Health inspection·July 12, 2024

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 maintain an effective pest control program to keep the facility free of pests for 181 out of 181 residents, when on 7/9/2024 the dish washing station was observed with roaches crawling in the sink with dirty dishes, numerous roaches crawling up the walls and dishwasher. The floor to the dish washing room had roaches crawling into the dish racks located near the sink on the floor where dirty dishes were placed to go into the dishwasher. The clean dish area had roaches crawling around the counter and wall. The dishwasher itself had roaches swimming in the water inside. The walls of the dishwashing area had roaches nesting in the corners. Residents Affected - Many This failure resulted in an unsanitary work environment where food was prepared and had the potential to cause harm to 181(the census during the survey) residents due to cross contamination and transmission of infections from cockroaches' infestation that could place residents at risk for food borne illnesses. Because of the serious potential harm for food borne illness and cross contamination of resident meals for all 181residents who received prepared meals from the kitchen related to the dish washing station which was observed with roaches crawling in the sink with dirty dishes, numerous roaches crawling up the walls and dishwasher. The floor to the dish washing room had roaches crawling into the dish racks located near the sink where dirty dishes are placed to go into the dishwasher. The clean dish area had roaches crawling around the counter and wall. The dishwasher itself had roaches swimming in the water inside. During an interview with the Infection Preventionist stated roaches are sanitary and had seen roaches in kitchen prior. During an interview with the administrator (ADM) and the Dietary supervisor both stated roaches had been seen prior but did not think it was an infestation. An Immediate Jeopardy (IJ a situation in which the provider's noncompliance with one or more conditions of participation have caused or is likely to cause serious injury, harm, impairment, or death to a patient) situation was called on 7/9/24 at 5:28 p.m., under Code of Federal Regulations §483.90(i)(4) with the Administrator (ADM), Director of Nurses (DON), Director of Staff Development (DSD), Assistant Director of Nurses/Infection Preventionist (ADON/IP), House Keeping Supervisor (HSKS), and Dietary Services Supervisor (DSS). The facility submitted an acceptable Plan of Removal (POR Version 3) on 7/11/24 at 5:01 p.m., which addressed the actions needed to remove the IJ situation. The POR included but was not limited to the following: 1) pest control was notified and immediately went to the facility to spray affected areas using insecticides, an aerosol mist, injecting gel bait into open areas to attract pest to bait and then exterminate them and to leave bait packs in the wall and under kitchen tables and appliances. Chemical barrier was set up around the dishwashing area to prevent insects from crossing over into the kitchen area. 2) Kitchen began using disposable plating temporarily, including plates, utensils, and cups, to avoid any potential contamination of washed plating. 3) All pots and pans were handwashed in the sink basins in the back of the kitchen away from the contaminated area. 4) the Dietary Staff immediately discarded any opened food items. 5) Page 1 of 6 055626 055626 07/12/2024 Healthcare Centre of Fresno 1665 M Street Fresno, CA 93721

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Dietary sanitation was immediately initiated for deep cleaning and disinfection, Areas deep cleaned and disinfected included dish cleaning, food preparation, food cooking, meal tray line, appliances, and food storage area. 6) Dietary Services Manager, under the direction of the Registered Dietitian, initiated an in service for dietary staff regarding Pest Control, Kitchen Sanitation and Maintaining Cleanliness in the kitchen. 7) lower part of the drywall was replaced, and the inner parts of the wall were baited and sprayed to prevent the harboring of bugs inside the wall. 8) Work which included removing drywall and insulation from the floor up four feet on the wall and replacing it with new drywall and insulation was conducted by facility maintenance crew 9) California Department of Healthcare access and information (HCAI) was onsite and verbally approved on 7/10/24 at 1:30 pm for the work on the wall. 10) A PIN 72 Emergency Work Authorization form was submitted via email. 11) A review of changes of condition in the last 14 days was conducted by the DON and ADON to ensure that residents are free from any signs and symptoms of food borne illnesses related to cockroach infestation in the kitchen 12) Department Managers and Housekeepers conducted room rounds to ensure resident rooms were free from roaches. 13) Kitchen staff would continue to clean the kitchen nightly by wiping down all surfaces, draining steam tables and sweeping and mopping the floor. Deep clean will be conducted daily which included cleaning the inside of major appliances and moving of appliances to sweep area behind them until it was determined that roaches had been eradicated from the kitchen. 14) Kitchen staff would inspect all food, plates, cup and utensils prior to plating and placing on the food cart to ensure that they are all pest free. 15) the Administrator initiated an in-service education to the Facility Staff regarding the Policy and Procedures for Pest control and Maintaining Cleanliness in the facility. 16) Pest Control would bait known areas of roach sightings in the dishwash areas and then seal up areas to prevent roaches from exiting. Sealing included putting a silicone barrier on all seams where roaches would exit the walls. 17) Sighting of insects or bugs in the facility would be recorded in a general ledger and when pest control returns for weekly visit, they would spray the area where a sighting has occurred. The components of the POR, training, and competencies of staff were validated onsite through observations, interviews, and record review. The IJ was removed onsite on 7/12/24 at 1:00 p.m. with the facility ADM. Findings: During a concurrent observation and interview on 7/9/24 at 11:07 a.m. with the dietary aide (DA) 1 and DSS in the dishwashing area within the kitchen, the dishwashing area was observed infested with roaches crawling on the walls and in the dishwasher. The dishwasher sanitizing water was observed to contain live roaches swimming in the sanitizer. The walls of the dishwashing room had five roaches nesting in the corners. Roaches were observed in the dish racks located on the floor. The DSS stated she had seen roaches last year but never to this extent and was not aware that they were all over the dishwashing room. DA 1 stated the dishwashing room was cleaned, sanitized, mopped and wiped down after every use. DA 1 stated the dishwashing room was cleaned to its entirety once a day. During a concurrent observation and interview on 7/9/24 at 11:12 a.m. with the ADM, the dishwashing room was observed infested with roaches crawling on the walls and in the dishwasher. The dishwasher sanitizing water was observed to contain live roaches swimming in the sanitizer. The walls of the dishwashing room had roaches nesting in the corners. Roaches were observed in the dish racks located on the floor. The ADM stated he was aware there were some roaches seen in the kitchen but was not aware it was to this extent. The ADM stated the pest control company was in the facility last week to treat active roaches in the kitchen. During an observation on 7/9/24 at 11:20 a.m. in the kitchen. The kitchen counter tops and underneath the counters were observed with food debris in different areas of the kitchen. Observation behind 055626 Page 2 of 6 055626 07/12/2024 Healthcare Centre of Fresno 1665 M Street Fresno, CA 93721

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the stove and oven revealed to have a black substance to the walls and floors with scattered food particles and trash. The kitchen walls had stained with an unknown yellow substance. The kitchen floorboards by the dishwashing room were detached from the wall with food particles. During an interview on 7/9/24 at 11:30 a.m. with DA 2, DA 2 stated he was in charge of the dishwashing room when scheduled. DA 2 stated when he arrived in the mornings, he observed there were many roaches. in the kitchen. DA 2 stated, when the dishwasher was turned off the roaches were noted to appear. DA 2 stated it was not sanitary to have the roaches all over the dishwashing room near all the clean dishes. DA 2 stated the roaches would at times get stuck in the dish racks. During an interview on 7/9/24 at 12:41 p.m. with Resident 5, Resident 5 stated he had seen roaches in the hallway and dining area on floors. Resident stated when the roaches were seen he had notified the facility staff. During a review of Resident 5's admission record, the AR indicated Resident 5 was admitted on [DATE] with diagnosis, paraplegia (Paralysis of the legs), type 2 diabetes mellitus, cervical disc degeneration (spinal disc wear down), anxiety (feeling of worry or fear), cervicalgia (neck pain), falls, weakness, anemia (lack of oxygen in the blood), chronic kidney disease and hypertension (high blood pressure). During a review of Resident 5's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/5/24, the MDS indicated, Resident 5's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 13 out of 15 (0 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 15) cognitively intact) which indicated Resident 5 was cognitively intact. During a concurrent observation and interview on 7/9/24 at 1:19 p.m. with the pest control representative (PCR) in the dishwashing room located in the kitchen, the PCR was observed spraying underneath the dishwashing sink and spraying the open areas of the dishwasher leading into the back wall. The roaches were observed scattering and crawling in different directions which included the floor, walls and ceiling of the dishwasher room. The roaches were observed crawling on the base boards and the floors near the tray line area. The PCR stated the spraying of the area would cause the roaches to scatter as they were actively being exterminated. The PCR stated he was not able to get to the entire back wall due to the dishwasher being attached to the back wall. The PCR stated the chemical used to spray the roaches would begin to exterminate them. The PCR stated a chemical barrier had been placed to isolate the roaches to the dishwashing area and prevent them from scattering further into the kitchen. During a concurrent observation and interview on 7/9/24 at 1:29 p.m. with the infection preventionist (IP a professional that serve on the front lines of healthcare every day, working to eliminate healthcare associated infections), the dishwashing room was observed infested with roaches crawling on the walls and in the dishwasher. The walls of the dishwashing room had roaches nesting in the corners. Roaches were observed in the dish racks located on the floor. The IP stated he was aware there were roaches in the kitchen but not to that extent. The IP stated, roaches are sterile insects, no studies that indicate they spread infections. The IP stated the roaches in the kitchen were not acceptable. During an interview on 7/9/24 at 3:09 p.m. with Resident 3, Resident 3 stated he was a resident of 055626 Page 3 of 6 055626 07/12/2024 Healthcare Centre of Fresno 1665 M Street Fresno, CA 93721

F 0925 Level of Harm - Minimal harm or potential for actual harm the assisted living area of the facility. Resident 3 stated the year, current president, and city where he resides. Resident 3 communicated and answered all questions asked. Resident3 stated he was a resident in the facility for years. Resident 3 stated he had observed roaches crawling by the kitchen. Resident 3 stated he had reported the sightings to multiple staff members but could not recall who specifically. Resident 3 stated he reported the roaches because the roaches were always there. Residents Affected - Many During a review of Resident 3's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses: type 2 diabetes mellitus (body has too much sugar in the blood), muscle weakness, hyperlipidemia (too much fats or lipids in the blood) and dorsalgia (back pain). During an interview on 7/9/24 at 3:23 p.m. with Resident 4, Resident 4 stated he was a resident of the assisted living area of the facility. Resident 4 stated the year, current president, and city where he resides. Resident 4 communicated and answered all questions asked. Resident4 stated he had seen roaches in the hallway on the first floor by the kitchen. Resident 4 stated he observed roaches every day and believed there might have been an infestation of roaches. During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses: weakness, absence of left leg below knee, chronic kidney disease (kidneys are damaged and cannot filter blood), type 2 diabetes mellitus, acute kidney failure (kidneys stop working properly), absence of right leg below knee, hyperlipidemia, muscle weakness. During a telephone interview on 7/10/24 at 9:39 a.m. with the Registered Dietitian (RD), the RD stated she was aware that there were roaches in the kitchen because they had been there for years but not to the extent that was being presented. The RD stated it was not sanitary to have roaches in the kitchen and it was important to keep the kitchen clean. During an interview on 7/10/24 at 10:26 a.m. with the regional dietary manager (RDM), the RDM stated she was aware of the roach problem in the kitchen and recommended for weekly pest control. The RDM stated the roaches in the kitchen were not sanitary. The RDM stated the expectation was for the dietary staff to clean the kitchen and establish systems that will assist them in keeping the roaches away. During a record review of facility's Pest control Service report, dated 6/4/2024, the report indicated, .checked in with kitchen staff let them know that sanitation is gonna play a big role, keeping the roaches under control . During a record review of the facility's Pest Control Service Report, dated 5/13/24, the report indicated, . I treated the baseboards around the kitchen areas and replace the glue boards as well. I did notice a smell coming from the drainage area in the food prepping line that needs to be cleaned to avoid possible insect activity around that area . During a record review of the facility's Pest Control Service Report, dated 3/22/24, the report indicated, . went to kitchen and talked to staff about any pest problems having. Baited for roaches in cracks and crevices. Recommended that they caulk and seal all cracks and crevices in kitchen . During a record review of the facility's Pest Control Service Report, dated 3/28/24, the report indicated, . at today's service I treated interior kitchen placed glue boards as well do to roach 055626 Page 4 of 6 055626 07/12/2024 Healthcare Centre of Fresno 1665 M Street Fresno, CA 93721

F 0925 activity . Level of Harm - Minimal harm or potential for actual harm During a record review of the facility's Pest Control Service Report, dated 1/17/24, the report indicated, . checked in with staff and management, kitchen wall leak damage, reports of roaches in walls . Residents Affected - Many During a record review of the facility's Pest control Service Report, dated 6/16/23, the report indicated, . spoke with kitchen supervisor and she said they saw activity coming from the prep line. Treated all bottom of prep line and base of kitchen to help eliminate activity . During an interview on 7/10/24 at 2:12 p.m. with Registered Nurse (RN) 1, RN 1 stated the roaches in the kitchen and possible food preparation areas was unsanitary. RN 1 stated the roaches were considered contaminated and introduce bacteria to food. RN 1 stated there was a potential for the contaminated food to cause gastrointestinal distress including food poisoning to all residents ingesting the food. During an interview on 7/11/24 at 1:28 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated it was important to maintain a clean and clutter free environment in order to not attract roaches. CNA 1 stated roaches had the potential to spread bacteria that could have potentially made residents sick. During an interview on 7/11/24 at 4:05 p.m. with DA 3, DA 3 stated the kitchen had an infestation in the past and had not seen the kitchen infested this bad until recently. DA 3 stated it was important to effectively clean the kitchen every day and checking hard to reach areas more proactively. DA 3 stated it was not sanitary to have roaches in the kitchen near clean dishes and food. During a telephone interview on 7/12/24 at 10:42 a.m. with the PCR, the PCR stated his recommendation was for the dietary staff to keep the kitchen clean. The PCR stated sanitation would play a big role in keeping the roaches away since the roaches live in cluttered dirty areas with food debris. During an interview on 7/12/24 at 11:22 a.m. with DA 4, DA 4 stated all staff had known about the roaches in the dishwashing room including the dietary supervisor. DA 4 stated it was an ongoing problem that needed to be addressed. DA 4 stated the dietary supervisor had informed dietary staff that if she was blamed for the roaches everyone in the kitchen was going down with her since everyone knew about them. During a review of the facility's job description titled, Dietary services Supervisor/Certified Dietary Manager, undated. The job description indicated, . principal responsibilities . maintains a safe and sanitary working environment in compliance with Federal and State of California guidelines . ensures exchange of essential information with all departments as necessary to ensure quality resident care . During a review of the facility's job description titled, Registered Dietitian, dated 10/9/23. The job description indicated, . essential duties and responsibilities . routinely inspect the food service area and practices for compliance with company policies, procedures, standards, and applicable federal, state, and local regulations . this position has kitchen oversight responsibility for safe food service . 055626 Page 5 of 6 055626 07/12/2024 Healthcare Centre of Fresno 1665 M Street Fresno, CA 93721

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's job description titled, Dietary Assistant/Dishwasher, undated. The job description indicated, . principal responsibilities . maintains a safe and sanitary work environment . reports problems and needs to the supervisor in a timely manner . During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated 1/1/12, the P&P indicated, . The facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests . procedure garbage and trash are not permitted to accumulate in any part of the facility . the maintenance department assists, when appropriate and necessary, with pest control services . pest control service provider the company will perform the following services . submit a site specific work plan for each area/department with recommendations on how to keep the facility pest free, department and area staff are responsible for carrying out these recommendations to prevent pests in their respective areas and keeping documentation in accordance with department and facility policies . During a review of the facility's P&P titled, Dietary Department General, dated 6/1/14, the P&P indicated, . The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs . the primary objectives of the dietary department include . maintenance of standards for sanitation and safety; maintenance of standards for quality of food . the dietary manager and/or dietitian are responsible for planning and providing dietary staff with in service education . the dietary manager is also responsible for the day-to-day education of dietary staff with regard to topics such as sanitation, food preparation . During a review of the facility's P&P titled, Dish Machine Operation and Cleaning, dated 10/1/14, The P&P indicated, . Purpose to establish guidelines for the use and cleaning of the dish machine . the dish machine will be sanitized between uses . sanitation of equipment the dish machine will be cleaned after each meal . remove debris and rinse the interior of the machine . on a weekly basis, clean the dish machine exterior with de liming solution . During a review of the facility's P&P titled, Food Storage, dated 6/25/19, the P&P indicated, . Procedure . keep work surfaces clean and orderly . the walls, ceilings, and floor should be maintained in good repair and regularly cleaned . monitor area routinely for pest activity . 055626 Page 6 of 6