Health inspection·March 11, 2022

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide services according to the accepted standards of clinical practice for two of 12 sampled residents (Residents 15 and 17) when: Residents Affected - Few 1. Resident 15 did not have arm sleeves to protect his skin on the arms as ordered; 2. Resident 17's Advair HFA (an inhaler type of prescription medicine used to treat asthma) was not administered per the manufacturer's specifications. These failures had the potential to affect the residents' health condition and care. Findings: 1. Review of Resident 15's physician order, dated 4/30/21, indicated arm sleeves on both upper extremities every shift. It indicated the resident was on aspirin (an antiplatelet drug preventing platelets [a component of the blood that stops bleeding] from clumping together to form a clot) daily. During an observation on 3/8/22 at 12:25 p.m. and 3/9/22 at 7:30 a.m., Resident 15 had multiple skin discolorations and a skin tear on both arms and hands. The resident was not wearing arm sleeves. During an observation and concurrent interview on 3/11/22 at 12:30 p.m., certified nursing assistant B (CNA B), who was involved in Resident 15's care, stated the resident did not wear arm sleeves and did not have them. 2. During a medication pass observation on 3/9/22 at 8:01 a.m., licensed vocational nurse C (LVN C) administered Resident 17's Advair HFA. After administering the first puff (inhalation), the resident did not close her mouth to hold her breath and breathe in. She started breathing out after getting the first puff. LVN C did not instruct the resident to hold her breath and breathe in. After five seconds, LVN C administered the second puff to the resident. During an interview on 3/9/22 at 1:39 p.m., LVN C stated the wait time should be three to five minutes between inhalations. Review of the facility's policy, Oral Inhalations, dated 5/2016, indicated, Hold breath for 5-10 seconds or as long as possible to allow medication to reach deeply into lungs, slowly exhale . if another puff of the same or different medication is required, follow the manufacturer's product information for administration instructions including the acceptable wait time between inhalations. Page 1 of 10 055311 055311 03/11/2022 Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of the manufacturer's package insert, dated 2/2021, indicated, After the spray comes out .take the inhaler out of your mouth and close your mouth .Hold breath for about 10 seconds or for as long as is comfortable. Breathe out slowly .wait about 30 seconds and shake the inhaler well for 5 seconds. Repeat the steps . Residents Affected - Few 055311 Page 2 of 10 055311 03/11/2022 Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901

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** 2. Review of Resident 15's care plans indicated the resident was at high risk for falls related to history of falls, confusion, gait, and balance problems. Review of Resident 15's clinical records indicated the resident had fall incidents on 1/18/21, 3/3/21, 10/12/21, 1/2/22, 1/24/22, 2/6/22, and 2/18/22. Review of Resident 15's IDT Fall Review, dated 1/19/21, indicated the IDT reviewed the resident's 1/18/21 fall incident and the IDT did not recommend any new interventions or revise the current interventions to prevent falls. Review of Resident 15's IDT fall review, dated 1/26/22, indicated the IDT reviewed the resident's 1/24/22 fall incident and one of the recommendations was to take the resident to assess for bathroom privileges after lunch. Review of Resident 15's IDT fall review, dated 2/8/22, indicated the IDT reviewed the resident's 2/6/22 fall incident and there was no new recommendation to prevent recurrent falls. During an interview on 3/10/22 at 12:19 p.m., the director of nursing (DON) and the SD, who participated in Resident 15's IDT meetings, stated after fall incidents, the IDT reviewed each fall incident and made recommendations to prevent recurrent falls. DON and the SD reviewed Resident 15's clinical records and confirmed that there were no new or revised recommendations for fall incidents on 1/19/21 and 2/8/22. The SD stated on 1/26/22, the IDT planned to assess the resident's toileting after lunch, but the plan was not communicated to the certified nursing assistants (CNAs) and there was no evidence the recommendation was implemented. Review of the facility's policy, Resident Falls Management, dated 11/2016, indicated after implementation of the plan, subsequent incidence of falls is followed by reevaluations, which includes discussion of possible interventions needed to prevent further recurrence. Based on observation, interview, and record review, the facility failed to provide a safe environment for three of 12 sampled residents (Residents 2, 15, and 23) when: 1. The interdisciplinary team (IDT, team of diverse caregivers involved in the treatment plan for the resident) recommendations were not implemented for Residents 2 and 15; 2. The IDT did not initiate or revise interventions to prevent recurrent falls for Resident 15; and 3. Resident 23's fall assessment was missing upon admission. These had the potential to result in falls and injuries to the residents. Findings: 1. Review of Resident 2's clinical record indicated she had diagnoses including Parkinson's disease (a disease that include symptoms of slowness of movements, muscle rigidity, involuntary 055311 Page 3 of 10 055311 03/11/2022 Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901

F 0689 tremors/shaking and impaired balance and posture) and hypertension (high blood pressure). Level of Harm - Minimal harm or potential for actual harm Review of Resident 2's Morse Fall Scale (a method of assessing a person's likelihood of falling), dated 4/13/21 indicated Resident 2 was a high risk for falls. Residents Affected - Few Review of Resident 2's IDT Fall Review, dated 8/16/21 indicated Resident 2 fell on 8/13/21. Resident 2 was found kneeling next to her bed. The IDT conclusions indicated staff will perform frequent rounding to assist resident with bathroom privilege, thirst or hunger. Review of Resident 2's IDT Fall Review, dated 12/29/21 indicated Resident 2 fell on [DATE]. Resident 2 was found sitting on the floor in her room. The IDT conclusions indicated the following: urinalysis (UA, a urine test that can check for infection or kidney problems) and culture and sensitivity (C&S, culture is a test to identify the bacteria causing an infection and sensitivity was used to identify which antibiotic can be used to treat the infection) as ordered; anticipate needs every shift; and reorientation as needed. Review of Resident 2's Lab Results Report, dated 1/1/22 indicated, NO UA RCVD [received] FOR UA C&S and RECOLLECT. There was no documentation that indicated the reason Resident 2's urine was not collected. During an interview on 3/10/22 at 1:15 p.m., the minimum data set coordinator (MDSC) stated the nurse assigned to Resident 2 should have collected a urine sample to send to the lab. The MDSC confirmed there were no other UA C&S results in Resident 2's chart. During an interview on 3/11/22 9:51 a.m., the staff developer (SD) stated there was no documentation that indicated staff frequently performed rounding to assist Resident 2. The SD stated staff are already anticipating Resident 2's needs and it was not a new intervention. 3. Review of Resident 23's face sheet indicated Resident 23 was an [AGE] year old female admitted on [DATE] with admitting diagnoses of generalized muscle weakness, chronic obstructive pulmonary disease (COPD, lung disease that blocks airflow making it hard to breathe), and diabetes mellitus type two (DM,chronic condition that affects the way the body processes sugar with the body not making enough insulin or being resistive to it). During record review and concurrent interview with the SD on 3/10/22 at 12:39 p.m., the SD confirmed the Morse falls risk assessment was missing for Resident 23 upon admission. The SD confirmed the Morse falls risk assessment should have been completed on admission. Record review of the facility's policy titled Fall Evaluation (MORSE Scale) and Management, revised February 2000, indicated the licensed nurse should complete the Morse falls risk assessment on admission and based on that score determine if the resident is at a low risk, a moderate risk, or a high risk for falls. Per policy, appropriate care plan interventions should be developed based on the assessed risk level. 055311 Page 4 of 10 055311 03/11/2022 Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901

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. Based on observation, interview, and record review, the facility failed to ensure nursing staff assessed one of 12 sampled residents (Resident 7) for removal of an indwelling catheter (a tube inserted into the bladder to drain urine). This failure had the potential for the resident to have an unnecessary indwelling catheter with increased risk of catheter related complications i.e., infection. Findings: During an observation on 3/8/22 at 9:14 a.m., Resident 7 had an indwelling catheter with a drainage bag. Review of Resident 7's Nursing Progress Notes, dated 2/19/22, indicated the resident was transferred to an acute care hospital for respiratory failure. Review of Resident 7's Discharge Summary from the acute care hospital, dated 2/21/22, indicated the resident was discharged with the indwelling catheter. Review of Resident 7's CARE CONFERENCE, dated 2/23/22, indicated on 2/21/22, the resident was readmitted to the facility. During a record review and concurrent interview, on 3/10/22 at 12:37 p.m., the director of nursing (DON) reviewed Resident 7's clinical records and stated there was no documented evidence the staff assessed whether the resident's indwelling catheter was necessary upon admission. Review of the facility's policy, Evaluation for Indwelling Catheters, dated 2/2018, indicated, Residents admitted with indwelling catheters have them removed when there is no valid medical justification, and Each resident is evaluated at admission .for indwelling catheter usage .when possible, discontinue the indwelling catheter usage and initiate toileting/retraining evaluation protocol as appropriate. Resident admitted with an indwelling catheter not meeting the clinical conditions . have catheter usage discontinued within 3 to 5 days as appropriate per physician order. 055311 Page 5 of 10 055311 03/11/2022 Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure an attending physician visited and evaluated one of 12 sampled residents (Resident 8) in a timely manner. This failure had the potential to delay identifying the resident's medical needs and providing necessary care and treatment appropriately. Residents Affected - Few Findings: Review of Resident 8's Physician Notes indicated the resident was seen by the attending physician on 9/8/21. During an interview on 3/11/22 at 8:19 a.m., the director of nursing (DON) stated the resident did not like her attending physician, the facility found another physician, and the new attending physician would start providing services for Resident 8. The DON stated the Medical Record staff (MR) monitors the physicians' progress notes indicating the physicians visit the residents on a regular basis. During an interview on 3/11/22 at 12:35 p.m., the MR stated she did not monitor if the physicians visited the residents and made their progress notes. During a phone interview on 3/11/22 at 1:20 p.m., Resident 8's attending physician (AP A) stated the resident refused to have AP A come into her room and she could not assess the resident. AP A stated September 2021 was her last visit to see the resident and complete a physical examination. 055311 Page 6 of 10 055311 03/11/2022 Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident 15's physician order, dated 1/31/22, indicated the resident was on Seroquel (an antipsychotic medicine to treat schizophrenia [a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others]). Residents Affected - Few Review of Resident 15's AIMS assessment indicated it was done on 7/1/20, 2/17/21 and 9/7/21. During an interview on 3/10/22 at 9:42 a.m., the director of social service (DSS) reviewed Resident 15's clinical records and stated the resident had taken Seroquel since 2020. During an interview on 3/11/22 at 11:10 a.m., the staff developer (SD) stated the staff assess the residents who take antipsychotic medications, completing AIMS quarterly when their comprehensive care plans are reviewed. SD stated Resident 15's AIMS assessment was not done quarterly. During record review of the facility's policy Psychotropic Drugs, updated January 2019, indicated monitoring for appropriate diagnosis of behavioral symptoms and monitoring for any side effects of the drug that may be considered unnecessary. Based on interview and record review, the facility failed to ensure adequate monitoring of psychotropic medications for two of 12 sampled residents (Residents 5 and 15) when the side effects of Ambien (medication used to treat insomnia, a sleep disorder) were not monitored for Resident 5 and the Abnormal Involuntary Movement Scale (AIMS, test to monitor movement disorders in a person taking an antipsychotic medication) assessment was not completed for Resident 15. These failures had the potential to result in unnecessary medications. Findings: Review of Resident 5's clinical record indicated he had diagnoses including cervical disc disorder (changes in the cervical [neck] part of the spine, resulting in pain, tingling, or numbness) with telepathy (injury to the spinal cord). Review of Resident 5's physician orders indicated he had an order for Ambien tablet 10 milligrams (mg, unit of measurement) give 10 mg by mouth every 24 hours as needed for insomnia, dated 3/5/22. Resident 5 also had discontinued order for Ambien tablet 10 mg give 10 mg by mouth every 24 hours as needed for insomnia, dated 2/18/22. Review of Resident 5's medication administration record (MAR, record of medications given), dated February 2022 indicated Ambien 10 mg was given each day from 2/18/22 to 2/28/22. Review of Resident 5's MAR, dated March 2022 indicated Ambien 10 mg was given on 3/1/22, 3/2/22, 3/6/22, 3/7/22, and 3/8/22. There was no documentation that indicated side effects of Ambien were monitored for Resident 5 in February 2022 and March 2022. During an interview on 3/09/22 at 21:25 p.m., the minimum data set coordinator (MDSC) confirmed there was no side effect monitoring for Resident 5 in February and March 2022. The MDSC stated side effects of Ambien should be monitored. 055311 Page 7 of 10 055311 03/11/2022 Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901

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. Based on interview and record review, the facility failed to ensure two of 12 sampled residents (Residents 6 and 11) had gradual dose reduction (GDR) attempts for their psychotropic medications (drugs that affects brain activities associated with mental processes and behavior). This failure resulted in the residents not having the opportunity to be free from the unnecessary psychotropic medications. Findings: 1. Review of Resident 6's Note to Attending Physician/Prescriber, dated 9/15/21, indicated the resident had been taking the antidepressant, paroxetine (antidepressant medication), 20 milligrams (mg) once a day and the consultant pharmacist recommended gradual dose reduction (GDR). Resident 6's attending physician (AP A) responded by checking, Resident with good response, maintain the current dose. The form's section for the attending physician/prescriber to indicate clinical rationale for continuing medication dosage was blank. During a record review and concurrent interview with the director of social service, on 3/10/22 at 9:47 a.m., the DSS reviewed Resident 6's clinical record and stated there was no documented clinical rationale to continue the current dose of paroxetine. During a phone interview on 3/11/22 at 1:30 p.m., AP A stated she did not document a clinical rationale to continue Resident 6's paroxetine dose. 2. Review of Resident 11's physician order, dated 9/13/21, indicated the resident's target behaviors (behaviors monitored by the staff for the use of psychotropic medications) were unhappiness as evidenced by sad facial expression. Resident 11's associated triggers were missing family/home and wanting to be with his family. Review of Resident 11's physician order, dated 9/24/21, indicated Celexa (a medication for the treatment of depression) 20 mg at bedtime. Review of Resident 11's Note to Attending Physician/Prescriber, dated 1/26/22, indicated a consultant pharmacist reviewed the resident's drug regimen and recommended gradual dose reduction (GDR) for Celexa. The attending physician declined by checking, Resident with good response, maintain the current dose. The form's section for the attending physician/prescriber to indicate clinical rationale for continuing medication dosage was blank. During a record review and concurrent interview with the DSS on 3/9/22 at 2:49 p.m., the DSS stated Resident 11's Celexa was initiated on 7/6/21. She reviewed target behavior monitoring sheets, from 8/2021 to 2/2022, and stated the resident had not shown any behaviors. The DSS reviewed Resident 11's clinical records and stated there was no documented clinical rationale to continue the current dose. During a phone interview with AP A, on 3/11/22 at 1:20 p.m., Resident 11's AP A stated she did not document a clinical rationale to continue the current dose of Celexa. 055311 Page 8 of 10 055311 03/11/2022 Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901

F 0758 Level of Harm - Minimal harm or potential for actual harm During record review of the facility's policy Psychotropic Drugs, updated January 2019, indicated the GDR consists of tapering the resident's daily dose determine if the resident's symptoms can be controlled by a lower dose of medication. The policy indicated the physician should a provide a justification including clinical appropriateness for continued medication use/dose. Residents Affected - Few 055311 Page 9 of 10 055311 03/11/2022 Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review, the facility failed to ensure rooms [ROOM NUMBER] had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive in the facility. Findings: Review of the facility's Client Accommodations Analysis indicated rooms [ROOM NUMBER] were approved for two beds and measured 74.25 square feet per resident, 78.48 square feet per resident, and 76.30 square feet per resident respectively. During the survey, there were no concerns from residents and staff regarding room size. Continuance of the room waiver is recommended. 055311 Page 10 of 10