Health inspection·April 7, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 call light (a device used by a resident to signal their need for assistance from facility staff) was not within reach for two of four residents (Residents 9 and 20) reviewed for call light. Residents Affected - Few This failure had the potential to place Residents 9 and 20 at risk of harm, as residents would be unable to call for help, or alert staff in the event of an incident. Findings: 1. During a review of Resident 9's clinical record titled, admission Record (contains demographic and medical information), it indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (not enough oxygen in a person's blood), dysphagia (difficulty swallowing), and hyperglycemia (increased blood sugar levels). During a concurrent observation and interview on April 6, 2023, at 1:32 PM, with the Physical Therapist (PT 1), in Resident 9's room, Resident 9's was lying in bed. Resident 9's call light was on the on the floor, at right side of the bed. Its button was touching the floor. It was not within Resident 9's reach. The PT 1 verified Resident 9's call light was on the floor. 2. During a review of Resident 20's admission Record, it indicated Resident 20 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side (complete paralysis [loss of function] and partial weakness following a stroke), repeated falls (more than two falls in a six-month period), and major depressive disorder (persistent feeling of sadness and loss of interest). During an observation, on April 7, 2023, at 8:44 AM, in Resident 20's room, Resident 20 was sleeping in bed. Resident 20's call light was hanging on the urinal (used to collect urine) holder on the right side of bed, and the red button of the call light was touching the floor. The call light was not within Resident 20's reach. During a follow up observation and interview, on April 7, 2023, at 8:48 AM, Resident 20 attempted to reach his call light and stated that he could not reach it [call light]. During a concurrent observation and interview, on April 7, 2023, at 8:52 AM, in Resident's 20 room, with the Minimum Data Set Nurse (MDS Nurse) verified the call light was not easily accessible to Resident 20. Page 1 of 25 055129 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0558 During a review of the facility's undated policy and procedure (P&P) titled, Call Light, the P&P indicated, . place the call device within resident's reach. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055129 Page 2 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

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 interview and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were accurately completed to reflect the resident's status, care, and services in the skin conditions under Section M for two of three residents (Residents 299 and 350) reviewed for Resident Assessment. Residents Affected - Few These failures had the potential to cause inaccuracy in identifying Resident 299's and 350's care and support needs. Findings: 1. During a review of Resident 299's admission Record (a document that contains demographic and clinical data), it indicated Resident 299 was admitted to the facility on [DATE], with diagnoses which included hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and hypertension (when your blood pressure is higher than the recommended level). During a concurrent interview and record review, on April 6, 2023, at 1:21 PM, with the Minimum Data Set Nurse (MDS Nurse), the MDS Nurse reviewed Resident 299's clinical record which indicated, an initial admission record assessment and admission note was conducted for Resident 299 on March 16, 2023. Further review indicated Resident 299 did not have pressure injury/ulcer (an open wound on the skin caused by a long period of constant pressure) upon admission. The MDS Nurse was not able to find documented evidence that Resident 299 had a pressure injury upon admission. During further record review and interview, with MDS Nurse, on April 6, 2023, at 1:30 PM, the MDS Nurse reviewed Resident 299's MDS admission Assessment (a comprehensive assessment for a resident that must be completed within 14 days after admission), dated March 23, 2023, under Section M titled Skin Conditions, which indicated Resident 299 had an Unhealed Pressure Ulcer/injuries category stage 3 [sore that involved skin loss throughout the entire thickness of the skin], and it was present on admission. The MDS Nurse further stated, it was coded in error. 2. During a review of Resident 350's admission Record, it indicated Resident 350 was initially admitted to the facility on [DATE], with diagnoses which included hyperlipidemia, major depressive disorder and hypertension. During a concurrent interview and record review, on April 6, 2023, at 1:40 PM, with the MDS Nurse, the MDS Nurse reviewed Resident 350's clinical record which indicated a skin pressure weekly assessment was conducted for Resident 350 on February 7, 2023. The assessment indicated .Pressure ulcer review .Present on admission [marked] No .Onset date 2/6/23. The MDS Nurse was not able to find documented evidence that Resident 350 had pressure injury upon admission. During further record review and interview, with the MDS Nurse, on April 6, 2023, at 1:55 PM, the MDS Nurse reviewed Resident 350's MDS admission Assessment, dated February 9, 2023, on section M titled Skin Conditions, which indicated, Resident 350 had an Unhealed Pressure Ulcer/injuries category unstageable - deep tissue injury [sore as 'purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue], and it was present on admission. The MDS Nurse further stated, it was coded in error. 055129 Page 3 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review, with the MDS Nurse, on April 7, 2023, at 10:30 AM, the MDS Nurse reviewed the RAI manual, revised October 2019, which indicated .The RAI process .require that (1) the assessment accurately reflects the resident's status .It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound.Steps for Assessment 1. Review the medical record, including skin care flow sheets or other skin tracking forms. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review . Steps 3: Determine Present on Admission For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement. 1. Review the medical record for the history of the ulcer/injury admitted to the facility without a pressure ulcer/injury. During the stay .develops . pressure ulcer. This is a facility acquired pressure ulcer and was not present on admission. The MDS Nurse stated that the facility did not follow the RAI manual. 055129 Page 4 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a care plan (a summary of a resident's health conditions, specific care needs, and current treatments) were developed for two of two residents (Resident 9 and 46) reviewed for care planning when: 1. For Resident 9, a care plan was not developed for her behavior of removing her nasal cannula (a pronged device used to administer oxygen). This failure had the potential for Resident 9's oxygen needs not being met. 2. For Resident 46, a care plan was not developed when Resident 46 repeatedly refused weekly weights. This failure has the potential for Resident 46's weight changes not being identified and addressed which could place his health at risk. 3. For Resident 46, a care plan was not developed for his refusal of anti-coagulant medications (used to prevent blood clots). This failure had the potential for Resident 46 developing a deep vein thrombosis (blood clot forming in a deep, large vein) causing life threatening complications such as pulmonary embolism (a sudden blockage in a lung), heart attack, or ischemic stroke (blockage in the brain). Findings: 1. During an observation, on April 4, 2023, at 10:21 AM, outside the facility's gym, Resident 9 was sitting up in her wheelchair and was being wheeled by a staff member into the Activities room. Resident 9's nasal cannula was connected to a portable tank on the back of her wheelchair. During a concurrent observation and interview, on April 4, 2023, at 12:53 PM, in Resident 9's room, Resident 9 was not wearing her nasal cannula. A Certified Nursing Assistant (CNA 1) verified the finding, and stated Resident 9 likes to take it [nasal cannula] off and chew on it. During a concurrent observation and interview, on April 4, 2023, at 4:11 PM, in Resident 9's room, with the Director of Nursing (DON), Resident 9 was sitting in bed, without her nasal cannula. The DON verified the finding. During a review of Resident 9's clinical record titled, admission Record (contains demographic and medical information), it indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (not enough oxygen in a person's blood), dysphagia (difficulty swallowing), and hyperglycemia (increased blood sugar levels). During a review of Resident 9's physician's order, it indicated Resident 9 had an order for .CONTINUOUS OXYGEN AT 1-2 L [liters- unit of measurement]/MIN [minute] and titrate [continuously measure and adjust the balance of] as needed VIA NASAL CANNULA/MASK [a device used to administer oxygen] TO KEEP OXYGEN SATURATION [amount of oxygen in blood] ABOVE 90% and CHECK O2 [oxygen] SATS [saturation] 055129 Page 5 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0656 as needed for SOB [shortness of breath]. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 9's Care Plan (contains a plan of care for resident) for Altered respiratory status/difficulty breathing, dated February 17, 2023, it indicated .goal .will maintain normal breathing pattern as evidenced by normal respirations .interventions .provide oxygen as ordered: CONTINOUS OXYGEN AT 1-2 L/MIN and titrate as needed VIA NASAL CANNULA/MASK TO KEEP OXYGEN SATURATION ABOVE 90%. Further review indicated there was no interventions addressing Resident 9's behavior in removing the nasal cannula. Residents Affected - Few During a concurrent interview and record review of facility's undated policy and procedure (P&P) titled Care Planning, with the DON, on April 5, 2023, at 9:46 AM, the DON reviewed the P&P, which indicated, . the interdisciplinary team (IDT) shall develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs . The DON stated the policy was not followed for Resident 9 when Resident 9's behavior in removing the nasal cannula was not identified and care planned. 2. During a concurrent observation and interview, with Resident 46, on April 4, 2023, at 11:04 AM, Resident 46 was lying in bed, talking on his cellphone. Resident 46 stated, he was a vegan (a person who does not eat any food or food products that comes from animals) and the facility was not able to accommodate his dietary needs. Resident 46 stated he has not been weighed at the facility since his admission on [DATE]. During a review of Resident 46's admission Record, it indicated Resident 46 was admitted to the facility on [DATE], with diagnoses which included history of falling and difficulty in walking. During a review of Resident 46's physician's order, dated March 10, 2023, it indicated, WEEKLY WEIGHTS X [times] 4 WEEKS, every day shift every 7 day(s) for 4 Weeks .End date 04/08/2023 (April 8, 2023). During an interview, on April 4, 2023, at 10:04 AM, with a Restorative Nursing Assistant (RNA 1), RNA 1 stated Resident 46 was weighed on admission March 10, 2023, and he refused all other weekly weights due to pain. RNA 1 stated she informed the supervising nurse and the DON regarding Resident 46's refusals to be weighed and they were aware of him refusing everything. During a concurrent interview and record review, on April 7, 2023, at 08:30 AM, with the DON, the DON reviewed Resident 46's Medication Administration Record (MAR-form that helps keep track of every dose administered to residents), for the month of March 2023, which indicated, Resident 46 refused Weekly Weights on March 18, 2023 and March 25, 2023. The DON reviewed Resident 46's clinical records and stated there was no care plan developed for Resident 46's refusal of weight monitoring. During a review of the facility's undated policy and procedure (P&P) titled, Nursing Administration: Care and Treatment - Comprehensive Person-Centered Care Planning, the P&P indicated, .5. The resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternative means to address risk. 3. An observation of medication administration for Resident 46 by a Licensed Vocational Nurse (LVN 1) was conducted on April 6, 2023, at 5:54 A.M., in Resident 46's room. Resident 46 was lying in bed 055129 Page 6 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0656 and refused all morning medications. LVN 1 stated Resident 46 repeatedly refuses medication. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 46's physician orders, dated March 10, 2023, it indicated Resident 46 had an order to receive Clopidogrel Bisulfate (a blood thinner) Tablet 75 MG (milligram - a unit of measurement) Give 1 tablet by mouth one time a day for DVT PROPHYLAXIS (prevention). Residents Affected - Few During a concurrent interview and record review, on April 7, 2023, at 8:30 AM, with the DON, the DON reviewed Resident 46's MAR, for the month of March, 2023, which indicated, Resident 46 refused Clopidogrel Bisulfate tablet 13 times on the following dates: i. March 15, 2023 at 9 AM ii. March 16, 2023 at 9 AM iii. March 18, 2023 at 9 AM iv. March 20, 2023 at 9 AM v. March 22, 2023 at 9 AM vi. March 24, 2023 at 9 AM vii. March 25, 2023 at 9 AM viii. March 26, 2023 at 9 AM ix. March 27, 2023 at 9 AM x. March 28, 2023 at 9 AM xi. March 29, 2023 at 9 AM xii. March 30, 2023 at 9 AM xiii. March 31, 2023 at 9 AM The DON stated there was no care plan developed for Resident 46's repetitive medication refusal. The DON further stated Resident 46 was at risk for developing a blood clot due to being bed bound and refusing the blood thinner medication. During a review Resident 46's MAR, from April 1, 2023 through April 5, 2023,it indicated Resident 46 refused Clopidogrel Bisulfate tablet four times on the following dates: i. April 1, 2023 at 9 AM ii. April 2, 2023 at 9 AM iii. April 3, 2023 at 9 AM 055129 Page 7 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0656 iv. April 5, 2023 at 9 AM Level of Harm - Minimal harm or potential for actual harm During a review of the facility's undated policy and procedure (P&P) titled, Nursing Administration: Care and Treatment - Comprehensive Person-Centered Care Planning, the P&P indicated, .5. The resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternative means to address risk. Residents Affected - Few 055129 Page 8 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe environment was maintained for one of two residents (Resident 37) reviewed for accidents when there was no oxygen sign posted outside of Resident 37's room. This failure has the potential to increase the risk of injuries, which could threaten the welfare, health, and safety of Resident 37. Findings: During a review of Resident 37's medical record, the admission Record (clinical records with demographic information) indicated Resident 37 was admitted to the facility on [DATE], with diagnoses which included pyothorax (presence of pus in the pleural cavity-space between lungs and chest), follicular lymphoma (cancer in the lymphatic system-organs that fight infections and other diseases) and emphysema (lung disease that makes difficult to breath). During a review of Resident 37's Physician's Order, dated March 29, 2023, it indicated PRN [as needed] OXYGEN AT 2-3 L [liters- unit of measurement]/ MIN [minute] VIA NASAL CANNULA/MASK TO KEEP OXYGEN SATURATION [Sat-level of absorption] ABOVE 90% . During a concurrent observation and interview, with a Licensed Vocational Nurse (LVN 2), in Resident 37's room, on April 4, 2023, at 12:33 PM, Resident 37 was sitting on his wheelchair with a portable oxygen tank (a tank that delivers oxygen) strapped at the back of the wheelchair. Resident 37 was receiving oxygen through a nasal cannula (tube used to deliver oxygen). There was no Oxygen in Use sign outside Resident 37's room. LVN 2 acknowledged the finding. During a follow up interview, with LVN 2, on April 4, 2023, at 12:47 PM, LVN 2 LVN 2 stated there should have been an Oxygen in Use sign outside Resident 37's room door. During an interview, with the Director of Nursing (DON), on April 5, 2023 at 12:05 PM, the DON stated Resident 37 was receiving oxygen and there must be a sign outside his room indicating he was on oxygen therapy. 055129 Page 9 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to follow the physician's order for urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) care for one resident (Resident 12) reviewed for urinary catheter. This failure has the potential for Resident 12 to be at risk of Urinary Tract Infection (UTI- clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract), placing his health and safety to be jeopardized. Findings: During an observation in Resident 12's room, on April 4, 2023 at 9:00 AM, Resident 12 was lying in bed in a semi-upright position, watching television. Resident 12 had a catheter attached to a urinary bag. During a record review of Resident 12's admission Record (record that contains pertinent information), it indicated Resident 12 was admitted to the facility on [DATE] with the diagnoses of hypertensive heart and chronic kidney disease with heart failure, (where high blood pressure damages the small blood vessels in your kidneys), urinary tract infection (an infection in any part of the urinary system), major depressive disorder (a mood disorder that causes feeling of sadness and loss of interest) and other obstructive and reflux uropathy (when urine can't flow through the ureter, bladder and flows backwards). During a record review of Resident 12's physician's order, May 27, 2021, it indicated Resident 12 had an order for licensed nurses to Clean catheter with soap and water every shift. During a concurrent interview and record review, with the Director of Nursing (DON), on April 6, 2023, at 1:30 PM, the DON reviewed Resident 12's Treatment Administration Record (TAR) for March 2023 and April 2023, which indicated the urinary catheter care was not provided to Resident 12 on the following shifts: i. March 4, 2023, on AM shift (7AM to 3 PM) ii. April 4, 2023, on PM shift (3 PM to 11 PM) iii. April 5, 2023, on PM shift (3 PM to 11 PM) The DON acknowledged Resident 12 did not receive urinary catheter care on those shifts. During a review of the facility's undated policy and procedure (P&P) titled, Catheter Care, Indwelling, the P&P indicated, . It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN [as needed] for soiling . PURPOSE: .To promote hygiene, comfort and decrease risk of infection for catheterized residents. During a review of the facility job description for a Licensed Vocational Nurse, dated December 17, 2021, it indicated, . Administer services within the applicable scope of nursing practice, which 055129 Page 10 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0690 may include catheterization, . as appropriate and in accordance with applicable standards. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055129 Page 11 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 nursing staff provided adequate monitoring for one of three residents (Resident 451) reviewed for dialysis (process of removing excess water and toxins from the blood by using a machine and an artificial kidney), when Resident 451 was not monitored by the nursing staff after missing two dialysis treatments. Residents Affected - Few This failure had the potential to compromise Resident 451 health due to missed dialysis treatments and increased the risk for complications such as fluid overload (too much fluid in the body). Findings: During a concurrent observation and interview, on April 4, 2023, at 10:30 AM, with Resident 451, Resident 451 was lying in bed, playing games in an electronic device. Resident 451 stated he missed a dialysis treatment last month, March 2023. During a review of Resident 451's admission Record (clinical record with demographic information), it indicated, Resident 451 was initially admitted to the facility on [DATE], with diagnoses of type two diabetes mellitus (high blood sugar levels), end stage renal disease (when kidneys cease functioning) and dependence of renal dialysis. During a review of Resident 451's physician order, dated April 3, 2023, it indicated Resident 451 had an order for Dialysis type: Hemodialysis on Mon [Monday]-Wed [Wednesday]-Fri [Friday] (9:30 AM- 1:45 PM) . During an interview and record review, on April 6, 2023, at 1:13 PM, with the Director of Nursing (DON), the DON reviewed Resident 451's progress notes and acknowledged Resident 451 missed a dialysis treatment on March 27, 2023 and April 5, 2023. The DON was not able to find documented evidence to indicate Resident 451 was monitored for signs of complications after his missed dialysis treatments. The DON further stated when residents miss dialysis, it is the nurse's responsibility to monitor for signs of complications for 72 hours and to document it in the medical records. The facility was not able to provide policies and procedures regarding resident's missing dialysis treatments. During a review of a facility document titled License Vocational Nurse/License Practical Nurse Job Description, dated December 17, 2021, it indicated, . Examine the resident and his/her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical, emotional or mental problems . Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures and applicable state and federal regulations. 055129 Page 12 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure laboratory (lab) procedures were implemented for one of two residents (Resident 46) reviewed for anticoagulant (preventing blood clots) medication use when: 1. Resident 46's physician was not notified of abnormal laboratory result. 2. Blood work was missed for one of four sample residents (Resident 46). These failures had the potential for Resident 46 to develop a deep vein thrombosis (DVT - blood clot forming in a deep, large vein) causing life threatening complications such as pulmonary embolism (a sudden blockage in a lung), heart attack, or ischemic stroke (blockage in the brain). Findings: During a concurrent observation and interview, with Resident 46, on April 4, 2023, at 11:15 AM, in Resident 46's room, Resident 46 was lying in bed, not moving his right leg. Resident 46 stated, his right knee had no strength, and he has not been out of bed since his admission on [DATE]. Resident 46 further stated there had been no blood work done for him for some time. During a review of Resident 46's admission Record (contains demographics and medical information), it indicated Resident 46 was admitted to the facility on [DATE], with diagnoses which include history of falling and difficulty in walking. During a review of Resident 46's physician's order, dated March 10, 2023, it indicated, LAB: ROUTINE CBC (Complete Blood Count - a test that counts the cells that make up the blood ), BMP (Basic Metabolic Panel - blood work that measures eight different substances in your blood) ON MONDAY AND THURSDAYS (START 03/13/23). During a review of Resident 46's physician order, dated March 10, 2023, it indicated Resident 46 had an order to receive Clopidogrel Bisulfate (a blood thinner) Tablet 75 MG (milligram - a unit of measurement) Give 1 tablet by mouth one time a day for DVT PROPHYLAXIS (prevention). During a review of the Resident 46's care plan (a summary of a resident's health condition, specific care needs, and current treatments), dated March 11, 2023, the care plan indicated, Anticoagulant therapy (CLOPIDOGREL) and ASA (Aspirin-medication use to prevent blood clots) r/t (related to) DVT PROPHYLAXIS . Labs as ordered. Report abnormal lab results to the MD (Medical Doctor) . During a review of Resident 46's laboratory results, it indicated HIGH for platelets (blood cells that help form blood clots to stop bleeding - normal reference range is between 163 to 337 x [times] 1000/uL [microliter - a unit of volume], a high number puts an individual at risk for developing blood clots in the blood stream) on the following: i. Platelet result dated April 2, 2023: 515 x [times] 1000/uL and high. ii. Platelet result dated April 3, 2023: 482 x [times] 1000/uL and high. 055129 Page 13 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0773 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review, with the Director of Nursing (DON), on April 6, 2023 at 10:14 AM, the DON reviewed Resident 46's clinical record and was unable to find documented evidence to indicate Resident 46's physician was notified of the abnormal laboratory results on April 2, 2023 and April 3, 2023. The DON stated the facility practice was for the licensed nurses to print and review the laboratory results daily, and to notify the physician of any abnormal results. Residents Affected - Few During a review of the facility's undated policy and procedure (P&P) titled, Diagnostic Test: Lab Procedures, the P&P indicated, . 4. The physician will be notified of lab results. 2. During a concurrent interview and record review, on April 6, 2023, at 10:14 AM, with the DON, the DON reviewed Resident 46's clinical record and verified Resident 46's order for CBC and BMP was not completed on the following dates: i. March 13, 2023 ii. March 16, 2023 iii. March 20, 2023 iv. March 23, 2023 v. March 27, 2023 vi. March 30, 2023 During a review of the facility's undated P&P titled, Diagnostic Test: Lab Procedures, the P&P indicated, . 1. When receiving an order for daily, weekly, monthly, quarterly, bi-annually, annually or stat [immediately] lab complete a laboratory requisition for the draw . 3. The phlebotomist will check the lab folder/binder to complete lab work ordered. 055129 Page 14 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure food prepared for residents on a pureed diet (blended to pudding consistency) was palatable for lunch on April 5, 2023, when five of five residents (Residents 6, 9, 14, 24, and 35) on a pureed diet were served pureed cauliflower and peas that was not palatable and did not taste comparable with the cauliflower and peas served to the residents receiving a regular diet (diet with no restrictions). Residents Affected - Few This failure had the potential to cause the Residents 6, 9, 14, 24, and 35 to experience a decrease in food intake which could lead to poor nutrition and health outcomes for these vulnerable residents in the facility. Findings: During a review of the facility document titled, Diet Type Report, dated April 4, 2023, the document indicated five of the 52 residents, Residents 6, 9, 14, 24, and 35), were on a pureed diet. During an interview, on April 4, 2023, at 12:28 PM, in Resident 42's room, Resident 51 stated he did not like the food in the facility. He further stated meats were tough and the food had no flavor. A lunch taste test was conducted on April 5, 2023, at 12:06 PM, near the Conference Room, with the Dietetics Service Supervisor (DSS). Sample lunch trays of the regular diet and pureed diet were tested for palatability, appearance, texture, and temperature. The sample trays consisted of roast turkey, sweet potatoes, rosemary cauliflower, and peas, and fresh green salad. The regular vegetables tasted buttery and flavorful. The pureed vegetables tasted bland and did not have a buttery flavor. Its' taste was not comparable in flavor to the regular vegetables served. The DSS stated the pureed vegetables tasted bland and did not taste like the regular vegetables. During an interview, with Registered Dietician (RD), on April 5, 2023, at 12:41 PM, the RD stated the pureed diet meals should taste like the regular diet meals. 055129 Page 15 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to provide a food alternative meal that was of similar nutritive value for two of two residents (Residents 101 and 13) reviewed for food alternate meal, when Residents 101 and 13 refused the meal offered on April 4, 2023. This failure had the potential to lead to decrease calorie and nutrient consumption for Residents 101 and 13, who are medically compromised. Findings: During an observation, in the dining room, on April 4, 2023, at 12:10 PM, Resident 101 was seated in the dining table. Resident 101's meal tray contained lasagna, green beans, garlic bread and peanut butter cookie. He stated he does not eat pasta or bread. A Restorative Nurse Assistant (RNA 1) asked him if he would like an alternate. He said yes. RNA 1 brought him a half of a tuna sandwich. Resident 101 ate the tuna from inside of the sandwich and left the bread. During an observation, on April 4, 2023, at 12:12 PM, in the dining room, Resident 13 stated she did not want to eat the lasagna and she asked RNA 1 for a grilled cheese. A few minutes later, she was given a plate with a grilled cheese sandwich. During an interview, with the Dietary Service Supervisor (DSS), on April 4, 2023, at 2:30 PM, he stated when residents are offered meal alternates, they should receive the full meal in addition to the alternate entrée. He stated Resident 13 should have received the grilled cheese with the side dishes that were offered that day and Resident 13 should have received a full tuna sandwich, not a half. During an interview, with the Registered Dietitian (RD), on April 6, 2019, at 12:41 PM, the RD stated meal alternates should be of similar nutritive value as the main meal being served. The RD further stated they should receive the entrée alternate with the sides being served that day. During a review of the facility's policy and procedure titled Food Substitution for Residents Who Refuse Meal, dated 2018, it indicated, Residents will be provided a suitable nourishing alternate meal after the planned, served meal has been refused. 055129 Page 16 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 7. During a concurrent observation and interview, with a License Vocational Nurse (LVN 3), on April 4, 2023, at 10:15 AM, in Resident 26's room, there were three half egg sandwiches on Resident 26's bedside table. LVN 3 inspected the sandwiches and stated the three half egg sandwiches had a label with a date April 3, 2023. she further stated it was from the day before. LVN 3 stated it should have been not left overnight. During an interview, on April 6, 2023, at 2:00PM, with the Director of Staff Development (DSD), the DSD stated the practice was for staff to come back and check if the resident consumed the food and discard them accordingly. The DSD further stated it should have not been left at the bedside overnight. A review of facility's undated policy and procedure titled Infection Prevention-Foodborne Illness, indicated, Intent: . It is the policy of the facility to procure, store, prepare, distribute, and serve food under sanitary conditions following proper sanitation and food handling practices to prevent the outbreak of foodborne illness in accordance with State and Federal Regulations . Procedures: . 11. Food left out at room temperature for more than two (2) hours will be discarded . Based on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when: 1. The stainless-steel wall backsplash, behind the stove and the steam table, had food splash and white-water splash. 2. There were food crumbs and trash under the stove. The food preparation area drawer was lined with paper and had crumbs underneath. The front drawer had black grime. A tray lined with foil stored condiments (oil, vinegar, soy sauce) had crumbs and spills. A metal pan with clean serving spoons, lined with parchment paper, had crumbs underneath. There were trash and food crumbs under the handwashing sink and condiment shelf. 3. The stainless-steel shelves, storing clean pots and pans, were lined with grip liner and had crumbs underneath. The shelf above the drink dispenser had black grime and dust. 4. The microwave had yellow buildup on the sides. The can opener blade have residue and the base had food spills. 5. In the walk in refrigerator, there were spilled red and white liquid on the floor, under the shelf. In the dry storage, the floor in 3 of the 4 corners had food crumbs, trash, dry noodles, chocolate chips, cobwebs, and dead bugs. 6. The resident food fridge, was overpacked. The temperature was not maintained at 41 degrees Fahrenheit (unit of measurement) from April 1, 2023 to April 4, 2023. Most of the food items were not labeled and dated. 7. Three half egg sandwiches were left over night at Resident 26's bed side table. These failures had the potential to expose 52 highly susceptible residents who received food from 055129 Page 17 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the kitchen to foodborne illness (illness caused by ingestion of contaminated food or beverages) due to cross- contamination (the transfer of harmful substances or disease- causing microorganisms to food). Findings: 1. During a concurrent observation and interview, with the Dietetics Service Supervisor (DSS) on April 4, 2023, at 8:30 AM, in the kitchen, the stainless-steel wall backsplash, behind the stove and the steam table, had food splash and white-water splash. The DSS stated areas should be kept clean and free of stains after each meal preparation. During an interview, with the Registered Dietitian (RD), on April 6, 2023, at 12:41 PM, the RD stated the stainless-steel wall behind the stove and the steam table should be kept clean and she expects the staff to wipe it down after each meal. During a record review of facility's policy titled Sanitation, dated 2018, it indicated The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over stove, which will be cleaned by the maintenance staff. A review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. 2. During a concurrent observation and interview, with the DSS on April 4, 2023, at 8:40 AM, there were food crumbs and trash under the stove. The food preparation area drawer was lined with paper and had crumbs underneath. The front drawer had black grime. A tray lined with foil stored condiments (oil, vinegar, soy sauce) had crumbs and spills. A metal pan with clean serving spoons, lined with parchment paper, had crumbs underneath. There were trash and food crumbs under the handwashing sink and condiment shelf. The DSS stated areas should be kept clean and free of crumbs, grime, dirt, stain and spills. He stated they were not able to do the regular cleaning. During an interview with the RD, on April 6, 2023, at 12:41 PM, the RD stated under the stove, cook preparation area drawer, metal pans with serving spoons, and the floor under the handwashing sink and condiment shelf should be kept clean. The RD further stated utensils should be removed out of the drawer, and bins and liners should be removed and cleaned underneath. She also stated under the stove should be swept up regularly. A review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicated The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 3. During a concurrent observation and interview, with the DSS, on April 4, 2023, at 8:40 AM, in the kitchen, the stainless-steel shelves, storing clean pots and pans, were lined with grip liner and had crumbs underneath. The shelf above the drink dispenser had black grime and dust. The DSS stated the area should be kept clean and free of stains after each meal preparation. 055129 Page 18 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with the RD, on April 6, 2023, at 12:41 PM, the RD stated, her expectation was for the stainless-steel shelves storing clean pots and pans, and the shelf above the drink dispenser to be cleaned and maintained weekly and as needed. A review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 4. During a concurrent observation and interview, with the DSS, on April 4, 2023, at 8:45 AM, in the kitchen, the microwave had yellow buildup on the sides. The can opener blade have residue and the base had food spills. The DSS stated they will get a new microwave to replace a new one and the can opener should be kept clean after use. During an interview with the RD, on April 6, 2023, at 12:41 PM, the RD stated, the microwave and the can opener should be kept clean after each use. During a record review of facility's P&P titled Sanitation, dated 2018, it indicated The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over stove, which will be cleaned by the maintenance staff. A review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-601.11, indicates The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 5. During a concurrent observation and interview, with the DSS, on April 4, 2023, at 8:50 AM, in the kitchen, inside the walk in refrigerator, there were spilled red and white liquid on the floor, under the shelf. In the dry storage, the floor in 3 of the 4 corners had food crumbs, trash, dry noodles, chocolate chips, cobwebs, and dead bugs. The DSS stated that the floor and corner areas should be kept clean and free of spills, food crumbs and trash. During an interview with the RD, on April 6, 2023, at 12:41 PM, the RD stated, the floor under shelf of walk-in refrigerator and dry storage floors and back corners should be kept clean and should be swept up and mopped out regularly. A review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 6. During a concurrent observation and interview, with the DSS, on April 4, 2023, at 8:55 AM, in the kitchen, the resident food fridge, was overpacked. Most of the food items were not labeled and 055129 Page 19 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0812 Level of Harm - Minimal harm or potential for actual harm dated. The DSS reviewed the resident food fridge temperature log, which indicated the temperature was not maintained at 41 degrees Fahrenheit from April 1, 2023 to April 4, 2023. The DSS acknowledged the resident food fridge was not monitored and checked. He stated it was the nursing department who maintains the fridge. He further stated when the temperature was not at 41 degrees Fahrenheit or below, it should be reported immediately to Maintenance and the food should be discarded. Residents Affected - Many During a review of the facility document titled Refrigerator Temperature, dated 2023, it indicated the temperature of the resident food refrigerator was above 41 degrees Fahrenheit on the following dates: i. April 1 was 52 degrees Fahrenheit ii. April 2 was 44 degrees Fahrenheit iii. April 3 was 50 degrees Fahrenheit iv. April 4 was 48 degrees Fahrenheit During an interview with the RD, on April 6, 2023, at 12:41 PM, the RD stated, the resident refrigerator in the staff lounge should be checked everyday, and the foods should be labeled and dated. He further stated the foods that are outdated should be thrown away. The RD stated if the refrigerator was not within temperature below 41 Fahrenheit, staff should notify DSS and Maintenance immediately. During a review of the facility's undated policy and procedure titled Policy for food brought from outside, it indicated 7. Perishable foods must be stored in re-sealable containers in the refrigerator. Container will be labeled with the resident's name, receiving date and use by date (3 days). 8. The nursing staff will be responsible for discarding perishable foods on or before the use by date. 15. The refrigerator will be cleaned by the housekeeping staff weekly and the microwave on a daily basis. 17. The nursing staff is responsible to monitor and record the refrigerator temperature twice a day. Refrigerator temperature standards are less than or equal to 41 degrees Fahrenheit. During a review of the FDA Federal Food Code, dated 2022, 3-501.16, it indicated Time/Temperature control for safety food shall be maintained: (2) At 5ºC (41ºF) or less. And Maintaining TCS (time/temperature control for safety foods) foods under the cold temperature control requirements prescribed in this code will limit the growth of pathogens that may be present in or on the food and may help prevent foodborne illness. 055129 Page 20 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure accurate documentation for one of two residents (Resident 299) reviewed for pressure ulcer/injury (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) when a Treatment Nurse (TN 1) did not follow the facility policy and procedure for documenting the change of condition for Resident 299. This failure could have potentially caused a delay of healing for Resident 299's wound. Findings: During a review of Resident 299's admission Record (clinical record with demographic information), the admission Record indicated, Resident 299 was admitted to the facility on [DATE], with diagnoses which included a displaced fracture (gap that formed around the broken bone) of greater trochanter of right femur (bone that attaches to the hip) and hypertension (increased blood pressure). During a review of Resident 299's physician order, dated March 18, 2023, it indicated wound care treatment orders for Resident 299's right posterior (back) lower leg. During a concurrent observation and interview on April 5, 2023, at 9:52 AM, Resident 299 was lying in bed, getting wound care treatment from TN 1. Resident 299 had an open wound at his right posterior lower leg. Resident 299 stated the wound developed at the facility. During a concurrent interview and record review with TN 1, on April 5, 2023, at 11:14 AM, TN 1 reviewed Resident 299's clinical record and could not find any change of condition documentation addressing Resident 299's right posterior lower leg wound, which she identified on March 18, 2023. TN 1 further stated it should have been done on March 18, 2023. (18 days ago.) During a concurrent interview and record review with TN 1, on April 5, 2023, at 4:07 PM, TN 1 reviewed the facility's undated P&P titled, Change of Condition Report, which indicated, . 4. Document resident change of condition in the medical records . 5. All attempts to reach the physician and responsible party will be documented in the nursing progress notes . TN 1 stated the policy was not followed. 055129 Page 21 of 25 055129 04/07/2023 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 their infection control practices were implemented in accordance with their policy and procedure when: Residents Affected - Few 1. Resident 35's nasal canula tubing (NC-tubing that delivers oxygen) did not have a date to indicate when it was changed. 2. In the care area, two staff members were not wearing masks. 3. 17 seat cushions were stored on the floor, across the nurse's station. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 52 medically compromised residents and staff in the facility. Findings: 1. During a review of Resident 35's admission Record (clinical record with demographic information), it indicated, Resident 35 was admitted on [DATE], with the diagnoses of dementia (problems with remembering, thinking or making decisions), dysarthria (slurred or slow speech) following cerebral infarction (disrupted blood flow to the brain), and major depressive disorder (feeling of sadness). During an observation, on April 4, 2023, at 10:10 AM, with a Restorative Nursing Assistant (RNA 1), in the dining room, Resident 35 was in his wheelchair, wearing a NC connected to the portable oxygen tank (a metal cylinder containing oxygen under pressure) running at 2 Liters (L- unit of measurement). The NC tubing did not have a date to indicate when it was changed. RNA 1 stated Resident 35's NC did not have a date labeled. During a concurrent observation and interview, with the Infection Preventionist (IP), on April 4, 2023, at 10:21 AM, in the dining room, the IP confirmed there was no date on Resident 35's NC and stated her expectation is that all NC tubing should be labeled with the date, so staff know how old the tubing is and when to change it. During a follow up interview and record review, with the IP, on April 5, 2023, at 4:04 PM, the IP reviewed the facility's undated policy and procedure (P&P) titled, Oxygen Therapy, which indicated, .Oxygen tubing to be replaced every week . The IP stated the policy was not followed. 2a. During an interview with the Administrator (Admin), on April 4, 2023, at 8:00 AM, the Admin stated it was the facility's policy to require all staff and visitors to wear a mask when entering the facility. During an observation, on April 5, 2023, at 7:15 AM, a Certified Nursing Assistant (CNA 2) arrived at the facility and walked directly to the nurse's station. CNA 2 was not wearing a mask. CNA 2 stated she was supposed to wear a mask but forgot to place one on. During an interview with the IP, on April 5, 2023, at 7:19 AM, the IP stated all staff were expected to wear a mask upon entering the facility. 055129 Page 22 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review with the IP, on April 5, 2023, at 4:05 PM, the IP reviewed the facility's undated P&P titled, Wearing of Masks, which indicated, .It is the policy of this facility to provide ensure that staff and residents are wearing the appropriate Masks . The IP stated the policy was not followed. 2b. During an observation, on April 6, 2023, at 5:40 AM, a [NAME] (Cook 1) entered through the side entrance door, near the kitchen, and walked down the hallway past resident rooms (Rooms 15, 17, 18, 19, 20, 21, 22, 24, and 26). [NAME] 1 was not wearing a mask. [NAME] 1 stated she was supposed to wear a mask. During an interview, with the Admin, on April 6, 2023, at 5:43 AM, the Admin stated he saw [NAME] 1 come in through the side entrance and walk down the hallway without a mask. The Admin stated [NAME] 1 should have worn a mask. A review of the facility's undated P&P titled, Wearing of Masks, indicated, .It is the policy of this facility to provide ensure that staff and residents are wearing the appropriate Masks . 3. During a concurrent observation and interview, with the IP, on April 4, 2023, at 7:49 AM, 17 seat cushions, stacked into three rows, were stored on the floor, across the nurse's station. Three of the 17 seat cushions were touching the floor. The IP acknowledged the finding and stated the cushions were used in the patio for the residents. During a concurrent interview and record review, with the IP, on April 5, 2023, at 4:06 PM, the IP reviewed the facility's undated P&P titled, Environmental Conditions/ Environmental Rounds, which indicated, . It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public . The IP stated the policy was not followed because the cushions should not have been stored on the floor because of the potential risk for infection due to residents using those patio seat cushions to sit on. 055129 Page 23 of 25 055129 04/07/2023 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, interview, and record review, the facility failed to ensure two rooms (rooms [ROOM NUMBERS]) accommodate no more than four residents per room when rooms [ROOM NUMBERS] had 5 beds in each room. This failure had the potential for the residents housed in room [ROOM NUMBER] and 2 to not have the ability to move about freely if the five beds limited their personal space. Findings: During a concurrent interview and record review, with the Administrator (Admin), on April 4, 2023, at 9:16 AM, the Admin reviewed the Entrance Conference Checklist and stated the facility had room waivers for rooms [ROOM NUMBERS], with five beds each. During an environmental tour with the Maintenance Supervisor (MS), on April 5, 2023, at 10:00 AM, two resident rooms had five beds each. The residents' rooms and their measurements of livable space were noted as follows: i. room [ROOM NUMBER] (5 beds) measured: 636.39 sq. ft. [square feet] (127.28 sq. ft. per resident) ii. room [ROOM NUMBER] (5 beds) measured: 643.97 sq. ft. [square feet] (128.80 sq. ft. per resident) During a follow up interview with the Admin, on April 6, 2023, at 12:05 PM, the Admin confirmed the measurements for two of the 23 residents' rooms and two of these did not meet the accommodation requirement per each room. The rooms were not crowded and did not impose any safety hazards to the residents. There were no complaints of space or room issues from the residents occupying these rooms. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency. 055129 Page 24 of 25 055129 04/07/2023 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe environment for one of 23 rooms (room [ROOM NUMBER]), when in room [ROOM NUMBER], a power cord from Bed B was dangling and extending to the power outlet of Bed A. This failure had the potential for the facility staff and residents to trip and fall. Findings: During a concurrent observation and interview, with the Maintenance Supervisor (MS), on April 6, 2023, at 12:40 PM, in room [ROOM NUMBER], a power cord from Bed B was dangling and extending to the power outlet of Bed A. The MS verified the finding and stated the dangling cord was a safety hazard. During a concurrent interview and record review with the MS, on April 6, 2023 at 1:00 PM, the MS reviewed the facility's undated policy and procedure titled, Environmental Conditions/Environmental Rounds, which indicated, .Is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public through monthly environmental rounds . The MS confirmed the room was not safe. 055129 Page 25 of 25