Health inspection·May 9, 2019

F 0578 Level of Harm - Potential for minimal harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, nursing staff did not have readily accessible information for the treatment decisions documented in the Physician Order for Life-Sustaining Treatment (POLST, an approach to end-of-life planning where patients choose what treatments they do or do not want and their wishes are documented as physician orders) for one (Resident 201) of six sampled residents with POLST orders. For Resident 201, the failure to include her POLST in her medical record had the potential to result in provision of unwanted resuscitation (treatment to restore breathing and/or circulation) if her breathing and heart were to cease functioning. Findings: A review of Resident 201's admission Record indicated the facility admitted Resident 201 on 4/24/19, with an included diagnosis of fracture of the thoracic vertebra (broken spine). During an interview with Licensed Vocational Nurse (LVN) 2 and concurrent review of Resident 201's clinical record on 5/7/19 at 9:52 a.m., LVN 2 stated Resident 201's clinical record did not have a POLST. LVN 2 stated she would provide resuscitation and send Resident 201 to the hospital in the event Resident 201 stopped breathing. During an interview with Social Services Director (SSD) on 5/8/19 at 8:41 a.m., SSD stated Resident 201's clinical record did not contain the POLST orders. SSD stated the POLST was currently waiting for a physician signature, inside the attending physician's signature binder. A review of Resident 20's POLST dated 4/29/19, and signed by Resident 201's representative, indicated Resident 201's code status as DNR(Do Not Resuscitate)/Allow Natural Death. Page 1 of 6 055534 055534 05/09/2019 The Reutlinger Community 4000 Camino Tassajara Danville, CA 94506

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, for one (Resident 5) of four residents with pressure ulcers (A pressure ulcer develops when one or more layers of skin and tissue are damaged as a result of continuous pressure to the area.), the facility failed to follow Resident 5's care plan to turn and reposition to avoid further breakdown of Resident 5's Stage II pressure injury. Residents Affected - Few This failure had the potential for Resident 5's Stage II pressure ulcers to worsen. Findings: Review of Resident 5's medical record indicated that Resident 5 had a Stage II pressure injury located on his right buttock. During an interview on 5/7/19, at 1:25 p.m., Responsible Party (RP) 1 stated that nursing staff did not position Resident 5 correctly and it was not right that Resident 5 was positioned on his back, which was on top of the pressure ulcer. During an observation and concurrent interview on 5/8/19, at 8:25 a.m., Resident 5 was observed in the supine position in his bed. Resident 5's daughter stated that Resident 5 was in the supine position when she had arrived around 8 a.m. Certified Nurse Assistant (CNA) stated that she would not position a resident on the pressure ulcer site. CNA stated that she was not aware Resident 5 had a pressure ulcer. CNA stated that Resident 5's nurse would inform her if any of her residents had a pressure ulcer, and stated that Resident 5's nurse did not inform her. During an interview on 5/8/19, at 8:30 a.m., License Vocational Nurse (LVN) 2 stated Resident 5 had a pressure ulcer on his coccyx. LVN 2 stated that Resident 5 was to be repositioned every two hours. LVN 2 stated that Resident 5's pressure ulcer could worsen if position on top of it. Review of Resident 5's care plan, The resident has a stage 2 pressure ulcer (Right Buttock) r/t (related to) Impaired mobility, poor appetite, initiated on 4/15/19, instructed as followed: Interventions .Follow facility policies/protocols for the prevention/treatment of skin breakdown .The resident needs reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Review of Resident 5's turn and reposition documents dated from 5/6/19 to 5/9/19, showed no documentation or evidence that Resident 5 was repositioned as followed: 5/6/19 from 8 a.m. to 4 p.m., 5/7/19 from 12 a.m. to 2 p.m., 5/8/19 from 12 a.m. to 2 p.m., and 5/9/19 from 8 a.m. to 12 p.m. Resident 5 was also positioned supine and on top of his Stage II pressure injury as followed: 5/6/19 from 2 a.m. to 4 a.m., and 6 p.m. to 8 p.m., 055534 Page 2 of 6 055534 05/09/2019 The Reutlinger Community 4000 Camino Tassajara Danville, CA 94506

F 0684 5/7/19 from 8 p.m. to 10 p.m., Level of Harm - Minimal harm or potential for actual harm 5/8/19 from 8 p.m. to 10 p.m., and 5/9/19 from 12 a.m. to 2 a.m. Residents Affected - Few 055534 Page 3 of 6 055534 05/09/2019 The Reutlinger Community 4000 Camino Tassajara Danville, CA 94506

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility stored 37 of 37 vials of various vaccines in an unlocked refrigerator with no method of monitoring temperature control, comingled with staff food items, and in a shared office with the social worker (SW) who was not a nurse, and was not licensed to have access to vaccines. These failures had the potential for the medications to become ineffective, contaminated, or diverted for unauthorized use. Findings: During an observation in the shared office of the social worker (SW) and the Director of Staff Development (DSD) on 5/9/19 at 8:46 a.m., a mini-refrigerator contained the following vaccines: two boxes of influenza (flu) vaccine [Fifteen vials of 0.5 ml (milliliter)]; one tuberculin vial [5 tu(tuberculin unit)/0.1ml]; five vials of hepatitis b vaccines, and one vial of pneumococcal 13-valent conjugate vaccine. During an observation and concurrent interview with the Director of Nursing (DON) in the shared office of SW and DSD, on 5/9/19 at 9 a.m., DON stated the mini-refrigerator was used by the social worker to store her personal food items. DON confirmed the vaccines in the mini-refrigerator should not be stored in the DSD office, but in the medication room. DON stated the mini-refrigerator had no thermometer to ensure the vaccines storage temperature met the manufacturer's instructions of storage at 36 degrees Fahrenheit (F, a unit of temperature measurement) to 42 F. DON stated the vaccines would not be used, but destroyed, since the actual storage temperature was unknown. During an observation and concurrent interview in the DSD office, with the DSD, on 5/9/19 at 9:59 a.m., DSD confirmed the mini-refrigerator contained vaccines. DSD stated she had forgotten the vaccines were in the mini-refrigerator, which did not have a thermometer, or a temperature log. Review of the facility's policy and procedure titled, Medication Storage Storage of Medication, with a date of 11/7, indicated as followed: 4.1 Storage of Medication. Policy. Medications and vaccines are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures .11. Medications requiring 'refrigeration' or 'temperatures between 2 C (36 F) and 8 C (46 F)' are kept in a refrigerator with a thermometer to allow temperature monitoring .A daily recorded temperature should be documented and signed off. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. A facility policy should be developed which describes the steps that will be followed if temperature falls out of range. A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits .13. Refrigerated medications should be kept in closed and labeled containers, with internal medications separated from external medications and all medications segregated from fruit juices, applesauce, and other foods used in administering medications. Any other foods such as employee lunches and activity department refreshments should not be stored in this refrigerator. 055534 Page 4 of 6 055534 05/09/2019 The Reutlinger Community 4000 Camino Tassajara Danville, CA 94506

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow food service safety measures by: Residents Affected - Some 1. Cooking staff did not wash hands between glove changes during tray line service. 2. Ice machine filters had layers of gray particulate matter. 3. The nursing station ice machine drip tray had layers of foreign substances. These failures placed residents at risk to acquire food borne illness and infection. Findings: 1. During an observation in the kitchen on 5/8/19 at 11:30 a.m., [NAME] (CK) 1, a member of the kitchen tray line staff, wore gloves on both hands while he scooped food onto each resident plate. During tray line service, CK 1 removed his gloves, used the gloves to wipe his hands and forearms, then donned new gloves without performing hand hygiene. During an interview on 5/8/19 at 12:30 p.m., the Director of Dining Services (DDS) stated kitchen staff were required to wash their hands after removing gloves and before donning new gloves. During an interview with Infection Control Nurse (ICN) on 5/9/19 at 9:59 a.m., ICN stated it was possible for a tray line worker to contaminate resident food if the worker omitted hand hygiene between glove changes. A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised 8/15, indicated as followed: Policy Statement. The facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .m. after removing gloves .Applying and Removing Gloves. 1. Perform hand hygiene before applying non-sterile gloves. 2. During an observation and concurrent interview on 5/9/19, at 8:09 a.m., the ice machine located in the kitchen had a vent for the collection of dust particles. Environmental Services (ES) pulled out the filters of the ice machine's vent and confirmed there was a build-up of dust. The ES stated he cleaned the vent filters every two weeks, but did not maintain a log for documentation of filter cleaning dates. During an interview on 5/9/19, at 9:59 a.m., the ICN stated the ice machine's vent filters should be cleaned to prevent the spread of infection as dust accumulation could cause respiratory infection or aggravate respiratory distress in residents with impaired breathing conditions such as asthma. A review of the facility's policy and procedure titled, Ice Machines and Ice Storage Chests, revised 1/12, indicated as followed: Policy Statement. Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy Interpretation and Implementation . 3. Our facility has established procedures for cleaning and disinfecting ice 055534 Page 5 of 6 055534 05/09/2019 The Reutlinger Community 4000 Camino Tassajara Danville, CA 94506

F 0812 machines and ice storage chests which adhere to the manufacturer's instructions. Level of Harm - Minimal harm or potential for actual harm A review of the manufacturer's instructions for the kitchen ice machine, issue date 9/23/16, indicated, A. Maintenance Schedule. The maintenance schedule below is a guideline. More frequent maintenance may be required depending on water quality, the appliance's environment, and local sanitation regulations Frequency: Bi-Weekly. Area: Air Filters. Task: Inspect. Wash with warm water and neutral cleaner if dirty. Residents Affected - Some 3. During an observation and concurrent interview on 5/9/19 at 8:09 a.m., the ice machine located at the nurse's station had white substances on the drip tray. ES was shown the white substances and stated that the white substances might have been from the water build up. ES stated that the janitor would clean the drip tray every two weeks. ES stated there was no log that documented the last time the drip tray was cleaned. During an interview on 5/9/19, at 9:59 a.m., the ICN stated the drip tray of the ice machine should be cleaned to prevent the spread of infection. A review of the manufacturer's instructions for the nurse station ice machine, dated 10/14, indicated, Maintenance and Cleaning. There are five areas of maintenance: 1. Drip tray and drain system .Drip tray. It is important to keep the drip tray clean of trash. Remove any as soon as it is noticed. Pour hot water into the tray on a regular basis to keep the drain open. Over time the drip tray and cup rest may become coated with scale or dirt. It can be removed to be scrubbed at a wash sink. A review of the facility's policy and procedure titled, Ice Machines and Ice Storage Chests, revised 1/12, indicated as followed: Policy Statement. Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy Interpretation and Implementation. 1 b. Waterborne microorganisms naturally occurring in the water source .2. To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: .f. Clean and sanitize the tray and ice scoop daily .3. Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. 055534 Page 6 of 6