Health inspection·July 14, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 a physician Informed Consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) was obtained for two of six sampled residents (Resident 11 and Resident 56) when: Residents Affected - Some 1. Resident 11 was administered lorazepam (medication used to treat anxiety [intense excessive, and persistent worry and fear about everyday situations]) without current and updated informed consent. 2. Resident 56 was administered escitalopram (brand name) and trazodone (medications used to treat depression [mood disorder characterized by feelings of sadness and loss of interest]) on 6/27/23 to 7/11/23 and informed consent was not obtained prior to medication administration. These failures resulted in Resident 11 and Resident 56 to be administered with psychotropic medications and not fully informed of the risk and benefits and did not have the knowledge to make an informed decision which placed Resident 11 and Resident 56 at a potential risk for negative side effects. Findings: 1. During an observation on 7/10/23, at 9:50 a.m., in room [ROOM NUMBER], Resident 11 was laying in bed in the lowest position, Resident 11 did not answer to questions asked. During a review of Resident 11's, admission Record (AR - document with resident information), dated 7/12/23, the AR indicated, Resident 11 was admitted on [DATE], with diagnoses which included palliative care (specialized care for people with serious illness), fracture of right femur (break in the hip bone), and anxiety. During a review of Resident 11's, Order Summary Report, dated 7/12/23, the Order Summary Report indicated, . Lorazepam 2 MG [milligram-unit of measurement] /ML [milliliter-unit of measurement] Give 0.25 ml by mouth every 8 [eight] hours related to Anxiety Disorder . During a concurrent interview and record review on 7/12/23, at 10:32 a.m., Resident 11's electronic record order for lorazepam was reviewed with the Director of Staff Development (DSD). The DSD stated the lorazepam order was revised on 6/1/23 with the dose increased to every eight hours. The DSD stated the lorazepam consent was signed on 3/28/23 for 0.25 ml po (by mouth) BID (twice a day) and every 4 hours prn (as needed) X 30 days. The DSD stated there should have been a new consent (informed) for lorazepam when the frequency was increased (total daily dosage). Page 1 of 40 055573 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 7/13/23, at 9:08 a.m., Resident 11's order for lorazepam was reviewed with Licensed Vocational Nurse (LVN) 2 LVN 2 stated, Resident 11's current lorazepam consent was not valid because there was an increase in the dose. LVN 2 stated there should have been a new consent obtained and signed by the medical doctor and the resident or resident representative for the new order. LVN 2 stated the medication should not have been given until a consent was signed. During a concurrent interview and record review on 7/14/23, at 1:55 p.m., Resident 11's psychotropic medication Informed Consent form was reviewed with the Director of Nursing (DON). The DON stated Resident 11's Informed Consent for lorazepam was signed on 3/28/23. The DON stated the lorazepam order was revised and the frequency was increased on 6/1/23 from twice a day to every eight hours. The DON stated Resident 11 was administered lorazepam medication from 6/1/23 - 7/14/23. The DON stated there should have been an informed consent for the new order of lorazepam (increased daily dosage) before administering the medication to Resident 11. 2. During a concurrent observation and interview on 7/10/23, at 8:35 a.m., in Resident 56's room, Resident 56 was sitting up in bed watching television. Resident 56 had on oxygen via nasal cannula (small flexible tube to deliver supplemental oxygen) connected to an oxygen concentrator at bedside. Resident 56 stated she was in the hospital for a few days for a bladder infection and respiratory infection and was in the facility to get therapy. During a review of Resident 56's, admission Record (AR), dated 7/12/23, the AR indicated, Resident 56 was admitted on [DATE], with diagnoses which included sepsis (body's extreme response to an infection), depression and insomnia (difficulty in falling and staying asleep). During a review of Resident 56's, Order summary Report, dated 7/12/22, the Order Summary indicated, . [escitalopram brand name] 20 MG Give one tablet by mouth one time a day for sadness r/t [related to] death of spouse related to Depression . traZODone 50 MG Give 1 tablet by mouth at bedtime related to Depression . During a review of Resident 56's, Medication Administration Record (MAR- a document that shows the medications ordered and taken by an individual), dated 6/1/23-6/30/23, and 7/1/23-7/31/23, the MAR indicated, escitalopram oxalate medication was administered every day starting from 6/27/23 thru 6/30/23 and 7/1/23 thru 7/11/23. During a review of Resident 56's, MAR, dated 6/1/23-6/30/23, and 7/1/23-7/31/23, the MAR indicated, trazodone medication was administered every day starting from 6/26/23 thru 6/30/23 and 7/1/23 thru 7/10/23. During a concurrent interview and record on 7/12/23, at 9:26 a.m., Resident 59's order summary for escitalopram and trazodone was reviewed by LVN 11. LVN 11 stated Resident 59's medications were ordered when resident was admitted on [DATE]. LVN 11 stated the Informed Consents for the escitalopram and trazodone was signed on 7/11/23. LVN 11 stated the escitalopram was administered to Resident 11 daily from 6/27/23-6/30/23 and from 7/1/23-7/11/23 without a signed informed consent. LVN 11 stated the trazodone was administered to Resident 59 daily from 6/26/23-6/30/23 and from 7/1/23-7/10/23 without a signed informed consent. LVN 11 stated psychotropic medications should have had a signed informed consent prior to administration of the medications. LVN 11 stated the licensed nurse who received the order should have obtained an Informed Consent and explained the risk and benefits to Resident 59 prior to administration of medications. 055573 Page 2 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 7/14/23, at 8:15 a.m., with the Medical Records Director (MRD/LVN), the MRD/LVN stated licensed nurses were responsible in getting the Informed Consent signed by the MD and resident or family. The MRD/LVN stated licensed nurses were not supposed to administer psychotropic medications without a signed Informed Consent. The MRD/LVN stated Informed Consent for psychotropic medications were important because there were mind altering medications. The MRD/LVN stated residents and families needed to be informed of the side effects and benefits of medications and make a sound decision to consent to the use of medications. During an interview on 7/14/23, at 1:50 p.m., with the DON, the DON stated licensed nurses were responsible in making sure there was a signed Informed Consent for psychotropic medications in order to administer the medication to a resident. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/2021, the P&P indicated, . 1. Federal and State laws guarantee certain basic rights to all residents of this facility . be informed of his or her rights and responsibilities . be informed of, and participate in, his or her care planning and treatment . During a review of the facility's policy and procedure (P&P) titled, Psychoactive Drug Management, dated 9/22, the P&P indicated, . C. Whenever an order is obtained for psychoactive medication(s), the Licensed Nurse verifies with the resident/Responsible Party that informed consent has been obtained prior to administering the medication ordered . D. The Licensed Nurse will contact the resident and or responsible party and verify that the physician obtained consent for the medication prior to administering the medication ordered . 055573 Page 3 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0583 Keep residents' personal and medical records private and confidential. 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 protect the privacy of personal information for one of three sampled residents (Resident 2) when Registered Nurse (RN) left her workstation computer open and unattended with resident information exposed to public view. Residents Affected - Few This failure resulted in violation of Resident 2's rights to confidentiality and the potential for unauthorized access to Resident 2's personal information. Findings: During a concurrent observation and interview on 7/11/23, at 7:05 am., in station 1 hallway, a medication cart was parked outside of room [ROOM NUMBER], the computer on the medication cart was left open and unattended by RN. The computer screen displayed Residents 2's name, photo, room number, allergies and a list of prescribed medications visible to everyone who passed by the medication cart out in the hallway. During a review of Resident 2's admission Record (AR- document which contain patient personal information), dated 7/13/23, the AR indicated Resident 2 was admitted in the facility on 1/8/15. During an interview on 7/11/23, at 7:15 a.m., with the RN, the RN stated she was inside room [ROOM NUMBER] when her workstation was left unattended. The RN stated her computer screen was open and displayed Resident 2's information. The RN stated she should not have left her computer screen open and available for anyone who passed by to view Resident 2's information. During an interview on 7/14/23, at 1:54 p.m., with the Director of Nursing (DON), the DON stated the expectation was for licensed nurses to place their computers on privacy screen mode when they are not in front of their computers. The DON stated computer screens that were open gave other residents and visitors access to resident information they were not supposed to see. The DON stated it was a Health Insurance Portability and Accountability Act (HIPAA- is a legislation which provides security provisions and data privacy in order to keep patients' medical information safe) violation and should not happen. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/21, the P&P indicated, . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: . privacy and confidentiality . 055573 Page 4 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS -assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of six sampled residents (Resident 11) when Resident 11's antipsychotic medication (used to treat severe mental disorder in which a person loses the ability to recognize reality or relate to others) use was inaccurately coded on the MDS assessment. Residents Affected - Few This failure had the potential to result in Resident 11's care needs not met. Findings: During a review of Resident 11's admission Record (document with resident demographic and medical diagnosis information), dated 7/12/23, indicated Resident was admitted in the facility on 12/22/22 with diagnoses which included unspecified psychosis (mental health problem that causes people to perceive or interpret things differently from those around them) and anxiety (feeling of fear, dread, and uneasiness). During a review of Resident 11's, Order Summary Report, dated 7/12/23, the Order Summary Report indicated, . Lorazepam 2 MG [milligram-unit of measurement] /ML [milliliter-unit of measurement] Give 0.25 ml by mouth every 8 hours related to ANXIETY DISORDER . Olanzapine Oral Tablet 7.5 MG . Give 1 tablet by mouth one time a day related to UNSPECIFIED PSYCHOSIS . During a concurrent interview and record review on 7/12/23, at 3:15 p.m., Resident 11's quarterly MDS assessment dated [DATE], section N was reviewed by the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 11 received antipsychotic and antianxiety medications. MDSN stated Resident 11's use of antipsychotic medication was not coded on the quarterly MDS assessment. MDSN stated Resident 11 should have been coded as receiving antipsychotic medications. During an interview on 7/14/23, at 2:15 p.m., with the Director of Nursing (DON), the DON stated the MDSN and other staff who completed MDS assessment needed to ensure resident assessments were complete and accurate. During an interview on 7/14/23, at 5:30 p.m., with the Administrator (ADM), ADM stated, the MDS assessment should have been accurate. The ADM stated staff were expected to complete MDS assessment with accuracy. During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, dated 3/2022, the P&P indicated, . Any person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment . 055573 Page 5 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of six sampled residents (Resident 56) when Resident 56 was on continuous oxygen (a life supporting component of air) therapy for her respiratory illness. This failure placed Resident 56 at a potential risk for her oxygen care needs not met. Findings: During a concurrent observation and interview on 7/10/23, at 8:35 a.m., with Resident 56's room, Resident 56 was sitting up in bed watching television. Resident 56 was on oxygen via nasal cannula (small flexible tube to deliver supplemental oxygen) connected to an oxygen concentrator (medical device that produces oxygen) at bedside. Resident 56 stated the oxygen helped her breathing. During a review of Resident 56's admission Record (AR-a document with personal identifiable and medical information), dated 7/12/23, the AR indicated, Resident 59 was admitted on [DATE] with diagnoses which included sepsis (body's extreme response to an infection), pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs may fill with pus or fluid), and chronic obstructive pulmonary disease (COPD- group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 56's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment, dated 6/30/23, indicated the Brief Interview for Mental Status (BIMS) score was 15 out of 15 (a BIMS score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 59 was cognitively intact in decision making. During a concurrent interview and record review on 712/23, at 9:30 a.m., Resident 56's physician orders was reviewed by Licensed Vocational Nurse (LVN) 11. LVN 11 stated Resident 56's physician orders indicated oxygen was prescribed on 7/9/23. LVN 11 stated she did not find a care plan for Resident 56's oxygen use. LVN 11 stated there should have been a care plan developed. LVN 11 stated it was the charge nurse's responsibility to initiate a care plan. During a concurrent interview and record review on 7/12/23, at 3:15 p.m., Resident 56's care plan was reviewed by the Minimum Data Set Nurse (MDSN). The MDSN stated she did not find an oxygen care plan for Resident 56. MDSN stated a care plan should have been initiated when Resident 56 started using oxygen. During an interview on 7/14/23, at 1:46 p.m., with the Director of Nursing, the DON stated the Licensed Nurses should have developed a care plan for Resident 56's oxygen needs. The DON stated the nurse receiving the order was responsible in developing the care plan at the time the order was received. The DON stated oxygen was considered a treatment and should be care planned. The DON stated care plan should be individualized because it provided a guide for the nursing staff on how to care for the resident. During a review of the facility policy and procedure (P&P) titled, Care Plan . dated 8/25/21, the 055573 Page 6 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few P&P indicated, . care plan for each resident that includes the instructions needed to provides effective and person-centered care of the resident that meet professional standards of quality of care shall be developed . During a review of the facility's policy and procedure (P&P) titled, Care Plan Comprehensive, dated 8/25/21, the P&P indicated, . An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident . Each resident's comprehensive care plan is designed to . incorporate identified problem areas . Incorporate risk and contributing factors associated with identified problems . Build on the resident's individualized needs . Reflect treatment goals . 055573 Page 7 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to timely revise and implement a person-centered comprehensive care plan for 3 of 12 residents (Residents 2, 26 and 66) when: 1. Resident 66's care plan reflected active interventions for treatment to his right foot even after having a right below the knee amputation (surgical removal of limb). This failure placed Resident 66 at a potential risk of his right lower leg care needs not to be met. 2. Resident 12 no longer used a communication board (paper with words and pictures) to communicate with staff. This failure placed Resident 12 at a potential risk of not being able to communicate her needs due to not having a tool to help communicate. 3. Resident 26's care plan reflected ongoing physical therapy, occupational therapy and speech therapy (therapies to help improve one's mobility, activities of daily living and speaking services). This failure placed Resident 26 at a potential risk for his current care needs not to be met. Findings: 1. During an observation on 7/10/23, at 9:25 a.m., Resident 66 was lying in bed. Resident 66 had bilateral (both) below the knee amputations. During a review of Resident 66's admission Record (AR), dated 7/13/23, the AR indicated, Resident 66 was admitted to the facility on [DATE], with diagnoses which included chronic ulcer (open sores that will not heal) of other part of right foot, type 2 diabetes mellitus (affects how the body uses sugar - high sugar in the blood), acquired absence of right and left leg below the knee (removal of the legs below the knees) and hypertension (high blood pressure). During a review of Residents 66's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 6/14/23, the MDS indicated, Resident 66's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 10 of 15 (a score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired, and 0-7 indicates severe impairment). The BIMS assessment indicated Resident 66 had moderate cognitive impairment. During a concurrent interview and record review on 7/13/23, at 10:54 a.m., Resident 66's physician's orders and care plan was reviewed by Licensed Vocational Nurse (LVN) 4. The physician's orders indicated, . Monitor right BKA for bleeding and infection . LVN 4 stated Resident 66's right leg (below the knee) was amputated in June. Resident 66's care plan for right lateral heel arterial ulcer dated 4/21/23 indicated, . Discoloration to right Lateral heel, Arterial Ulcer . Discoloration will be resolve without complications . Revision on: 7/6/2023 . Float right heel and left stump with pillows . Resident 66's care plan for diabetes dated 9/20/22 indicated, . Diabetic foot check daily. Observe feet/toes/ankles/soles/heels noting alteration in skin integrity, color, temperature and cleanliness [9/20/22] . Inspect shoes for proper fit . LVN 4 stated Resident 66 no longer had feet (both). LVN 4 stated interventions for foot care were still active in the care plan. LVN 4 stated the care plans were not accurate and should have been discontinued. LVN 4 stated care plans were important to make sure residents receive individualized care. 055573 Page 8 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 7/13/23, at 2:04 p.m., with the Medical Records Director (MRD/LVN), the MRD/LVN stated Resident 66's care plans for care to his right foot should have been discontinued after his right lower leg was amputated. The MRD/LVN stated care plans should have been updated (revised) by the nurses weekly when they complete the weekly summaries and if there was a change of condition. During a concurrent interview and record review on 7/13/23, at 3:46 p.m., Resident 66's wound care plan was reviewed by the Director of Nursing (DON). The DON stated the care plan indicated to float Resident 66's heels. The DON stated Resident 66 did not have feet anymore. The DON stated the care plans were not accurate and should have been updated to reflect Resident 66's care needs. 2. During an observation on 7/10/23, at 10:39 a.m., in Resident 12's room, Resident 12 was sitting in her wheelchair holding her right arm with her left hand and a specialized touch pad call light with a red plus sign symbol was laying on the bed next to her. During an observation on 7/12/23, at 11:00 a.m., in Resident 12's room, Resident 12 was not in her room. There was no writing boards, cards or papers used for communication purposes on her bed, table or on the walls. During a review of Resident 12's AR, the AR indicated, Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnoses included . HEMIPLEGIA AND HEMIPARESIS FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE AFFECTING RIGHT DOMINANT SIDE [weakness and paralysis to the right side of the body after blood flow stopped in a part of the brain] . APHASIA FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE [language disorder affecting an individual's speech after blood flow stopped in a part of the brain] . FACIAL WEAKNESS [inability to filly move muscles in the face] . CONTRACTURE, RIGHT ELBOW [fixed tightening of the right elbow affecting movement] . During a review of Resident 12's MDS, dated 4/19/23, the MDS indicated, Resident 12's BIMS indicated a score of 8. Resident 12 had moderate cognitive impairment. During an interview on 7/13/23, at 12:40 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 12 was able to answer yes or no questions but otherwise did not talk. CNA 1 stated, Resident 12 used to have a communication paper (with pictures and words) used to express what she needed and felt. CNA 1 stated Resident 12 pointed to the picture or word she wanted to communicate to the other person. CNA 1 stated, Resident 12's communication paper got lost and she had not seen it anymore. During an interview on 7/13/23, at 12:41 p.m., with LVN 1, LVN 1 stated, there was no communication board in Resident 12's room. LVN 1 stated, Resident 12 was hard to communicate with at first but she was able to communicate by verbalizing yes or no and with facial grimacing. During a concurrent interview and record review on 7/14/23, at 9:50 a.m., Resident 12's care plan was reviewed by LVN 1. The care plan indicated . The resident has impaired communication . difficult making self-understood (expressive), resident is non-verbal points to what she needs and able to say yes. (Communication board/binder is available) . Provide communication board/binder (and enc. [encourage] to use) to help the resident communicate wants and needs . LVN 1 stated, Resident 12's use of the communicate board (lost) had not been resolved yet and was still active. During a concurrent interview and record review on 7/14/23, at 5:25 p.m., Resident 12's care plans were reviewed by the DON. The DON stated, the importance of revising care plans was to create a plan 055573 Page 9 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of care for resident's present condition. DON stated, she had never seen Resident 12 using a communication board. DON stated she had not seen Resident 12 show interest in using one. DON stated, Resident 12's use of a communication board should have been removed in the care plan since it had not been used for sometime, being lost. 3. During an observation on 7/10/23, at 10:28 a.m., in Resident 26's room, Resident 26 was laying on an air mattress which had curved edges and had pillows under her left side of her body. During a review of Resident 26's AR, the AR indicated, Resident 26 was admitted to the facility on [DATE]. Resident 26's diagnoses included . UNSPECIFIED DEMENTIA (condition of progressive loss of memory, language and other thinking abilities) . HEMIPLEGIA AND HEMIPARESIS FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE AFFECTING LEFT NON-DOMINANT SIDE (weakness and paralysis to the left side of the body after blood flow stopped in a part of the brain) . MUSCLE WEAKNESS (decreased strength in muscles) . DYSPHAGIA . During a review of Resident 26's MDS, dated 5/18/23, the MDS indicated, Resident 26's BIMS indicated a score of 3. Resident 26 had severe cognitive impairment. During an interview on 7/13/23, at 1:04 p.m., with CNA 1, CNA 1 stated, Resident 26 laid on an air mattress and required two staff members for repositioning in bed. CNA 1 stated Resident 26 only had one functional hand. During a concurrent interview and record review on 7/14/23 @ 10:10 a.m., Resident 26's care plans were reviewed. The care plan for ADL care indicated . PT/OT/SP [Physical Therapy/Occupational Therapy/ Speech Therapy] treatment as ordered by physician/mid-level provider . The care plan for Fall indicated, . Resident is at risk for falls: limited mobility . Resident will have no falls with injury x [for] __90_ days . Therapy/Rehab-PT Treatment _3__ x [three times] per week as indicated . LVN 1 stated, she had not seen therapy staff members do any type of exercises with Resident 26. During an interview on 7/14/23, at 10:13 a.m., with the Speech Language Pathologist (SLP) 1, SLP 1 stated, Resident 26 had been seen for physical therapy from 5/13/23 through 6/6/23, occupational therapy from 5/16/23 through 6/5/23 and speech therapy from 5/16/23 through 6/5/23. The SLP 1 stated Resident 26 was no longer receiving PT, OT and Speech Therapy services. During an interview on 7/14/23, at 5:25 p.m., with the DON, the DON stated, the importance of revising care plans was to create a plan of care for resident's present condition. The DON stated, Resident 26 refused to go to physical therapy, occupational therapy and speech therapy anymore. The DON stated the care plan should have been updated to reflect Resident 26's refusal of therapies and its discontinuation. During a review of Resident 26's PT Discharge Summary, undated, the Discharge Summary indicated . Dates of Service: 5/13/2023- 6/6/2023 Physical Therapy . D/C Reason (Discharge Reason): Maximum Potential Achieved . During a review of Resident 26's OT Discharge Summary, undated, the Discharge Summary indicated . Dates of Service: 5/16/2023- 6/5/2023 Occupational Therapy . D/C Reason: Maximum Potential Achieved . During a review of Resident 26's SLP (Speech Language Pathology- evaluation and treatment of communication disorders) Discharge Summary, undated, the Discharge Summary indicated . Dates of Service: 055573 Page 10 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5/16/2023- 6/5/2023 Dysphagia (problems using the mouth to control food and liquids) Therapy . D/C Reason: All Goals Met/Remaining in Facility . During a review of the facility's policy and procedure (P&P) titled, CARE PLAN COMPREHENSIVE, dated 8/25/21, the P&P indicated, . PURPOSE . An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident . Build on the resident's individualized needs, strengths, preferences . Reflect the resident's expressed wishes regarding care and treatment goals . Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident's condition change . 055573 Page 11 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 meet professional standards of practice for 4 of 12 sampled residents (Residents 22, 28, 47 and 22 ) when: Residents Affected - Some 1. Licensed Vocational Nurse (LVN) 6 failed to follow the manufacturers direction to shake tube feeding formula prior to hanging and administering to Resident 22. This failure placed Resident 22 at a potential risk to not receiving the amount of nutrition ordered by the physician. 2. LVN 6 signed the electronic Medication Administration Record (eMAR- legal record of drug administration to a patient at a facility by a health care professional) prior to administering Resident 22's medications. This failure resulted in inaccurate charting and placed Resident 22 at a risk to not receive the medication ordered. 3. LVN 11 did not follow medication administration direction when she gave medication to Resident 47 without giving food. This failure had the potential to put Resident 47 at risk for stomach upset. 4. A small medication cup filled with brown liquid was left on top of Resident 28's bedside table accessible to other residents. This failure had the potential for Resident 28 to not receive a prescribed medication and for other residents to have access to the medication. 5. Resident 22's gastrostomy tube (G-tube-a tube inserted through the abdominal wall to deliver liquid nutrition) enteral (tube feeding) formula bottle (liquid nutrition) and tubing were not labeled and dated according to the facility's policy and procedure (P&P). This failure had the potential for Resident 22 to suffer from a gastrointestinal illness (illness of the digestive system including the stomach and intestines) and possibly cause diarrhea and dehydration. Findings: 1. During a concurrent observation, interview and record review on 7/12/23, at 8:10 a.m., in room [ROOM NUMBER], LVN 6 observed preparing Resident 22's tube feeding formula. LVN 6 primed (ready for use) the tubing for the formula and connected to Resident 22. LVN 6 did not shake the bottle of feeding formula. LVN 6 reviewed the label attached to the bottle of the formula, and stated she had never shaken well the feeding formula bottle prior to hanging and connecting to Resident 22. LVN 6 stated the formula could have settled on the bottom of the bottle when it was in storage. LVN 6 stated Resident 22 may not received the same amount of calories per hour as ordered by the physician since she did not follow the instruction on the bottle. LVN 6 stated she was supposed to shake the bottle well before giving to the resident. During a review of Resident 22's admission Record, dated 7/12/23, the admission record indicated, Resident 22 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), dysphagia (difficulty or discomfort in swallowing foods or liquids) and aphasia (language disorder affecting ability to communicate). During an interview on 7/14/23, at 2:15 p.m., with the Director of Nursing (DON), the DON stated the licensed nurses should have read the formula label and followed instructions. The DON stated the nurse should have shaken the bottle well as per instructions. The DON stated Resident 22 was at risk 055573 Page 12 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for not receiving the same amount of calories because the bottle was not shaken well. The DON stated the formula could have settled at the bottom of the bottle. The DON stated the bottle had to be shaken well to mix the formula properly. The DON stated the nurse should have shaken the formula bottle well. Review of facility's policy and procedure (P&P) titled, Enteral feeding-Safety Precautions, dated 11/18, the P&P indicated, . 1. All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities 2. The facility will remain current in and follow accepted best practices in enteral nutrition . Review of professional reference, www.abbottnutrition.com dated, 2023, the professional reference indicated, . Instruction for Use: . Shake well prior to opening . Failure to follow the Instruction for Use Increases the potential for microbial contamination and may reduce hangtime . Turn container upside down and SHAKE VIGOROUSLY, using twisting motion for at least 10 seconds . 2. During a concurrent observation and interview on 7/12/23, at 8:10 a.m., in station 2 hallway, LVN 6 prepared Resident 22's medications and clicked (checked as given) each medications in the eMAR as she popped each medications in a small medication cup. LVN 6 administered the medications to Resident 22. LVN 6 stated she had always clicked and saved in the eMAR after she popped each medication from the bubble pack to make sure she has all the medications. LVN 6 stated she did not know it was wrong to click prior to administering medications. During an interview on 7/14/23, at 5:30 p.m., with the Administrator (ADM), the ADM stated the nurse should have administered the medication to the resident before documenting in the eMAR. During a review of facility's P&P titled, Documentation of Medication Administration, dated 4/07, the P&P indicated, . The facility shall maintain a medication administration record to document all medications administered . 2. Administration of medication must be documented immediately after (never before) it is given . 3. During a concurrent observation and interview on 7/11/23, at 8:30 a.m., in Station 2 (two) hallway outside of room [ROOM NUMBER], LVN 11 prepared Resident 47's medication which included Carvedilol (used to treat high blood pressure) Oral Tablet to be given with food. LVN 11 administered medication to Resident 47 with water and did not give food as indicated in the medication direction. LVN 11 reviewed Resident 47's medication direction after she administered medication. LVN 11 stated, she should have given food to Resident 47 when she administered the medication according to the direction. LVN 11 stated the medication could irritate Resident 47's stomach and cause discomfort. During a review of Resident 47's admission Record, dated 7/12/23, the admission record indicated, Resident 47 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure), muscle weakness and pain in right hip. During a review of Resident 47's eMAR, dated 7/1/23-7/31/23, the eMAR indicated, . Carvedilol Oral Tablet 3.125 MG . Give with food . During an interview on 7/13/23, at 2:48 p.m., with LVN 5, LVN 5 stated it was important to follow the direction when administering medications to residents. LVN 5 stated when a medication direction was to be given with food, the medication must be given with food like crackers or apple sauce. LVN 5 stated it was done to prevent the resident from having an upset stomach. Resident 47 should have 055573 Page 13 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0658 been given food when he was given the medication. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/14/23, at 2:05 p.m., with the DON, the DON stated the nurse should have given Resident 47 some food with his medication. The DON stated the nurse should have followed the direction of the medication. Residents Affected - Some According to Lexicomp, a nationally recognized drug reference, the use of carvedilol may cause . Feeling Dizzy, tired and weak . Administer carvedilol immediate-release tablets with food to decrease the risk of orthostatic hypotension [low blood pressure that happens when standing after sitting or lying down] . Administer carvedilol phosphate extended-release capsules with food; administration with food has been shown to increase the bioavailability of the extended-release capsules . 4. During an observation on 7/10/23, at 9:42 a.m., in Resident 28's room, Resident 28 was not in her room. There was a 30 ml medicine cup half-filled with brown liquid on top of the bedside table. The medication cup was available and accessible to other residents to consume. During an interview on 7/10/23, at 9:43 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she was the CNA for Resident 28. CNA 3 stated the medicine cup with the brownish liquid was for Resident 28. CNA 3 stated the nurse had left the medicine cup for Resident 28 to drink. CNA 3 stated Resident 28 did not drink it and left it on top of her bedside table. During a concurrent observation and interview on 7/10/23, at 9:50 a.m., with LVN 1, LVN 1 stated the medication cup with the brown liquid was a protein supplement for Resident 28. LVN 1 stated she left the medication cup in Resident 28's bedside table. LVN 1 stated, she should not have left it unattended. LVN 1 stated the protein supplement was prescribed to Resident 28. LVN 1 stated, leaving medicine cup on the bedside made it accessible for other residents to grab it (medicine cup with protein supplement) and drink it. LVN 1 stated if consumed by other residents, it could potentially cause allergic reactions. LVN 1 stated Resident 28 did not drink the supplement as prescribed by the doctor. During a review of Resident 28's, admission Record, dated 7/12/23, the admission Record indicated, Resident 28 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis, End Stage Renal Disease (kidneys are no longer able to work at a level needed for day-to-day), and anemia (blood does not have enough healthy red blood). During an interview on 7/13/23, at 10:15 a.m., with LVN 2, LVN 2 stated prescribed medications including protein supplements were not to be left in residents room unattended. LVN 2 stated other residents could go in the room and drink the supplement which could potentially cause an untoward reaction to the resident. During a concurrent observation and interview on 7/10/23, at 9:45 a.m., with DON, the DON stated the nurse should not have left it at bedside because other residents could go in the room and drink the liquid protein which could potentially make them sick. DON stated the nurse should have made sure Resident 28 drank the protein supplement and not left it on top of Resident 28's bedside table. During a review of facility's P&P titled, General Dose Preparation and Medication Administration, dated 1/1/13, the P&P indicated, . Facility staff should not leave medications or chemicals unattended . 055573 Page 14 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. During an observation on 7/10/23 at 9:53 a.m. in Resident 22's room, Resident 22 was observed lying in bed with his G-tube connected to a feeding pump running at 55 cc (cubic centimeters- unit of measurement) per hour. The enteral formula bottle and tubing connected to Resident 22 were not labeled or dated. During a review of Resident 22's Admissions Record (AR), undated, the AR indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses which included, encounter for palliative care, COPD, hemiplegia and hemiparesis following cerebral infarction (stroke-caused by disrupted blood flow to the brain), dysphagia, and protein-calorie malnutrition (lack of sufficient nutrients in the body). During a review of Residents 22's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 22's Brief Interview of Mental Status assessment (BIMS - assessment of cognitive status for memory and judgement) was based on staff assessment. The BIMS indicated Resident 22's cognition was severely impaired. During a concurrent observation and interview on 7/12/23 at 10:22 a.m. with Licensed Vocational Nurse (LVN) 6 in Resident 22's room, Resident 22's G-tube was connected to tubing and the enteral formula bottle. Resident 22's formula bottle had a label attached labeled with the resident's name, room number, nurses name, date and time prepared. LVN 6 reviewed the label and stated the label was not filled out completely and was missing the formula name, date and time it was hung. LVN 6 stated she did not date the tubing separately. During an interview on 7/14/23, with the Director of Nursing (DON), the DON stated the enteral formula bottle should have been dated with the initials of the resident, name of the nurse who hung the feeding and the date and time the feeding was hung. The DON stated the label was included in the package with the feeding supplies was expected to be filled out completely. The DON stated the tubing should have been labeled and dated separately. The DON stated it was an infection control issue if the formula and tubing were not changed every 24 hours and could cause residents to have gastrointestinal illnesses. During a review of the facility's P&P titled, Enteral Feedings-Safety Precautions, dated 11/2018, the P&P indicated, . To ensure the safe administration of enteral nutrition . facility will remain current in and follow accepted best practices in enteral nutrition . Preventing errors in administration . Check the enteral nutrition label against the order before administration. Check the following information . Resident name . Date and time formula was prepared . On the formula label document initials, date and time the formula was hung . During a professional reference review, retrieved from https://www.nutritioncare.org/uploadedFiles/01_Site_Directory/Guidelines_and_Clinical_Resources/EN_Pathway/Boullata_ titled, ASPEN Safe Practices for Enteral Nutrition Therapy, dated January 2017, the reference indicated, . Organizations can standardize safety practices for EN [enteral nutrition], such as those related to decreasing risk for enteral misconnections . labeling of tubes . Identification and confirmation of solutions label . 055573 Page 15 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide proper maintenance and care for residents with foley catheter (indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag) for one of two sampled residents (Resident 65) when Resident 65's urinary catheter bag was touching the floor on three separate occasions. This failure resulted in compromised urine drainage and accumulation of a large amount of sediment in the urinary catheter tubing and placed Resident 65 at a potential risk for catheter contamination, urinary retention (unable to empty the bladder) and a urinary tract infection (UTI-an infection in any part of the urinary system [kidneys, ureters, bladder]). Findings: During an observation on 7/12/23, at 3:30 p.m., Resident 65 was lying in bed resting. Resident 65's bed was in the lowest position and the foley catheter bag hanging on the bed frame, folded in half and touching the floor. Resident 65's catheter tubing was filled with cloudy, dark yellow urine which caused the tubing to appear opaque (not transparent). During a review of Resident 65's admission Record (AR), dated 7/12/23, the AR indicated, Resident 65 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), sequelae of cerebral infarction (residual effects from disrupted blood flow to the brain), obstructive and reflux uropathy (urine cannot drain and backs up into the ureter [the duct by which urine passes from the kidney] and kidneys). During a review of Residents 65's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [thought process] and physical function) Assessment dated 3/31/23, the MDS indicated, Resident 65's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) score was 0 out of 15 (a score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired, and 0-7 indicates severe impairment). The BIMS assessment indicated Resident 65's cognition was severely impaired. During a review of Resident 65's MDS - Section H Bladder and Bowel, dated 6/30/23, the MDS indicated, Resident 65 had an indwelling catheter. During a concurrent observation and interview on 7/12/23, at 3:38 p.m., in Resident 65's room, Resident 65 was lying in bed. Resident 65's catheter bag was hanging on his bedframe and the catheter bag folded in half, touching the floor. Resident 65's catheter tubing was full of cloudy urine. Certified Nursing Assistant (CNA) 11 stated, the bag was folded and touching the floor. CNA 11 stated, Resident 65 was a fall risk and the bed had to be in the lowest position. CNA 11 lifted the catheter bag off the frame and floor. CNA 11 stated, When I lifted the bag up, all the urine ran out of the tubing into the bag so I can tell the tubing was not draining. CNA 11 stated Resident 65 could have UTI if the urine was not able to drain into the bag properly. During a concurrent observation and interview on 7/12/23, at 3:56 p.m., in Resident 65's room, Resident 65's catheter tubing had cloudy urine and the urine bag was touching the floor. Licensed 055573 Page 16 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Vocational Nurse (LVN) 7 stated, Resident 65's urine was cloudy in the tubing. LVN 7 stated, Resident 65's catheter was not draining correctly which could cause the urine to back up into his bladder and result in kidney issues or UTI. LVN 7 stated, the catheter bag on the floor could cause an infection to Resident 65. During a concurrent observation and interview on 7/13/23, at 9:19 a.m., in Resident 65's room, Resident 65 was lying in bed with bed in the lowest position. Resident 65's catheter bag was hung on the bedframe. Resident 65's catheter bag and tubing were touching the floor. CNA 12 stated the resident's bed had to be kept in the lowest position to prevent falls, so they were unable to keep the catheter bag off the floor. Resident 65's catheter tubing had sediment in dark yellow urine. During an interview on 7/13/23, at 12:58 p.m., with LVN 4, LVN 4 stated Resident 65 had the urinary catheter due to prostate (a gland surrounding the neck of the bladder) issues. LVN 4 stated Resident 65 had a history of UTIs. LVN 4 stated sediments in the urine could cause the urine to not drain properly which could lead to an infection and kidney failure. During an interview on 7/13/23, at 4:05 p.m., with the Director of Nursing (DON), the DON stated a catheter bag touching the floor was an infection control issue. The DON stated the bag folded in half did not allow the urine to drain properly. During a review of Resident 65's Order Summary Report (OS), dated 7/2023, the OS indicated . Foley catheter 14 FR [French-size of catheter] with 10 cc [cubic centimeters-unit of measurement] balloon to bedside straight drainage for diagnosis/Hx [history] of urinary retention . During a review of Resident 65's urinary care plan dated 8/12/22, the care plan indicated, . Resident is at risk for UTI related to indwelling urinary catheter . Assess resident's catheter for presence of cloudy, foul-smelling urine from catheter . During a concurrent observation and interview on 7/14/23 at 9:50 a.m. with LVN 8, Resident 65 was lying in bed, his catheter bag was placed away from the bed closer to the wall, next to the trash can. The catheter was not hanging on the bedframe in a position to allow for drainage. LVN 8 stated If it [urine bag] is not hung freely then the urine can back up and we have bigger problems, he [Resident 65] could get a UTI. LVN 8 stated the catheter bag in a basin on the floor was an infection control issue. During a review of the facility's policy and procedure titled, Urinary Catheter, dated 11/15/2021, the P&P indicated, . Purpose . To decrease/eliminate difficulties associated with urinary catheter use . During a review of a professional reference titled, the Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 781-782 indicated, . Management of the Patient with and Indwelling (Self-Retaining) Catheter and Closed Drainage System . Care of the indwelling catheter . Backward and forward displacement of the catheter introduce contaminants into the urinary tract . Maintaining a closed drainage system . 2. Maintain unobstructed urine flow . Keep the bag off the floor . Prevents bacterial contamination . 055573 Page 17 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured the administration of medications to meet residents needs for one of six sampled residents (Resident 35) when Resident 35's Benazepril (brand name [medication used to treat high blood pressure]) was not available for administration for 8 days (7/4/23, 7/5/23, 7/6/23, 7/7/23, 7/8/23, 7/9/23, 7/10/23 and 7/11/23). This failure had the potential for Resident 35's blood pressure to be uncontrolled and lead to serious medical condition. Findings: During a concurrent medication pass observation and interview on 7/11/23 at 7:15 a.m., at Station 1, RN was preparing Resident 35's medications after checking blood pressure which was 168/93. RN did not administer Resident 35's benazepril medication. RN stated the medication was not available to give to Resident 35. RN stated Resident 35's B/P was at 168/93 and could go higher. RN stated having high blood pressure could result to a more serious health condition because the medication was not administered. RN stated follow-up with the pharmacy should have been done. During a review of Resident 35's admission Record, dated 7/12/23, the admission record indicated, Resident 35 was admitted in the facility on 7/6/22, with diagnoses which included hypertension (pressure in the blood vessels are too high) and muscle weakness. During a review of Resident 35's eMAR (Electronic Medical Administration Record) dated 7/1/23-7/31/23, the eMAR indicated, Resident 35 did not received benazepril brand name medication on 7/4/23, 7/5/23, 7/6/3, 7/7/23, 7/8/23, 7/9/23, 7/10/23 and 7/11/23. During a review of Resident 35's Progress Notes, dated 7/14/23, the Progress Notes indicated, . 07/04/2023 07:48 . [ Benazepril brand name] Tablet . Pending delivery from Pharmacy . 07/05/2023 09:14 . pending delivery from pharmacy . 07/06/2023 09:27 . pharmacy pending delivery . 07/07/2023 07:44 . pending pharmacy delivery . 07/11/2023 07:34 . During a concurrent interview and record review on 7/13/23, at 1:24 p.m., Licensed Vocational Nurse (LVN) 1 reviewed Resident 35's clinical record. LVN 1 stated she worked with Resident 35 on 7/7/23 and 7/8/23. LVN 1 stated she put hold in the eMAR for 7/7/23 and 7/8/23 for benazepril (brand name) medication because it was not available to give. LVN 1 stated she did not remember checking the OMNICELL (automated medication dispensing cabinet) if the medication was available. LVN 1 stated she did not remember calling pharmacy to follow up on the medication delivery. LVN 1 stated she did not remember notifying the Director of Nursing (DON) of the medication not available for Resident 35. LVN 1 stated she did not remember notifying the physician of Resident 35 not receiving the medication. LVN stated she should have notified the DON and the physician and called the Pharmacy to follow-up. LVN 1 stated Resident 35's B/P could go higher and lead to serious medical condition. During a concurrent interview and record review on 7/13/26. at 2:56 p.m., with LVN 3, LVN 3 reviewed Resident 35's clinical record and stated she worked with Resident 35 on 7/9/23. LVN 3 stated she did not administer Resident 35's blood pressure medication because it was not available. LVN 3 stated was not aware of the medication being unavailable since 7/4/23. LVN 3 stated she should have 055573 Page 18 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few checked (called) with pharmacy and checked the omnicell. LVN 3 stated she should have called the physician to notify of the medication not available. LVN 3 stated Resident 35's blood pressure could get even higher and possibly lead to stroke or heart attack. During an interview on 7/14/23, at 2:05 p.m., with the DON, the DON stated the nurse should have called the physician the first day the medication was not available. The DON stated the nurse should have called the physician to check medication availability right away. The DON stated the licensed nurse should have picked up the phone to follow up with the pharmacy and the physician. The DON stated the physician could have given another medication order while waiting for the medication to be available from the pharmacy. The DON stated Resident 35 could potentially get into serious medical condition and send out to acute hospital. During a review of facility's policy and procedure (P&P), titled, Medication Shortages/Unavailable Medications, dated 1/1/13, the P&P indicated, . 2. If a medication shortage is discovered during normal Pharmacy hours: Facility nurse should call Pharmacy to determine the status of the order . Facility should notify Pharmacy and arrange for an emergency delivery . If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or directions . If an emergency delivery is unavailable from Pharmacy or a Third Party Pharmacy . Facility should obtain alternate Physician/Prescriber orders, as necessary . During a review of facility's policy and procedure, titled, Reordering, Changing, and Discontinuing Orders, dated, 1/1/13, the P&P indicated, . Facility staff should reorder medications using an electronic list of residents and medications due . facility should review the transmitted reorders for status and potential issues and Pharmacy response . 055573 Page 19 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent (eight percent) when: Residents Affected - Few 1. Registered Nurse (RN) did not administer Resident 35's benazepril (brand name [medication used to treat high blood pressure]) medication during medication pass. This failure had the potential for Resident 35's blood pressure to go higher and lead to serious medical condition. 2. RN administered diltiazem (medication used to treat high blood pressure) medication to Resident 68 with blood pressure of 157/71 and pulse rate of 51. This failure resulted in Resident 68 receiving her blood pressure medication not as prescribed by the physician and had the potential for Resident 68's blood pressure and pulse to go lower and lead to serious medical condition. Findings: 1. During a concurrent observation and interview on 7/11/23 at 7:15 a.m., in Station 1, RN was passing medication. RN checked Resident 35's blood pressure which was noted as 168/93. RN prepared Resident 35's medications and administered two of three medications scheduled for Resident 35. RN stated she did not administer benazepril (brand name) to Resident 35 because it was not available. RN stated she should given the medication to Resident 35 as ordered since Resident 35's blood pressure was 168/93. RN stated Resident 35's blood pressure could go higher and cause more serious health condition since the medication was not administered. During a review of Resident 35's admission Record, dated 7/12/23, the admission record indicated, Resident 35 was admitted in the facility on 7/6/22, with diagnoses which included hypertension (pressure in the blood vessels are too high) and muscle weakness. During a review of Resident 35's eMAR (Electronic Medical Administration Record) dated 7/1/23-7/31/23, the eMAR indicated, (Benazepril brand name) Tablet 20 MG . Take 1 tablet by mouth . for Hypertension . Resident 35 did not received benazepril (brand name) on 7/11/23. During a review of Resident 35's Progress Notes, dated 7/14/23, the Progress Notes indicated, . 07/11/2023 07:34 . pending pharmacy delivery . During an interview on 7/14/23, at 2:05 p.m., with the Director of Nursing (DON), the DON stated the nurse should have called the pharmacy when the medication was not available for administration. DON stated the licensed nurse should have picked up the phone to follow up with the pharmacy and the physician. DON stated the nurse should have called the physician and let him know while waiting for the medication to be available from the pharmacy. DON stated Resident 35's blood pressure had the potential to go higher and lead to serious medical condition. During a review of facility's policy and procedure (P&P) titled, Medication-Related Errors, dated 5/1/10, the P&P indicated, . Omission Error: Facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contradictions . During a review of facility's P&P titled, Medication Shortages/Unavailable Medications, dated 1/1/13, the P&P indicated, . 2. If a medication shortage is discovered during normal Pharmacy hours: Facility nurse should call Pharmacy to determine the status of the order . Facility should notify 055573 Page 20 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Pharmacy and arrange for an emergency delivery . If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or directions . If an emergency delivery is unavailable from Pharmacy or a Third Party Pharmacy . Facility should obtain alternate Physician/Prescriber orders, as necessary . 2. During a concurrent observation and interview on 7/11/23, at 7:45 a.m., at Station 1, RN was passing medication. RN took Resident 68's blood pressure (157/71) and pulse (51). RN prepared medications including diltiazem and administered to Resident 68. RN reviewed Diltiazem order and direction in the bubble pack (blister pack-individually sealed tablets). RN stated the direction was to hold the medication if the SBP (Systolic blood pressure-pressure in the arteries when the heart beats) was less than 100 and pulse rate was less than 60. RN stated she administered the medication because the blood pressure was 157/71. RN stated she did not realize the pulse was 51 and the direction was to hold if pulse was less than 60. RN stated she should have held (not give) the medication because the pulse could go even lower which could lead to serious medical condition for Resident 68. During a review of Resident 68's Order Summary Report, dated 7/12/23, the Order Summary Report, indicated, . dilTIAZem HCl [Hydrochloride-acid salt] ER Oral Capsule Extended Release 12 hour 120 MG [milligram-unit of measurement] Give 1 [one] capsule by mouth . Hold for SBP less than 100 or pulse less than 60 . During a concurrent interview and record review on 7/13/23, at 2:05 p.m., LVN 1 reviewed Resident 68's eMAR for the month of July 2023. LVN 1 stated she worked with Resident 68 on 7/2/23, 7/7/23 and 7/8/23. LVN 1 stated Resident 68's diltiazem order had instructions to hold the medication if the SBP was less than 100 and pulse less than 60. LVN 1 stated administering the medication to Resident 68 with a pulse of 51 could potentially dropped her pulse and lead to serious medical condition. During an interview on 7/14/23, at 2:15 p.m., with the DON, DON stated the nurse should have held Resident 68's diltiazem medication and notified the physician. DON stated the nurse should have followed the direction in the medication bubble pack to hold medication for the parameters indicated. DON stated Resident 68's pulse was already low and administering the medication could lead to a lower pulse rate. DON stated very low pulse could result to Resident 68 being sent out to the hospital. During a review of facility's P&P titled, Medication-Related Errors, dated 5/1/10, the P&P indicated, . If a medication reaches a resident in error, Facility should: Notify Physician/Prescriber and obtain further instructions and/or orders . Medications error: Dispensing to the resident a medication other than that ordered by Physician/Prescriber . According to Lexicomp, a nationally recognized drug reference, the use of diltiazem may result in . slow heartbeat, abnormal heartbeat that is new or worse . Heart failure . 055573 Page 21 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles when: 1. One Fluticasone Prop 50mcg (microgram -a unit of measure) spray (medication used to treat allergy) was opened with no label of used-by date or open date and another bottle of Fluticasone was expired. This failure had the potential to decrease the medication potency that could compromise the therapeutic effectiveness when used by Resident 138 and Resident 69. 2. Resident 81's Ipratropium/Albuterol (medication used to prevent and treat difficulty breathing, wheezing, shortness of breath) medication was expired. This failure had the potential to decrease the medication potency that could compromise the therapeutic effectiveness when used by Resident 81. 3. Resident 22's Insulin Lispro (medication used to treat diabetes[high blood sugar]) was opened with no indication of used-by date or when the insulin was opened. This failure had the potential for Resident 22 to not receive the full therapeutic effect of the medication which could lead to lower or higher blood sugar results which could lead to more serious medical complications. Findings: 1. During a concurrent observation and interview on 7/14/23, at 9:06 a.m., in Station 2, there was a medication cart (cart 4). The medication cart contained Fluticasone with no opened date or used by date and another bottle of Fluticasone had an expiration date of 6/1/23. LVN 7 stated the nurse who opened Resident 138's Fluticasone should have labeled it with the open date. LVN 7 stated, the fluticasone was good for 30 days after it was opened. LVN 7 stated the other bottle of Fluticasone was expired. LVN 8 stated the expired bottle of Fluticasone should have been discarded and not kept in the medication cart available for use to Resident 69. LVN 8 stated administering the medications (Fluticasone) to Residents' 138 and 69 would not have been effective. LVN 7 stated the medications had already lost its potency when used after it's used-by date. During a review of Resident 138's clinical record titled, admission Record, (AR -document containing resident personal information) dated 7/14/23, the AR indicated, Resident 138 was admitted to the facility on [DATE] with diagnoses which included . Hemiplegia and Hemiparesis[weakness to one side of the body] and hypertension [high blood pressure]) . During a review of Resident 138's Order Summary Report, dated 7/14/23, the Order Summary Report indicated, . Fluticasone Propionate Suspension 50 MCG [microgram-unit of measurement]/ACT [actuation] 1 spray in each nostril every 24 hours as needed for Allergies . During a review of Resident 69's AR, dated 7/14/23, the AR, indicated, Resident 69 was admitted to the facility on [DATE] with diagnoses which included . Rhabdomyolysis [breakdown of muscle tissue] and Hemiplegia and Hemiparesis . During a review of Resident 69's Order Summary Report, dated 7/14/23, the Order Summary Report indicated, . Fluticasone Propionate Nasal Suspension 50MCG/ACT . 1 [one] spray in both nostrils two 055573 Page 22 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0761 times a day . Level of Harm - Minimal harm or potential for actual harm During an interview on 7/14/23, at 2:05 p.m., with the Director of Nursing (DON), the DON stated medications should have been labeled once it was opened to ensure potency of medications. DON stated administering an expired medication to a resident may cause side effects and complications. DON stated the expired and unlabeled medications should not have been stored in the medication cart to avoid administering the medications to Resident 138 and Resident 69. Residents Affected - Some 2. During a concurrent observation and interview on 7/14/23, at 9:10 a.m., in Station 2, there was a medication cart (cart 4). The medication cart contained Ipratropium-Albuterol 0.5-3MG (milligram-unit of measurement)/3AMPUL (ampule-small sealed single dose vial) with an opened date of 6/28/23. LVN 7 stated the box of medication (ipratropium-albuterol) was only good for 14 days after it was opened, according to manufacturer's guideline. LVN 7 stated the medication should have been discarded and not stored in the medication cart. LVN 7 stated the expired medication could be administered to Resident 81 which could result in Resident 81 experiencing side effect of the medication. During a review of Resident 81's AR, dated 7/14/23, the AR indicated, Resident 81 was admitted to the facility on [DATE], with diagnoses which included . mild intermittent asthma [airway becomes swollen and narrow making it difficult to breath] and muscle weakness . During a review of Resident 81's Order Summary Report, dated 7/14/23, the Order Summary Report indicated, . Ipratropium-Albuterol Solution 0.5MG/3ML 3ml inhale orally every 6 [six] hours as needed for SOB [shortness of breath] or Wheezing [high pitched whistling sound made while breathing] . During an interview on 7/14/23, at 2:04 p.m., with the DON, the DON stated Resident 81's ipratropium-albuterol medication should not have been stored in the medication cart to avoid administering the medication to Resident 81. DON stated the medication was only good for 14 days after the foil pouch was opened. DON stated the medication foil pouch was opened 6/28/23 and it was past the 14 days. DON stated the medication should have been pulled out of the medication cart. 3. During a concurrent observation and interview on 7/14/23, at 9:13 a.m., in Station 2, there was a medication cart (cart 4). The medication cart contained Insulin Lispro K 100UNIT/ML with no opened date or used by date. LVN 7 stated the insulin should have been labeled with open date when the medication was opened. LVN 7 stated, the medication should have been discarded and not stored in the medication cart. LVN 7 stated, being stored in the medication cart made it (insulin) available for use (for residents). LVN 7 stated, she did not know if it was expired because there was no opened by date. During a review of Resident 22's AR, dated 7/14/23, the AR indicated, Resident 81 was admitted to the facility on [DATE] with diagnoses which included . Diabetes Mellitus [high blood sugar] . During a review of Resident 22's Order Summary Report, dated 7/14/23, the Order Summary Report indicated, . Insulin Lispro [1 Unit Dial] Subcutaneous [under the skin] Solution Pen-injector 100 UNIT/ML . During an interview on 7/14/23, at 2:10 p.m., with DON, the DON stated Resident 22's insulin was supposed to be labeled when it was first used and the used-by date to avoid giving the medication past it used-by date. DON stated expired medications were not to be stored in the medication cart to avoid administering to residents. 055573 Page 23 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 7/14/23, at 5:25 p.m., with the Administrator (ADM), the ADM stated the licensed nursing staff were responsible in making sure medications were labeled with the open date and used-by date, and expired medications to be discarded. ADM stated the expired medications and medications with no labels should have been pulled out of the medication cart to avoid use to residents. During a review of facility's policy and procedure (P&P) titled, Storage and Expirations of Medications, Biologicals, Syringes and Needles, dated, 1/1/13, the P&P indicated, . 4. Facility should ensure that medications and biologicals: 4.1 Have an Expiration Date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines . 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility should record the date opened on the medication container when the medication has a shortened expiration date once opened . 055573 Page 24 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure the planned menu was followed for one of 81 residents (Resident 83) when incorrect portion sizes of the spinach au gratin and baked sweet potatoes was served to Resident 83 during lunch on 7/11/23. This failure had the potential for Resident 83 to receive the wrong caloric intake and not meet his nutritional needs. Findings: During a concurrent observation and interview on 7/11/23, at 12:55 p.m., in the kitchen, Assistant Supervisor (AS) served a gray scoop (4 oz.[ounce - unit of measure]/ 1/2 cup) of spinach au gratin, a gray scoop of baked sweet potatoes to a large portion meal. AS stated, the large portion tray received same sized gray scoops of the spinach au gratin and baked sweet potatoes as a regular tray. During a concurrent interview and record review on 7/12/23, at 2:55 p.m., the Tuesday (Day 24) Lunch Diet Guide Sheet, dated 5/8/23, was reviewed. The Diet Guide Sheet indicated, the large meal was to receive 2/3 cup of Spinach Au Gratin and 2/3 cup of Baked Sweet Potatoes. The Certified Dietary Manager (CDM) stated, the large portion meal served to Resident 83 for lunch on 7/11/23 was ½ cup of Spinach Au Gratin and ½ cup of Baked Sweet Potatoes. The CDM stated Resident 83 did not receive 2/3 cup of Spinach Au Gratin and 2/3 cup of Baked Sweet Potatoes according to the Diet Guide . During an interview on 7/14/23, at 2:55 p.m., with the CDM, the CDM stated, the gray-colored scoop was equivalent to 4 oz (1/2 cup). The CDM stated, the white-colored scoop was equivalent to 6 oz (2/3 cup). The CDM stated it was important to follow the menu to maintain the correct nutritional value, add variety to resident's diet and maintain resident's weights. During a phone interview on 7/14/23, at 4:17 p.m., with the Registered Dietician (RD), the RD stated, the gray-colored scoop (#8 scoop) was equivalent to 4 ounces. The RD stated, the menu (portions) should have been followed as listed. The RD stated following the correct portions and items during meal plating adhered to the prescribed diet order which met residents nutritional needs. During an interview on 7/14/23, at 5:15 p.m., with the Director of Nursing (DON), the DON stated, the dietary menu was important to follow in order to maintain the calories and nutritional value for residents. During a review of the contracted company's policy and procedure (P&P) titled, Menus, dated 9/17, the P&P indicated, . Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines . Menu cycles will include standardized recipes . Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal . 055573 Page 25 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

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 ensure professional standards for food safety guidelines were followed when: Residents Affected - Many 1. There was no air gap (a fixture that provides back-flow prevention) underneath the food prep sink and the two-compartment sink. 2. Three silver-colored pitchers had grime and build up inside. 3.There were Saltine crackers and graham crackers past the use by date. 4. A package of hot dog buns and a package of sliced bread did not have labels identifying the open dates and use by dates. 5. A container of applesauce did not have the use by date. 6. The freezer temperature reading was 12 °F (degrees fahrenheit [scale of temperature]). These failures had the potential to result in foodborne illnesses (illness caused by consuming contaminated food) from the growth of microorganisms for the 80 residents eating food prepared in the facility's kitchen. Findings: 1. During a concurrent observation and interview on 7/10/23 at 9:11 a.m. in the kitchen, the two-compartment sink had no air gap with the piping be routed into the wall. The Certified Dietary Manager (CDM) stated, there was no air gap under the two-compartment sink and the piping went into the wall. During a concurrent observation and interview on 7/10/23 at 2:01 p.m. in the kitchen, there was no air gap under the food prep sink. The CDM stated, there was no air gap under the food prep sink and that the piping went into the wall. During an interview on 7/12/23 at 2:48 p.m. with the CDM, the CDM stated the importance of having air gaps under sinks was to prevent backflow and contamination from coming back into the sink. During an interview on 7/14/23 at 4:19 p.m. with the Registered Dietician (RD), the RD stated, kitchen sink should be kept clean (from backflow) and maintained working properly for clean food preparation. During an interview on 7/14/23 at 5:31 p.m. with Director of Nursing (DON), DON stated, it was important to maintain food preparation area (sinks) in clean condition since food prepared in a dirty area could negatively affected the residents. During a review of the professional reference titled, USFDA [United States Food and Drug Administration] Food Code, dated 2022, the USFDA Food Code indicated, . Section 5-402.11 . a direct connection may not exist between the sewage system and a drain originating from equipment in which food, 055573 Page 26 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0812 portable equipment, or utensils are placed . Level of Harm - Minimal harm or potential for actual harm 2. During a concurrent observation and interview on 7/10/23 at 9:02 a.m., in the kitchen, three silver-colored pitchers were on a bottom shelf and build up of grime was noted in all three pitchers. CDM stated, the three pitchers were used to serve tea. CDM stated, the inside of each pitcher felt like it contained sticky grime and could have been build up of hard water. Residents Affected - Many During an interview on 7/12/23 at 2:49 p.m. with CDM, CDM stated, kitchen tools and equipment should have properly cleaned and maintained for use. During an interview on 7/14/23 at 4:19 p.m. with RD, RD stated, kitchen items (pitchers) should have been kept clean and sanitary for food preparation for residents. During an interview on 7/14/23 at 5:31 p.m. with Director of Nursing (DON), DON stated, it was important to maintain kitchen items and tools for food preparation in clean condition since food served in dirty items could negatively affected the residents. During a review of the contracted company's policy and procedure (P&P) titled, Equipment, dated 9/17, the P&P indicated, . All foodservice equipment will be clean, sanitary, and in proper working order . All food contact equipment will be cleaned and sanitized after every use . During a review of the professional reference titled, USFDA [United States Food and Drug Administration] Food Code, dated 2022, the USFDA Food Code indicated, . Section 4-601.11 . Equipment food-contact surfaces and utensils shall be clean to sight and touch . 3. During a concurrent observation and interview on 7/10/23 at 9:16 a.m., in the kitchen pantry, there were graham crackers in a bin with a handwritten label with USB 5/8/23. There were also saltine crackers in a bin with a handwritten label with USB 4-15-23. The [NAME] (CK) stated, one bin contained graham crackers with a label indicating to use by 5/8/23 and the other bin contained saltine crackers with a label indicating to use by 4/15/23. During an interview on 7/12/23 at 2:45 p.m. with CDM, CDM stated, both the saltine crackers and graham crackers were expired. CDM stated, staff should have adhered to expiration dates. During an interview on 7/14/23 at 5:31 p.m. with Director of Nursing (DON), DON stated, food (expired) served could negatively affect the residents. 4. During a concurrent observation and interview on 7/10/23 at 8:58 a.m. in the kitchen, a package of sliced bread and a package of hot dog buns did not have a label on either package. CK stated, there should have been a label on the bread package and the hot dog bun package with the date it was opened and the use by date. CDM stated, there should have been labels added to indicate when the items were opened and what the use by date was. During an interview on 7/12/23 at 2:45 p.m. with CDM, CDM stated, labels should have clearly contained a prepared date and a use by date so that policies were followed and staff could adhere to expiration dates. During a review of the contracted company's policy and procedure (P&P) titled, Receiving, dated 9/17, the P&P indicated, . All food items will be appropriately labeled and dated either through 055573 Page 27 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0812 manufacturer packaging or staff notation . Level of Harm - Minimal harm or potential for actual harm 5. During a concurrent observation and interview on 7/10/23 at 9:00 a.m. with CDM, in the kitchen, a container of applesauce was in a reusable plastic container in the 3-door fridge and had a label with the writing Applesauce 7/6/23. CDM stated, the label currently on the applesauce container indicated the date it was prepared but there should have been a use by date on the label. Residents Affected - Many During an interview on 7/12/23 at 2:45 p.m. with CDM, CDM stated, labels should have clearly contained a prepared date and a use by date so that policies were followed and staff could adhere to expiration dates. During a review of the contracted company's policy and procedure (P&P) titled, Receiving, dated 9/17, the P&P indicated, . All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation . During a review of the contracted company's policy and procedure (P&P) titled, Food Storage: Cold Foods, dated 4/18, the P&P indicated, . All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA [Food and Drug Administration] Food Code . All foods will be stored wrapped or in covered containers, labeled and dated . 6. During a concurrent observation and interview on 7/10/23 at 9:04 a.m. in the kitchen, there was a two-door standing freezer which had condensation on the outside of the closed doors. The freezer door had a thermometer with a reading of 12 °F. CDM stated, the thermometer reading was 12 °F and the doors had been closed long enough to be cooled properly. During a concurrent observation and interview on 7/12/23 at 12:22 p.m., in the kitchen, there was a two-door standing freezer with a thermometer which read 12 °F. CDM stated, the freezer had been closed long enough to be adequately cooled. Director of Operations for Healthcare Services Group (DOHSG) stated, the thermometer reading was 12 °F and it should be zero degrees. During an interview on 7/12/23 at 2:47 p.m. with CDM, CDM stated, the freezer temperature should have been at 0°F or below to make sure food doesn't go bad, thaw and perish. During an interview on 7/14/23 at 4:19 p.m. with RD, RD stated, kitchen equipment should have been kept in proper working condition for food storage. During a review of the contracted company's policy and procedure (P&P) titled, Equipment, dated 9/17, the P&P indicated, . All foodservice equipment will be . in proper working order . During a review of the contracted company's policy and procedure (P&P) titled, Food Storage: Cold Foods, dated 4/18, the P&P indicated, . All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA [Food and Drug Administration] Food Code .Freezer temperatures will be maintained at a temperature of 0°F or below . 055573 Page 28 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to contain garbage and refuse (nonhazardous solid waste) properly for three out of four dumpsters when the dumpster lids were not have securely closed lids. Residents Affected - Some This failure had the potential to attract rodents, insects and flies and spread infection which placed residents at risk for foodborne illness. Findings: During a concurrent observation and interview on 7/10/23 at 1:58 p.m. with Certified Dietary Manager (CDM), in the back parking lot of the facility, there were four dumpsters. One dumpster had a lid which was fully open. A second dumpster had a lid that was propped open due to trash piled up underneath the lid. A third dumpster had two lids that were ill-fitting which created a gap between the lids. CDM stated, the lids to the three dumpsters were not closed securely. CDM stated staff were to keep the lids completely closed after opening. CDM stated, bugs and rodents could have entered the dumpsters with the lids open. During a concurrent observation and interview on 7/13/23 at 9:00 a.m. with Maintenance Director (MD), in the back parking lot of the facility, there were four dumpsters. One of the dumpsters had a gap between the two lids due to ill-fitting lids. MD stated, the gap created between the two lids was approximately 6 inches in width at the top and then tapered down towards the bottom. MD stated, the gap allowed cats, rats and pests to get in and eat in the dumpsters. MD stated, It was everyone's responsibilities to keep the lids closed when the dumpsters got full and overflowed. During an interview on 7/14/23 at 5:18 p.m. with Director of Nursing (DON), DON stated, the lids to the dumpsters should have been kept closed and fitted properly. DON stated, bugs or pests could have gotten inside the dumpsters which was in close proximity to the building. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, dated 10/17, the P&P indicated, . All food waste shall be kept in containers . All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use . Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests . Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter . During a review of the professional reference titled, USFDA [United States Food and Drug Administration] Food Code, dated 2022, the USFDA Food Code indicated, . Section 5-501.113 . Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered . With tight-fitting lids or doors if kept outside the food establishment . 055573 Page 29 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records were complete, accurately documented in accordance with accepted professional standards of practice for eight of 38 residents (Residents 22, 26, 29, 32, 55, 59, 66 and 73) when: Residents 22, 26, 29, 32, 55, 59, 66 and 73's Physician Order for Life Sustaining Treatment (POLST- a document indicating wishes for end-of-life care) were incomplete in the residents medical record. This failure had the potential risk for Residents' 22, 26, 29, 32, 55, 56, 59, 66 and 73's end-of-life care decisions to not be followed in case of an emergency. Findings: 1. During a review of Resident 22's admission Record (AR), undated, the AR indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses which included encounter for palliative care (specialized care for people with a serious illness), chronic obstructive pulmonary disease (group of diseases which causes blocked airflow and difficulty breathing), hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness) following cerebral infarction (stroke- disrupted blood flow to the brain ), dysphagia (difficulty swallowing) following cerebral infarction, and protein-calorie malnutrition (low protein intake causing poor nutrition). During a concurrent interview and record review on 7/12/23, at 9:26 a.m., Resident 22's POLST form, dated 6/27/23 was reviewed. Licensed Vocational Nurse (LVN) 6 stated, Resident 22's POLST form Section D which indicated if the resident had an advance directive was incomplete. LVN 6 stated POLST forms needed to be accurate and complete to reflect a resident's wishes for treatment if they were to stop breathing. During a concurrent interview and record review on 7/12/23, at 9:38 a.m., Residents 22's POLST form was reviewed. The Medical Records Director (MRD/LVN)stated the POLST was not complete because it did not indicate if Resident 22 had an advance directive. The MRD stated the POLST needed to be accurate to ensure the resident's decision for emergency care and end-of-life treatment was respected. During an interview on 7/14/23, at 1:46 p.m., with the Director of Nursing (DON), the DON stated POLST forms need to be completed as soon as possible to ensure a resident's care decisions were followed in case of an emergency. The DON stated the nurses were responsible to make sure the form was complete and filled out as soon as possible after admission. 2. During a review of Resident 29's AR, undated, the AR indicated, Resident 29 was admitted to the facility on [DATE], with diagnoses which included acute kidney failure (kidneys stop working and not able to remove waste from blood), neuropathy (disorder affecting peripheral nerves) and hypertension (high blood pressure). During a concurrent interview and record review on 7/12/23, at 9:26 a.m., Resident 29's POLST form, dated 11/24/20, was reviewed. LVN 6 stated, Resident 29's POLST form Section D which indicated if the resident had an advance directive or who the POLST information was discussed with were incomplete. LVN 6 stated POLST forms needed to be accurate and complete to reflect a resident's wishes for treatment if they were to stop breathing. 055573 Page 30 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 7/12/23 at 9:38 a.m., Residents 29's POLST form was reviewed. The MRD/LVN stated the POLST was not complete because it did not indicate who the POLST was discussed with or if Resident 29 had an advance directive. The MRD stated the POLST form needed to be accurate to ensure the resident's decisions for emergency care and end-of-life treatment was respected. During an interview on 7/14/23, at 1:46 p.m., with the DON, the DON stated POLST forms need to be completed as soon as possible to ensure a resident's care decisions were followed in case of an emergency. The DON stated the nurses were responsible to make sure the form was complete and filled out as soon as possible after admission. 3. During a review of Resident 55's AR, undated, the AR indicated Resident 55 was admitted to the facility on [DATE], with diagnoses which included hypertensive chronic kidney disease (damage to the kidneys from high blood pressure), type 2 diabetes mellitus (affects how the body uses sugar), end stage renal disease (permanent chronic kidney disease) and dependence on dialysis (procedure to remove waste from blood). During a concurrent interview and record review on 7/12/23, at 9:26 a.m., Resident 55's POLST form, dated 2/11/21, was reviewed. LVN 6 stated, Resident 55's POLST form Section D which indicated if the resident had an advance directive or who the POLST information was discussed with were incomplete. LVN 6 stated POLST forms needed to be accurate and complete to reflect a resident's wishes for treatment if they were to stop breathing. During a concurrent interview and record review on 7/12/23, at 9:38 a.m., Residents 55's POLST form was reviewed. The MRD/LVN stated the POLST was not complete because it did not indicate who the POLST was discussed with or if Resident 55 had an advance directive. The MRD stated the POLST form needed to be accurate to ensure the resident's decisions for emergency care and end-of-life treatment were respected. During an interview on 7/14/23, at 1:46 p.m., with the DON, the DON stated POLST forms need to be completed as soon as possible to ensure a resident's care decisions were followed in case of an emergency. The DON stated the nurses were responsible to make sure the form was complete and filled out as soon as possible after admission. 4. During a review of Resident 59's AR, undated, the AR indicated, Resident 59 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (not enough oxygen in the body), heart failure (heart does not pump as well as it should), type 2 diabetes mellitus and cerebral infarction. During a concurrent interview and record review on 7/12/23, at 9:26 a.m., Resident 59's POLST form, dated 6/14/23, was reviewed. LVN 6 stated, Resident 59's POLST form Section D which indicated if the resident had an advance directive or who the POLST information was discussed with were incomplete. LVN 6 stated POLST forms needed to be accurate and complete to reflect a resident's wishes for treatment if they were to stop breathing. During an interview on 7/14/23, at 1:46 p.m., with the DON, the DON stated POLST forms need to be completed as soon as possible to ensure a resident's care decisions were followed in case of an emergency. The DON stated the nurses were responsible to make sure the form was complete and filled out as soon as possible after admission. 055573 Page 31 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0842 Level of Harm - Minimal harm or potential for actual harm 5. During a review of Resident 66's admission Record (AR), dated 7/13/23, the AR indicated, Resident 66 was admitted to the facility on [DATE], with diagnoses which included traumatic subdural hemorrhage (blood collects between the skull and the brain), chronic ulcer of other part of right foot (open sores that will not heal), type 2 diabetes mellitus (affects how the body uses sugar), acquired absence of right and left leg below the knee (removal of the legs below the knees) and hypertension (high blood pressure). Residents Affected - Some During a concurrent interview and record review on 7/12/23, at 9:26 a.m., Resident 66's POLST form, dated 9/19/22, was reviewed. LVN 6 stated, Resident 66's POLST form Section D which indicated if the resident had an advance directive or who the POLST information was discussed with were incomplete. LVN 6 stated POLST forms needed to be accurate and complete to reflect a resident's wishes for treatment if they were to stop breathing. During a concurrent interview and record review on 7/12/23, at 9:38 a.m., Residents 66's POLST form was reviewed. The MRD/LVN stated the POLST was not complete because it did not indicate who the POLST was discussed with or if Resident 66 had an advance directive. The MRD/LVN stated the POLST form needed to be accurate to ensure the resident's decisions for emergency care and end-of-life treatment were respected. During an interview on 7/14/23, at 1:46 p.m., with the DON, the DON stated POLST forms need to be completed as soon as possible to ensure a resident's care decisions were followed in case of an emergency. The DON stated the nurses were responsible to make sure the form was complete and filled out as soon as possible after admission. 6. During a review of Resident 26's AR, the AR indicated, Resident 26 was admitted to the facility on [DATE]. Resident 26's diagnoses included . UNSPECIFIED DEMENTIA (condition of progressive loss of memory, language and other thinking abilities) . HEMIPLEGIA AND HEMIPARESIS FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE AFFECTING LEFT NON-DOMINANT SIDE (weakness and paralysis to the left side of the body after blood flow stopped in a part of the brain) . MUSCLE WEAKNESS (decreased strength in muscles) . DYSPHAGIA (problems using the mouth to control food and liquids) . During a concurrent interview and record review on 7/12/23 at 10:15 a.m., Resident 26's POLST form was reviewed. MRD/LVN stated, Resident 26's POLST form was missing the Discussed With selection, the Advance Directive selective and the Relationship of the individual who signed the POLST in Section D and the back side of the POLST form was left blank. MRD/LVN stated, all sections of the front and back of the POLST form should have been completely filled out. MRD/LVN stated, the POLST form should have been accurately filled out to ensure the resident's end-of-life wishes were carried out. During an interview on 7/14/23 at 5:22 p.m. with the DON, the DON stated, a POLST form should have been completely and accurately filled out to know the resident's code status in the event of an emergency. 7. During a review of Resident 32's AR, the AR indicated, Resident 32 was admitted to the facility on [DATE]. Resident 32's diagnoses included . ALZHEIMER'S DISEASE, UNSPECIFIED (progressive disease that impairs memory and mental functions) . DYSPHAGIA . ESSENTIAL (PRIMARY) HYPERTENSION (high blood pressure with no identifiable cause) . ADULT FAILURE TO THRIVE (decline in adults with less appetite, weight loss and less activity) . During a concurrent interview and record review on 7/12/23 at 10:15 a.m., Resident 32's POLST form 055573 Page 32 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was reviewed. MRD/LVN stated, Resident 32's POLST form was blank on the back side of the POLST form. MRD/LVN stated, all sections of the front and back of the POLST form should have been completely filled out. MRD/LVN stated, the POLST form should have been accurately filled out to ensure the resident's end-of-life wishes were carried out. During an interview on 7/14/23 at 5:22 p.m. with DON, DON stated, a POLST form should have been completely and accurately filled out to know the resident's code status in the event of an emergency. 8. During a review of Resident 73's AR, the AR indicated, Resident 73 was admitted to the facility on [DATE]. Resident 73's diagnoses included ENCOUNTER FOR PALLIATIVE CARE (specialized medical care for those with a serious illness) . ANEMIA, UNSPECIFIED (blood doesn't have enough healthy red blood cells) . HYPERLIPIDEMIA, UNSPECIFIED (high concentration of fats in the blood) . ESSENTIAL (PRIMARY) HYPERTENSION . During a concurrent interview and record review on 7/12/23 at 10:15 a.m., Resident 73's POLST form was reviewed. MRD/LVN stated, Resident 73's POLST form was missing the Discussed With selection, the Advance Directive selective and the Relationship of the individual who signed the POLST in Section D and the back side of the POLST form was left blank. MRD/LVN stated, all sections of the front and back of the POLST form should have been completely filled out. MRD/LVN stated, the POLST form should have been accurately filled out to ensure the resident's end-of-life wishes were carried out. During an interview on 7/14/23 at 5:22 p.m. with Director of Nursing (DON), DON stated, a POLST form should have been completely and accurately filled out to know the resident's code status in the event of an emergency. During a review of the facility's policy and procedure (P&P) titled Do Not Resuscitate Order, dated March 2021, the P&P indicated, . Our facility will not use cardiopulmonary resuscitation and related emergency measure to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect . A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate .) and placed in the front of the resident's medical record . In addition to the advance directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include . Physician Orders for Life-Sustaining Treatment (POLST) . During a professional reference review retrieved from National Institutes of Health (NIH- a United States government agency that supports and conducts medical research) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5023617/, dated 10/31/16, . POLST is a . document, with the goal of translating a discussion between a patient and/or his/her surrogate decision-maker and a physician into a medical order set . POLST can help reduce unwanted hospitalizations and honor a patient's end-of-life wishes . POLST forms are binding medical orders . An order as important as POLST should have a carefully documented informed consent process . 055573 Page 33 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a concurrent observation and interview on 7/11/23, at 7:30 a.m., in the hallway by Resident 68 and Resident 33's room, the RN was passing medications. The RN checked Resident 68's blood pressure using an arm cuff and did not sanitize the blood pressure cuff. The RN walked to Resident 33's (roommate) bedside and placed the used, unsanitized blood pressure cuff on Resident 33's arm. The RN walked out of Resident 68 and Resident 33's room and prepared medications. The RN stated she did not sanitize the blood pressure cuff after she used it on Resident 68. RN stated she should have sanitized the blood pressure cuff after each use and before using the blood pressure cuff on another resident. RN stated it was an infection control issue and may cause cross contamination of infection. Residents Affected - Some During a review of Resident 68's admission Record (AR- document containing resident personal information), dated 7/12/23, the AR indicated, Resident 68 was admitted to the facility on [DATE], with diagnoses that included . hypertension (high blood pressure) and heart failure . During a review of Resident 33's AR, dated 7/12/23, the AR indicated, Resident 33 was admitted to the facility on [DATE], with diagnoses which included, . Hypertension, Diabetes (high blood sugar level) and dementia [group of thinking and social symptoms that interferes with daily functioning] . During an interview on 7/13/23, at 2:20 p.m., with CNA 15, CNA 15 stated any equipments used on residents should have been sanitized after each use especially if it was used with multiple residents. CNA 15 stated the blood pressure cuff should have been sanitized after each resident use and before using on another resident. CNA 15 stated it was an infection control issue and may cause cross contamination. During an interview on 7/14/23, at 2:20 p.m., with the DON, the DON stated the blood pressure cuff should have been sanitized using the sanitizing wipes after every use on residents. The DON stated it was an infection control issue which could cause cross contamination. The DON stated, . We want to isolate an infection if there was one and not spread to the whole facility . During a review of facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment undated, the P&P indicated, . Reusable items are cleaned and disinfected or sterilized between residents . Reusable resident care equipment is decontaminated and/or sterilized between residents . During a review of the professional reference, retrieved from https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html, titled, Disinfection and Sterilization, Guideline for Disinfection and Sterilization in Healthcare Facilities dated 2008, the professional reference indicated, . Recommendation . Process noncritical patient-care devices using a disinfectant and the concentration of germicide . Disinfect noncritical medical devices (example blood pressure cuff) with EPA (U.S.Environmental Protection Agency) registered hospital disinfectant using the label's safety precautions and use directions . Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient) . Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent infections for three of 12 sampled residents (Residents 4 and 22, and 33) when: 055573 Page 34 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. Resident 4's room entry did not have signage indicating he was on Enhanced Barrier Precautions (EBPgown and glove use during high contact resident care activities, designed to reduce transmission MDROs [organisms resistant to multiple antibiotics]) or indicate what precautions and personal protective equipment (PPE-items worn to protect healthcare worker from body fluids and infectious diseases) were required. This failure had the potential to infect staff, residents and other visitors with Methicillin Resistant Staphylococcus Aureus (MRSA- a bacteria which is difficult to treat due to resistance to antibiotics) and spread it to others. 2. Resident 22's gastrostomy tube (G-tube -tube inserted through the abdominal wall to deliver liquid nutrition) enteral syringe (used to deliver water and medications through G-tube) was placed in a plastic bag hung at bedside with enteral formula (liquid nutrition mixture) in the tip of the syringe. This failure had to potential to expose Resident 22 to bacteria and cause gastrointestinal illness. 3. Registered Nurse (RN) failed to sanitize (disinfect) the blood pressure cuff (device used to measure the pressure of blood in the circulatory system) in between use for Resident 68 and Resident 33. This failure had the potential to result in cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and transmission of infection between residents. Findings: 1. During an observation on 7/10/23, at 9:20 a.m., room [ROOM NUMBER] had a cart with PPE next to the door There was no signage to indicate what precautions were to be taken to enter the room or care for either resident. During a review of Resident 4's admission Record (AR-a document with personal identifiable and medical information), undated, the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses which included encounter for palliative care (specialized care for people with a serious illness), chronic obstructive pulmonary disease (COPD-group of diseases which causes blocked airflow and difficulty breathing), and MRSA. During a review of Residents 4's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [thought process] and physical function) Assessment, dated 4/28/23, the MDS indicated Resident 4's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement on a scale of 1-15 with 15 being the highest score) was 4. Resident 4's cognition was assessed as severely impaired. During a review of Resident 4's Order Summary Report (OS), dated 7/13/23, the OS indicated, . Enhanced Barrier Precautions every shift for MRSA to lungs/urine . During a concurrent observation and interview on 7/10/23, at 10:04 a.m., in the hallway by Resident 4's room with Certified Nursing Assistant (CNA) 5, the PPE cart was next to the door. CNA 5 stated there should have been a sign at the entrance of Resident 4's room to indicate necessary precautions for working with the resident. CNA 5 stated she thought Resident 4 had an infection in his bowel and she wore a gown and gloves when providing him personal care. CNA 5 stated a sign by the door was important for staff and visitors to be alerted for Resident 4's requirement of special precautions during care. CNA 5 stated it was important to wear the required PPE to protect yourself and others from spreading germs. 055573 Page 35 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 7/10/23, at 11:17 a.m., with CNA 8, CNA 8 stated signage was hung above the PPE carts next to the resident's door. CNA 8 stated Resident 4 had MRSA which was contagious (spread through direct and indirect contact) and signage next to the door alerted staff to wear a gown and gloves when providing personal care. CNA 8 stated, Resident 4 had MRSA in his urine and it could get on your clothes during care and spread MRSA to the other residents. Residents Affected - Some During an interview on 7/14/23, at 8:45 a.m., with the Infection Preventionist (IP), the IP stated there was no signage on the door or above the PPE cart. The IP stated there had been no sign since Resident 4 had changed rooms 11 days ago. The IP stated Resident 4 was on EBP due to colonized (germs live in the body without causing illness) MRSA in the urine. The IP stated Resident 4 had a urinary catheter (tube placed in the body to drain and collect urine) and all staff performing catheter care needed to wear gloves, gown, eye protection and a mask. The IP stated it was important to have signage with the necessary precautions to take along with the PPE cart to alert staff on how to protect themselves and prevent the spread of MRSA to the other residents. During an interview on 7/14/23, at 10:05 a.m., with Licensed Vocational Nurse (LVN) 8, LVN 8 stated transmission-based precautions signage was important to have outside of a resident's room because it notified anyone entering the room what precautions to take and what PPE needed to be worn. LVN 8 stated she was not notified by the night shift nurse regarding Resident 4 being on EBP. LVN 8 stated, she realized Resident 4 required EBP when she saw the signage next to his door. LVN 8 stated having EBP helped prevent spreading MRSA to the other residents. During an interview on 7/14/23, at 4:06 p.m., with the Director of Nursing (DON), the DON stated Resident 4 was on EBP because he had MDRO. The DON stated Resident 4 required EBP for all care activities. The DON stated there should have been an EBP signage posted by the resident's door. The DON stated Resident 4's door did not have EBP signage posted prior to 7/10/23. The DON stated the staff and visitors would not know Resident 4 required special precautions which could cause a spread of infection to others. During a review of the facility's Policy and Procedure (P&P) titled, Isolation-Categories of Transmission-Based Precautions, dated 9/2022, the P&P indicated, . Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection . has a laboratory confirmed infection . is at risk of transmitting the infection to other residents . transmission based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person . when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution . The signage informs the staff of the type of CDC precaution(s), instructions for the use of PPE, and/or instructions to see a nurse before entering the room . contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment . these strategies may differ on the prevalence 4 incidence of the MDRO in the facility . additional usage of PPE (enhanced barrier precautions) may be used for residents who do not meet criteria for contact precautions but are infected or colonized with MDROs . During a professional reference review, retrieved from https://www.cdc.gov/hai/pdfs/containment/PPE-Nursing-Homes-H.pdf titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, the reference 055573 Page 36 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated, . Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality . Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs tarted gown and glove use during high contact resident care activities . EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices . Infection or colonization with an MRDO . Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE 2. During an observation on 7/12/23, at 9:58 a.m., Resident 22 was lying in bed. Resident 22's was receiving enteral formula through his G-tube via pump. Resident 22 had a clear plastic bag with an enteral syringe in it hanging on the pump pole. The syringe had enteral formula in the tip and was placed in a wet and soiled plastic bag. During a review of Resident 22's AR, undated, the AR indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses which included, encounter for palliative care, COPD, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness) following cerebral infarction (stroke-caused by disrupted blood flow to the brain), dysphagia (difficulty swallowing) following cerebral infarction, and protein-calorie malnutrition (lack of sufficient nutrients in the body). During a review of Residents 22's MDS Assessment, dated 7/5/23, indicated a BIMS of 0 indicating Resident 22's cognition was severely impaired. During a concurrent observation and interview on 7/12/23, at 10:22 a.m., in Resident 22's room, there was a plastic bag with the syringe in it hanging on the enteral pump pole. LVN 6 stated she had difficulty with the pump because it was beeping. LVN 6 stated the MRD/LVN had come in to help troubleshoot the pump. LVN 6 stated the MRD/LVN had aspirated for residual (use of enteral syringe to assess the formula tolerance) and placed the syringe back in the bag without rinsing it. LVN 6 stated the syringe should have been rinsed clear and dried prior to placing it in the plastic bag due to the risk of contamination. During a review of Resident 22's OS dated 7/2023, the OS indicated, . Enteral Feed Order every shift [brand name of formula] 1.5 cal [calorie] administer continuous via pump . During an interview on 7/13/23, at 10:45 a.m., with the MRD, the MRD/LVN stated she was able to see formula in the tip of the syringe in the plastic bag. The MRD/LVN stated she had used the syringe to aspirate for enteral formula to assess if G-tube was blocked, causing the pump to beep. The MRD/LVN stated there was no residual withdrawn so she placed the syringe back into the bag. The MRD/LVN stated formula left in the syringe could have cause Resident 22 to become ill with a bacterial infection. The MRD/LVN stated the syringe was not clean when she placed it back in the bag. The MRD/LVN stated she should have rinsed the syringe. During an interview on 7/14/23, at 4:52 p.m., with the DON, the DON stated Resident 22's syringe was dirty in the plastic bag. The DON stated, the bacteria can grow fast . should not leave it [syringe] in there [the plastic bag] . if the syringe is not changed, [it could cause] stomach issues, if someone sees it they should change it at the same time. 055573 Page 37 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's P&P titled, Enteral Feedings-Safety Precautions, dated 11/2018, the P&P indicated, . ensure the safe administration of enteral nutrition . All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent . Preventing contamination . Maintain strict aseptic technique at all times when working with enteral nutrition systems and formulas . Use only sterile or purified water for formula constitution, medication dilution, and flushes before and after medication administration . use only enteral tubing, syringes and devices . check gastric residual volume as ordered . During a professional reference review, retrieved from https://www.nutritioncare.org/uploadedFiles/01Site_Directory/Guidelines_and_Clinical_Resources/EN_Pathway/Boullata_e titled ASPEN Safe Practices for Enteral Nutrition Therapy, dated January 2017, the reference indicated, . Reduce potential for touch contamination of EN-related equipment . keep all equipment, including syringes and containers for flush and medication administration, as clean and dry as possible. Store clean equipment away from potential sources of contamination . 055573 Page 38 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed ensure their policy and procedure was followed for one of five sampled residents (Resident 29) when there was no documentation of Resident 29's education of the risk and benefits and his refusal of the Influenza vaccine (a preparation used to stimulate body's immune response against infection by flu viruses). Residents Affected - Few This failure had the potential for Resident 29 of not being informed on the risks and benefits of receiving the influenza vaccine and not being able to make an informed decision. Findings: During a review of Resident 29's admission Record (AR-a document with personal identifiable and medical information), undated, the AR indicated, Resident 29 was admitted to the facility on [DATE] and Resident 29 was [AGE] years old. During concurrent interview and record review on 7/14/23 at 2:37 p.m. with the Infection Preventionist (IP), Resident 29's medical record for Influenza Immunization Informed consent forms was reviewed. The IP stated Resident 29 refused the Influenza vaccine on 11/24/2020. The IP stated, there was no other consent forms in Resident 29's medical record. The Update Immunization dated 10/31/2022 indicated Resident 29 was administered Influenza vaccine by facility staff. There was no consent for 10/31/22 vaccination. The IP stated the consent/refusal form signed by resident on 11/24/2020 gave the facility consent to administer the Influenza vaccine without an annual consent form. The IP stated the facility sent letters to resident representatives to call the facility if Influenza vaccine was refused. The IP stated the residents in the facility were given the opportunity to consent or refuse immunization. The IP stated, . as far as documenting the refusal or consents, I don't have documentation . The IP stated the importance of obtaining a consent form for immunizations was to provide education of the risks and benefits of vaccinations and to give the residents an opportunity to consent or refuse the vaccination. The IP stated it was important to have documentation of refusal and completed consent forms to help prevent further infection. The IP stated, documentation was not completed annually for Influenza vaccination status which meant the resident did not have the option to consent or refuse the influenza vaccine. During an interview on 7/14/23 at 4:06 p.m. with the Director of Nursing (DON), the DON stated facility consent forms were signed annually. The DON stated, the facility mailed a VIS (Vaccine Information Statement) to resident representatives annually. The DON stated the importance of having an annual consent form was to give the resident representative or the resident the opportunity to consent or refuse the Influenza vaccination. The DON stated the Influenza informed consent form should have been documented annually, if it was not documented it was not done. During review of the facility's Policy & Procedure (P&P) titled, Influenza Vaccine, dated 3/2022. The P&P indicated, . All residents . will be offered the influenza vaccine annually to encourage and promote the benefits . Prior to vaccination, the resident . will be provided information and education regarding the benefits and potential side effects . Provision of such education shall be documented in the . medical record . A resident's refusal . shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record . 055573 Page 39 of 40 055573 07/14/2023 Kingsburg Center 1101 Stroud Ave Kingsburg, CA 93631

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain kitchen equipment in safe operating condition when the steamer machine in the kitchen was leaking and dripping liquid onto towels placed under the equipment. Residents Affected - Many This failure had the potential to impact the ability of dietary staff to prepare food in a safe and sanitary manner which could affect the residents health. Findings: During a concurrent observation and interview on 7/10/23, at 9:03 a.m., in the kitchen, the steamer machine was leaking from the front bottom right and left corners onto two white towels which were lined with a brown substance. The Certified Dietary Manager (CDM) stated, the towels were placed under the steamer machine to catch the dripping water. During an interview on 7/12/23, at 2:49 p.m., with CDM, CDM stated, the steamer machine in the kitchen was dripping onto towels which caused the towels to be lined with a brown substance. CDM stated, kitchen equipment should have been kept functioning properly to facilitate food preparation for the residents. During an interview on 7/14/23, at 4:19 p.m., with the Registered Dietician (RD), the RD stated, kitchen equipment should have been maintained in clean, working order so it would not cause injuries to employees or residents since parts can break off into the food. RD stated, kitchen equipment should have been kept clean and working properly for sanitary purposes so residents could be served food prepared properly and safely. During an interview on 7/14/23, at 5:31 p.m., with the Director of Nursing (DON), the DON stated, maintaining kitchen equipment in safe, clean and working condition was important to ensure food was prepared safely. The DON stated food prepared in an unsanitary (using leaky equipment) manner could negatively affect the residents. During a review of the contracted company's policy and procedure (P&P) titled, Equipment, dated 9/17, the P&P indicated, . All foodservice equipment will be clean, sanitary, and in proper working order . All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials . During a review of the professional reference titled, USFDA [United States Food and Drug Administration] Food Code, dated 2022, the USFDA Food Code indicated, . Section 5-501.11 . Proper maintenance of equipment to manufacturer specification helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk . 055573 Page 40 of 40