Health inspection·August 25, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) assessment accurately reflected resident's current status for one of three sampled residents (Resident 64) when MDS assessments failed to accurately code the functional limitations according to the Resident Assessment Instrument (RAIguidelines on gathering definitive information on a resident's strengths and needs) guidelines. Residents Affected - Few This failure had the potential for Residents 64 not being provided with the necessary care and services to meet his healthcare needs. Findings: During a concurrent observation and interview on 8/22/23 at 11:09 a.m. with Resident 64, Resident 64 was observed in his wheelchair with a contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) left hand. Resident 64 stated, he had left sided weakness related to previous stroke (damage to the brain from interruption of its blood supply). During a review of Resident 64's admission Record, dated 8/24/23, the admission Record indicated, Resident 64 was admitted to the facility 7/13/23 with diagnosis which included but not limited to .Delusional Disorder (A delusion is an unshakable belief in something that's untrue) .Delirium due to known physiological condition (steady decline in thinking ability) .Unspecified Dementia, unspecified severity, with other behavioral disturbance (affecting memory, thinking and social abilities) . Hallucination (an experience involving the apparent perception of something not present) . During a review of Resident 64's Minimum Data Set (MDS-a resident assessment tool used to identify cognitive and physical functional level assessment) Assessment, dated 7/20/23, the MDS indicated Resident 64's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) score was 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 64 had no cognitive impairment. During a concurrent interview and record review on 8/24/23 at 2:40 p.m. with Licensed Vocation Nurse (LVN) 1, Resident 64's MDS assessment, Section G (section G), dated 7/20/23 was reviewed. Resident 64's section G indicated, Functional Limitation .no impairment .Upper extremity (shoulder, elbow, wrist, hand) . LVN 1 stated, no impairment was inaccurate for Resident 64. LVN 1 stated, Resident 64 has left sided weakness due to a stroke. LVN 1 stated it was important to have section G accurate in order to provide Resident 64 with the appropriate care. Page 1 of 17 055475 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 8/24/23 at 2:50 p.m. with [NAME] President of Clinical Services (VP), Resident 64's MDS assessment, Section G (section G), dated 7/20/23 was reviewed. VP stated section G was inaccurate for Resident 64. VP stated, Resident 64's section G indicated no impairment or functional limitation for range of motion. VP stated, that was inaccurate assessment for Resident 64. VP stated Resident 64 has left sided weakness her expectation is for staff to correctly assess residents. During a concurrent interview and record review on 8/24/23 at 2:52 p.m. with MDS Coordinator LVN (MDS LVN), Resident 64's MDS assessment, Section G (section G), dated 7/20/23 was reviewed. Section G indicated, Resident 64 had no impairment to his upper extremities. MDS LVN stated section G was inaccurate. MDS LVN stated, Resident 64 was admitted with left sided weakness related to a stroke. MDS LVN stated, accurate assessments are important to reflect the Resident 64's current condition, in order to provide appropriate care. During a concurrent interview and record review on 8/25/23 at 9:24 a.m. with MDS LVN, the facility's policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessment, dated January 2018, the P&P indicated, .Any person who completes any portion of the MDS assessment .The information captured on the assessment reflects the status of the resident . MDS LVN stated, the P&P was not followed. MDS LVN stated, Resident 64 might not have received the care he needed. During an interview on 8/25/23 at 9:55 a.m. with Director of Nurses (DON), the DON stated the MDS nurse did not follow policy. The DON stated the assessment was not accurate or correct for Resident 64. DON stated her expectation is that resident would be accurately assessed. DON stated, Resident 64's inaccurate assessment could lead to a delay in care. DON stated, she was unsure of what manual was used by the MDS staff to complete assessments. During a review of the facility's document titled MDS Assessment Coordinator, (job description) dated 10/19/2015, the job description indicated, .Maintaining standards of practice for resident assessment .Ensuring exchange of essential information necessary for the accurate completion of resident assessment .Comprehensive knowledge of nursing principles required, including the ability to recognize and identify symptoms . Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2019. The RAI process indicated, .the assessment accurately reflects the resident's status . documentation that contributes to identification and communication of a resident's problems, needs, and strengths, that monitors their condition on an on-going basis, and that records treatment and response to treatment, is a matter of good clinical practice and an expectation of trained and licensed health care professionals. Good clinical practice is an expectation of [Center for Medicare & Medicaid Services] .Section G . this section assess the need for assistance with activities of daily living (ADLs), altered gait and balance, and decreased range of motion. 055475 Page 2 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

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 residents environment remained free of accidents and hazards when: 1. Four of 41 residents' rooms (Residents 6, 54, 64 and 73) had unsecured, exposed electrical cable wires and were hanging from the ceiling within arm's reach. 2. Six of 41 residents' rooms (Resident 3, 4, 63, 67, 68 and 71) had water leaking in the bathroom from a clogged swamp cooler line. These failures had the potential to place residents and staff at risk for accident hazards such as electrocution, skin burns, slip and fall, ceiling collapse and avoidable resident and staff injury. Findings: 1. During a concurrent observation and interview on 8/22/23 at 10:22 a.m. with Resident 73 in her room, unsecured exposed cable wires hung from ceiling tiles within arm's reach were observed. Resident 73 sat in her wheelchair next to her bed and stated the cable wires have been hanging for as long as she can remember. Resident 73 stated it was unsafe. During a concurrent observation and interview on 8/22/23 at 11:09 a.m. with Resident 64 in his room, unsecured exposed cable wires hung from ceiling tiles within arm's reach were observed. Resident 64 stated the cable wires have been hanging for some time. Resident 64 did not know how long the wires had been hanging. Resident 64 stated the wires bother him. Resident 64 stated, if he was better, he would fix the wires himself. During an observation on 8/23/23, at 11:30 a.m., in Resident 6 and 54's room, two black electrical wires were observed to be exposed and hanging from the wall next to the bathroom door, approximately 36 inches in length. The exposed electrical wires were within reach of residents. During a concurrent observation and interview on 8/23/23, at 11:59 a.m., with Licensed Vocational Nurse (LVN) 4, inside Resident 6 and 54's room, LVN 4 stated the electrical and cable wires were exposed and hanging out from the wall next to the bathroom door and were within reach of residents. LVN 4 stated the exposed electrical wires were dangerous and could cause electrocution to anyone touching it [electrical wire]. LVN 4 reviewed the maintenance log located at the nurses' station and stated he can't find a note indicating the exposed electrical wires were reported. LVN 4 stated staff were supposed to document any maintenance issues in the maintenance log, and it was not done. During a concurrent observation and interview on 8/24/23, at 10:22 a.m., with Maintenance Supervisor (MS), inside Resident 6 and 54's room, MS stated the electrical and cable wires were exposed and hanging out from the wall next to the bathroom door and were within reach of residents. MS stated the electrical and cable wires should be tied and secure to the wall and they were not. During a concurrent interview and record review, on 8/24/23, at 10:28 a.m., with the MS, the facility's Station 1 Maintenance Log (log), (undated) was reviewed. The log indicated, . Maintenance Needs . [room number] has no call light, call bell given . Response . 8/21/23 . MS stated there was no 055475 Page 3 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documented report for exposed electrical and cable wires for Resident 6 and 54's room. MS stated staff were supposed to report any maintenance issues by using the log and it was not done. MS stated he checks the log daily and walks around the building every day and inquires with the nurses for any problem such as non-working call lights, bed repairs, or repainting. MS stated the exposed electrical and cable wires were dangerous and could cause electrocution to anyone touching it, including residents. MS stated the facility must provide a hazard free environment for residents. During a concurrent observation and interview on 8/24/23 at 11:31 a.m. with Maintenance Supervisor (MS), in Resident 73 and 64's room unsecured exposed cable wires hung from ceiling tiles, the cable wires were within arm's reach of the residents. MS stated cable wires should not hang down. MS stated it posed a hazard and residents could choke or get electrocuted from them. MS stated his staff was responsible for building safety. MS stated, any visible wires should be secured. During a concurrent observation and interview on 8/24/23 at 1:21 p.m. with License Vocational Nurse (LVN) 3, in Resident 73 and 64 rooms' unsecured exposed cable wires hung from ceiling tiles were observed. LVN 3 stated the wires posed a risk to the residents, resident could choke and injure themselves if the wires were pulled on. LVN 3 stated residents could also get electrocuted. LVN 3 stated maintenance oversees maintaining the facility building and nursing staff can place hazard concerns on a maintenance repair log. LVN 3 reviewed the maintenance repair log and there were no concerns regarding hanging cable wires found from December 2022 to August 2023. LVN 3 stated hanging wires should be addressed immediately because they are a safety concern. During a concurrent observation and interview on 8/24/23 at 1:32 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 73 and 64 rooms unsecured exposed cable wires hung from ceiling tiles, within arm's reach of the residents were observed. CNA 1 stated hanging cable wires were not safe for residents because they could pull on the cords, injure themselves and they could choke on them. During an interview on 8/25/23 at 9:52 a.m., with the Director of Nurses (DON), the DON stated the expectations are for wires to be secured and prevent any hazards or risk for choking and injury. During an interview on 8/25/23, at 12:10 p.m., with the Administrator (ADM), ADM stated the exposed electrical and cable wires inside Resident 6 and 54's room were not acceptable and should be fixed. ADM stated the exposed electrical wires could potentially injure residents and staff. During a review of the facility's document titled, Job Description: Maintenance Director, dated 10/2015, the document indicated, . Position Summary: The Maintenance Director is responsible for the overall maintenance operation of the center .Maintains the building in good repair and free of hazards such as those caused by electrical, plumbing, heating and cooling systems . During a review of the facility's policy and procedure (P&P) titled, Physical Plant Interior Maintenance, dated 4/2005, the P&P indicated . All interior areas of the building are inspected within a one-month period to ensure proper condition and function . Interior maintenance of the physical plant is an essential function of the preventive maintenance program to assure employee and resident safety . 2. During an observation on 8/22/23, at 11:06 a.m., inside the bathroom between Resident 3, 4, 63, 67, 68 and 71's rooms the bathroom floor was wet, slippery and water was dripping from the ceiling. There was no visible signage indicating that the area was off limits for residents or staff to access the bathroom. 055475 Page 4 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 8/22/23, at 11:08 a.m., with MS, inside the bathroom between Resident 3, 4, 63, 67, 68 and 71's rooms . MS confirmed the floor was wet, slippery, and water was dripping from the ceiling. MS stated the water was coming from the swamp cooler drain line and probably was clogged up resulting in water leaking into the ceiling. When MS accessed the swamp cooler cover from the bathroom ceiling, more water came out from the ceiling. MS examined the drain line and confirmed that it was clogged. MS stated he was not aware of the problem and called another maintenance staff to help dry the floor. During a concurrent interview and record review, on 8/24/23, at 10:28 a.m., with the MS, the facility's Station 1 Maintenance Log (log), undated was reviewed. The log indicated, . Maintenance Needs . [room number] has no call light, call bell given . Response . 8/21/23 . MS stated there was no documented issue reported for water leaking above the bathroom between Resident 3, 4, 63, 67, 68 and 71's rooms. MS stated staff was supposed to report any maintenance issues by using the log and it was not done. MS stated he checks the log daily and walks around the building MS stated the wet floor and water leaking from the ceiling were dangerous. MS stated, water on the floor could cause a slip and fall to residents and staff. MS stated a ceiling could potentially collapse because of water build up. MS stated the facility must provide a hazard free environment for residents. During an interview on 8/25/23, at 12:12 p.m., with the Administrator (ADM), ADM stated the wet floor and water leaking from the bathroom ceiling were not acceptable and should be fixed. ADM stated the wet floor could potentially injure residents and staff. During a review of the facility's document titled, Job Description: Maintenance Director, dated 10/2015, the document indicated, . Position Summary: The Maintenance Director is responsible for the overall maintenance operation of the center .Maintains the building in good repair and free of hazards such as those caused by electrical, plumbing, heating and cooling systems . During a review of the facility's policy and procedure (P&P) titled, Physical Plant Interior Maintenance, dated 4/2005, the P&P indicated . All interior areas of the building are inspected within a one-month period to ensure proper condition and function . Interior maintenance of the physical plant is an essential function of the preventive maintenance program to assure employee and resident safety . 055475 Page 5 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

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 provide routine dental care for one of three sampled residents (Resident 79) according to the facility's policy and procedure titled, Dental Services, when Resident 79 had not been seen for routine dental services since being admitted to the facility on [DATE]. Residents Affected - Few This failure resulted in Resident 79 not having a dental appointment since admission and wanting dentures. Findings: During a record review of Resident 79's admission Record (AR), dated 8/25/23, the AR indicated, Resident 79 was admitted to the facility on [DATE] and had .Unspecified Protein-Calorie Malnutrition . (a disorder caused by lack of proper nutrition or an inability to absorb nutrients from food). During a record review of Resident 79's Minimum Data Set (MDS), assessment (an evaluation of a resident's cognitive and functional status) dated 7/11/23, the MDS indicated the Brief Interview for Mental Status (BIMS) score (an assessment of a resident's cognitive status for memory recall) was 9 (a score of 13 - 15 indicated the resident is cognitively intact [alert and oriented to self, place, time, and situation], 8 12 indicated moderately impaired, and 0 - 7 indicated severe impairment). During a record review of Resident 79's Order Details (OD), dated 1/10/23, the OD indicated, Diet Type: Regular. Diet Texture: Regular. Fluid Consistency: Regular Liquids. During a concurrent observation and interview on 8/22/23 at 2:55 p.m., with Resident 79, in Resident 79's room, Resident 79 had three upper teeth on the right side, no upper front teeth and no left upper teeth, and had eight teeth on the lower front and left lower side. Resident 79 had eleven teeth in total (adults have 28 to 32 teeth). Resident 79 stated, she used the three upper teeth on the right and lower front teeth to chew food. Resident 79 stated, she had not seen a dentist since admitted to the facility in January. Resident 79 stated, she would like to see the dentist to get dentures (a removable plate or frame holding one or more artificial teeth) to assist her with chewing food. During a concurrent interview and record review on 8/24/23 1:26 p.m., with the Director of Nursing (DON), Resident 79's Care Plan (CP), dated 1/11/23 was reviewed. The CP indicated, [name of Resident 79] has oral/dental health problems .Interventions .Coordinate arrangements for dental care, transportation as needed/as ordered . The DON stated, facility residents were provided routine dental care once a year. The DON stated, Resident 79 should had been evaluated by a dentist. During a concurrent interview and record review on 8/25/23 at 8:26 a.m., with the Social Services Director (SSD), Resident 79's Social Services Assessment (SSA), was reviewed. The SSA indicated, a baseline comprehensive SSA was completed on 1/9/23 there was no dental assessment completed. The quarterly SSA completed on 4/6/23 indicated no dental assessment. The quarterly SSA completed on 7/7/23 indicated no dental assessment. The SSD stated, the facility's dentist came to the facility once a month to provide dental care for the residents. The SSD stated, Resident 79 had not been seen. During an interview on 8/25/23 at 10:20 a.m., the DON stated, she expected staff to accurately assess residents with dental needs. Social Services and Dietary Services were responsible to ensure 055475 Page 6 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0790 resident's dental needs were met. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 8/25/23 at 10:52 a.m., with the Dietary Supervisor (DS), Resident 79's Dietary Assessment (DA), dated 1/22/23 was reviewed. The DA indicated, .Eating/Chewing .Own Teeth . [marked] No . The DS stated, a regular diet was appropriate if a resident did not complain of discomfort. The DS stated, she did not recall if Resident 79 had missing teeth. Residents Affected - Few During a review of the facility's Policy and Procedure (P&P) titled, Dental Services, dated 1/2018, the P&P indicated, Policy: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Process .Routine and 24-hour emergency dental services are provided to our residents through . a contract agreement with a licensed dentist that comes to the facility monthly .referral to the resident's personal dentist .all dental services provided are recorded in the resident's medical record . 055475 Page 7 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to provide the correct diet for one of ten sampled residents (Resident 54) during lunch tray assembly when Resident 54 was on a fortified diet (an enrichment of food to increase calorie and protein to sustain or gain weight) and dietary staff did not follow the facility's policy and procedure titled, Fortification of Food: Increasing calories and/or protein in the diet to provide Resident 54 with 1 tablespoon (Tbsp - unit of measurement) of extra tartar sauce (a condiment made of mayonnaise mixed with other ingredients) and 2 teaspoons (tsp - unit of measurement) of extra salad dressing. This failure had the potential to result in Resident 54 to not receive the adequate nutritional requirement to sustain or gain weight. Findings: During a record review of Resident 54's admission Record (AR), dated 8/24/23, the AR indicated, Resident 54 was admitted to the facility on [DATE] and was on hospice (palliative care for terminally ill residents) with altered mental status (change in mental function), blindness, and protein-calorie malnutrition (reduced availability of nutrients leading to changes in body composition and function). During a record review of Resident 54's Order Listing Report (OLR), dated 6/15/23, the OLR indicated, Resident 54 was on a Fortified diet Mechanical Soft Texture (food that is chopped, grounded, or pureed to accommodate with swallowing), Regular Liquids consistency. During a record review of the facility's [name of company] Weekly Guidelines for Summer 2023 - Week 4 Fortified Lunch, the guideline indicated, 1 Tbsp extra tartar sauce. 2 tsp extra salad dressing. During a record review of Resident 54's Lunch Slip (LS; a piece of paper with the resident's meal preferences), dated 8/23/23, the LS indicated, Diet Order: Mech Soft, Fortified Diet, Thin Liquids. During a concurrent observation and interview on 8/23/23 at 11:50 a.m., in the facility's kitchen, with Dietary Aid (DA) 1 and the Dietary Supervisor (DS), Resident 54's lunch tray assembly was observed. There was one 1 Tbsp tartar sauce container and one salad dressing packet on the tray. The DS stated, the lunch tray was not assembled correctly according to Resident 54's lunch slip. The DS stated, the lunch tray should have been assembled according to the Weekly Guidelines for Summer 2023 - Week 4 Fortified Lunch guideline, 1 Tbsp extra tartar sauce and 2 tsp extra salad dressing, to ensure Resident 54 received the needed extra calories for weight gain. During a concurrent interview and record review on 8/24/23 at 11:08 a.m., with the Registered Dietician (RD), Resident 54's Nutrition/Dietary Note (NDN), dated 7/19/23 was reviewed. The NDN indicated, Resident 54's weight was 91 pounds on 7/4/2023. The RD stated, Resident 54 had diet recommendations to be on a fortified diet while on hospice. The RD stated dietary staff were expected to follow the recommended dietary order. During a review of the facility's policy and procedure (P&P) titled, Fortification of Food: Increasing calories and/or protein in the diet, dated 2023, the P&P indicated, Policy: The enrichment of 055475 Page 8 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few foods will be done on an individual basis for the residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. Purpose: The goal is to increase the calorie and/or protein density of the foods commonly consumed by the resident to promote improvement in their nutrition status. Procedure: Identification of the residents in need of fortification will be done by the Facility's Registered Dietician or the [Food Nutrition Service] Director. The physician will then order a 'Fortified Diet' . Calories and/or protein will be added to selected foods. The Facility Registered Dietician or [Food Nutrition Service] Director will select fortification method from the list provided for foods commonly or agreed upon to be consumed or utilize the [name of company] Fortified Menu Plan. Food & Nutrition Services staff will be familiar with the fortification process for each item chosen to be used at the facility . 055475 Page 9 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 store food according to the facility's policy and procedure titled, Storage of Food and Supplies, when two of four sampled plastic bin containers with ready to eat dry cereal were labeled with incorrect use by dates (date in which the item must be used). This failure did not meet the professional standards for food safety, had the potential to cause foodborne illness (sickness due to eating contaminated food), and loss of nutritional efficacy (value). Findings: During a concurrent observation and interview on 8/22/23 at 10:00 a.m., with the Dietary Supervisor (DS), in the facility's kitchen pantry (area where dry goods are stored), one 20 liter (L-unit of measurement) plastic bin container with [brand name] ready to eat dry cereal was labeled, Received date: 8/21/23. Use by date: 8/13/24. The second 20 L plastic bin container with [brand name] ready to eat dry cereal was labeled, Received date: 8/21/23. Use by date: 6/8/24. The DS stated, the use by dates were incorrect. The DS stated, ready to eat dry cereal were dry goods that should have been dated according to the facility's Dry Goods Storage Guidelines (DGSG), The DS stated, ready to eat dry cereal came in large bulk packages which required to be stored in large plastic bin containers for easy access and the opened shelf life was two months. During a concurrent interview and record review on 8/24/23 at 10:32 a.m., with the Dietary [NAME] (DC), the use by date label on the two 20 L plastic bin containers with ready to eat dry cereal were reviewed. The DC stated, ready to eat dry cereal were stored in the plastic bin containers for easy access. The DC stated, the plastic bin containers required a received date and use by date. The DC, stated, the dates indicated how long food was good for and ensure efficacy of food to obtain maximal nutritional value. The DS stated, the use by date for opened ready to eat dry cereal was two months. The DS stated, the use by date of 8/13/24 and 6/8/24 on the labels were incorrect. During a concurrent interview and record review on 8/24/23 10:51 a.m., with Dietary Aid (DA) 2, the use by date label on the two 20 L plastic bin containers with ready to eat dry cereal and the facility's DGSG, dated 2023 were reviewed. DA 2 stated, ready to eat dry cereal was taken out of the original package and placed in an air-tight sealable plastic bin container with a received date and use by date label. DA 2 stated, the use by date for dry ready to eat cereal was three months. DA 2 stated, the facility's DGSG indicated the use by date for dry goods was two months. DA 2 stated, the use by date of 8/13/24 and 6/8/24 on the labels were incorrect. DA 2 stated, serving outdated food can become stale (no longer fresh and pleasant to eat), lose nutritional value, and could potentially cause foodborne illnesses. During a record review of the facility's Dry Goods Storage Guidelines (DGSG), dated 2023, the DGSG indicated, This storage length is to be followed unless you have manufacturer's recommendation indicating otherwise . Cereal, ready to eat (These items do not need to be refrigerated after opening. Keep them dry & tightly covered. Opened on shelf: 2 months. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, dated 2023, the P&P indicated, Policy: Food and supplies will be stored properly and in a safe 055475 Page 10 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0812 Level of Harm - Minimal harm or potential for actual harm manner. Procedures for dry good storage .Dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc.) should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized . Bins/containers are to be labeled, covered and dated .Food stores should be in food groups to facilitate storing, locating, and taking inventories . All food products will be used per the times specified in the Dry food Storage Guidelines . Residents Affected - Few During a professional reference review retrieved from https://ask.usda.gov/s/article/How-long-can-I-store-cereal#:~:text=The%20Food%20Marketing%20Institute%27s%20%22T titled, How long can I store cereal? dated 3/6/23, the professional reference review indicated, The Food Marketing Institute's 'The Food Keeper' recommends storing ready-to-eat cereal at room temperature for 6 to 12 months. Cook-before-eating cereals, such as oatmeal, can be stored for 12 months. After opening, store ready-to-eat cereal at room temperature for 3 months and cook-before-eating cereal for 6 to 12 months. 055475 Page 11 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the policy and procedure titled, Hospice Program for eight of eight sampled residents (Residents 25, 26, 47, 54, 55, 81, 85, and 291) when the facility failed to ensure hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) personnel caring for residents under hospice services were provided orientation to the facility's policies and procedures. This failure had the potential to place Residents 25, 26, 47, 54, 55, 81, 85, and 291 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness. Findings: During an interview on 8/23/23, at 8:09 a.m., with Hospice Registered Nurse (RNCM), in Station 1 hallway, RNCM stated, she was the assigned RNCM for Resident 25 and Resident 54 for over a month. RNCM stated, she performs skilled nursing assessment for Resident 25 and Resident 54 and collaborates with facility staff in implementing the hospice plan of care for the two hospice residents assigned to her. RNCM stated, she does not recall having an orientation on the facility's policy and procedures or meeting the facility's Hospice Coordinator. RNCM stated, I met the facility's Director of Nursing and Administrator on my first visit to the facility. RNCM 1 was unable to identify the Social Services Director as the facility's designated Hospice Coordinator. During a concurrent interview and record review, on 8/23/23, at 10:06 a.m., with the Social Services Director (SSD), the facility's Hospice Program Policy and Procedure (P&P), dated 2/2018 was reviewed. The P&P indicated, .Our facility has designated [name and title] to coordinate care provided to the resident by our facility staff and the hospice staff .Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . SSD stated, I am the facility's designated Hospice Coordinator. SSD stated, she does not have any record or proof that an orientation on the P&P of the facility to hospice staff caring for facility residents was done and she failed to follow their hospice policy. SSD stated, the lack of orientation to the facility's policy and procedure to hospice personnel could potentially result in not meeting the medical, physical, emotional, and spiritual needs of residents receiving hospice care. During a concurrent interview and record review, on 8/25/23, at 12:15 p.m., with the Director of Nursing (DON), the facility's Hospice Program Policy and Procedure (P&P), dated 2/2018 was reviewed. The P&P indicated, .Our facility has designated [name and title] to coordinate care provided to the resident by our facility staff and the hospice staff .Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . DON stated, the DSD is the facility's designated Hospice Coordinator. DON stated, she does not have any record or proof that an orientation on the P&P of the facility to hospice staff caring for facility residents was done. DON stated, the facility failed to follow its own hospice policy. DON stated, the lack of orientation to the facility's policy and procedure to hospice personnel could potentially result in not meeting the medical, physical, psychosocial, and spiritual needs of Residents 25, 26, 47, 54, 55, 81, 85, and 291. 055475 Page 12 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 25's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/25/23, the AR indicated, Resident 25 was admitted from an acute care hospital on 5/23/19 to the facility, with diagnoses which included Cerebral Infarction (stroke), Dementia (a chronic or persistent disorder of the mental processes marked by memory disorder, personality changes, and impaired reasoning), Hypertension (high blood pressure) Type 2 Diabetes Mellitus (high blood sugar), Palliative Care (specialized medical care to ease symptoms without curing the underlying disease for people living with a serious illness), and Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness). During a review of Resident 25's Order Summary Report (OSR), dated 8/25/23, the OSR indicated, . Admit under [Name of Hospice Agency] with diagnosis Senile Degeneration of Brain (loss of intellectual ability) . Order date 5/30/23 . During a review of Resident 26's AR, dated 8/25/23, the AR indicated, Resident 26 was admitted from an acute care hospital on 3/21/23 to the facility, with diagnoses which included Senile Degeneration of Brain, Anxiety Disorder, Hypertension, and Palliative Care. During a review of Resident 26's OSR, dated 8/25/23, the OSR indicated, . Resident admitted under [Name of Hospice Agency] . Order date 3/22/23 . During a review of Resident 47's AR, dated 8/25/23, the AR indicated, Resident 47 was admitted from an acute care hospital on 3/15/23 to the facility, with diagnoses which included Myotonic Muscular Dystrophy (progressive muscle weakness and wasting), Anxiety, and Human Immunodeficiency Virus Disease (HIV life threatening infection, transmitted through direct contact with HIV-infected body fluids, blood). During a review of Resident 47's OSR, dated 8/25/23, the OSR indicated, . Resident admitted under [Name of Hospice Agency] . Order Date 3/16/23 . During a review of Resident 54's AR, dated 8/25/23, the AR indicated, Resident 54 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Sepsis (is a potentially life-threatening condition caused by the body's response to an infection), Pneumonia (lung infection caused by bacteria), Respiratory Failure (a serious condition that makes it difficult to breath), Heart Failure (the heart cannot pump blood or fill adequately), and Schizophrenia (chronic and severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). During a review of Resident 54's OSR, dated 8/25/23, the OSR indicated, . admitted to [Name of Hospice Agency] . Order Date . 6/23/23 . During a review of Resident 55's AR, dated 8/25/23, the AR indicated, Resident 55 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Cerebral Infarction, Dysphagia (swallowing difficulty), Anxiety Disorder, Bipolar Disorder (define), Protein-Calorie Malnutrition (not consuming enough protein and calories), Hypertension, and Palliative Care. During a review of Resident 55's OSR, dated 8/25/23, the OSR indicated, . admitted to [Name of Hospice Agency] . Order Date . 11/9/22 . 055475 Page 13 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 81's AR, dated 8/25/23, the AR indicated, Resident 81 was admitted from an acute care hospital on 3/2/23 to the facility, with diagnoses which Dementia, Anxiety Disorder, Adult Failure to Thrive (progressive weight loss, decreased appetite, poor nutrition, and inactivity) and Palliative Care. During a review of Resident 81's OSR, dated 8/25/23, the OSR indicated, . Resident admitted to [Name of Hospice Agency] . Order Date 3/3/23 . During a review of Resident 85's AR, dated 8/25/23, the AR indicated, Resident 547 was admitted from an acute care hospital on 7/6/23 to the facility, with diagnoses which included Dementia, Hypertension, Weakness, Anxiety Disorder, and Alzheimer's Disease (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). During a review of Resident 85's OSR, dated 8/25/23, the OSR indicated, . Admit to Hospice Care Hospice Services [Name of Hospice Agency] . Order Date . 7/6/23 . During a review of Resident 291's AR, dated 8/25/23, the AR indicated, Resident 291 was admitted from an acute care hospital on 8/17/23 to the facility, with diagnoses which included Dementia, Type 2 Diabetes Mellitus, Hypertension, and Chronic Obstructive Pulmonary Disease (COPD- is a chronic inflammatory lung disease that causes obstructed airflow of the lungs). During a review of Resident 291's OSR, dated 8/25/23, the OSR indicated, . Resident got admitted under [Name of Hospice Agency] . Order Date . 8/18/23 . During a review of the facility's P&P titled, Hospice Program, dated 2/2018, the P&P indicated, .Our facility has designated [name] RN/DON to coordinate care provided to the resident by our facility staff and the hospice staff .Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents .Coordinated care plans for residents receiving hospice services . in order to maintain the resident's highest practicable physical, mental and psychosocial well-being . 055475 Page 14 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

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. Based on observation during the survey period of 8/22/23 to 8/25/23, the facility failed to provide and maintain a minimum of at least 80 square feet of space per resident in 17 resident rooms (Rooms 6, 7, 8, 9, 10, 11, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27). This failure had the potential for residents to not have reasonable privacy or adequate space. Findings: During an environment tour with the Maintenance Supervisor on 8/24/23 at 10:31 a.m., the inspection indicated the following rooms did not meet the minimum square footage as required by regulation. These rooms were as follows: Rm # SQ. FT # of Residents 6 236 3 7 232.7 3 8 231.9 2 9 231.9 3 10 231.9 055475 Page 15 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0912 3 Level of Harm - Potential for minimal harm 11 233.5 Residents Affected - Some 3 17 228.5 3 18 231.9 3 19 231.9 3 20 232.7 3 21 235.2 3 22 231.9 3 23 231.9 3 055475 Page 16 of 17 055475 08/25/2023 Main West Postacute Care 812 West Main Street Turlock, CA 95380

F 0912 24 Level of Harm - Potential for minimal harm 231.9 3 Residents Affected - Some 25 231.9 3 26 231.9 3 27 226.8 3 However, variations were in accordance with the needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Recommend waiver. _____________________________________ Health Facilities Evaluator Supervisor Signature Date Request waiver. ____________________________ Administrator Signature Date 055475 Page 17 of 17