Health inspection·April 8, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 one of 14 sampled residents (Resident 17), who had a history of depressed mood and suicidal ideation (thoughts about intentionally hurting self or causing own death) was adequately assessed, monitored, and followed up as indicated in the facility's policy and procedure. This failure placed Resident 17 at risk for self-injury. Findings: According to the admission Record Resident 17 was admitted to the facility in the summer of 2021 with multiple diagnoses including adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life) with depressed mood. Review of Resident 17's Minimum Data Set (MDS, an assessment tool) dated 1/30/22, indicated resident had clear speech, was able to express his ideas and wants and was cognitively intact. Review of Resident 17's mood assessment indicated resident verbalized that in the last 14 days he was feeling down, depressed, or hopeless and nearly every day he had thoughts that he would be better off dead, or hurting yourself in some way. A review of Resident 17's MDS mood assessment, dated 10/30/21, indicated that the resident verbalized in the last 14 days he felt bad about himself or that he was a failure. In addition, Resident 17 verbalized that he was depressed or hopeless, and had thoughts that he would be better off dead, or hurting yourself in some way. A review of the SBAR (Situation, Background, Assessment, and Recommendation, amethod of charting), dated 9/13/21, at 3 p.m., indicated Resident 17 experienced suicidal ideation and verbalized he will kill himself. The SBAR documentation indicated Resident 17 was sent to the emergency room (ER) for evaluation. A review of Resident 17's clinical records indicated a Psychiatric Consultation was done on 9/16/21. The psychiatrist documented that per nursing, Resident 17 expressed he wants to kill himself .said he wants to die . The psychiatrist outlined a Treatment Plan for Resident 17 and directed the facility to Continue . monitoring [resident] of [sic] behavioral symptoms .Continue to monitor statements and remove dangerous items if any specific statements are made such as removing ligature (cords), bags, sharp objects, and ensure patient does not hoard meds [medications] .Follow -up: Arrange in 3-4 months or sooner as indicated. Page 1 of 9 055242 055242 04/08/2022 Fairmont Rehabilitation Hospital 950 S. Fairmont Avenue Lodi, CA 95240

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the clinical records indicated there was no documented evidence the facility arranged for Resident 17's follow up with the psychiatrist as indicated in his recommendation. A review of Resident 17's SBAR, dated 4/1/22 at 7 p.m., indicated Resident 17 had a change of condition manifested by increased confusion, agitation, and suicidal ideation. The document indicated Resident 17 verbalized thoughts of harming/killing himself. The document indicated the facility notified resident's caregiver and the caregiver stated, this is not the very first time this happened. According to the document, Resident 17's physician was notified and the resident was sent to ER for evaluation. According to nurse's progress notes, dated 4/2/22 at 2:55 a.m., Resident 17 returned to facility without any new orders. The nurse documented that the resident was to be monitored for suicidal ideation every 15 minutes for 72 hours, all cords from resident's room were removed, and he had to have plastic utensils for 72 hours. A review of Resident 17's clinical records, including electronic records, failed to reveal hospital records, including physician's evaluation regarding resident's verbalization of suicidal ideation and that resident was safe to return. During an interview on 4/6/22 at 2:50 p.m., Medical Records Staff (MRS) stated she was aware of the resident's visit to the ER on [DATE]. The MRS stated she was not able to find hospital records sent with the resident. The MRS stated she did not follow up and did not request resident's records from ER yet. A review of Resident 17's clinical records failed to reveal documented evidence the facility followed up with the resident's verbalization of hopelessness and suicidal ideation from 9/13/21 to 4/6/22. There was no documented evidence social services followed up on the resident's depressed mood and suicidal ideation and assessed the resident from 9/13/21 until 4/6/22. There was no documented evidence of a care plan with the interventions for each episode of resident's suicidal ideation to guide the resident's care and to ensure the resident's safety. A review of Resident 17's Medication Administration Records (MARs) from September 13, 2021 until April 6, 2022, indicated that there was no documented evidence that the facility was monitoring the number of episodes of Resident 17's verbalization of hopelessness and suicidal ideation and behavioral symptoms of depressed mood. During a concurrent observation and interview on 4/6/22, at 2:25 p.m., Resident 17 was observed alone in a wheelchair in his room. Resident 17's TV was off and the room was dark. The window curtain was closed and the curtain separating resident's bed from another bed was pulled over. Resident 17 stated, I'm very upset . I need to go home and they won't let me go. Resident 17 explained that his wife was sick and he wanted to go home to be with her. Resident 17 continued, If they don't allow me, in a few days they will need to bring a box here . to take my body if I don't go home .It's my secret how I'm going to do it .I'm trained, I served in special air force .Nobody seems to care. That's ok, I'll take care of this. During an interview on 4/6/22 at 3:20 p.m., a Certified Nursing Assistant 2 (CNA 2) stated he took care of Resident 17 frequently and was familiar with the resident. CNA 2 stated, He [Resident 17] is very alert and oriented, he knows what he wants, when he wants, and how he wants. CNA 2 stated he observed Resident 17 to be sad and [he] told me he was sad and depressed because he couldn't go home. 055242 Page 2 of 9 055242 04/08/2022 Fairmont Rehabilitation Hospital 950 S. Fairmont Avenue Lodi, CA 95240

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/6/22, at 3:25 p.m., Licensed Nurse 2 (LN 2 ) stated she was assigned to Resident 17 on 4/2/22, the same day resident came back from ER. LN 2 stated during the shift change she was informed that the resident was sent to ER because he was suicidal. LN 2 stated she was not aware Resident 17 had a psychiatric evaluation for suicidal ideation at the ER or if there were any records pertaining to his visit to the ER. LN 2 stated when she assessed Resident 17, the resident told her, I'm okay, I feel better. I didn't mean to do it. I just want to go home. LN 2 was asked what was implemented to ensure that the resident's safety was maintained while in the facility. LN 2 stated that for 72 hours after the incident, the facility monitored Resident 17 frequently, removed all the cords from his room, and ensured that he did not have sharp objects in his room. LN 2 stated that for the last two days she was assigned to Resident 17, he did not verbalize any thoughts that he wanted to hurt or kill himself. LN 2 stated the facility did not monitor the number of episodes of Resident 17's depressed mood, or verbalization of hopelessness and/or suicidal ideation. During a concurrent interview and record review on 4/6/22, at 3:35 p.m., the Social Services Director (SSD) stated he was aware of Resident 17's suicidal ideation and ER visit on 4/1/22. The SSD stated Resident 17 had episodes of verbalizing thoughts of killing himself in September and November of 2021, and had been evaluated by a psychiatrist in the past. Upon reviewing the psychiatrist's progress notes, dated 9/16/21, the SSD confirmed the psychiatrist recommended to follow up with him in 3-4 months. The SSD stated he did not arrange for Resident 17 to follow up with a psychiatrist as he recommended. The SSD stated, Not done. Not sure why. In our stand up meeting we discuss resident's needs for follow up, but I can't recall if we discussed his. The SSD stated, I have not followed up with him, haven't interviewed and have not assessed him .Generally I would follow up with him regarding his intentions to hurt himself immediately or within 72 hours, but I did not follow up. The SSD was asked if it was arranged for Resident 17 to be evaluated by a psychiatrist after 4/1/22 incident. The SSD stated, I believe there was an order for psychiatry referral, but I did not contact a psychiatrist. During an interview on 4/6/22, at 4:05 p.m., The Director of Nursing (DON) stated Resident 17 denied he was going to hurt himself when she interviewed him the following day. The DON stated there was no Interdisciplinary Team Meeting (IDT -members from different disciplines who get together to assess, coordinate, and manage resident's care) regarding Resident 17's suicidal ideation, but his behaviors and care needs were discussed in the facility's stand up meeting. The DON stated she expected the SSD's follow up and resident's assessment to be done as soon as possible, but it was not done. The DON stated Resident 17 should have a care plan for suicide precautions, but was not able to locate it. During a follow up interview and record review on 4/6/22, at 4:30 p.m., the DON provided Resident 17's care plan initiated on 9/30/21. The care plan indicated the focus: Resident at risk for psychosocial wellbeing r/t [related to] x 1 episode of experiencing suicidal ideation. 11/5/21 Resident had talked about hurting himself after finding his wife was moving to [out of state] with family. The documentation revealed the care plan was resolved on 11/13/21, 8 days after Resident 17 verbalized suicidal ideation and made a statement of hurting himself. The DON was unable to explain why the care plan was resolved and stated that Resident 17 should have a current care plan with interventions to ensure the resident was safe. During a follow up interview and record review with the SSD on 4/8/22, at 10:20 a.m., Resident 17's MDS mood assessments, dated 10/30/21 and 1/30/22, were discussed. The SSD stated on 1/30/22 Resident 17's depression score was 6 which indicated a mild depression. The SSD stated the assessment was performed by the Social Services Assistant. The SSD continued, My assistant did the assessment and I 055242 Page 3 of 9 055242 04/08/2022 Fairmont Rehabilitation Hospital 950 S. Fairmont Avenue Lodi, CA 95240

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some signed the MDS. I don't recall if I had noticed that resident verbalized he had thoughts of hurting himself nearly every day. The SSD indicated that by signing the MDS, it verified that he had reviewed the mood assessment. The SSD further stated the care area should be prompted and the resident should be followed up immediately for his statements of wanting to hurt himself. The SSD stated, I did not follow up with him. A review of the facility's undated policy titled, Depression, indicated, Staff will evaluate residents/patients (especially, those with a high-risk history .signs and symptoms may include .depressed mood .almost every day .thoughts of death or suicide, feelings of helplessness, worthlessness or hopelessness .the physician will identify the need for additional testing and/or consultation (psychiatric, psychological, etc) .the staff .will monitor .will document approaches, timetables, and goals of treatment in the interdisciplinary care plan. During an interview with the DON on 4/8/22, at 10:30 a.m., the DON stated that she was not aware that Resident 17 verbalized he had thoughts of hurting himself nearly every day. The DON stated Resident 17's statements of suicidal ideation should have been discussed during the IDT meeting and the care plan with measurable interventions and suicidal precautions to guide resident's care should have been initiated. A review of the facility's undated policy titled, Suicide Threats, indicated, Resident suicide threats shall be taken seriously and addressed appropriately .A psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated .staff will monitor the resident's mood and behavior and update care plans accordingly. 055242 Page 4 of 9 055242 04/08/2022 Fairmont Rehabilitation Hospital 950 S. Fairmont Avenue Lodi, CA 95240

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 prepare meals that conserved flavor when one of 14 sampled residents (Resident 43) complained about the texture of the food. Residents Affected - Few This failure had the potential for residents to lose their appetite, not be able to enjoy meals and had the potential for Resident 43 to lose weight. Findings: In an interview on 4/5/22 at 10:20 a.m., Resident 43 stated that she did not enjoy the food, vegetables are all soggy . On 4/6/22 at 3:57 p.m., observed carrots boiling in water on low heat. Thirty four minutes later, at 4:31 p.m., the carrots were observed still boiling in water on low heat. In an observation and concurrent interview on 4/6/22 at 4:35 p.m., observed Dietary Aide 2 (DA 2) adding a cup of water into the carrots and stated . it is running out of water and doesn't want it to burn . In an observation and concurrent interview with RD on 4/6/22 at 4:40 p.m., the RD looked at the carrots boiling in water and stated that .this is unacceptable, carrots have lost their nutritive value. The RD told DA 2 to throw the carrots away. In a concurrent interview on 4/6/22 at 4:42 p.m., [NAME] 2 stated that .these are 100% frozen carrots, there is no recipe to boil carrots . In a concurrent interview on 4/7/22 at 2:55 p.m., Resident 43 stated that she .did not enjoy the food, vegetables are mushy and soggy . A test tray was requested on 4/7/22 at 1:00 p.m., 4 surveyors from the Department stated that they found the vegetables mushy. RD who tasted the vegetables from the test tray stated, For this type of population this is perfect. In a concurrent interview on 4/8/22 at 2:52 p.m., Registered Dietician Consultant (RDC) stated there was a recipe. The RDC retrieved a recipe from a binder titled, Recipe: Fresh Carrots .cooking time: about 10-20 minutes, temperature: steam or boil .directions: cook carrots until tender, drain . The RDC stated that, The carrots need to be fork tender. The carrots taken from freezer should not take longer to get to the right texture. A review of the facility's policy titled, Food Preparation, Section 7.1, dated 2018, .Food shall be prepared by methods that conserve nutritive value, flavor and appearance .Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide .Prepare foods as close as possible to serving time to preserve nutrition, freshness and to prevent overcooking . A review of the facility's policy titled, Food Preparation, Section 7.3, dated 2018, .Cook vegetables in small amount of water for a short amount of time . 055242 Page 5 of 9 055242 04/08/2022 Fairmont Rehabilitation Hospital 950 S. Fairmont Avenue Lodi, CA 95240

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 identify and prevent hazards at specific points of food handling when: Residents Affected - Many 1. Ice was built up in the freezer; 2. Four cans had dents; 3. The Dietary Aide did not wear a beard net while handling food; and 4. The [NAME] did not follow the recipe. These failures had the potential to put 50 vulnerable residents receiving food from the kitchen at risk for foodborne illnesses. Findings: 1. During the initial tour of the kitchen on 4/5/22, starting at 8:48 a.m., accompanied by the [NAME] 1 and Dietary Services Supervisor (DSS), an ice buildup was observed on top of an aluminum surface of a food tray in the refrigerator and ice was observed on a rack in the freezer. In a concurrent interview with DSS on 4/5/22 at 8:48 a.m., the DSS stated that he . did not catch it earlier, I will have the maintenance to look at it. The ice on the food tray is not good, if someone tries to wipe the ice off the food tray, they can rip the aluminum foil and contaminate the food. In a concurrent interview on 4/7/22 at 7:29 a.m., Registered Dietician (RD) stated that, .ice on the aluminum foil of the food tray could cause food burn and is unacceptable. Ice buildup in the freezer is due to condensation, is not good, will ruin the food . A review of the facility's policy titled, Sanitation, section 8.1 dated 2018, indicated, .All equipment shall be maintained as necessary and kept in working order .Employees are to alert the Food & Nutrition Services (FNS) Director immediately to any equipment needing repair to the maintenance man. The FNS Director (and/or [NAME] in his absence) will report any equipment needing repair to the maintenance man. The maintenance department will assist Food & Nutrition Services as necessary in maintaining equipment . According to the 2017 Federal Food and Drug Administration (FDA) Food Code 4-501.11 Good Repair and Proper Adjustment indicates, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements . 2. During the initial tour of the kitchen on 4/5/22, starting at 8:48 a.m., accompanied by [NAME] 1 and Dietary Services Supervisor (DSS) it was observed that 4 dented cans were on the shelf in the dry storage room. [NAME] 1 stated that dented cans are no good for cooking. In a concurrent interview on 4/5/22, at 9:05 a.m., the DSS stated that foods from dented cans cannot be used and must be set aside to return to the food service company. 055242 Page 6 of 9 055242 04/08/2022 Fairmont Rehabilitation Hospital 950 S. Fairmont Avenue Lodi, CA 95240

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many In a concurrent interview on 4/7/22 at 7:29 a.m., RD stated that dented cans should be identified and put away to be returned. A review of the facility's policy titled, Storage of Food and Supplies dated 2017, indicated, . Food in unlabeled rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used. 3. During observation of tray line on 4/7/22, starting at 11:50 a.m., Dietary Aide 2 (DA 2) was observed without a beard net. In a concurrent interview, DA 2 stated that he forgot to wear the beard net. DA 2 stated that it is important to wear a beard net to protect the hair from falling into the food, if hair falls into the food, it had the potential to make residents sick. In a concurrent interview on 4/7/22 at 11:50 p.m., RD stated that, . I expect kitchen staff to wear hair and beard covering because it is an infection control issue. A review of the facility's policy titled, Dress Code for women and men dated 2018, indicated, . Personal Hygiene and appropriate dress are a very important part of the total appearance of the Food & Nutrition Services Department. All clothing should be in good repair. Appearance is a very important in maintaining a high standard of food service .Beards and mustaches (any facial hair) must wear beard restraints . 4. During a visit to the kitchen on 4/6/22, starting at 3:57 p.m., [NAME] 2 was observed adding a liquid mixture from a mixing container into a grinder. [NAME] 2 stated that he was preparing an alternative to pasta salad. [NAME] 2 stated that he added a mixture to the grinder that had pasta salad, he made the mixture with honey, mustard, some oil, vinegar, and salt. After testing the consistency with a spatula [NAME] 2 stated it is not turning out the way I like. He further stated that he is now preparing a new mixture. Without the use of measuring device, [NAME] 2 poured vinegar in a mixing container, added salt, oil, mustard and honey and used whisk to mix the mixture and then poured some mixture from the mixing container into the grinder. [NAME] 2 then used a spatula and put the content from the grinder into the container. In a concurrent interview, [NAME] 2 stated that .did not really have a recipe for alternatives. I just look at the recipe online and make it . In a concurrent interview on 4/6/22 at 4:40 p.m., RD stated, .food needs to be prepared by following a recipe, if someone says they prepare food without following a recipe that is wrong . A review of the facility's policy titled, Food Preparation Section 7.1, dated 2018, indicated, .The facility will use prepared recipes, standardized to meet the residents census .The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. Recipes are specific as to portion yield, method of preparation, amount of ingredients, and time and temperature guide. A review of the undated facility's policy titled, Standardized Recipes, indicated, .Standardized recipes will be used to prepare foods . 055242 Page 7 of 9 055242 04/08/2022 Fairmont Rehabilitation Hospital 950 S. Fairmont Avenue Lodi, CA 95240

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed for a census of 50, when: Residents Affected - Some 1. A staff person did not perform hand hygiene after glove removal; and 2. A Covid-19 screening was not conducted upon entrance to the facility. These failures increased the potential for the spread of communicable diseases or infections. Findings: 1. In an observation conducted on 4/7/22 at 10:06 a.m., the Nursing Assistant (NA) removed her gloves after putting the dirty linen inside the laundry bin and then proceeded to get clean linens. The NA did not perform hand hygiene after glove removal. In an interview on 4/7/22 at 10:20 a.m., the NA confirmed she did not perform hand hygiene after removing her gloves and/or prior to handling the clean linens. In an interview on 4/7/22 at 11:45 a.m., the Director of Staff Development (DSD) stated her expectation was for staff to perform hand hygiene in between glove use. A review of an undated facility's policy and procedure titled, Handwashing/Hand Hygiene indicated, .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap .and water for the following situations: .After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment [equipment worn to minimize exposure to a variety of hazards, this include gloves]. 2. In an observation and concurrent interview with Certified Nursing Assistant (CNA) 1 on 4/7/22 at 5:00 a.m., Department arrived at the facility and knocked at the door. CNA 1 opened the facility door after the Department introduced themselves. CNA 1 did not ask the Department to check their temperature, or ask any screening questions, and did not document visitor entry. In a concurrent interview on 4/7/22 at 5:10 a.m., CNA 1 stated. I did not check your temperature, there is a book there to write down everything, Covid screening questions. In a concurrent interview on 4/7/22 at 5:14 a.m., Licensed Nurse (LN) 1 stated, that we do not have visitors at this time. If we have a visitor, we check their temperature, ask them Covid screening questions, what are they are here for. LN1 further stated that she did not check department's temperature, did not ask any screening questions. In a concurrent interview on 4/7/22 at 3:28 pm, the Director of Nursing (DON) stated that every person who comes in the facility had to be screened, their temperature needs to be checked, questions need to be asked. A review of the facility policy titled, Facility visitation guidance- Covid-19-PHE, revised dated 03/08/21, indicated, .Screening of all who enter the facility for Signs and Symptoms of Covid-19 055242 Page 8 of 9 055242 04/08/2022 Fairmont Rehabilitation Hospital 950 S. Fairmont Avenue Lodi, CA 95240

F 0880 (e.g., temperature checks, questions or observations about signs and symptoms), and denial of entry of those with signs and symptoms. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055242 Page 9 of 9