Health inspection·June 27, 2019

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** 3. The record review of Resident 6's admission Record indicated Resident 6 was re-admitted to the facility on [DATE] with multiple diagnoses that included dementia without behavioral disturbance. A record review of the Order Summary Report dated 6/26/19 indicated an order dated 3/17/16 for Resident 6 to receive Seroquel 25 mg, one half tablet by mouth at bedtime for associated agitated behavior which causes distress related to mild cognitive impairment. The record review of Resident 6's psychotropic medication care plan initiated on 3/25/19 indicated the goal was for Resident 6 to be free of psychotropic drug-related complications that included movement disorder, discomfort, hypotension and constipation. The interventions identified included for staff to monitor for side effects and effectiveness of the medication every shift, consult with pharmacy and attending physician for dosage reduction, at least every three months, discuss with attending physician and family regarding ongoing need for use of the medication, and review behaviors, alternate therapies attempted and review their effectiveness. Resident 6's care plan also indicated, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. During an interview and concurrent review of Resident 6's Medication Administration Record (MAR) with Licensed Vocational Nurse 2 (LVN 2) on 6/26/19 at 1:26 p.m., LVN 2 stated she was Resident 6's charge nurse but did not know if Resident 6 had any behavior that warranted use of Seroquel. Resident 6's MAR for June 2019 indicated Resident 6 received Seroquel 25 mg, half tablet at bedtime. LVN 2 confirmed there was no monitoring of target behavior in the MAR or Treatment Administration Record (TAR). LVN 2 also stated side effects from Seroquel included changes in level of consciousness, episodes of confusion, increased sleepiness and abnormal heart rate, but these side effects were not identified or monitored in both TAR and MAR. The record review of the policy and procedure, Comprehensive Care Planning updated 10/19/17 indicated the facility must develop and implement a comprehensive person-centered care plan for each resident, staff will implement each resident's care plan according to the methods indicated, and the facility must establish, document and implement the care and services to be provided to each resident. Based on interview and record review, the facility failed to develop a comprehensive care plan for three (Residents 1, 6, 22) of 15 sampled residents when staff did not develop a plan of care for Resident 1's Chronic Congestive Heart Failure [CHF -heart does not pump blood adequately] and monitor for digoxin (heart medication) toxicity, Resident 22's dental issues and concerns that could effect the nutritional intake, and monitor Resident 6's Seroquel (antipsychotic medication used to treat Page 1 of 12 055156 055156 06/27/2019 St Paul's Towers 100 Bay Place Oakland, CA 94610

F 0656 hallucinations, delusions, severe depression .) for potential side effects. Level of Harm - Minimal harm or potential for actual harm These failures had the potential for Residents 1, 6, and 22 to not receive individualized care based on their medical and nursing assessments and planned accordingly to meet the residents' care needs. Residents Affected - Few Findings: 1. A record review of the admission Records indicated that Resident 1 was admitted on [DATE] with multiple diagnosis including, CHF, chronic atrial fibrillation (an irregular heart beat that causes the top chambers of your heart to quiver) and dyspnea (difficulty breathing). The record review of the physician's order dated 9/2/17 indicated, Digoxin Tablet 125 micrograms (mcg), Give 0.5 tablet by mouth one time a day related to Diastolic CHF). In an interview with the Director of Nurses (DON) on 6/26/19 at 1:50 p.m., DON stated she was not able to provide a documented baseline (starting point) digoxin level result or that the staff were monitoring Resident 1 for signs and symptoms of digoxin toxicity. A record review of Resident 1's clinical record indicated Resident 1's last electrocardiogram (ECG) that records the electrical heart rhythm pattern was dated 9/2/17. The record review of the Medication Regimen Review (MRR) completed by pharmacy dated 4/23/19 indicated, This resident has experienced a recent fall on 4/20/19. The MMR indicated the pharmacist had recommended to hold digoxin for systolic blood pressure (SBP or top number < (less than) 110 & Pulse < 60, including to monitor laboratory tests to prevent digoxin toxicity. In a telephone interview with the Pharmacist (RP 1) on 6/26/19 at 10 a.m., RP 1 stated Digoxin should have at least a baseline level and repeat levels taken to monitor the digoxin's efficacy and toxicity. RP 1 stated Resident 1 and 6 should be closely monitored for signs and symptoms of digoxin toxicity including hypotension (low BP) and confusion that could lead to falls. In an interview with DON on 6/26/19 at 10 a.m., DON confirmed there was no care plan developed to monitor Resident 1's digoxin medication for life-threatening toxicity. 2. A record review of the admission Records indicated Resident 22 was admitted on [DATE] with multiple diagnoses including, unspecified dementia without behavioral disturbance (a person loses the ability to think, remember, learn, make decisions, and solve problems), dysphagia (difficulty swallowing foods or liquids), and major depressive disorder. In an observation and concurrent interview on 6/25/19 at 9:48 a.m., Resident 22 was awake sitting in a chair in her room when she opened her mouth and complained that her upper dentures were not fitting properly and it hurts when she eats. A record review of the document, Weight and Vitals Summary indicated Resident 22 weighed 123.4 pounds (lbs) on admission, and on 4/1/19 weighed 117 lbs. Further review reflected on 5/1/19 her weight was 115.6 lbs. and on 6/1/19, her weight decreased to 114.8 lbs. According to the Nutrition Quarterly Review dated 4/29/19, Resident 22 had a 5.2% weight loss in 055156 Page 2 of 12 055156 06/27/2019 St Paul's Towers 100 Bay Place Oakland, CA 94610

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few three months and was, at risk for unintended weight loss for advanced age, depression, dementia, and needs assistance with Activities of Daily Living (ADL's). In a telephone interview with Resident 22's daughter (FM 1) on 6/26/19 at 11:20 a.m., FM 1 stated she had asked the social worker (SSD) in February 2019 for a dental hygienist or dentist to examine Resident 22's dentures. FM 1 stated she did not receive any communication from the facility regarding Resident 22's dental care since admission. In an interview with SSD on 6/26/19 at 11:40 a.m., SSD stated she was not aware that Resident 22 had denture problems and could not recall the conversation she had with FM 1 regarding Resident 22's dental concerns. A record review of the physician's order dated 1/29/19 indicated, Dental consult to evaluate and treat if necessary. The record review of the Minimum Data Sheet [MDS -a comprehensive, standardized assessment of each resident's functional capabilities and health needs] dated 4/29/19 indicated, Resident 22 needs one person physical assistance when eating. The MDS indicated Resident 22 did not have issues with dentures which was contrary to the resident and family's concern. In an interview with DON on 6/26/19 at 10 a.m., DON confirmed there was no care plan to address Resident 22's denture concerns and nutritional status. 055156 Page 3 of 12 055156 06/27/2019 St Paul's Towers 100 Bay Place Oakland, CA 94610

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure medication and biologicals were current and safe for use on residents when one bottle of Aspirin (medication used for pain, inflammation or blood thinning), and two bottles of glucometer (a blood glucose monitoring device) control solutions were expired. This failure had the potential to put the residents at risk for receiving medication that was not effective beyond their expiration dates, and inaccurate test results from using expired glucometer control solutions. Findings: During the medication room inspection on 6/26/19 at 8 a.m., an unopened bottle of Aspirin (ASA) 325 milligrams (mg) containing 100 tablets and expiration date of February 2019 was observed in the cabinet stored with currently used over-the-counter (OTC) medications. In an interview with the Licensed Vocational Nurse (LVN 1) on 6/26/19 at 8 a.m., LVN 1 stated the expired bottle of ASA should not be stored with the currently used medications, and the expired bottles will be discarded. During a Medication Cart (MC 2) inspection on 6/26/19 at 8 a.m., two bottles of Assure Prism Multi Control Solution 1 and 2 Glucometer test control solutions had an expiration date of May 2019. A record review of the policy, Discontinuing Medications dated 10/13/11 indicated, Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy . No other policy was provided for disposition of expired medications and biologicals. According to Arkray USA makers of Assure Prism Multi Control Solution 1 and 2 QA/QC (quality assurance/quality control) Manual used by the facility indicated, Do not use Assure Prism Multi Control Prism solutions beyond expiration date. This may cause inaccurate results. [Ref: http://www.arkrayusa.com/diabetes-management/sites/arkrayusa.com.diabetes-management/files/AssurePrismMulti_QA-Q 055156 Page 4 of 12 055156 06/27/2019 St Paul's Towers 100 Bay Place Oakland, CA 94610

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A record review of Resident 6's admission Record indicated Resident 6 was re-admitted to the facility on [DATE] with multiple diagnoses that included dementia (condition where memory and decision making skills is impaired affecting daily life function) without behavioral disturbance. The record review of Resident 6's Order Summary Report dated 6/26/19 indicated an order for Seroquel dated 3/17/19 25 milligram (mg), one half tablet by mouth at bedtime for associated agitated behavior which causes distress related to mild cognitive impairment. A review of Resident 6's admission MRR and Monthly Drug Regimen Review report dated 3/18/19 by RP 1 indicated Seroquel may require additional documentation in Resident 6's medical record for target behavior and treatment goals. During an interview with DON on 6/27/19 at 9:54 a.m., DON stated RP 1's recommendation dated 3/17/19 was not followed-up with the attending physician. Further record review of the admission Drug Regimen Report for Resident 6 dated 4/23/19 indicated the use of Seroquel at bedtime for associated agitated behavior required more specific tangible, measurable behavior for the indication of Seroquel. During an interview and concurrent record review with DON on 6/27/19 at 9:54 a.m., DON stated the consultant pharmacist's review for April 2019 was not followed through because he was not given a copy of it. DON also stated the MRR for May 2019 was already completed and he could not find the copy of the review. During a subsequent interview with DON on 6/27/19 at 10:54 a.m., DON stated upon a resident's admission to the facility, a copy of the medication orders were sent to the pharmacy for review and recommendations. DON further stated RP 1 would send a copy of the review to the facility and licensed nurses would review and follow the recommendation(s) by contacting the attending physician for review or approval. DON stated he was responsible to make sure that any recommendations made by RP 1 were followed through. A review of the policy and procedure, Medication Regimen Review And Reporting, copyright 2007 indicated the consultant pharmacist reviews the medication regimen of each resident at least monthly. Resident specific MRR recommendations are documented and acted upon by the nursing department and physician. A record of the consultant pharmacist's recommendations is made available in an easily retrievable format to nurses, physicians, and the care planning team. The consultant pharmacist's recommendations shall be acted upon within 30 calendar days. Based on observation, interview, and record review, the facility failed to follow the policy and procedure and act upon the pharmacist's identified medication irregularities on the Medication Regimen Review (MRR) report for three (Residents 1, 6, 26) of 15 sampled residents as follows: 1. For Resident 1, the monitoring of digoxin (heart medication) to ensure maximal efficacy and minimal risk for digoxin toxicity. 055156 Page 5 of 12 055156 06/27/2019 St Paul's Towers 100 Bay Place Oakland, CA 94610

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. For Resident 26, the monitoring of serum blood levels of potassium and magnesium related to digoxin therapy, including the blood pressure (BP) hold (do not give) parameters ordered by the physician which was not implemented. 3. For Resident 6, the admission Regimen Review and Monthly Drug Regimen Review for use of the antipsychotic medication, Seroquel (treats symptoms of hallucinations, delusions, severe depression .) was not followed up for the medical indication and justification for its use. These failures had the potential to result in adverse effects and not achieving optimal health when staff did not act upon the pharmacist's recommendations and made a referral for the physicians' documented review. Findings: 1. A record review of the admission Records indicated that Resident 1, an elderly resident was admitted on [DATE] with multiple diagnoses including, chronic atrial fibrillation (CHF-an irregular heart beat that causes the top chambers of your heart to quiver) and dyspnea (difficulty breathing). The record review of the physician's order dated 9/2/17 indicated, Digoxin Tablet 125 micrograms (mcg), Give 0.5 tablet by mouth one time a day related to diastolic congestive heart failure [CHF -a condition in which the heart doesn't pump blood adequately]. In an interview with the Director of Nurses (DON) on 6/26/19 at 1:50 p.m., DON was unable to provide a baseline (starting) digoxin level result for Resident 1 or documentation that staff were monitoring for digoxin toxicity. A review of Resident 1's clinical record indicated Resident 1's last electrocardiogram (ECG) that traces the electrical activity of the heart and rhythm pattern was dated 9/2/17. The record review of the MRR dated 4/23/19 for Resident 1 indicated, This resident has experienced a recent fall on 4/20/19. The MMR indicated the pharmacist had recommended the need to hold (do not give) parameters for Systolic (top number) Blood Pressure (SBP) < (less than) 110 & Pulse < 60 and the need to monitor laboratory tests to prevent digoxin toxicity. In a telephone interview with the registered pharmacist (RP 1) on 6/26/19 at 10 a.m., RP 1 stated digoxin should have at least a baseline (starting) level and repeat levels taken to monitor digoxin's efficacy and toxicity. RP 1 further stated that Residents 1 and 26 should be closely monitored for signs and symptoms of digoxin toxicity including hypotension (low BP), and confusion that could lead to falls. According to the facility provided pharmacy document, Digoxin Monitoring Parameters dated 6/26/19 indicated, Digoxin - Drug Information. Heart rate and rhythm should be monitored along with periodic ECGs to assess desired effects and signs of toxicity; baseline and periodic serum creatinine (blood test that reflects kidney function). 2. A review of the admission Records indicated Resident 26 was admitted on [DATE] with multiple diagnoses including, heart failure, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), syncope (fainting) and collapse. 055156 Page 6 of 12 055156 06/27/2019 St Paul's Towers 100 Bay Place Oakland, CA 94610

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The record review of the physician's order dated 11/21/18 indicated, Digoxin Tablet 125 mcg Give 1 tablet by mouth one time a day for heart failure . The record review of the MRR dated 4/23/19 indicated the physician did not order serum potassium and magnesium to prevent any digoxin toxicities. The MRR indicated that Resident 26 had experienced a fall on 3/5/19. RP recommended to the Physician to place hold parameters for Pulse < 60 for digoxin 125 mcg. According to Wolters, Kluwer literature review titled, Use of Digoxin in Heart Failure with Reduced Ejection Fraction dated 9/4/18 indicated, When digoxin levels are monitored, the serum digoxin level should be measured when steady state is achieved, which is 7 to 10 days for most patients . For patients with Heart Failure, the target serum digoxin level for maximal efficacy and minimal risk for toxicity is between 0.5 and 9 ng (nanogram)/ml (milliliter) . Monitoring may be repeated yearly if the patient is subsequently stable . A record review of the High Priority request on 3/15/19 by RP 1 indicated RP 1 was not able to review Resident 26's complete blood count and basic metabolic panel (electrolytes) tests that were ordered on 1/2/19. Lab (laboratory) results could not be found in resident's chart. PLEASE Note: This comment has been repeated for the 3rd month in a row. Further record review for Resident 26 indicated the most recent clinical lab results were dated 11/23/18, and the last ECG was faxed to the physician on 9/23/18. There was no documentation the facility followed-up on the pharmacist's recommendations for Resident 1 and Resident 26 or Resident 26's ordered lab tests. 055156 Page 7 of 12 055156 06/27/2019 St Paul's Towers 100 Bay Place Oakland, CA 94610

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for one of 12 sampled residents (Resident 6), the facility failed to ensure that Resident 6 was given antipsychotic (medication that treats psychosis) medication for a specific documented condition when Resident 6 was given Seroquel (an antipsychotic) without an identified target behavior. This failure had the potential to result in the unnecessary continued use of antipsychotic medication without a clear medical indication for its use and had the potential for adverse side effects. Findings: A record review of Resident 6's admission Record indicated Resident 6 was re-admitted to the facility on [DATE] with multiple diagnoses that included dementia (condition where memory and decision making skills is impaired affecting daily life function) without behavioral disturbance. The record review of Resident 6's Order Summary Report dated 6/26/19 indicated an order dated 3/17/16 for Resident 6 to receive Seroquel 25 milligram (mg), one half tablet by mouth at bedtime for associated agitated behavior which causes distress related to mild cognitive impairment. A record review of Resident 6's psychotropic medication care plan initiated on 3/25/19 indicated the goal was for Resident 6 to be free of psychotropic drug-related complications that included movement disorder, discomfort, hypotension (low blood pressure), and constipation. The interventions identified included for staff to monitor for side effects and effectiveness of the medication every shift, consult with pharmacy and the attending physician for dosage reduction at least every three months, to discuss with attending physician and family regarding ongoing need for use of medication, and review behaviors, alternate therapies attempted and review their effectiveness. Resident 6's care plan indicated, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. During an interview and concurrent review of Resident 6's Medication Administration Record (MAR) with Licensed Vocational Nurse 2 (LVN 2) on 6/26/19 at 1:26 p.m., LVN 2 stated she was Resident 6's charge nurse and did not know if Resident 6 had any behaviors that warranted use of Seroquel. Resident 6's MAR for June 2019 indicated Resident 6 received Seroquel 25 mg, half tablet every bedtime. LVN 2 confirmed there was no monitoring of target behavior in the MAR or Treatment Administration Record (TAR). LVN 2 further stated that Seroquel side effects included changes in level of consciousness, episodes of confusion, increased sleepiness and abnormal heart rate which were not monitored. During an interview with the Director of Nursing (DON) on 6/26/19 at 1:44 p.m., DON stated Resident 6 had been on Seroquel before admission to the facility. DON further stated if a resident was admitted with an order for anti-psychotic medication, the pharmacist and the Interdisciplinary Team (IDT), a group composed of other health team members from different departments) would sit down to discuss the need for continued use of the medication. DON confirmed there was no IDT notes in the clinical record of having discussed the use of Seroquel with the pharmacist. A record review of the policy and procedure, Psychotropic Drugs last updated 11/1/17 indicated the 055156 Page 8 of 12 055156 06/27/2019 St Paul's Towers 100 Bay Place Oakland, CA 94610

F 0758 following: Level of Harm - Minimal harm or potential for actual harm - If a resident is admitted to the SNF [Skilled Nursing Facility] already on a psychotropic medication, the attending physician in collaboration with the consultant pharmacist must re-evaluate the use of the medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission. Residents Affected - Few - The staff will observe, document and report to the attending physician information regarding the effectiveness of the psychotropic medication. - Nursing staff will document in detail an individual's target symptoms. Staff should monitor the resident's behavior assessment record for residents receiving psychotropic medication. Staff should monitor behavior triggers, episodes, and symptoms by indicating the number and intensity of symptoms. 055156 Page 9 of 12 055156 06/27/2019 St Paul's Towers 100 Bay Place Oakland, CA 94610

F 0790 Provide routine and 24-hour emergency dental care for 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 assist and provide one (Resident 22) of 15 sampled residents with dental services in a timely manner. This failure resulted in Resident 22's denture discomfort, the inability to eat preferred foods, and weight loss. Residents Affected - Some Findings: The record review of the admission Records indicated Resident 22, an elderly frail resident was admitted on [DATE] with multiple diagnoses including, unspecified dementia without behavioral disturbance (a person loses the ability to think, remember, learn, make decisions, and solve problems), dysphagia (difficulty swallowing foods or liquids), and major depressive disorder. In an observation and concurrent interview in Resident 22's room on 6/25/19 at 9:48 a.m., Resident 22 opened her mouth and complained that her upper dentures were not fitting properly and it hurts when she eats. A record review of the Weight and Vitals Summary record reflected Resident 22 weighed 123.4 pounds (lbs) on admission. Further review indicated a steady decline in weight on 4/1/19 of 117 lbs, and on 5/1/19 her weight was 115.6 lbs. Resident 22's current weight taken on 6/1/19 was 114.8 lbs. According to the Nutrition Quarterly Review dated 4/29/19, Resident 22 had a 5.2% weight loss in three months and was at risk for unintended weight loss for advanced age, depression, dementia, and needs assistance with Activities of Daily Living (ADL's). In a telephone interview with Resident 22's daughter (FM 1) on 6/26/19 at 11:20 a.m., FM 1 stated she had asked the Social Worker (SSD) on February 2019 for a Dental Hygienist or Dentist to examine Resident 22's dentures. FM 1 further stated she did not receive any communication from the facility regarding Resident 22's dental care since admission. In an interview with SSD on 6/26/19 at 11:40 a.m., SSD stated she was not aware that Resident 22 had denture issues and could not recall the conversation with FM 1 regarding Resident 22's dental concerns. The record review of the physician's order dated 1/29/19 indicated, Dental consult to evaluate and treat if necessary. A record review of the policy, Dental Consultant dated 10/6/11 indicated for staff to arrange for the . dental assessment of each resident within ninety (90) days of admission. 055156 Page 10 of 12 055156 06/27/2019 St Paul's Towers 100 Bay Place Oakland, CA 94610

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a sanitary manner when: Residents Affected - Some 1. Inside the walk-in refrigerator # 1 and # 2, there were multiple food items that were stored beyond their use-by date. 2. The walk-in (#3) freezer had a frosty interior with build-up of formed ice from the ground and up to the ceiling. Multiple boxes inside the freezer were also frosty that included 11 containers of beef broth. A container of multiple packages of beef liver was on the freezer floor. 3. A dietary staff entered the kitchen and walked back and forth near the trayline without wearing a hair cover. 4. The ice machine in the kitchen was not sanitized according to the manufacturer's instructions. These failures had the potential to result in food borne illnesses. Findings: 1. During an initial kitchen observation and concurrent interview with Registered Dietician (RD) on 6/25/19 at 8:48 a.m., the walk-in refrigerator #1 had the following: - An opened container of black beans prepared 6/19/19 had a use-by date 6/23/19. - Three packages of beef ribs that were pulled out 6/20/19 had a use-by date 6/24/19. - An opened container of lemon juice had a use-by date 6/22/19. During further kitchen observation, the refrigerator #2 had the following: - An open container of pure goat milk cheese and use-by date 6/18/19 (8 days past). - An open package of shredded cheese and use-by date 6/24/19. - An open half-full package of unmixed coleslaw and use-by date 6/23/19. - An open container of duck oil and use-by date 6/13/19. The Nutrition Care Manager (CM) removed all the above food items and stated these needed to be thrown out because they were past their use-by dates. 2. During an observation of the kitchen's walk-in freezer (#3) and concurrent interview with RD on 6/25/19 at 8:48 a.m., the freezer had a frosty interior with build-up of formed icicles from the ground up to the ceiling. Boxes that were stored by the freezer door were also frosty, including 11 containers of beef broth. A container of multiple packages of beef liver was stored on the freezer floor. RD stated the container should be stored on the shelf above the floor. 055156 Page 11 of 12 055156 06/27/2019 St Paul's Towers 100 Bay Place Oakland, CA 94610

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of the policy and procedure, Production, Purchasing, Storage and section, Food And Supply Storage last revised January 2019 had indicated, all food items shall be stored in such a manner to prevent contamination to maintain the safety and wholesomeness of food. Foods past the use-by date should be discarded. For frozen storage, food items must be stored six inches above the floor. 3. During the trayline observation and concurrent interview with RD on 6/26/19 at 11:30 a.m., Dietary Staff (DS) 1 entered the kitchen and walked back and forth by the trayline area without wearing a hair cover. RD stated DS 1 should be wearing a hair cover while inside the kitchen. The record review of the policy and procedure, Orientation And Education and section, Uniform Dress Code last revised January 2019, indicated associates working with food should wear the approved hair restraint when on duty. 4. During a follow-up observation in the kitchen and concurrent interviews with the Regional Executive Chef (REC) and RD on 6/26/19 at 11:40 a.m., the kitchen ice machine had a build up of whitish, sticky material on the exterior. The cover and the air filter were dusty. REC stated he cleaned and sanitized the ice machine every month by doing the following steps: Remove ice from the bin, rinse the bin with warm or hot water, wipe the interior down to dry, wipe with a sanitizing cloth wet and the quaternary solution that was used for the three-compartment sink, and let the interior air dry. REC further stated he removed some parts of the ice machine cover for sanitizing. Inside the ice machine cover was a copy of the manufacturer's instructions for use and maintenance of the ice machine that included steps in sanitizing. REC stated he did not follow the instructions indicated on the cover because it was a long process. The instructions included 20 steps for cleaning and another 31 steps for initial and final sanitizing that included removing all the parts thoroughly and replacing the parts in their correct position. REC also stated he was responsible for cleaning and changing the air filter. REC confirmed the ice machine exterior and the air filter were dirty. RD stated she was not sure when it was last cleaned. 055156 Page 12 of 12