Health inspection·October 14, 2022

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow their medication and pain management policy and procedure to ensure standards of professional practice were maintained during Medication Administration for a census of 115 when: Residents Affected - Some 1. Pain was not assessed properly for Resident 66; 2. Glycolax powder (a medication used for constipation) was not administered as ordered for Resident 26; 3. Blood pressure (BP) was not checked as ordered prior to giving medication for Resident 85; 4. Medications administered or held were on not documented in a timely manner for Resident 16; and 5. Resident 16's electronic medical record was not protected during medication administration. These failures had the potential to negatively impact the resident's health outcomes. Additionally, failure to protect health records denied residents their rights to privacy of their information. Findings: 1. According to Resident 66's 'admission Record' he was admitted to the facility recently with multiple diagnoses that included fracture of the left ulna (a forearm bone) and unspecified pain. During a medication administration observation on 10/12/22, starting at 7:46 a.m., Licensed Nurse (LN) 1 was observed as she prepared and administered medications to Resident 66. LN 1 administered the scheduled medications and left the room to the hallway. LN 1 was observed standing next to the medication cart located in the hallway and loudly called out Resident 66's name and asked him if he was in pain and what the level of the pain was. LN 1 did not go inside Resident 66's room to assess his pain, it's origin or provide him with personal privacy. Resident 66 responded in a loud voice, '10' (most severe pain on a scale of 0-10). LN 1 prepared 2 tablets of Tylenol for a total of 650 milligrams (mg, unit of measurement) and gave to Resident 66 and proceeded to the next resident. A review of Resident 66's physicians 'Order Summary Report' indicated he was on Tylenol 325 mg ordered to be given 2 tablets every 6 hours as needed for pain or headache, order dated 5/24/22. In a follow up interview with LN 1 on 10/12/22, at 9:15 a.m., LN 1 stated she had asked Resident 66 if the Tylenol she gave him for pain was effective at 8:05 a.m., then stated at 9 a.m. LN 1 was asked if she had documented the pain in Resident 66's record and stated she had not because the Page 1 of 17 055481 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some computer network was down. LN 1 further confirmed her computer network was currently working but she had not documented Resident 66's pain, more than an hour following the administration of Tylenol for verbalized pain of 10 out of 10. A review of the facility's 'Pain Management' policy guidelines dated 4/2016 indicated, It is the policy of this facility to assess [resident] . when pain medication is given . Pain medication shall be given before the pain becomes severe. Response to pain shall be documented on the electronic Medication Administration Record (MAR) within half hour of administration of a pain medication. 2. According to Resident 26's 'admission Record' she was admitted to the facility in 2021 with multiple diagnoses that included dementia and weakness. On 10/12/22, starting at 8 a.m., LN 1 was observed as she prepared and administered medication to Resident 26. LN 1 mixed the glucolax powder with approximately 2.5 ounces (unit of measurement) of apple juice and used the mixture in administering other scheduled medications. LN 1 did not give Resident 26 water or juice after the administration. A review of Resident 26's physician's 'Order Summary Report' reflected an order dated 4/28/22 for glycolax powder to be given 17 grams (gm, unit of measure) mixed in 4-8 ounces of juice or water once daily for constipation. In a concurrent interview with LN 1 on 10/12/22, shortly after 8 a.m., she stated she did not measure the amount of apple juice she used to mix the glycolax powder as per the physician's orders and she should have used the measuring cup provided. LN 1 confirmed she used approximately 2.5 ounces and the order had directed to use 4-8 ounces of water or juice. A review of the facility's 'Medication Administration .' policy and procedure dated 5/16/2018, indicated, 'Medications are administered as prescribed in accordance with good nursing principles and practices . Medications are administered in accordance with written orders of the prescriber . At least 4 ounces of water or other acceptable liquid are given with oral medications .' 3. According to Resident 85's 'admission Record' she was admitted to the facility originally over 3 years ago with multiple diagnoses which included diabetes and hypertension. On 10/12/22, starting from 8:31 a.m., LN 2 was observed as she prepared and administered medications to Resident 85. LN 2 did not check the resident's BP per the physician orders prior to giving her Lisinopril, a blood pressure medication. A review of Resident 85's physician 'Order Summary Report' contained an order for Lisinopril 20 mg to be administered daily for hypertension. The order directed staff to hold the medication when the SBP (systolic blood pressure; the UPPER number represents the pressure on the blood vessels as the heart contracts/beats) was less than 100. An interview conducted with LN 2 on 10/12/22, at 9 a.m., she stated she used the BP obtained by a nursing assistant before breakfast around 7 a.m. to determine if she was to hold or give the BP medication. LN 2 stated she only rechecked a resident's blood pressure if the one documented by the nursing assistant was out of the normal range. A review of the facility's 'Medication Administration .' policy and procedure dated 5/16/2018, 055481 Page 2 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0658 Level of Harm - Minimal harm or potential for actual harm indicated, Medications are administered as prescribed in accordance with good nursing principles and practices . Medications are administered in accordance with written orders of the prescriber. 4. Resident 16's 'admission Record' reviewed indicated the facility admitted her over 5 years ago with multiple diagnoses that included hypertension and atrial fibrillation (an irregular, often rapid heart rate). Residents Affected - Some During a Medication Administration Observation on 10/12/22, starting from 8:21 a.m., LN 2 was observed as she prepared and administered medication to Resident 16. LN 2 stated she was to hold Resident 16's BP medications based on the BP documented by the nursing assistant before breakfast which was low. LN 2 then proceeded to the nurse's station and brought with her a BP machine and obtained the resident's BP and reported it was very low and held 3 BP medications. LN 2 administered one medication during this observation. Resident 16's physician's 'Order Summary Report' printed on 10/12/22 indicated the resident was on amlodipine 5 mg, lasix 20 mg and metoprolol 50 mg for hypertension to be given daily (scheduled at 8 a.m., on the MARs) and be held for SBP less than 110. The resident was also on apixaban/eliquis (a blood thinner) 5 mg twice daily for atrial fibrillation (scheduled at 8 a.m. and 5 p.m. on the MARs) A review of Resident 16's Medication Administration Record (MARs) printed on 10/12/22 at 10:18 a.m., reflected no documentation for the 3 BP medications that LN 2 had held and the eliquis that she administered. During an interview and concurrent MAR review with LN 2 on 10/12/22, shortly after 10:18 a.m., she confirmed she had not documented she had held the 3 BP medications. LN2 stated she should have documented soon after she completed administering medications to the resident. A review of the facility's 'Medication Administration .' policy and procedure dated 5/16/2018, indicated, The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given . If medication doses are withheld, . the physician is notified. Nursing documents the notification and physician response. 5. During a Medication Administration Observation on 10/12/22, starting from 8:21 a.m., LN 2 was observed as she prepared and administered medication to Resident 16. LN 2 entered Resident 16's room and left the computer screen open displaying the resident's information. The computer was mounted on the top surface of the medication cart. Two Certified Nursing Assistants (CNAs) were observed moving the cart away to gain entry into and out of the room to pick up the meal trays. An interview conducted with LN 2 on 10/12/22, at 9 a.m., she stated she should have used the lock screen option to protect the resident's information when she turned away from the medication cart where the computer was placed. A review of the facility's 'Medication Administration .' policy and procedure dated 5/16/2018 indicated, The cart [where the computer was placed] must be clearly visible to the personnel administering medications . must be inaccessible to residents or others passing by. In addition, privacy is maintained at all times for all resident information . by going to privacy screen on the computer. The Director of Nursing (DON) was interviewed on 10/12/22 at 3:25 p.m. and she stated she expected the Licensed Nurses to provide privacy while assessing the resident's pain and document the pain 055481 Page 3 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some level before and after the medications are administered on the MAR. The DON further stated the nurse who gave the glucolax should have followed the physician orders for reconstituting the powder included in the body of the order. The DON stated she expected the nurses to obtain the vital signs including the BP prior to giving BP medications that have hold parameters stipulated by the prescriber in the body of the orders. The DON stated she expected the nurses to lock the computer screen before they walked away for the safety and security of residents' electronic medical records. During a follow up interview and review of Resident 16's MAR with the DON on 10/13/22, at 8:37 a.m., she stated she expected LN 2 to document medications held or administered on the MAR immediately. 055481 Page 4 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three residents (Resident 47, Resident 81, and Resident 113) were assisted with Activities of Daily Living (ADL) when fingernails were long and had blackish substance underneath the nails, for a census of 115. Residents Affected - Some These failures increased the potential to result in skin problems or injuries. Findings: A review of Resident 47's clinical record indicated a diagnoses including dementia (memory loss that interferes with daily functions) and macular degeneration (a condition that causes vision loss). A Minimum Data Set (MDS, an assessment tool) dated 8/9/22, indicated Resident 47 had severe cognitive impairment and required assistance with personal hygiene. A concurrent observation and interview was conducted on 10/11/22 at 12:34 p.m. with Certified Nursing Assistant 1 (CNA 1). Resident 47 had long fingernails and had blackish substance underneath her nails. The CNA 1 confirmed the finding and stated Resident 47's fingernails were long and dirty. A review of Resident 81's clinical record indicated a diagnoses including Parkinson's disease (a progressive disease that affects movement). A MDS dated [DATE], indicated Resident 81 had moderate cognitive impairment and required assistance with personal hygiene. In an initial observation on 10/11/22 at 10:40 a.m., Resident 81's fingernails were long with blackish substance underneath her nails. A concurrent observation and interview was conducted on 10/11/22 at 4:24 p.m. with the CNA 2. The CNA 2 confirmed the finding and stated Resident 81's fingernails were a little bit long and dirty. The CNA 2 further stated Resident 81 had episodes of refusing to have her nails trimmed. A review of Resident 81's nursing progress note prior to 10/11/22 did not indicate refusal of care. A review of Resident 113's clinical record indicated a diagnoses including dementia and glaucoma (a condition that can cause vision loss). A MDS dated [DATE], indicated Resident 113 had severe cognitive impairment and required assistance with personal hygiene. During an initial observation on 10/11/22 10:03 a.m., Resident 113 had long fingernails with blackish substance underneath her nails. A concurrent observation and interview was conducted on 10/11/22 at 1:03 p.m. with the CNA 3. The CNA 3 confirmed the finding and stated Resident 113's fingernails were long and dirty and needed to be trimmed. An interview was conducted with the Director of Nursing (DON) on 10/14/22 at 8:25 a.m. The DON stated her expectation was for facility staff to assist dependent residents with ADL. The DON further stated, the CNA's should always check resident's fingernails daily. If a resident continues to refuse assistance with care, the CNA should report it to the charge nurse. 055481 Page 5 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0677 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure revised October 2010 and titled, Care of Fingernails/Toenails indicated, The purposes of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .The following information should be recorded in the resident's medical record .If the resident refused the treatment, the reason(s) why and the intervention taken .Notify the supervisor if the resident refuses the care. Residents Affected - Some 055481 Page 6 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interview and record review, the facility failed to ensure Range of Motion (ROM, the degree of movement that occurs at a given joint during an exercise program) exercises were provided as ordered for one resident (Resident 81), for a census of 115. This failure increased the potential for Resident 81 to experience further reduction in ROM. Findings: A review of Resident 81's clinical record indicated a diagnoses including dislocation of right hip and presence of right artificial hip joint. A Minimum Data Set (MDS, an assessment tool) dated 8/25/22, indicated Resident 81 had moderate cognitive impairment and functional limitation in ROM on both lower extremity. Review of Resident 81's physician's order dated 8/26/22 indicated, RNA [Restorative Nursing Assistant] for ROM 3x/week .every day shift . A concurrent interview and record review with the Licensed Nurse 3 (LN 3) was conducted on 10/14/22 at 12:51 p.m. LN 3 confirmed Resident 1 had no documented RNA for ROM from 10/1/22 to 10/12/22. There was no documented evidence in Resident 81's clinical records as to why ROM was not provided by RNA 3x a week from 10/1 to 10/12/22. In an interview on 10/14/22 at 12:53 p.m., the Director of Nursing (DON) stated a physician's order should be followed. The DON further stated if a resident refused a treatment, the refusals should be documented and the physician should be informed. A review of the facility policy revised April 2008 and titled, Charting and Documentation indicated, .All . services performed .must be documented in the resident's clinical records .Documentation of procedures and treatments shall include care-specific details and shall include .Whether the resident refused the procedure/treatment .Notification of .physician or other staff, if indicated . 055481 Page 7 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of two residents, (Resident 269) who received renal hemodialysis (HD, a treatment necessary for kidney failure to remove unwanted toxins, waste products, and excess fluids by filtering the blood), when the facility failed to communicate and collaborate with the transport agency. Residents Affected - Some This failure resulted in fatigue and frustration when transportation was delayed for an hour or more on multiple occasions. Findings: A review of the admission Record indicated Resident 269 was admitted to the facility earlier this year with multiple diagnoses which included the after care after right hip surgery, end stage kidney failure resulting in the need for dialysis. A review of the Minimum Data Set, (MDS, resident assessment and care screening tool), dated 9/25/22 indicated Resident 269's brief interview of mental status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 13 (a score of 13-15 indicated intact cognition). Resident 269 was totally dependent on the staff for transfer and locomotion. Resident 269 received hemodialysis prior to entering the facility and continued treatments while residing in the facility. A review of Resident 269's physician's order, dated 9/20/22, indicated dialysis at the local dialysis center every Monday, Wednesday and Friday at 9:00 a.m. During an observation and interview on 10/11/22 at 2:20 p.m., Resident 269 was observed sitting in a wheelchair in her room with her husband at the bedside. Resident 269 looked tired and stated she had just returned from the dialysis center. Resident 269 stated that normally she was getting dialysis three days per week, but today she had an additional dialysis per her physician's order. Resident 269 added, she was completely wiped out. [I] had to wait for transportation for 50 minutes after I completed dialysis. Resident 269 stated the transport did not come to pick her up after she had finished her dialysis and the dialysis nurse had to call the facility to inquire regarding the transportation delay. Resident 269 stated the facility informed the nurse that the transport will pick the resident up in 15-20 minutes as he was in a different city. Resident 269 stated, I was too tired to wait for him, was hungry . so I called my husband to pick me up. Lucky that he was at home. Resident 269 stated that this was not the first time she had to sit and wait for the transportation to bring her back to the facility. Resident 269's husband confirmed that on multiple occasions the transportation company did not pick his wife from the dialysis center in a timely manner. Resident 269 stated she was constantly late for lunch and even though the facility sent a sandwich with her, she was still hungry. During an observation on 10/12/22, at 3:45 p.m., Resident 269 was observed being wheeled into her room by her husband. Resident 269 stated she was not picked up from dialysis center as soon as her dialysis was completed and she did not want to wait, so her husband brought her back from the dialysis center. Resident 269's husband stated it was very disappointing that his wife had to wait for transportation and that they could not rely on the facility's process with arranging the transport. A review of Resident 269's, I need dialysis, care plan dated 9/20/22, indicated staff was to 055481 Page 8 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some encourage the resident to go for the scheduled dialysis appointments every Monday, Wednesday and Friday at 9 a.m. The care plan did not include any interventions to ensure the timely transportation arrangements to and from dialysis center. During an interview on 10/13/22, at 8:40 a.m., the Unit Clerk (UC) stated it was her responsibility to arrange transportation for all residents, including transporting Resident 269 to and from the dialysis center. The UC stated she was aware that the transportation company used by the facility sometimes was late to pick up Resident 269. The UC stated the resident informed her that she did not like to sit and wait for transportation once dialysis was done. The UC stated if the transportation company was not able to pick up the resident from the dialysis center, she arranged to have the facility's courtesy van to transport Resident 269 to or from the dialysis. The UC stated on Tuesday, 10/11/22 at 1:15 p.m., the nurse from dialysis center notified the facility that the resident had completed dialysis and was waiting for a ride back to the facility, but the transport was not there yet. The UC stated sometimes Resident 269's husband brought the resident back from dialysis center. During an interview on 10/13/22, at 8:57 a.m., the Receptionist stated that on 10/11/22 Resident 269 called the facility around 1 p.m., and told [name of the transport company] was supposed to pick her up, but didn't come, and she was already waiting. I told her I will send our orderly [van], but she didn't want to wait. A review of clinical records had no documented evidence of collaboration and communication between the facility and transport company in ensuring that Resident 269 was transported to and from dialysis in a timely manner. During an interview on 10/13/22, at 9:40 a.m., the Administrator stated the facility did not have a contract or agreement with the transport company. During an interview on 10/14/22, at 10:05 a.m., the dialysis center nurse (DCN) stated Resident 269 was the center's patient prior to being admitted to the facility and that she provided dialysis treatment to the resident on a regular basis. The DCN stated Resident 269 started dialysis treatment at 9:15 a. m., and was ready for pick up around 12:40 p.m. The DCN stated since Resident 269 was admitted to the facility, most of the time she had been picked up late. The DCN stated that once Resident 269 completed her dialysis treatment, the dialysis staff took her to the general area in lobby and she had to wait for transportation. The DCN stated that Resident 269 did not like to sit and wait for her ride back to the facility and complained of being tired. The DCN stated sometimes the dialysis center staff had to assist Resident 269 with her care needs while she was waiting for the transport. The DCN stated very frequently the dialysis center staff had to call the transportation company and the facility to remind them that they needed to send the transport to pick the resident from the center. The DCN stated that sometimes the transport company told them that the resident needed to wait an hour or longer because they were busy or out of area. The DCN added, If her husband is available, he'll pick her up. If not, she had to wait longer. A review of the nursing progress notes indicated that on 9/21, 9/23, 9/28, 10/7, and 10/11/22, Resident 269 arrived back from the dialysis center between 2:15 - 2:30 p.m., and on 10/12/22 she arrived at 3:30 p.m., which indicated that Resident 269 had to wait for her ride for one and a half hours or longer. A review of the dialysis service agreement between the facility and dialysis center provider, dated 10/31/12, indicated that the facility had the sole responsibility for arranging all of the facility 055481 Page 9 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0698 resident transportation to and from the dialysis clinic. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/13/22, at 1:55 p.m., the Director of Nursing (DON) stated she was not aware of any concerns related to Resident 269's delays with transporting her from dialysis center. The DON stated the unit clerk was responsible for arranging the transportation to make sure the resident was picked up from the dialysis center in a timely manner. The DON stated the facility did not have the policy regarding arranging for transportation. Residents Affected - Some 055481 Page 10 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 maintain the kitchen in sanitary condition by failing to ensure the Quaternary Ammonium sanitizing solution (a chemical agent used to destroy germs) used for sanitizing kitchen surfaces and equipment had the required concentration to be effective and Dietary Aide 2 failed to follow proper hand hygiene between tasks. These failures had the potential to result in foodborne illness to 114 vulnerable residents receiving food from the facility kitchen. Findings: On 10/11/22 at 8:25 a.m., during an initial kitchen tour accompanied by the Dietary Supervisor and [NAME] 1 a red bucket containing clear solution inside was observed on the shelf. [NAME] 1 explained the solution in the red bucket was filled with Quaternary Ammonium solution to sanitize the clean surfaces after they were cleaned with soap and water. On 10/11/22, at 8:55 a.m., the Dietary Aide 1 stated the concentration of the chemical should be 200 ppm (parts per million, the concentration of the solution). After DA 1 dipped an orange test strip into the bucket to check the concentration of the sanitizer, the test strip got wet, and did not change the color of the strip. DA 1 compared the wet test strip with the control indicator on the test strip container. DA 1 stated if there was the required chemical concentration of 200 ppm, the test strip would have changed the color from orange to green, but it did not. The DA 1 used a second test strip to check the chemical sanitizer concentration in the red bucket and the strip did not change color. [NAME] 1 validated that the test strip did not change color as there was not enough sanitizer in the bucket. On 10/11/22, at 9 a.m., [NAME] 1 was asked to check the level of the sanitizing solution concentration in the bucket stored in the dishwashing room. When [NAME] 1 dipped the test strip into the sanitizing solution, the strip turned light green. [NAME] 1 compared the test strip color to the container's label and stated the concentration was about 100 ppm. [NAME] 1 explained that test strip indicated the sanitizing concentration was not at the required concentration and should be at 200 ppm. [NAME] 1 stated the concentration of the sanitizer solution was checked earlier that morning around 5:30 a.m., and the solution was replaced later after sanitizing the kitchen surfaces. During an interview on 10/11/22, at 9:05 a.m., the Registered Dietician (RD) acknowledged that both buckets with sanitizing solution were not at the required level for sanitizing kitchen's clean surfaces. RD stated it was very important to have sanitizing solution with correct concentration to disinfect kitchen surfaces and to prevent possible foodborne illness. A review of the facility's policy titled, QUATERNARY AMMONIUM LOG POLICY, revised 2018, indicated the facility will test the concentration of the ammonium in the quaternary sanitizer to ensure the effectiveness of the solution . The quaternary solution for sanitizing clean work surfaces in the kitchen will be made according to the instructions on the product container .The solution will be replaced when the reading is below 200 ppm. The replacement solution will be tested prior to usage. On 10/13/22, 9:05 a.m., during the dishwashing process DA 2 was observed picking up clean dishes from the dishwashing machine, placing them on the dish rack and taking them to the storage area. DA 2 055481 Page 11 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0812 Level of Harm - Minimal harm or potential for actual harm was wearing gloves. In between handling the clean dishes, DA 2 was observed using a rag from the sanitizing solution to sanitize the soiled food carts. Wearing the same gloves, DA 2 proceeded to handle clean glasses and tray covers without performing hand hygiene and putting new gloves on. During a follow up interview DA 2 acknowledged that she should have washed her hands and replaced gloves after handling the soiled food cart. Residents Affected - Some During an interview on 10/13/22, at 9:20 a.m., the RD stated that it was her expectation that the handwashing and glove change was done in between different tasks, including handling clean dishes and sanitizing dirty food carts. A review of the facility's 'GLOVE USE POLICY,' dated 2020, indicated that the appropriate use of gloves was essential in preventing food borne illness. The policy directed the kitchen staff to wash hands when changing to a fresh pair. Gloves must never be used in place of hand washing. The policy indicated that gloves needed to be changed before beginning a different task. The 2017 Federal Food Code, Section 2-301.14, titled, When to Wash, indicated, Food employees shall clean their hands .including working with .clean equipment and utensils .and (E) After handling soiled EQUIPMENT . 055481 Page 12 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

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 115 when: Residents Affected - Some 1. Reusable equipment was not sanitized after use and between residents for (Resident 16, Resident 26, and Resident 85) and, proper hand hygiene was not followed during medication administration for Resident 85; 2. Resident 268, who had an infectious condition, shared a room with a vulnerable resident, and 3. There was no Contact Isolation Precautions signage posted informing visitors that the resident was on isolation precautions (measures taken to prevent the spread of germs/infection from one person to another). These failures had the potential to spread infection between and among the residents. Findings: 1. According to Resident 66's 'admission Record' he was admitted to the facility recently with multiple diagnoses that included hypertension and unspecified pain. According to Resident 26's 'admission Record' she was admitted to the facility last year with multiple diagnoses that included dementia and hypertension. According to Resident 85's 'admission Record' she was admitted to the facility originally over 3 years ago with multiple diagnoses which included diabetes and hypertension. Resident 85 had a surgically placed stomach tube for administering medications and artificial nutrition. Resident 16's 'admission Record' reviewed indicated the facility admitted her over a 5 years ago with multiple diagnoses that included hypertension and atrial fibrillation (an irregular, often rapid heart rate). During a 'Medication Administration Observation' on 10/12/22 starting from 7:46 a.m., Licensed Nurse (LN) 1 was observed as she prepared and administered medications to residents in hall #4. LN 1 was observed as she checked the blood pressure for Resident 66 after which she placed the BP cuff on top of the medication cart next to the medication preparation area. LN 1 did not clean or sanitize the BP cuff after use or clean the preparation area prior to proceeding to prepare the medications for Resident 26. LN 1 was observed as she checked Resident 26's BP in another room without sanitizing the cuff prior to using it and placed it back near the medication preparation area. A concurrent interview with LN 1 on 10/12/22 shortly after 7:46 a.m., LN 1 stated she should have sanitized the BP cuff after each use and between residents before placing it on the medication preparation area using the sani cloth wipes. During a 'Medication Administration Observation' on 10/12/22 starting from 8:21 a.m., LN 2 was observed as she prepared and administered medications to residents in hall #6. LN 2 walked to the nurse's station and got a blood pressure (BP) cuff and checked Resident 16's BP. LN 2 then placed the BP cuff on top of the medication cart next to the medication preparation area without sanitizing it. LN 055481 Page 13 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2 then proceeded to prepare medication for Resident 85 who was in another room. LN 2 was wearing gloves. LN 2 brought in the prepared medications and placed them on the resident's table. LN 2 then re-adjusted the resident's chair, pulled the privacy curtains, left the room to bring a stethoscope, checked the resident's stomach tube placement using the stethoscope (an instrument used to listen to the heart beats, lung sounds and bowel sounds), proceeded to the bathroom to get some more water twice and completed the medication administration. LN 2 did not perform hand hygiene or sanitize her hands during this observation. LN 2 was ready to proceed to the next room without sanitizing the stethoscope that she had used for Resident 85. During an interview with LN 2 on 10/12/22, at 9 a.m., LN 2 stated she should have sanitized the BP cuff and stethoscope after each use using the sani cloth wipes before placing them on the medication cart. LN 2 further stated she should have performed hand hygiene, changed her gloves between tasks while administering medications to Resident 85 to prevent the spread of infections. A review of the facility's policy titled, 'Medication Administration -General Guidelines' dated 5/16/18 indicated, Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of medications given via [stomach] tubes. The facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment dated 2/20/18 indicated, Non-Critical items are those that come in contact with intact skin . blood pressure cuffs . Most non-critical reusable items can be decontaminated where they are used . Reusable items are cleaned and disinfected or sterilized between residents . stethoscope, durable medical equipment . During an interview with the Director of Nursing (DON) on 10/12/22 at 3:25 p.m. the DON stated she expected the Licensed Nurses to sanitize reusable equipment after use and to practice hand hygiene during medication administration as per the infection control policies. 2. A review of the admission Record indicated Resident 268 was admitted to the facility earlier this year with multiple diagnoses which included inflammation of the large intestine and Clostridium Difficile (C-Diff, an easily spread bacteria, that causes diarrhea and stomach pain). Resident 268's clinical records indicated that the resident continued having diarrhea and received a laboratory result that was positive for C-Diff on 10/10/22. According to the clinical records, Resident 268 was on Contact Isolation Precautions. During an observation on 10/11/22, at 1:40 p.m., the door to Resident 268's room was closed. An isolation cart containing gloves, blue isolation gowns and other garments or equipment designed to protect the wearer from infection was observed outside of the room. There was a sign posted on the wall outside the room indicating, PLEASE REPORT TO NURSES' STATION BEFORE ENTERING ROOM. There was no signage indicating that the two residents residing in the room were on Contact Isolation precautions. During the interview on 10/11/22, at 1:42 p.m., LN 4 stated one of the residents residing in the room, Resident 268 was on Contact Isolation precautions due to recent diagnosis of C-Diff. LN 4 stated Resident 268's roommate, Resident 269 was not on isolation precautions. LN 4 stated Resident 269 went to dialysis treatment today. LN 4 stated there was no need to separate Resident 269 in a different room because Resident 268 was non-ambulatory and there was no contact between these residents. LN 4 stated there was no need to post the contact isolation precaution sign as long as there was a sign 055481 Page 14 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0880 to report to nurses before entering the room. Level of Harm - Minimal harm or potential for actual harm A review of the admission Record indicated Resident 269 was admitted to the facility earlier this year with multiple diagnoses which included end stage kidney disease resulting in the need for dialysis. Residents Affected - Some A review of the Minimum Data Set, (resident assessment and care screen tool), dated 9/25/22 indicated Resident 269's brief interview of mental status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 13 (a score of 13-15 indicated intact cognition). During an observation on 10/11/22, at 2:05 p.m., Resident 269's husband was stopped by LN 4 while attempting to wheel the resident in wheelchair into her room. LN 4 explained to the resident and her husband that the resident had been moved to a different room. During an interview on 10/11/22, at 2:20 p.m., Resident 269 was sitting in wheelchair in her new room with husband at bedside. Resident 269 stated she just came back from dialysis and found out that the facility moved her to a different room. Resident 269 stated the nurse explained she was moved because my roommate is on quarantine. Resident 269 stated she hoped that whatever her roommate had was not contagious and did not get transmitted to her while she resided in the same room with Resident 268. Resident 269 stated it was upsetting that nobody talked to her regarding her roommate having infection and being on quarantine. During an interview with the DON on 10/13/22, at 1:50 p.m., the DON stated the facility received results of laboratory testing indicating that Resident 268 was C-Diff positive more than 24 hours ago. The DON stated Resident 269 was vulnerable with compromised immunity and to protect her from highly contagious C-Diff infection, she should have been moved to a different room immediately. The DON stated it was a standard practice to move the resident to a different room as soon as the facility found that Resident 268 was positive for C-Diff. The DON stated, As soon as I found out in our morning stand up meeting, I directed staff to move the roommate [Resident 269] to a different room. The DON stated having 'report to nursing' sign posted by the room was not adequate to inform the staff and visitors about contact isolation. The DON stated there should be a visible contact isolation sign posted next to the room entrance to warn the visitors to put isolation gown and gloves before entering the room. During an interview on 10/14/22, at 12:20 p.m., the Infection Preventionist (IP) stated C-Diff infection was highly contagious and the infection control goal was to protect residents and visitors from spreading the infection to others. The IP stated the measures to prevent the infection from spreading included posting a contact isolation precaution sign, wearing isolation gowns, gloves, and handwashing. The IP stated she was not aware there was no contact isolation sign posted by Resident 268's room. The IP was asked if it was appropriate to keep a C-Diff positive resident in the same room with the resident who had no C-diff infection, the IP stated that the individual assessment was necessary before making that decision. The IP stated she was not aware if the facility assessed Resident 269 or discussed a need to move her to a different room after the facility received report of C-diff positive roommate. A review of the undated facility's policy and procedure titled, INFECTION CONTROL CLOSTRIDIUM DIFFICILE, indicated that the goal for implementing infection control measures was to prevent the spread of communicable diseases and conditions. The policy indicated that Clostridium difficile infection (CDI) was the most frequent cause of diarrhea in adults. According to the policy the risks factors 055481 Page 15 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0880 Level of Harm - Minimal harm or potential for actual harm for developing of CDI included age greater than 65 years .antibiotic therapy .severe underlying disease .confinement in a long-term care .Residents with active diarrhea diagnosed as having CDI should be placed in Contact Isolation .Patients can be grouped (cohorted) with other patients with C-diff. Individual resident assessment is always necessary to determine appropriate roommates for those with C-Diff. Residents Affected - Some 055481 Page 16 of 17 055481 10/14/2022 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 on observation, interview, and facility document review, the facility failed to provide 80 square feet of living space per resident in rooms 24, 33, 43, and 68. This failure had the potential to compromise the residents' care and privacy. Findings: Review of a facility request for the square footage room waiver dated 9/17/2019, indicated the following multiple resident bedrooms measured less than 80 square feet (sq. ft.) per resident: room [ROOM NUMBER] measured 74 sq. ft. per resident, Rooms 33 measured 71.5 sq. ft. per resident, Rooms 43 measured 77.5 sq. ft. per resident; and, Rooms 68 measured 73.5 sq. ft. per resident. During an interview on 10/11/22, at 12:47 p.m., with the Certified Nursing Assistant (CNA)1, CNA 1 stated residents in room [ROOM NUMBER] needed assistance with transfer. One resident requires Hoyer lift for transfers and CNA 1 stated they have enough space to maneuver the Hoyer lift and provide care for residents in this room. room [ROOM NUMBER], 43 and 68 did not have four residents during the recertification survey but were considered four-bed rooms. The rooms were observed to be clutter free and residents had enough room for privacy and individual space. None of the rooms were observed to inhibit the staff to provide care to the residents and the residents received adequate care. The staff and the residents moved freely in the rooms. The Department recommends a continuation of the room waivers for rooms 24, 33, 43, and 68. 055481 Page 17 of 17