Health inspection·July 15, 2021

F 0578 Level of Harm - Potential for minimal harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accuracy and congruency of resident life-sustaining treatment orders across the resident medical record, for one out of 18 sampled residents (Resident 17). This failure had the potential for resident harm, as the lack of accuracy and congruency of the resident's life-sustaining treatment orders could have resulted in medical intervention and treatment, in response to a change of condition for Resident 17, that was not following physician orders, nor per the wishes of Resident 17. Findings: During a review of the Physician Orders for Life-Sustaining Treatment (POLST) document for Resident 17, dated [DATE], the POLST document indicated the physician orders to be followed for Resident 17 included: Cardiopulmonary Resuscitation (CPR): . Do Not Attempt Resuscitation/DNR (Allow Natural Death) . Comfort-Focused Treatment . During a review of the physician orders for Resident 17 in the electronic health record (EHR), dated [DATE], the physician orders for Resident 17's life-sustaining treatment indicated, Full Treatment/Full Code. This physician order, documented in the EHR for Resident 17, was not accurate nor congruent with the completed POLST document signed by Resident 17's physician on [DATE]. During a concurrent interview and record review, on [DATE], at 5:06 PM, with the Director of Nursing (DON), Resident 17's POLST document and physician orders within the EHR, dated [DATE] & [DATE] respectively, were reviewed. The DON reviewed Resident 17's POLST document and EHR physician orders and confirmed the error within the EHR physician orders. The DON stated the physician orders within the EHR should have been updated to be congruent with the completed and physician-signed POLST document for Resident 17. The DON further stated the EHR should have been updated upon the completion and signing of the POLST document, on [DATE]. During a review of the facility's policy and procedure (P&P) titled, Physician Orders for Life Sustaining Treatment (POLST), dated [DATE], the P&P indicated, . POLST is a form recognized as a way to communicate physician and nurse practitioner's orders based on an individual's wishes for life-sustaining treatments across healthcare settings . POLST form will be added to the record inventory list and an order to follow POLST instructions will be added to the physician orders . Page 1 of 13 055129 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the reporting of all allegations of resident abuse within the facility, when a resident's (Resident 17) resident-on-resident abuse allegation against another resident (Resident 2) was not reported to the State Survey Agency. This failure had the potential to negatively effect the safety and psychosocial well-being of all 46 residents in the facility, as the facility failed to ensure their abuse reporting responsibilities were applicable towards all residents in the facility. Findings: During an interview on July 12, 2021, at 11:24 AM, with Resident 17, Resident 17 stated a lady named [First Name of Resident] hit her on her back but was unsure when it happened. Resident 17 further stated she reported this incident to a nurse but was unable to recall who the nurse was. During a review of the admission Record for Resident 17, containing the resident's demographics and medical summary, dated July 13, 2021, the document indicated Resident 17 was admitted to the facility on [DATE], and had medical diagnoses that included hypertensive heart disease with heart failure (heart disease caused by long-term high blood pressure), chronic viral Hepatitis C (long-term virus infection of the liver), and muscle weakness. During an interview on July 12, 2021, at 11:38 AM, with the Director of Nursing (DON), the DON stated the facility was aware of the allegation of resident-on-resident abuse made by Resident 17 against another Resident named [First Name of Resident] (Resident 2). The DON further stated the allegation was investigated, and the facility was unable to substantiate the alleged abuse. During a review of the admission Record for Resident 2, containing the resident's demographics and medical summary, dated July 15, 2021, the document indicated Resident 2 was admitted to the facility on [DATE], and had medical diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (disabled movement on the right-side of her body caused by a stroke), Alzheimer's disease (brain disorder affecting memory, cognition, and behavior), and unspecified dementia with behavioral disturbance (brain disorder affecting memory, cognition, and behavior). During an interview on July 15, 2021, at 4:43 PM, with the DON, the DON stated a Certified Nursing Assistant (CNA 3) was present during the alleged incident of resident-on-resident abuse between Resident 17 and Resident 2, allegedly occurring in resident room [ROOM NUMBER] at the time, when both residents were sharing the same room. The DON further stated CNA 3 had stated and certified nothing had happened between the two residents involved, and no contact or abuse occurred between Resident 17 and Resident 2, as alleged by Resident 17. The DON further stated the residents were separated, to avoid any potential future conflict. During an interview on July 15, 2021, at 4:48 PM, with the DON, the DON stated this incident of alleged resident-on-resident abuse was not documented and was not reported externally. The DON further stated this alleged incident involving Resident 17 and Resident 2 occurred on June 8, 2021. During an interview on July 15, 2021, at 5:27 PM, with the Administrator (Admin), the Admin stated 055129 Page 2 of 13 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he was aware of the alleged incident of resident-on-resident abuse endorsed by Resident 17, and that it was mentioned during the facility's Stand-up, which involved change-of-shift communication amongst staff members in the morning hours. The Admin further stated the alleged incident was not documented, nor was it reported to the State Survey Agency. The Admin further stated the resident-on-resident abuse allegation from Resident 17, against Resident 2, was not an abuse allegation, in his opinion. The Admin further stated the CNA (CNA 3) was in the resident room, and certified nothing had happened between the residents, but that Resident 17 did allege Resident 2 had hit her. During a review of the Section C, Cognition Patterns of the Minimum Data Set (MDS - resident assessment tool used in skilled nursing facilities) completed for Resident 17, dated June 7, 2021, the document indicated Resident 17 had a BIMS Summary Score (Brief Interview for Mental Status - a standardized assessment of a resident's mental capacity, with 15 being the highest/best score achievable, and 00 being the lowest/poorest score) of 14 out of 15. During a review of the Section C, Cognition Patterns of the MDS completed for Resident 2, dated May 24, 2021, the document indicated Resident 2 had a BIMS Summary Score of seven out of 15. During a review of the facility's policy and procedure (P&P) titled, Elder / Dependent Adult Abuse, dated January 19, 2018, the P&P indicated, . 1. This facility will protect the rights, safety and wellbeing of each resident (regardless of physical or mental condition), for whom we provide care and treatment against any and all forms of physical, verbal, sexual, mental abuse . No department head, supervisor or employee of the facility shall in any way inhibit or impede reporting duties, nor take retaliatory action against any employee, agent, relative, resident, volunteer or other person for reporting an actual/known, suspected or alleged abuse of any type . Facility will conduct an immediate investigation of any allegation of any form of abuse. If reportable, facility will document a written abuse report on SOC 341 . and submit to the appropriate agencies . Facility will have evidence that all alleged violations are thoroughly investigated . 055129 Page 3 of 13 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a documented and thorough investigation was initiated and completed for any and all allegations of resident abuse within the facility, when a resident's (Resident 17) resident-on-resident abuse allegation against another resident (Resident 2) was not documented, nor was subject to a documented investigation. This failure had the potential to negatively effect the safety and psychosocial well-being of all 46 residents in the facility, as the facility failed to ensure their alleged abuse incident documentation and investigative responsibilities were applicable towards all resident abuse allegations in the facility. Residents Affected - Few Findings: During an interview on July 12, 2021, at 11:24 AM, with Resident 17, Resident 17 stated a lady named [First Name of Resident] hit her on her back but was unsure when it happened. Resident 17 further stated she reported this incident to a nurse but was unable to recall who the nurse was. During a review of the admission Record for Resident 17, containing the resident's demographics and medical summary, dated July 13, 2021, the document indicated Resident 17 was admitted to the facility on [DATE], and had medical diagnoses that included hypertensive heart disease with heart failure (heart disease caused by long-term high blood pressure), chronic viral Hepatitis C (long-term virus infection of the liver), and muscle weakness. During an interview on July 12, 2021, at 11:38 AM, with the Director of Nursing (DON), the DON stated the facility was aware of the allegation of resident-on-resident abuse made by Resident 17 against another Resident named [First Name of Resident] (Resident 2). The DON further stated the allegation was investigated, and the facility was unable to substantiate the alleged abuse. During a review of the admission Record for Resident 2, containing the resident's demographics and medical summary, dated July 15, 2021, the document indicated Resident 2 was admitted to the facility on [DATE], and had medical diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (disabled movement on the right-side of her body caused by a stroke), Alzheimer's disease (brain disorder affecting memory, cognition, and behavior), and unspecified dementia with behavioral disturbance (brain disorder affecting memory, cognition, and behavior). During an interview on July 15, 2021, at 4:43 PM, with the DON, the DON stated a Certified Nursing Assistant (CNA 3) was present during the alleged incident of resident-on-resident abuse between Resident 17 and Resident 2, allegedly occurring in resident room [ROOM NUMBER] at the time, when both residents were sharing the same room. The DON further stated CNA 3 had stated and certified nothing had happened between the two residents involved, and no contact or abuse occurred between Resident 17 and Resident 2, as alleged by Resident 17. The DON further stated the residents were separated, to avoid any potential future conflict. During an interview on July 15, 2021, at 4:48 PM, with the DON, the DON stated this incident of alleged resident-on-resident abuse was not documented and was not reported externally. The DON further stated this alleged incident involving Resident 17 and Resident 2 occurred on June 8, 2021. During an interview on July 15, 2021, at 5:27 PM, with the Administrator (Admin), the Admin stated 055129 Page 4 of 13 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he was aware of the alleged incident of resident-on-resident abuse endorsed by Resident 17, and that it was mentioned during the facility's Stand-up, which involved change-of-shift communication amongst staff members in the morning hours. The Admin further stated the alleged incident was not documented, nor was it reported to the State Survey Agency. The Admin further stated the resident-on-resident abuse allegation from Resident 17, against Resident 2, was not an abuse allegation, in his opinion. The Admin further stated the CNA (CNA 3) was in the resident room, and certified nothing had happened between the residents, but that Resident 17 did allege Resident 2 had hit her. During a review of the Section C, Cognition Patterns of the Minimum Data Set (MDS - resident assessment tool used in skilled nursing facilities) completed for Resident 17, dated June 7, 2021, the document indicated Resident 17 had a BIMS Summary Score (Brief Interview for Mental Status - a standardized assessment of a resident's mental capacity, with 15 being the highest/best score achievable, and 00 being the lowest/poorest score) of 14 out of 15. During a review of the Section C, Cognition Patterns of the MDS completed for Resident 2, dated May 24, 2021, the document indicated Resident 2 had a BIMS Summary Score of seven out of 15. During a review of the facility's policy and procedure (P&P) titled, Elder / Dependent Adult Abuse, dated January 19, 2018, the P&P indicated, . 1. This facility will protect the rights, safety and wellbeing of each resident (regardless of physical or mental condition), for whom we provide care and treatment against any and all forms of physical, verbal, sexual, mental abuse . No department head, supervisor or employee of the facility shall in any way inhibit or impede reporting duties, nor take retaliatory action against any employee, agent, relative, resident, volunteer or other person for reporting an actual/known, suspected or alleged abuse of any type . Facility will conduct an immediate investigation of any allegation of any form of abuse. If reportable, facility will document a written abuse report on SOC 341 . and submit to the appropriate agencies . Facility will have evidence that all alleged violations are thoroughly investigated . 055129 Page 5 of 13 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many 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 ensure the ice and water machine, used for resident consumption of ice and drinking water in the facility, was maintained in a clean and sanitary manner, and free from visible contamination indicative of foreign growth matter, for 46 out of 46 residents in the facility. This failure resulted in the residents being exposed to unsanitary and contaminated water and ice used for resident consumption, risking the likelihood of severe health consequences due to foodborne illness upon these vulnerable residents in the facility. Findings: During an interview on July 14, 2021, at 12:57 PM, with the Maintenance Director (Maintenance), the Maintenance stated the facility had only one ice machine. During a concurrent observation and interview on July 14, 2021, at 1:15 PM, with the Maintenance and the Administrator (Admin), within the employee breakroom area, the facility's ice and water machine was observed and surveyed. The following was observed within the ice and water machine's internal components: -Black-colored foreign matter was observed within the ice formation grate (part of the ice and water machine that is circulated with flowing water to form ice cubes) and was able to be removed with applied friction using a toothbrush, indicating the foreign matter was capable of becoming loose and contaminating the product ice and water. -Dark-colored foreign matter was observed along the many surfaces of the ice and water machine's internal components, including within the water-containment tray, which contained the source water for the machine. The Maintenance acknowledged and confirmed the toothbrush was able to remove black-colored foreign matter from the ice formation grate. The Maintenance further stated the following: -The foreign growth matter could indicate bacterial and mold growth inside the ice machine. -Gunk was visible within the machine's water tray, underneath the ice formation grate. -The facility's ice and water machine was not clean, nor acceptable for resident use in the facility. During a concurrent observation and interview on July 14, 2021, at 1:20 PM, with the Maintenance and the Admin, within the employee breakroom area, the facility's ice and water machine continued to be observed and surveyed. Surveyor completed a white paper towel test (taking a clean, white paper towel, and wiping the internal food safe surfaces of the ice machine that are expected to be clean, to verify if contaminants are able to be removed), and brown and orange matter was able to be removed from within the product ice containment bin ceiling surface. Both the Maintenance and the Admin observed the brown and orange matter on the white paper towel, removed from the ice product bin ceiling surface, and acknowledged it was not acceptable. The Maintenance further stated he just recently 055129 Page 6 of 13 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many cleaned the ice and water machine but did not document the recent cleanings. The Maintenance and Admin further stated the ice and water machine was not acceptable for use in the facility, due to the current state and condition of the machine. The Admin failed to provide a response when asked if the ice and water machine was clean to use for resident consumption. During an interview on July 14, 2021, at 2:13 PM, with the Admin, the Admin stated all of the ice and drinking water for resident consumption in the facility was provided from the contaminated ice and water machine that was earlier observed and surveyed in the facility. The Admin further stated the ice and water machine will be replaced, and no longer used in the facility. The Admin further stated all ice and water pitchers were removed from the residents. During an interview on July 15, 2021, at 9:19 AM, with the Dietary Director (DD), the DD stated when he checked on the contaminated ice and water machine, he never took the machine apart to look inside the machine, to verify the machine's internal components were clean and sanitary. During an interview on July 15, 2021, at 9:26 AM, with the DD, the DD stated and confirmed that the contaminated ice and water machine, found to have foreign growth matter, was the only machine of its kind in the facility, and it was used for all resident dietary needs in the facility. During an interview on July 15, 2021, at 10:20 AM, with the Registered Dietician Consultant (RDC), the RDC stated and confirmed she inspected the facility's ice and water machine every month, and she would document these inspections on monthly reports. During an interview on July 15, 2021, at 11:47 AM, with the RDC and the Nutrition Consultant Surveyor, the RDC stated the following: -The RDC stated she had been working with the facility since December 2020, and since starting her monthly rounds at the facility, she had some concerns with the cleanliness of the facility's ice and water machine, as documented in her monthly reports. The RDC further stated she would always notify the Admin regarding these concerns, and the Admin would have been aware of these concerns. -The RDC stated she would not open the ice and water machine to observe and verify the condition of the machine's internal components, and she would only observe and verify what was easily accessible upon the machine. The RDC further stated she documented that the facility's ice and water machine needed more attention towards cleanliness. -The RDC further stated she would only complete the white paper towel test within the final ice cube chute, and not within the actual product ice containment bin. -The RDC further stated as a Consultant, she would advise for the facility to follow the manufacturer guidelines in regard to cleaning the ice and water machine, and more often as needed. -The RDC further stated, based upon her expertise and the professional standards of practice for her specialty, no foreign matter or growth should exist within these ice and water machines used for resident consumption needs. During a concurrent interview and record review, on July 15, 2021, at 12:00 PM, with the RDC and the Nutrition Consultant Surveyor, the RDC's monthly reports titled, Dietary Services - Kitchen Sanitation / Food Storage, dated December 1, 2020 through June 28, 2021, were reviewed. The RDC reviewed 055129 Page 7 of 13 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0812 her monthly reports and stated the following: Level of Harm - Immediate jeopardy to resident health or safety -For her report completed for February 2021, she reviewed her documentation and stated her notes included cleanliness of the facility's ice and water machine was a concern, and how she discussed these concerns with the facility. Residents Affected - Many -For her report completed for March 29, 2021, she reviewed her documentation and stated her notes included cleanliness of the facility's ice and water machine was a concern, and the machine did not pass the white paper towel test. -For her report completed for May 10, 2021, she reviewed her documentation and stated her notes included her communication with the Admin in regards to the cleaning logs for the ice and water machine needing to be completed properly and the manufacturer guidelines needing to be followed. The RDC further stated she was never able to verify if the facility was completing and maintaining cleaning logs for their ice and water machine, and she would communicate this requirement to the Admin and to the DD, with the Admin stating to her that this was getting taken care of. The RDC further stated again the documentation in regard to the facility cleaning the ice and water machine was not available for her review, and she had never seen the available cleaning logs from the facility, in regard to their ice and water machine. The RDC further stated she would expect that the person responsible for cleaning the facility's ice and water machine was aware of how to take the machine apart to adequately clean the machine, and verify the cleaning was effective. During an interview on July 15, 2021, at 12:20 PM, with the RDC, the RDC stated typical contaminants that will grow and spread within an inadequately cleaned ice and water machine include bacteria and mold. During an interview on July 15, 2021, at 3:43 PM, with Licensed Vocational Nurses 1 & 2 (LVN 1) & (LVN 2), LVN 1 & LVN 2 both stated and confirmed that the water dispensed out of the facility's ice and water machine, including the machine that was found to be contaminated with foreign growth matter, was used for resident consumption needs, as well as for resident medication administration, including for the residents with feeding tubes (a tube surgically placed through a person's abdomen, to artificially provide nutrition and/or medication directly into the digestive system). During a review of RDC's monthly reports titled, Dietary Services - Kitchen Sanitation / Food Storage, dated December 1, 2020 through June 28, 2021, the documentation indicated the following: -For the monthly report dated February 26, 2021 through March 1, 2021, the document indicated, Per manufactures guidelines needs cleaning - does not appear appropriate. DSS to discuss (with) maintenance in regard to the deficient report item Ice machine clean and scoop clean; stored separately. -For the monthly report dated March 29, 2021, the document indicated, Discussed (with) DSS (Dietary Services Supervisor) and Administrator - guidelines for cleaning ice machine in regards to the deficient report items Cleaning documented routinely for ice machines in use & Sanitizing documented per Mfr. for ice machines in use. -For the monthly report dated May 10, 2021, the document indicated, Discussed (with) Maintenance and Administrator in regard to deficient report items Cleaning documented routinely for ice machines in use & Sanitizing documented per Mfr. (Manufacturer) for ice machines in use. 055129 Page 8 of 13 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many During a review of the [Name of Facility] Progress Notes for Residents 36, 44, 19, 24, & 37, dated July 14, 2021, the progress notes for these residents included, Assessed Resident at bedside in regards to GI (Gastrointestinal) Distress such as N/V (Nausea/Vomiting), Diarrhea, or Stomach Cramping D/T (due to) possible mold contamination of ice/ water machine . These assessments indicated the residents were exposed to the ice and water product from the facility's contaminated ice and water machine. During a review of the [Name of Facility] Progress Notes *New* for Residents 31, 4, & 32, dated July 14, 2021, the progress notes for these residents included, Assessed Resident at bedside for GI Distress such as N/V, Diarrhea, or Stomach cramping D/T possible mold contamination of ice/water machine . These assessments indicated the residents were exposed to the ice and water product from the facility's contaminated ice and water machine. During a review of the physician orders for Residents 31, 36, 4, 44, 19, 32, 24, & 37, dated July 14, 2021, the physician orders for these residents included, .Monitor for GI Distress: (0) No Symptoms, (1) Nausea, (2) Vomiting, (3) Stomach Cramping, (4) Diarrhea, (5) Fever ever shift for 3 Days Notify MD (Medical Doctor) is having any symptoms . During a review of the care plans for Residents 31, 36, 4, 44, 19, 32, 24, & 37, dated July 14, 2021, the care plans for these residents included, At risk for Transient GI Upset such as: Stomach cramping, Nausea, Vomiting, Diarrhea due to water ingestion from possible exposure to moldy ice machine . On July 14, 2021, at 4:55 PM, an Immediate Jeopardy (IJ - a situation that had threatened or was likely to threaten the health and safety of a patient) situation was called in the presence of the Administrator (Admin) and the Director of Nursing (DON), for noncompliance towards the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. The noncompliance regarded the facility's failure to ensure the ice and water machine, used for resident consumption of ice and drinking water in the facility, was maintained in a clean and sanitary manner, and free from visible contamination indicative of foreign growth matter. The Admin and the DON were verbally notified of the IJ situation. On July 15, 2021, at 8:55 AM, an acceptable corrective action plan (CAP) was provided by the facility, which included: [Name of Facility Letterhead] This document will serve as a credible allegation of our intent to correct the deficient practice identified. Preparation and/or execution of this CAP do not constitute admission or agreement, by the provider, of the executed solely because it is required by the provisions of Health and Safety Code Section 1280 and 42 C.F.R. 405.1907 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? All residents are potentially affected by the deficient practice were assessed for GI symptoms from the ice machine mold contamination such as nausea, diarrhea, stomach cramping, fever and vomiting and no residents were affected. 055129 Page 9 of 13 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Maintenance director assisted by Dietary supervisor immediately removed ice machine with its connective tubing from the designated area. Upon identification of the alleged deficient practice, Restorative Nurse Assistant and Infection Prevention (IP) Nurse pulled all water pitchers from each resident rooms. Assigned staff purchased multiple bags of ice from outside source as well as bottled water. Residents were immediately provided with new water pitchers with store bought bottled water and ice. Administrator purchased new ice machine and will immediately have it installed in addition to newly filtered water system in the designated area. All residents will be monitored for the next 72 hours for any sign and symptoms of GI distress. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? All residents are potentially affected by the alleged deficient practice as this has the potential to affect resident overall health condition. C. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur? Cleaning and the sanitation of the machine will be done by the maintenance director according to the manufacture recommendation, or minimum one time per month. Infection control nurse will monitor cleaning and sanitation of the machine on a monthly basis. Ice machine cleaning log will be kept in the designated area next to the ice machine. Administrator or Director of Nursing will ensure all above items are implemented. D. How the facility plans to monitor its performance to make sure that solutions are sustained? RD will conduct monthly inspection on the ice machine cleanliness. RD and Infection control nurse (IP) findings will be communicated to the Director of Nursing. Director of Nursing will monitor monthly for compliance. Director of Nursing will report findings identified to the QAA (refers to Quality Assurance) Committee during the monthly Quality Assurance Performance Improvement for the purpose of process improvement or changes to the plan to ensure substantial compliance with this plan of correction. Staff will be in serviced and trained today on how to operate and maintain the new machine. The IJ was abated on July 15, 2021, at 4:24 PM, in the presence of the DON, after onsite observation, interview, and record review verified the facility's implementation of the corrective action plan. 055129 Page 10 of 13 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0880 Provide and implement an infection prevention and control program. 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 that infection prevention was maintained when 1. All three of the shower beds in use were observed with numerous cracks in the plastic covering with the foam inside exposed, 2. A staff member entered a yellow zone room (isolation room housing a resident with a contagious disease) without personal protective equipment (the equipment such as gowns, gloves, masks, face shields that prevent spread of disease). These failures had the potential to spread infectious disease to all 46 residents within the facility. Residents Affected - Some Findings: 1. During an observation on July 12, 2021, at 10:05 AM, Resident 15 was observed being brought back from the shower on a shower bed made from blue plastic material. The material was cracked in numerous places, and the foam rubber inside the blue plastic material was exposed. During a concurrent interview with the Certified Nursing Assistant (CNA 3), CNA 3 stated the shower bed padding was cracked, and was unsure how the shower beds were sanitized. During an interview on June 12, 2021, at 10:10 AM with the shower team CNA (2), CNA 2 stated that all three of the shower beds had cracked padding, and that she had not yet reported it to maintenance. During an observation on June 12, 2021, at 10:21 AM, the three facility shower beds were observed to be discolored and cracked. During a concurrent interview with the Licensed Vocational Nurse Infection Preventionist (IP), the IP stated that all three of three of the facility's shower beds plastic covered foam pads were cracked and could not be effectively sanitized. During a review of the facility policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated/revised July 2014, the P&P indicated, .4. Reusable resident care equipment will be decontaminated and/or sterilized between residents . 2. During an observation on July 14, 2021, at 9:01 AM, Housekeeping was observed inside of room [ROOM NUMBER] indicated as a Yellow-Zone isolation room under contact and droplet precautions (Transmission-based precautions, requiring the wearing of a N95 mask, eye protection, gown, and gloves), without following the due transmission-based precaution that were posted on the doorway of room [ROOM NUMBER]. Housekeeping was observed as not wearing an N95 mask and gloves while inside the room [ROOM NUMBER] under contact and droplet precaution. During a concurrent observation and interview on July 14, 2021, at 9:10 AM, with Housekeeping, Housekeeping stated that she went into resident room [ROOM NUMBER] bed A to help fix and prepare bed A to be transferred to room [ROOM NUMBER]. Housekeeping further stated that she was aware that room [ROOM NUMBER] was under isolation precautions, as posted on the room doorway. When asked about the expectation for staff entering a resident room under isolation precautions within the Yellow-Zone, Housekeeping stated, to follow the indicated guidelines which included staff donning (putting-on) a gown, eye protection, gloves, and an N95 face mask. During an interview on July 14, 2021, at 9:44 AM with the DON (Director Of Nursing), the DON stated that all staff are required to wear complete PPE (Personal Protective Equipment) when entering resident's room in Yellow-Zone area as posted and indicated in the signage along the hallway of 055129 Page 11 of 13 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0880 Yellow-Zone area. Level of Harm - Minimal harm or potential for actual harm During an interview on July 14, 2021, at 9:56 AM, with the Infection Preventionist (IP) Nurse, the IP stated the expectation from staff entering a resident room under isolation precautions within the Yellow-Zone was to wear complete PPE and follow the indicated guidelines on the doorway signage, which included staff donning a gown, eye protection, gloves, and an N95 face mask. IP further stated these expectations apply to staff, even they are entering the resident room to provide direct or indirect patient care. Residents Affected - Some During a review of the CDC (Centers for Disease Control and Prevention) guidelines transmission-based precautions titled, Use Personal Protective Equipment (PPE) when Caring for Patient with Confirmed or Suspected COVID-19, dated June 3, 2020, the document indicated, . Preferred PPE- Use N95 or higher Respirator, Face shield or goggle, one pair of clean, non-sterile gloves, isolation gown . During a review of the facility's COVID-19 Mitigation Management Plan titled, Expanded Infection Control Guidance on Cohorting, dated December 15, 2021, the document indicated, . proper PPE (i,e.,gown, mask, shield, etc.) is used in yellow unit. 055129 Page 12 of 13 055129 07/15/2021 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure two rooms (room one and room two) housed no more than four residents per room, when each room was set up to house five residents each. This failure had the potential for the residents housed in room one and room two to not have the ability to move about freely if the five beds limited their personal space. Findings: During a tour of the facility on July 12, 2021, at 9:00 AM, the following observations were made: a. room [ROOM NUMBER] (one) was observed to have five beds and all were occupied, there were five closets, one for each resident. The room was very light, and there were five televisions, one for each resident. There were wheelchairs, oxygen concentrators, and walkers observed at the bedsides of the residents. The room was very spacious, not crowded, with room to move around. b. room [ROOM NUMBER] (two) was observed to have five beds, and three of them were occupied, there were five closets. Once again, the room was very light, and an exact replica of room [ROOM NUMBER], there were also wheelchairs, walkers, and oxygen concentrators in the room. The room was not at all crowded. During an interview on July 12, 2021, at 9:05 AM, with Resident 4, Resident 4 stated he liked his room very much, he had no complaints about the room or any of his four roommates, and stated it was a very nice facility. During an interview on July 12, 2021, at 9:30 AM, with Resident 31, Resident 31 stated she was not at all crowded in her room, and that she had no complaints about the room or the facility. During an observation and interview on July 12, 2021, at 1:00 PM, with the Maintenance Director in rooms [ROOM NUMBERS], the rooms were measured to be identical in size, both measuring 646.80 square feet, giving each resident 129.36 square feet. There was enough space to easily accommodate the needs of the residents in each room, and the comfort, health and safety of the residents were not compromised. 055129 Page 13 of 13