Health inspection·November 4, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment for a census of 50 when: 1. Safe water temperatures were not maintained in resident restrooms for 3 out of 5 halls (Hall A, Hall B, and Hall C) in the facility; and, 2. Fall interventions were not implemented for 3 of 21 sampled residents (Resident 22, Resident 23, and Resident 49), when a fall mat was not placed on the floor at bedside for Resident 22, Resident 23, and Resident 49. These failures had the potential to cause physical harm to the residents in the facility. Findings: 1. During a concurrent observation and interview on 11/3/22, at 2:27 p.m., with the Maintenance Director (MAIN) in Hall B, the MAIN confirmed the sink hot water temperatures were measured ranging from 129.4129.6 degrees Fahrenheit (F-scale for measuring temperature) for resident rooms 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19. The MAIN stated the sink hot water temperatures were too hot and the hot water temperature should not be above 120 degrees F. The MAIN further stated hot water temperatures above 120 degrees would increase the risk of burns for the elderly. During a concurrent observation and interview on 11/3/22, at 2:35 p.m., with the MAIN in Hall C, the MAIN confirmed the sink hot water temperatures were measured to be 129.6 degrees F for resident rooms [ROOM NUMBERS]. The MAIN stated the current sink hot water temperature was too hot and needed to be adjusted. During a concurrent observation and interview on 11/3/22, at 2:41 p.m., with the MAIN near the Hall A water heater, the MAIN confirmed the water heater temperature gauge was noted to be 134 degrees F. The MAIN stated the current temperature setting was too hot and it needed to be adjusted down to 120 degrees. The MAIN further stated this water heater supplied hot water to Halls A, B and half of Hall C so he expected all the resident restrooms in these halls to be affected. During a concurrent observation and interview on 11/3/22, at 2:45 p.m., with the MAIN in Hall A, the MAIN confirmed the sink hot water temperatures were measured ranging from 129.4- 129.6 degrees F for rooms 1, 2, 6 and 8. The MAIN stated the current sink hot water temperatures were too hot and needed to be adjusted. The MAIN confirmed there was no proof of documentation when the last time the Page 1 of 13 055662 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some water heater in Hall A was inspected to make sure it was set at the correct temperature setting. The MAIN further stated he expected all the water heaters to be inspected by maintenance on a weekly basis. During an interview with the Administrator (ADMIN) on 11/3/22, at 4:03 p.m., the ADMIN acknowledged the sink hot water temperatures for resident restrooms in Hall A, B and Hall C were noted to be above 120 degrees. The ADMIN stated hot water temperatures above 120 degrees could create a risk for burns for the residents in the facility. Review of an undated facility policy titled, Water Temperature and Control indicated, .Maintenance staff will check temperatures of water heaters, faucets, and showers daily .Temperature should be maintained between 110 F [Fahrenheit] and 120 F . 2a. A review of Resident 22's admission Record indicated Resident 22 was admitted to the facility in the Spring of 2017 with diagnoses which included difficulty in walking and a right knee contracture (loss of knee joint movement caused by changes in the surrounding tissue). A review of Resident 22's medical health record titled, Fall Risk Form, dated 9/21/22, indicated, .High Risk for Falling . Further review indicated Resident 22 had a history of falling. During a concurrent interview and record review with licensed nurse (LN) 6 on 11/3/22, at 5:51 p.m., LN 6 stated Resident 22 was considered to be at high risk for falls because sometimes she would try to get up from her wheelchair. LN 6 confirmed Resident 22's care plan indicated a mat was to be next to the bed as a fall intervention. During a concurrent observation and interview with LN 6 in Resident 22's room on 11/3/22, at 5:54 p.m., LN 6 confirmed there was no fall mat next to Resident 22's bed and a fall mat could not be found in the resident's room. LN 6 stated the fall mat should be in the resident's room. LN 6 further stated Resident 22's care plan was not being followed and it should be. LN 6 explained the risk for not following fall interventions could increase the potential for falls and injuries. 2b. A review of Resident 23's admission Record indicated Resident 23 was admitted to the facility in the Summer of 2021 with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and osteoporosis (a medical condition in which bones become weak and brittle). A review of Resident 23's medical health record titled, Fall Risk Form, dated 7/12/22, indicated, .High Risk for Falling . Further review indicated Resident 23 had a history of falling. A review of Resident 23's progress notes titled, IDT [Interdisciplinary team- a team of professional staff or a care team consisting of different disciplines] note, dated 11/3/22, indicated, .Follow up on incident on 10/31/22 when [Resident 23] was found face down on the floor .she was trying to adjust herself in the bed .lost her balance and fell out of bed .resident has bruising to right side of the face .will continue with the plan of care . During an interview on 11/3/22, at 5:21 p.m., certified nursing assistant (CNA) 3 stated Resident 23 was considered a fall risk because she had a recent fall. CNA 3 further stated she did not know of any other fall interventions for Resident 23 except to keep her bed low. 055662 Page 2 of 13 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review with LN 6 on 11/3/22, at 5:46 p.m., LN 6 stated Resident 23 was considered to be at risk for falls. LN 6 confirmed Resident 23's care plan indicated a mat next to the bed was to be used as an intervention. During a concurrent observation and interview with LN 6 in Resident 23's room on 11/3/22, at 5:49 p.m., LN 6 confirmed there was no fall mat next to Resident 23's bed. LN 6 further confirmed a fall mat could not be found in Resident 23's room. LN 6 stated the fall mat should be in the resident's room because of the risk of fall and injury for the resident. LN 6 further stated Resident 23's care plan was not being followed and it should be. 2c. A review of Resident 49's admission Record indicated Resident 49 was admitted to the facility in the Summer of 2022 with diagnoses which included osteoporosis, difficulty in walking, a broken right upper arm bone and syncope (fainting or passing out with a sudden or temporary lack of blood flow to the brain). A review of Resident 49's medical health record titled, Fall Risk Form, dated 8/26/22, indicated, .High Risk for Falling . Further review indicated Resident 49 had a history of falling. During a concurrent observation and interview with CNA 4 in Resident 49's room on 11/3/22, at 5:59 p.m., CNA 4 stated Resident 49 was at risk for falling, and she did not know of any fall interventions for the resident. CNA 4 confirmed there was no fall mat found on the floor next to the resident's bed. CNA 4 continued to look in Resident 49's room and stated she was unable to locate a fall mat in the room. During an interview on 11/3/22, at 6:03 p.m., the Infection Preventionist (IP) stated the purpose of fall care plans were to prevent falls, and the licensed nurses were responsible to follow a resident's fall care plan. During an interview on 11/3/22, at 6:12 p.m., the MDS Coordinator (MDS) explained a fall intervention with a mat meant a fall mat was supposed to be used for safety, to cushion a resident's fall and it was to be placed on the floor next to the resident's bed. The MDS stated all licensed staff were responsible to check if a resident's fall interventions were being followed. During a concurrent interview and record review with MDS on 11/3/22, at 6:15 p.m., the MDS confirmed Resident 49's fall care plan listed a fall mat as an intervention. The MDS further stated Resident 49's care plan was not being followed because a fall mat was not found next to the resident's bed. Review of the facility policy titled, Fall Prevention Program Policy and Procedure, dated, 6/26/2018, indicated, .To identify residents at risk for falls and provide interventions to reduce risk of falls and major injuries related to falls .Safety measures will be included in the plan of care for residents identified as having fall risks. Interventions may include but not limited to any of the following: a) Use of personal alarms, b) Use of seating devices . 055662 Page 3 of 13 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review the facility failed to ensure high risk medications (with potential to cause harm without careful monitoring) for diabetes (a disease that affect blood sugar) and a blood thinner (could cause bleeding) were monitored for possible adverse effects in two out of 21 sampled residents (Resident 10 and Resident 23). Residents Affected - Some These failures had the potential to affect safe medication monitoring by licensed staff. Findings: 1. During a medication pass observation on 11/1/22, at 9:21 AM, accompanied with Licensed Nurse 4 (LN 4), in facility's hall A, LN 4 administered a medication called Eliquis (also known as Apixaban, a blood thinner) to Resident 10 for a heart problem. LN 4 did not look for any sign or symptoms of bleeding or bruising. During a review of Resident 10's electronic medical record titled Medication Administration Record (or MAR, a list of medications and interventions nursing staff followed and documented), with date ranges of 10-1-22 to 10-31-22 and 11-1-22 to 11-30-22, the MAR did not show any nursing monitoring order or documentation for the blood thinner for the Eliquis order as follows: Eliquis Tablet 5 MG (or Apixaban, a blood thinner; mg is measure of unit); Give 5 mg by mouth two times a day . -Start Date- 05/07/21. During a review of Resident 10's electronic medical record, titled Order Summary Report (a monthly summary of all medication and non-medication orders by doctors), dated 11/3/22, the Order Summary indicated two medications for control of blood sugar as follows: a. Lantus insulin . (or also called Insulin Glargine, medication to control blood sugar) Inject 15 unit subcutaneously (shot under the skin) at bedtime . (given as a shot under the skin; unit is a measure of quantity); Start Date 10/19/22. b. Metformin .Tablet 500 MG (or Glucophage, a medicine used to treat blood sugar), Give 500 mg by mouth two times a day .; Start Date 02/24/21. Further review of the Order Summary Report did not show any monitoring parameters for nursing staff to watch for in cases of fluctuating blood sugar symptoms. Review of Resident 10's Care Plan (a nursing plan of care), last updated on 10/22, the Care Plan indicated THE POTENTIAL FOR ADVERSE DRUG EVENTS DUE TO THE FOLLOWING MEDICATIONS: ., GLUCOPHAGE, LANTUS, and ELIQUIS. The Care Plan further indicated ANTICOAGULANTS -- ANY OF THESE MAY INDICATE ADE (Adverse Drug Effects): BLEEDING, ., BRUISING, NOSEBLEEDS, BLOOD IN URINE, COUGHING UP BLOOD, ABRUPT ONSET HYPOTENSION (low blood pressure). 2. During review of Resident 23's electronic medical record titled Medication Administration Record or MAR, dated 11/22, the MAR record indicated Resident 23 was taking four medications to treat blood sugar disease as follows: a. Januvia Tablet 50 MG (also known as SITagliptin, used for blood sugar disease); Give 50 mg by 055662 Page 4 of 13 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0757 Level of Harm - Minimal harm or potential for actual harm mouth one time a day for DM (DM is same as Diabetes Mellitus or blood sugar disease); Start Date06/22/21. b. glipiZIDE Tablet 5 MG (medicine for blood sugar disease); Give 5 mg by mouth two times a day for DM . ; Start Date- 06/21/21. Residents Affected - Some c. metFORMIN . Tablet 1000 MG (medicine for blood sugar disease); Give 1000 mg by mouth two times a day for DM; Start Date- 06/21/21. d. Actos Tablet 15 MG (also known as Pioglitazone, used for blood sugar disease); Give 15 mg by mouth one time a day for Diabetes; Start Date-07/15/21. Further review of the MAR did not show if nursing staff were required to monitor, measure and/or document the side effects of medications used to treat blood sugar disease. Review of the Resident 23's Care Plan (a nursing plan of care), last updated on 10/22, the Care Plan indicated WILL HAVE NO UNRESOLVE EPISODES OF HYPER/HYPO GLYCEMIA [means having very high or very low blood sugar level]; . TAKE MEDICATIONS AS ORDERED: .GLIPIZIDE, JANUVIA, METFORMIN, ACTOS, . ;LABS WILL BE DONE AS ORDERED: HGB A1C (a blood test to measure long term sugar level in the body) EVERY THREE MONTHS . MY LAST HGB A1C WAS 6.O ON 2/17/22 . In an interview with Licensed Nurse (LN) 4 on 11/4/22, at 9:50 AM, at the main nursing station, LN 4 stated her work routine was to check for general side effects and if she noticed anything unusual, she would call the doctor and documented in the progress notes. LN 4 stated for blood thinner medication, she would check if resident had leg pain for possible blood clot and for diabetes, she would check for any mental status change if there was no order to measure the blood sugar. During an interview with the Infection Prevention Nurse (IP Nurse), on 11/04/22, at 2:45 PM, in the DON (Director of Nursing) office, the IP Nurse stated that side effect monitoring was not completed in the computerized chart due to a technological issue within the facility's computer system called PCC (Point Click Care; computerized charting system used by facility to document resident care). The IP Nurse stated that side effect monitoring records were not kept in the residents' paper chart (a hard copy/offline chart kept in the nursing station). In a telephone interview with Medical Doctor 1 (MD 1), on 11/4/22, at 11:09 AM, MD 1 stated he monitored a lab work (or blood test) called HGBA1C (a lab that measured blood sugar control over span of 3 months) to assess if the blood sugar was controlled on a long term basis. MD 1 stated he would check how nursing staff monitored the side effects of the medications including low blood sugar symptoms. Review of the facility's policy titled Medication Administration, dated 11/1/2015, the policy indicated Medications shall be administered by licensed Nursing staff according to good nursing procedure to limit error and to assure optimum desired effect from administered medications. 055662 Page 5 of 13 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to ensure a system was in place to monitor psychotropic medications (mind altering drugs) for adverse effects in two out of 21 sampled residents (Resident 11 and Resident 40). These failures had the potential to affect safe medication use and monitoring by licensed staff. Findings: 1. During review of Resident 11's electronic medical record titled Medication Administration Record (or MAR, listed medications and interventions nursing staff followed and documented), with the date range of 10/1/22 to 10/31/22, the MAR indicated the following psychotropic medication were administered on a daily basis: a. Abilify Tablet 2 MG (known as Aripiprazole, mind altering medication for mood); MG is milligram and a unit of measure); Give 2 mg by mouth at bedtime for . Depression disorder M/B [manifested by] frequent tearfulness, sad facial expressions, loss of appetite; Start Date-10/19/22. b. Mirtazapine (medication used to help mood and appetite) Tablet 7.5 MG; Give 1 tablet by mouth at bedtime for Depression M/B sad facial expressions, verbalizations of sadness; decreased appetite; Start Date- 08/12/22. c. Bupropion HCl ER . Tablet Extended Release (medication to help elevate the mood; ER a type of slow-release medication) 12 Hour 150 MG; Give 150 mg by mouth every 12 hours for depression M/B sad facial expressions, verbalizations of sadness; Start Date-12/05/19. Further review of the MAR and doctor's orders did not show if the nursing staff were monitoring and/or documenting the possible side effects of these mind-altering medications. Review of Resident 11's medical record, dated 10/22, titled Care Plan (Nursing Plan of care), the Care Plan indicated TAKE MEDICATIONS AS ORDERED: BUPROPION, REMERON, . ABILIFY. MY DOCTOR HAS DISCUSSED RISK VERSUS BENEFITS OF PSYCHOTROPIC MEDICATIONS WITH ME AND MY FAMILY . STAFF OBSERVES FOR AND REPORT ANY SIDE EFFECTS FROM MEDICATIONS . STAFF WILL OBSERVE FOR AND REPORT ANY SIGNS OF DEPRESSION OR ANXIETY. Review of the facility's Consultant Pharmacist's (CP- a health care professional who monitored and helped with medications use) Medication Regimen Review (a review of medications for safe medication use) for Resident 11, dated 7/6/22, indicated Fall reported last month. Medications that may contribute to falls are listed below with incidents of ADR's (Adverse Drug Reactions) . The CP provided the names of mind-altering medications Resident 11 was receiving and the possible side effects. CP was not available for an interview. 2. During review of Resident 40's electronic medical record titled Medication Administration Record with the date range of 10/1/22 to 10/31/22, the MAR indicated the following psychotropic medication were administered on daily basis: 055662 Page 6 of 13 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a. LORazepam Tablet 0.5 MG (mind altering medication used for anxiety; Give 1 tablet by mouth two times a day for Dementia (a form of forgetfulness and mood change) with behaviors, increased anxiety; Start Date- 09/14/22 b. Tofranil Tablet 50 MG (known as Imipramine, medication used for mood, itching or sleep); Give 50 MG by mouth every 8 hours for depression m/b anxiousness, striking out at others, inability to console or redirect; Start Date- 09/10/22 Further review of the MAR and doctor's orders did not show if the nursing staff were monitoring and/or documenting the possible side effects of these mind-altering medications. Review of the facility's Consultant Pharmacist's Medication Regimen Review, for Resident 40, dated 7/6/22, the review indicated Fall reported last month. Medications that may contribute to falls are listed . for resident assessment. The CP provided the names of mind-altering medications Resident 40 was receiving and the possible side effects. CP was not available for an interview. Review of the Resident 40's medical record, dated 10/22, titled Care Plan (Nursing Plan of care), the Care Plan indicated TAKE MEDICATIONS AS ORDERED: ATIVAN, TOFRANIL. MY DOCTOR HAS DISCUSSED RISK VERSUS BENEFITS OF PSYCHOTROPIC MEDICATIONS WITH ME AND MY FAMILY . STAFF OBSERVES FOR AND REPORT ANY SIDE EFFECTS FROM MEDICATIONS . STAFF WILL OBSERVE FOR AND REPORT ANY SIGNS OF DEPRESSION OR ANXIETY. In a telephone interview with Resident 40's family member (FM) on 11/3/22, at 11:54 AM, the FM stated she visited Resident 40 regularly and the mind-altering medications were adjusted when he acted up. Resident 40's FM stated, a while ago, when he was hospitalized , they discontinued the Tofranil because of blood pressure or heart issues but later was needed to be restarted to help calm him down. The FM stated Resident 40 had many heart problems and all the medications should be looked at closely. In an interview with Medical Doctor 1 (MD 1), on 11/4/22, at 11:09 AM, MD 1 stated Resident 40's medications, specifically Tofranil (or imipramine), was adjusted based on his behavior and the degree of drowsiness it was causing. MD 1 stated he was aware of the imipramine's side effect on older adults considering Resident 40's heart issues. MD 1 stated Resident 40 has been using this medication for many years and was initially used for severe itching unresponsive to multiple other medications. MD 1 stated the family was closely involved on his mind altering medications use. In an interview with the Infection Prevention Nurse (IP Nurse), on 11/3/22, at 3:25 PM, the IP Nurse stated the facility was aware of lack of side effect monitoring for psychotropic medications. IP Nurse added, the facility's pharmacist brought that to their attention when they started a new computer system. IP Nurse stated the computer program did not allow them to link monitoring parameters to the individual medication. IP Nurse added he was working on a way to fix the issues. IP Nurse stated the facility was not using an alternative method for side effect monitoring documentation. In an interview with Licensed Nurse 4 (LN 4), on 11/4/22, at 9:50 AM, at the main nursing station, LN 4 stated her work routine was to check for general side effects and if she noticed anything unusual, she would call the doctor and a document it in the computer as a progress note. Review of the facility's policy, titled Psychotropic Drug Use, dated 11/28/17, the policy indicated Purpose: To monitor for adverse or side effects of psychotropic medication and to prevent 055662 Page 7 of 13 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0758 unnecessary use of medications . All residents who receive a psychotropic medication will be monitored for side effects. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055662 Page 8 of 13 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on interview, observation, and record review the facility failed to ensure safe medication storage practices when: 1. Outdated medication and supplies were stored in the active storage areas in one out of one medication storage room. 2. Emergency kit (or Ekit, a sealed and labeled medication box for emergency use) labeled as Ear and Eye Emergency Kit contained an outdated eye medication in one out of two inspected Ekits. 3. Refrigerated vaccines were stored with food items and the temperature was not monitored twice daily in one out of four medication refrigerators. These failures had potential for medication error and unsafe medication use. Findings: 1. During a concurrent observation and interview on 11/1/22, at 10:09 AM, accompanied by Licensed Nurse (LN )1, in the facility's medication room, the following outdated medication and supplies were noted in the locked storage cabinet. LN 1 acknowledged the findings as follows: a. Glucometer (a machine that measures blood sugar) control solution (solution used to calibrate the glucometer machine), brand name McKesson True Matrix Level 2, two bottles expired on 7/31/2022. b. Glucometer control solution, brand name McKesson True Matrix Level 3, one bottle expired on 9/30/2022. c. Ear drops (Carbamide Peroxide- used for Earwax removal), one 15 mL (mL is measure of volume) bottle expired on 6/2022. d. Perineal and Skin Cleanser Rinse-Free (product used to clean the skin), seven 8-ounce (ounce is measure of volume) bottles expired on 8/2022. e. Hydrocortisone cream 1% UD 0.9 gm packets, one box, (topical steroid cream used for itching or allergy; % or percent is the potency strength; UD is unit dose packet; gm is gram or measure of the weight) was expired on 8/2022. f. Hydrogen peroxide bottle (antiseptic or antimicrobe topical solution), one 8-ounce bottle expired on 2/2022. 2. During a concurrent observation and interview on 11/1/22, at 10:40 AM, accompanied by LN 1, in the facility's main nursing station, the Ekit for ear and eye medications contained an outdated medication for an eye medicine called Neosporin Opth Oint 3.5 gm (an eye antibiotic medicine; opth means for the eye; Oint or ointment means a topical oily-like medicine). LN 1 acknowledged the finding. 3. During a concurrent observation and interview on 11/3/22, at 3:25 PM, accompanied by the 055662 Page 9 of 13 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Infection Prevention Nurse (IP Nurse), in the Director of Nursing's (DON) office, the IP Nurse stated the vaccines were stored in a small refrigerator in the DON's office. Further inspection of the vaccine refrigerator, indicated food items were stored on the top shelf and the refrigerator's door. Review of the Refrigerator TEMP [temperature] Check Log, posted on the outer refrigerator door, indicated the temperature documentation was performed once a day and it was missing the weekend temperature checks. The IP Nurse acknowledged the findings and was not sure why the vaccines were stored in an office versus the medication room with a secure lock and twice daily monitoring by nursing staff. Review of the facility's policy titled Emergency Medication Kits, dated 3/14/2016, indicated Emergency kit supplies shall be checked at least monthly by the pharmacist. Review of the facility's policy, titled Pharmacy Services Policy and Procedure, dated 2/26/2019, indicated Expired medications will be removed from med cart; nursing supervisors and a pharmacy representative shall randomly check med carts for expired medications. The policy on section H did not address vaccine storage and/or frequency of refrigerator temperature monitoring. Review of the Center for Disease Control ( or CDC, a U.S. federal government agency whose mission is to protect public health) guideline titled Vaccine Storage and Handling Toolkit, dated 4/22, last accessed on 11/8/22, via https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf , indicated Vaccines must be stored properly from the time they are manufactured until they are administered. Potency is reduced every time a vaccine is exposed to an improper condition. This includes overexposure to heat, cold, or light at any step in the cold chain. Once lost, potency cannot be restored. Exposure to any inappropriate conditions can affect potency of any refrigerated vaccine, but a single exposure to freezing temperatures . can actually destroy potency. Liquid vaccines . can permanently lose potency when exposed to freezing temperatures. The guideline further indicated Failure to store and handle vaccines properly can reduce vaccine potency, resulting in inadequate immune responses in patients and poor protection against disease .check and record the current temperature a minimum of 2 times per workday (at the start and end of the workday). 055662 Page 10 of 13 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

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 facility policy review, the facility failed to maintain cleanliness of the ice machine for a census of 50. Residents Affected - Some This failure had the potential for the residents in the facility to receive water and ice with contaminants that could lead to water borne illness. Findings: During an observation of the facility's ice machine in the west dining area with Dietary Manager (DM) on 11/2/22, at 11:00 a.m., maintenance staff opened the ice machine. The panel in front of the ice grid was removed. Surrounding the grid perimeter were brown/ black markings of approximately ¼ inch (unit of measurement) thickness.The center of the panel covering the ice grid had similar brown/black marks of approximately ¼ inch thickness.The DM acknowledged the markings. During an interview on 11/3/22, at 12:03 p.m., with the Administrator (ADM) confirmed that the maintenance department had no cleaning log for the ice machine. During an interview on 11/3/22, at 1:39 p.m., with the Infection Preventionist (IP), the IP stated the ice machine was used by both staff and residents. The IP further stated this could lead to infection to those consuming the ice. Review of a facility provided policy Ice Machine Cleaning Procedures (RDs for Healthcare) included the following: .the ice machine needs to be cleaned and sanitized monthly. The internal component cleaned monthly . and the date recorded when cleaned. Maintenance supervisor can keep this record or it can be posted on the ice machine. The U.S. Food and Drug Administration Food Code defined ice as food. This mandates ice to the same handling and cleanliness standards as everything else in food. Ice machine cleaning is governed by Food Law 2009 Chapter 4-part 602.11 section (E) item (4a and b), which states that the machines must be cleaned at a frequency specified by the manufacturer, which in most instances ranges from two to four times per year, or at a frequency necessary to preclude accumulation of soil or mold. 055662 Page 11 of 13 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

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** Based on observation, interview, and record review, the facility failed to ensure safe infection control practices for a census of 50 residents when: Residents Affected - Some 1. Licensed staff did not perform hand hygiene with hand sanitizer or soap and water while providing care during medication administration for Resident 3 and Resident 25. 2. Medication tray (small tray used to carry medication and supplies into residents' rooms) was not sanitized in-between resident care for Resident 3 and Resident 25. 3. Two direct care staff members did not wear the required personal protective equipment (PPE, includes gowns, gloves, eye protection, facemasks or respirators worn to prevent the spread of germs and infection) when providing care to residents on transmission-based precautions (TBP- infection control precautions for known or suspected infectious agents). These failures had the potential to spread infection in the facility. Findings: 1. During a medication pass observation on 11/02/22, at 4:00 PM, accompanied by Licensed Nurse (LN) 3, in facility's Hall D, LN 3 donned (put on) gloves, and entered Resident 3's room without sanitizing hands first. At 4:09 PM, LN 3 left Resident 3's room and doffed (took off) gloves without sanitizing hands. During a medication pass observation on, 11/02/2022, at 4:41 PM, in facility's Hall D, LN 3 donned gloves and entered Resident 25's room without sanitizing hands. LN 3 exited Resident 25's room at 4:50 PM, doffed gloves, and used hand sanitizer. During an interview with LN 3, on 11/02/22, at 5:05 PM, in facility's Hall D, LN 3 stated that facility staff was required to use hand sanitizer upon entrance and exiting the resident's room. In an interview with the Infection Prevention Nurse (IP Nurse), on 11/04/22, at 2:12 PM, in the DON (Director of Nursing) office, IP Nurse stated the facility's staff were expected per facility policy, and current standard of practice, to wash or sanitize hands prior to and on leaving a resident's room with either hand sanitizer or soap and water. Review of the facility's policy, titled 'Hand Washing', dated 05/01/20, indicated Hands are to be cleansed: a. Between residents and b. Before passing out trays or handling food. The facility's handwashing policy further stated, Antimicrobial hand sanitizer may be used between residents. 2. During a medication pass observation on 11/02/22, at 4:00 PM, accompanied by Licensed Nurse (LN) 3, in facility's Hall D, LN 3 used a medication tray to carry medications and supplies into Resident 3's room to administer medication. LN 3 did not clean or sanitize the tray upon exiting Resident 3's room. LN 3 used the same tray to carry medication and supplies to Resident 25's room at 4:41 PM. During an interview with LN 3, on 11/02/22, at 5:08 PM, in facility's Hall D, LN 3 stated she would have cleaned the tray if it had come into direct contact with residents. LN 3 acknowledged that she 055662 Page 12 of 13 055662 11/04/2022 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0880 Level of Harm - Minimal harm or potential for actual harm placed the tray directly on Resident 3 and Resident 25's side table which could contribute to contamination and spread of infection. During an interview with IP Nurse, on 11/04/22, at 2:22 PM, in the DON office, IP Nurse stated the medication tray should have been cleaned and sanitized if taken into a resident's room. Residents Affected - Some 3 a. During an observation on 11/2/22, at 12:09 p.m., certified nursing assistant (CNA) 2 entered room [ROOM NUMBER] without wearing a gown and gloves and closed the door. CNA 2 exited room [ROOM NUMBER] several minutes later with a black trash bag in her hands and walked down the hall to dispose the bag in another room. The outside of room [ROOM NUMBER] was noted with an enhanced standard/ barrier precautions sign. During an interview on 11/2/22, at 12:19 p.m., CNA 2 confirmed she was not wearing a gown and gloves when she entered room [ROOM NUMBER] before taking the resident to the bathroom. CNA 2 further confirmed room [ROOM NUMBER] was labeled as a room with TBP. CNA 2 stated the sign at the door meant all staff had to follow the instructions by performing hand hygiene, wear a gown, gloves and mask before entering the room. CNA 2 apologized and stated she should have worn the gown and gloves before entering room [ROOM NUMBER]. CNA 2 explained staff not wearing proper PPE created a risk for spreading infection to other residents. 3b. During an observation on 11/3/22, at 4:52 p.m., CNA 3 entered room [ROOM NUMBER] without wearing a gown and gloves and closed the door. CNA 3 exited room [ROOM NUMBER] several minutes later with a black trash bag in her hands and walked down the hall to dispose the bag in another room. The outside of room [ROOM NUMBER] was noted with an enhanced standard/ barrier precautions sign. During an interview on 11/3/22, at 5:08 p.m., CNA 3 confirmed she was not wearing a gown and gloves when she entered room [ROOM NUMBER] before taking the resident to the bathroom. CNA 3 further confirmed room [ROOM NUMBER] was labeled as a room with TBP. CNA 3 stated she initially did not see the sign but knew the sign at the door meant staff had to perform hand hygiene, wear a gown, gloves and mask before entering the room. CNA 3 stated she should have worn the gown and gloves before providing direct care to the resident. CNA 3 explained staff not wearing proper PPE was an infection control issue and it could be a risk to spread the disease. During an interview on 11/4/22, at 2:39 p.m., the Infection Preventionist (IP) acknowledged there were two staff members who did not wear the required PPE when providing direct care to residents on TBP. The IP stated he expected all staff members to wear a gown, gloves and/ or a face shield for possible splashing while providing care. The IP stated the signage posted for TBP gave step by step instructions for staff to follow before entering a resident's room to provide direct care. The IP explained some examples of direct care included changing a resident's brief or helping to toilet a resident. The IP stated he educated staff about wearing proper PPE when providing care to residents on TBP and it should have been done. The IP further stated staff not wearing proper PPE could risk the spread of infection to staff and residents in the facility. 055662 Page 13 of 13