Resident 71's plate and bowl and assisting Resident 38 with her meal; 2. CNA 6 did not perform hand hygiene after picking food up off the floor and before assisting two unknown residents out of the dining room; 3. Licensed nurse (LN) 8 and CNA 9 did not perform hand hygiene after contact with Resident 46. These failures placed Resident 38, Resident 71, Resident 46, and two unknown residents at risk for the spread of infection. Findings: 1. During a dining observation in the activity room on 3/5/19, at 12:20 p.m., CNA 4 assisted Resident 38 with her meal when Resident 5, who was seated at a different table, pounded his fist on the table, and yelled at Resident 71 who was trying to grab his (Resident 5's) dessert. CNA 4 got up, walked to Resident 5, touched his arm, and talked to him. CNA 4 then picked up Resident 71's plate and bowl which were on the edge of the table and placed it in front of Resident 71, who was seated across from Resident 5. CNA 4 went back to where she was seated before the incident and continued to assist Resident 38 with her meal. CNA 4 did not perform hand hygiene before assisting Resident 71 and 38. 2. During an observation in the activity room on 3/5/19, at 12:30 p.m., CNA 6 put gloves on to pick up food on the floor. After she picked up food off the floor, CNA 6 removed her gloves and then assisted residents out of the activity room. CNA 6 did not perform hand hygiene. In an interview with CNA 6 on 3/5/19, at 12:40 p.m., she said, I'm supposed to use hand sanitizer after picking up food on floor and in between pushing different residents' wheelchair. In an interview with CNA 7 on 3/5/19, at 12:45 p.m., CNA 7 said, I have to use hand sanitizer in between different residents, when assisting with meals, and when pushing different residents' wheelchairs. 3. On 3/5/19, at 3:35 p.m., CNA 9 was observed pushing a cart of water pitchers down the hall when LN 8 asked her for assistance to reposition Resident 46 in bed. CNA 9 left the cart of water pitchers outside Resident 46's room, put on gloves, and went inside the room to assist LN 8. After repositioning Resident 46, CNA 9 removed her gloves, and without washing her hands, continued to push the water pitcher cart down the hall. LN 8 removed her gloves and used the hand sanitizer on top of the medication cart. In a subsequent interview, CNA 9 was asked about hand hygiene practice after resident contact. CNA 9 said, I'm supposed to wash my hands, I'm sorry for that. LN 8 was asked if she was supposed to wash her hands or use hand sanitizer after repositioning a resident. LN 8 said, I'm supposed to wash my 055039 Page 13 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0880 hands. Level of Harm - Minimal harm or potential for actual harm The undated facility policy and procedure titled Handwashing indicated, All employees are required to follow the handwashing procedure. The use of gloves does not take the place of handwashing .a waterless hand sanitizer is used until access to soap and running water are available .Handwashing is required but not limited to the following: 1. Before and after every patient contact .5. After gloves or other PPE is removed (PPE-PERSONAL PROTECTIVE EQUIPMENT) . Residents Affected - Some 055039 Page 14 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0912 Level of Harm - Potential for minimal 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** c. On 3/5/19, at 9 a.m. an observation of room [ROOM NUMBER] revealed a room that was clean and bright due to the large window in the room. The room included three beds that were situated so maneuverability was maximized. The space around each bed was clutter free and enabled free access to the bed. On 3/6/19, at 7 a.m. Resident 88 was interviewed. He stated he was able to do many activities of daily living himself. He stated he could walk but used a wheelchair most of the time. He stated he had no problems maneuvering about his room, getting to the bathroom or accessing his bed. He stated he had no complaints about the size of the room. On 3/6/19, at 11 a.m. Resident 26 was interviewed. He stated he required a lot of assistance by facility staff for much of his activities of daily living. He stated it was difficult to maneuver around the room but he was able to access his bed and the bathroom with assistance. He stated he had not complained to anyone about his room and if offered another room he would decline; that he wanted to stay in his current room. d. On 3/5/19, at 9:30 a.m. an observation and concurrent interview was conducted in room [ROOM NUMBER]. The room included two beds positioned next to each other. The room was wider than it was deep with sufficient space to maneuver around each bed. The room was free of clutter but did contain personal items belonging to the residents. Resident 12 and Resident 13 resided in the room; they were a younger married couple who were at the facility short-term. Resident 13 stated Resident 12 was out of the room but somewhere in the facility. She stated she was pleased with the care they had received at the facility. She stated they kept the room clean and she didn't have any complaints or concerns regarding the room or the facility. Room Waiver recommended to continue, as contingent upon compliance with federal regulations at Resident Rights (481.10) and Physical Environment (483.90). Based on observation, interviews, and room dimension measurements obtained from the facility, rooms 5, 18, 22 and 45 measured less than 80 square feet per resident as required. This failure placed the residents in rooms 5, 18, 22, and 45 at potential risk to impede their care and highest possible level of functioning due to smaller than required square footage. Findings: On 3/7/19, room size measurements were obtained from the assistant administrator: a. room [ROOM NUMBER], a 3-bed room, measured 232.87 square feet, rather than the required 240 square feet; b. room [ROOM NUMBER] a 3-bed room, measured 231.2 square feet, rather than the required 240 square feet; c. room [ROOM NUMBER], a 3-bed room, measured 231.2 square feet, rather than the required 240 square feet; and 055039 Page 15 of 16 055039 03/08/2019 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some d. room [ROOM NUMBER], a 2-bed room, measured 142.5 square feet, rather than the required 160 square feet. a. There were three residents in room [ROOM NUMBER] (Resident 59, Resident 25, and Resident 46). All three residents were dependent on staff for activities of daily living (ADLs). Resident 59 and Resident 25 were non-interviewable. In an observation in room [ROOM NUMBER] on 3/5/19, at 10:05 a.m., no issue with staff maneuvering in the room during care was observed. In an interview with Resident 46 on 3/6/19, at 8:15 a.m., she said, Yeah, there's enough room here. In an interview with certified nurse assistant (CNA) 3 on 3/7/19, at 9:15 a.m., CNA 3 stated there was enough room to care for residents in room [ROOM NUMBER] and she had no trouble maneuvering care equipment (wheelchairs, lifts, etc.) in the room. b. In an observation in room [ROOM NUMBER] on 3/5/19, at 10:40 a.m., there was one resident in the room (Resident 33). The resident was non-interviewable. In a concurrent observation and interview with licensed nurse (LN) 7 on 3/6/19, at 3:34 p.m. in room [ROOM NUMBER], LN 7 stated there was enough space in the room to care for the resident and staff had enough room to maneuver care equipment. In a subsequent observation on 3/6/19, at 5 p.m., an unidentified male CNA had enough space to provide care to Resident 33. 055039 Page 16 of 16