Health inspection·May 31, 2019

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide one of 14 sampled residents with a dignified experience when he was told to have a bowel movement in the shower, after he tried to get up from the shower chair and walk to the bathroom. This failure led to Resident 402 feeling embarrassed and for the experience to not be homelike. Findings: During an interview on May 28, 2019 at 10:00 AM, Resident 402 stated that when he was in the shower with a certified nursing assistant (CNA 2) and occupational therapist (OT), he tried to stand up from the shower chair because he had to have a bowel movement (BM). He stated CNA 2 asked him to sit back down into the shower chair and said to have the BM in the shower chair. Resident 402 stated there was some feces (waste matter) on his legs that got onto his clean sheets. During a review of Resident 402's clinical record, the admission assessment dated [DATE] indicated Resident 402 is alert and orientated to time, place and person. The admission Assessment also indicated he was continent (able to control movements of the bladder and bowel). During an interview on May 28, 2019 at 3:06 PM, Certified Nursing Assistant 3(CNA 3) was caring for Resident 402 on the evening shift, CNA 3 stated that they usually ask a resident before starting the shower if they have to use the bathroom. If a resident has to go while in the shower, they take the resident to the bathroom. He stated he would never ask a resident to have a bowel movement in the shower. During an interview on May 28, 2019 at 3:45 PM, The CNA 2 that helped Resident 402 with his shower stated that she asked him to sit back down and have his bowel movement in the shower chair. CNA 2 confirmed that Resident 402 is able to walk on his own and is alert and orientated. During an interview on May 28, 2019 at 4:00 PM, with the Licensed Vocational Nurse (LVN 4), she stated that her expectation of staff is that they should take the resident to the bathroom, not tell them to have a BM in the shower. During an interview on May 28, 2019 at 4:16 PM, with the Occupational Therapist (OT), the OT stated she instructed him to have the bowel movement in the shower. During an interview on May 29, 2019 at 12:05 PM, the Director of Nursing (DON) stated that she Page 1 of 17 055693 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0557 would expect staff to use the bag that can be put on the shower chair for all residents, because you never know when the resident has to go. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055693 Page 2 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. 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 one of 14 sampled residents (Resident 403) had a Physicians order for padded side rails for a resident with a history of seizures. Residents Affected - Few This had the potential to result in Resident 403 being restrained without his consent. Findings: During an observation on May 28, 2019 at 10:24 AM, Resident 403 was sitting up in bed with padded half side rails. During a review of Resident 403's clinical record, the Resident admission assessment dated [DATE], indicated that Resident 403 has history of seizures (sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, movements and levels of consciousness). During a review of Resident 403's Minimum Data Set (MDS) (screening tool to assess residents), indicated that he had a restraint. There was no documented evidence of a Physician order for padded side rails in the chart. During an interview on May 28, 2019 at 11:00 AM, with Licensed Vocational Nurse (LVN 5), he confirmed that there is no physician order for padded side rails in the chart. During a concurrent interview on May 30, 2019 at 10:49 AM with the Director of Nursing (DON) and LVN 5, the DON stated there should be an order for side rails on admission. LVN 5 confirmed that there needs to be a physician order for padded side rails in order to use them. During a review of facility policy and procedure titled, Restraints dated on January 1, 2012, the policy indicated, that restraints require a physician order . 055693 Page 3 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

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** 2. During a review of Resident 49's closed record, it indicated Resident 49 was admitted on [DATE] and discharged home on Apri1 13, 2019. Residents Affected - Few A review of Resident 49's face sheet (demographic admission record) indicated she was initially admitted on [DATE] and readmitted on [DATE]. During an interview with Medical Record Director (MRD) on May 31, 2019 at 8:07 AM, she stated Resident 49 has two closed record files. Resident 49's first closed record was reviewed with the MRD and it indicated an admission date on March 21, 2019 and discharged date on April 2, 2019 to the hospital per family's request. The second closed record of Resident 49 indicated an admission date on April 4, 2019 and discharged date on April 13, 2019 to home. During an interview with the MDS Coordinator (MDS Nurse) on May 31, 2019 at 9: 30 AM, she confirmed Resident 49 was discharged to home on April 13, 2019. A review of Resident 49's MDS Discharge tracking record assessment was conducted with the MDS Nurse. She stated that MDS section A2100 (discharge status) was coded 03 (acute hospital). She confirmed that she entered the wrong code and it should have been coded as 01 (Community-private home). During concurrent interview with MDS Nurse, she stated the facility used as reference the CMS's (Centers for Medicare and Medical Services) MDS 3.0 RAI (Resident Instrument Assessment) Manual, dated October 2018. The MDS manual indicated the signature of the person who completed the MDS section should reflect the accuracy of the resident assessment information. Based on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS facility assessment tool) assessments, for two of 14 residents reviewed for (Residents 27 and 49), when: 1.For Resident 27, the MDS assessment, dated April 15, 2019, was not coded for fall since admission when the resident had an actual fall on April 13, 2019. 2.For Resident 49, the MDS assessment was inaccurately coded for discharged status. These failed practices had the potential to result in unmet care needs for Resident 27 and 49, which can potentially jeopardize their health and safety. Findings: 1. During a review of Resident 27's clinical record, the face sheet (contains demographic information) indicated Resident 27 was admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), osteoarthritis (joint pain from wear and tear). During an interview on May 28, 2019, at 10:55 AM, Resident 27 was lying on the bed. Resident 27 stated she had a fall last month during transfer in her room. 055693 Page 4 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0641 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 27's care plan (an individualized plan for the medical care of a resident) for Fall risk prevention and management indicated, resident had an actual fall on April 13, 2019. During a further review of facility's incident log for the month of April 2019, indicated, Resident 27 had a fall on April 13, 2019, at 1:25 PM, during transfer at resident's room without any injury. Residents Affected - Few A review of Resident 27's MDS, under Section J- Health conditions, dated April 15, 2019, indicated Resident 27, resident did not have any falls since admission or reentry. During a concurrent interview and record review with the MDS coordinator (MDS Nurse) on May 31, 2019, at 10:40 AM, the MDS Nurse reviewed Resident 27's fall risk prevention and management care plan and the facility's incident log for the month of April 2019, and confirmed Resident 27 had a fall on April 13, 2019. The MDS Nurse further reviewed Resident 27's MDS dated [DATE], Section J and stated the MDS should have been coded or marked as yes for fall. During a follow up interview with the MDS Nurse, on May 31, 2019, at 10:42 AM, the MDS Nurse reviewed Centers for Medicare and Medical Services (CMS's) MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2018. The MDS Nurse stated the manual was not followed. She further stated MDS nurses are expected to ensure accuracy of their assessments. The CMS's MDS 3.0 RAI Manual, revised October 2018, page J-31, indicated, steps for assessment . 4. Review nursing home incident reports, fall logs and the medical record . Code 1, yes: if the resident has fallen since the last assessment. Continue to number of falls since admission /entry or reentry or prior assessment . whichever is more recent . 055693 Page 5 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

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 interview and record review, the facility failed to ensure an individualized comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated, and implemented for two of 14 residents (Residents 5 and 24), when: 1.Resident 5 had an unwitnessed fall on January 11,2019, and the care plan was not updated until March 8, 2019. 2. Resident 24's medical record did not have documentation of a revised comprehensive care plan after Resident 24 experienced an unwitnessed fall on April 23, 2019. These failures had the potential to cause inadequate management and interventions by placing Resident's health and safety to at risk in order to prevent a recurrence. Findings: 1. During a review of Resident 5's face sheet (contains demographic information), the document indicated Resident 5 was admitted on [DATE], with a diagnoses of dementia (group of diseases with symptoms, which affect the way people think and interact with each other), hypertension (high blood pressure), and hemiplegia (partial paralysis on one side of the body). During a review of Resident 5's History and Physical Examination (H&P) dated October 3, 2018, indicated, resident did not have the capacity to make decisions. During a review of facility's incident log for the month of January 2019, indicated Resident 5 fell from his bed on January 11, 2019, at 5:00PM without any injury. During a review of Resident 5's care plan (an individualized plan for the medical care of a resident) indicated, Risk for falls/injuries .updated on March 8, 2019, found on floor January 19, with an intervention indicated fall risk assessment quarterly and after falls. During a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1) on May 30, 2019, at 10:54 AM, LVN 1 stated when a resident has a fall, whether witnessed or unwitnessed, the care plan should be updated on the day of incident, and the resident should be reassessed. LVN 1 further reviewed Resident 5's care plan risk for falls/injuries and confirmed the care plan was not updated on the day of actual fall. LVN 1 stated the resident should have been assessed for fall risk quarterly and that assessment was supposed to be done by May 23, 2019. During a concurrent interview and record review with the Director of Nurses (DON), on May 30, 2019, at 11:08 AM, the DON reviewed the facility's incident log for the month of January 2019, and verified Resident 5 had a fall on January 11, 2019. The DON, continued to review Resident 5's care plan for fall risk and the DON verified the care plan was not updated on the day of the actual fall. The DON further reviewed Resident 5's clinical record titled Fall risk data collection and stated the fall risk score was supposed to be reevaluated as per the care plan intervention quarterly by May 23, 2019. The DON was unable to find any documented evidence that a baseline care plan for fall had been developed. 055693 Page 6 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled Comprehensive person centered care planning revised on November 2018, indicated, .Comprehensive care plan .c. the comprehensive care plan will also be reviewed and revised at the following times: onset of new problems, change of condition, other times as appropriate or necessary . During a follow up interview and record review with the DON on May 31, 2019, at 2:02 PM, the DON reviewed the facility's policy and procedure titled Comprehensive person centered care planning revised on November 2018, and stated the facility did not follow this policy and procedure by revising the care plan for Resident 5. 2. During an interview with Resident 24 on May 28, 2019, at 10:51 AM, she stated that she fell about a month ago in her room. During a record review of the Resident 24's face sheet (contains demographic information) indicated that Resident 24 was readmitted [DATE] with diagnoses which included: difficulty in walking, muscle weakness (generalized), unspecified psychosis (conditions that affect the mind) not due to substance or known physiological conditions. During further record review of Resident 24's nursing progress notes dated April 24, 2019 indicated a conversation between staff and the resident discussing the incident when Resident 24 was found on the floor in her room on April 23, 2019. The doctor and the responsible party were notified of the fall. During an interview and concurrent record review with the Director of Nursing (DON) on May 31, 2019 at 11:25 AM, the DON stated that an Interdisciplinary Team (IDT-group of healthcare professionals) meeting should have happened. During an interview with a Licensed Vocational Nurse 1 LVN 1 on May 31, 2019 at 11:30 AM, stated nursing should have assessed the resident for pain and check the resident's mobility. LVN 1 further stated that a possible significant change should have been documented and the IDT should have met. During an interview with the Director of Staff Development (DSD) on May 31, 2019 at 11:37 AM, she stated that the IDT should meet and review the care plan and update it, as necessary, and ensure the post fall assessment has been completed on residents after a resident experiences a fall. The DSD stated that a post fall assessment packet was not completed for Resident 24 and that the IDT meeting did not meet after her unwitnessed fall on April 23, 2019. She also stated that Resident 24's comprehensive care plan was not revised or updated. A review of the facility's policy and procedures titled, Fall Management Program, dated as revised November 7, 2016 indicated, .II. A. Following each resident fall, the Licensed Nurse will perform a Post-Fall Assessment utilizing FA - 01 - Form A - Post-Fall Assessment, and update, initiate or revise a Plan of Care A review of the facility's policy and procedures titled, Comprehensive Person-Centered Care Planning, revised November 2018 indicated, .IV .c the comprehensive care plan will also be reviewed and revised at the following times: .i. Onset of new problem; ii. Change of condition 055693 Page 7 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician order for one of 14 sample residents (Resident 9) was carried out timely. This failure had the potential of not meeting the care and needs of the resident. Residents Affected - Few Findings: A review of Resident 9's face sheet (admission record) indicated she was admitted on [DATE], with a diagnoses of diabetes mellitus (high blood sugar) and chronic kidney disease (gradual loss of kidney function over a period of time). A review of Resident 9's laboratory test result of HgbA1C (HgbA1C (this test measures what percentage of hemoglobin is coated with sugar) - [a protein in red blood cells that carry oxygen] dated February 27, 2019 was 9.3 (Reference range 4.0-6.0). During a review of Resident 9's physician order dated February 28, 2019, indicated, an order for HgbA1C in three (3) months. During an interview with the Medical Record Director (MRD) on May 30, 2019 at 2:53 PM, she stated there was no other record of laboratory test in resident chart record other than the one done on February 27, 2019. The MRD stated that the physician order recapitulation (summary of order) for May 2019 indicated HgbA1c level was scheduled to complete on May 28, 2019. The MRD confirmed the laboratory test was not carried out timely per physician order. She showed that a laboratory slip requisition was completed but the date indicated a test date of June 6, 2019. During an interview with Licensed Vocational Nurse 3 (LVN 3) on May 31, 2019 at 2:14 PM, she stated that the recapitulation of physician order indicated the HgbA1c was supposed to be done on May 28, 2019 as shown on start date column. A review of facility's policy and procedure titled, Physician Orders, revised January 1, 2012 indicated, The Medical Records department will verify that physician orders are complete, accurate and clarified. VIII.Licensed Nurse receiving the order will be responsible for documenting and implementing the order. 055693 Page 8 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the post dialysis assessment was completed for one of 14 sampled residents (Resident 149). This failure had the potential of not meeting the needs of the resident after dialysis treatment. Residents Affected - Few Findings: During an interview with Licensed Vocational Nurse 1 (LVN 1) on May 29, 2019 at 5: 15 AM, she stated that Resident 149 was picked up for dialysis treatment. A review of Resident 149's face sheet (admission record) indicated he was admitted on [DATE], with diagnoses of Diabetes Mellitus (high blood sugar) and renal dialysis (process in removing waste, salt and extra fluids to prevent from building up in the body). Resident 149 is scheduled for dialysis treatment three times a week on Mondays, Wednesdays, and Fridays. During a review of Resident 149's post dialysis assessment record dated May 29, 2019, the blood sugar (BS) section was blank and BS result was not recorded. During an interview and a record review with LVN 1 on May 30, 2019 at 9:30 AM, she stated Resident 149 returned from dialysis on May 29, 2019 at 9:40 AM. The post dialysis care assessment form (NP-37 - Form A - Pre/Post Dialysis Assessment) dated May 29, 2019 was reviewed with LVN 1. She confirmed that there was no BS recorded upon resident return from dialysis on May 29, 2019. The LVN 1 further stated the blood sugar should have been done upon resident return from dialysis treatment since Resident 149 is diabetic. A review of the facility's policy and procedure titled, Dialysis Care, revised October 01, 2018 indicated, Purpose: To provide care for residents in renal failure and those residents who require ongoing dialysis treatments . IV. Communication and Collaboration: A. The Nursing Staff, Dialysis Provider Staff, and the Attending Physician (Dialysis Staff) will collaborate on a regular basis concerning resident's care as follows: . iv. Nursing staff may use NP -37-Form A- Pre/Post dialysis Assessment to convey information to the Dialysis Provider. VI. Documentation: A. All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident record. B. Documentation may include NP-37- Form A -Pre/Post Dialysis Assessment . 055693 Page 9 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview and record review, the facility's nursing staff failed to demonstrate competency in administration of medication when a Licensed Vocational Nurse 3 (LVN 3) administered Symbicort inhaler medication (medication to improve lung function) to Resident 399 without instructing the resident to rinse her mouth with water. This failure had the potential to cause harm by placing Resident 399 at an increased risk of developing an infection in the mouth and throat due to not rinsing. Findings: During an observation on May 29, 2019 at 8:19 AM, LVN 3 gave Resident 399 medication, Symbicort 160/4.5 micrograms( mcg a unit of measure) inhaler 2 puffs (a unit dose). LVN 3 did not have the resident rinse her mouth after using the inhaler. During a review of Resident 399's doctor's order dated May 9, 2019 indicated, Add to Symbicort order: wait 1 minute between puffs, rinse mouth after use. Symbicort manufacturer's instructions indicated, After you finish taking Symbicort (2 puffs), rinse your mouth with water. Spit out the water. Do not swallow it. During an interview with LVN 3, on May 29, 2019 at 12:18 PM, she stated that she did not instruct Resident 399 to rinse her mouth with water. She stated, I forgot. During an interview with Licensed Vocational Nurse 1 (LVN 1) on May 30, 2019 at 8:46 AM she stated that after Symbicort inhaler medication is administered the resident should be instructed to rinse their mouth. During an interview with the Director of Staff Development (DSD) on May 30, 2019 at 8:58 AM, she stated when administering Symbicort inhaler you shake the inhaler and explain to the resident to inhale the first puff and hold, then (depending on the doctor's orders) you wait a certain amount of minutes before administering the second puff. She indicated that after completion of the medication administration she would have the resident rinse by swishing and spitting out a sip of water. During an interview with the Director of Nursing (DON) on May 30, 2019 at 2:49 PM, regarding the administration of the inhaler medication, Symbicort, she stated, we go by the doctor's orders. She stated that typically if it's two puffs being given to the resident they usually wait 1-2 minutes between puffs and then the Resident rinses their mouth afterwards with water. She explained that the facility may also follow the manufacturer's insert. The facility's Policy and Procedure titled Medication Administration revised January 1, 2012 indicated, .Policy: I. A. ii. Medications and treatments will be administered as prescribed . A review of facility's document titled Charge Nurse: Job Description undated indicated, .General Duties and Responsibilities: Clinical .Prepare/administer medications as ordered by the physician . 055693 Page 10 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

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 safe and sanitary food preparation and storage practices in the kitchen when: Residents Affected - Few 1. One of two of the sanitation buckets for wiping down food contact surfaces had the improper concentration of sanitizer. 2. One tray and one plastic bin in the dry storage did not have a cleanable surface when it was lined with parchment paper (baking paper treated or coated to make them non-stick) and a paper towel and food was stored on top. These failures had the potential to lead to harmful bacteria and cross contamination that could lead to foodborne illness for a medically compromised population of 50 residents who received food from the kitchen. Findings: 1. During an observation and interview on May 28, 2019, at 8:25 AM with the Dietary Supervisor (DS), a red sanitation bucket used to clean food contact surfaces was in the sink. [NAME] 1 tested the concentration of the sanitizer and it was below 200 ppm (parts per million). The DS stated that staff may have accidently left the water running so it got diluted. During a review of the facility policy and procedure titled, Quaternary Ammonia Log Policy dated 2018, it indicated that the solution will be replaced when the reading is below 200 ppm. The concentration will be tested at least every shift or when the solution is cloudy . According to the Federal Food Code 2017, the inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmittable through food. 2.During an observation and concurrent interview on May 28, 2019 at 8:45 AM, with the DS in the kitchen dry storage, a tray was observed lined with parchment paper and some debris was observed under the paper. Canned goods were stacked on the tray for storage. The DS stated she was not sure why the tray was lined with paper. During an observation on May 29, 2019 at 7:04 AM, in the kitchen dry storage room, a plastic bin on the storage shelf containing fresh oranges was lined with paper towels. Debris was observed under the paper towels. During a review of the facility policy and procedure titled, Food Storage dated November 1, 2014, it indicated that shelving should be sturdy and provided with a surface which is smooth and easily cleaned . According to the Federal Food Code 2017, non-food contact surfaces should allow for easy cleaning and be free from unnecessary ledges, projections and crevices. 055693 Page 11 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** 3. During a review of Resident 40's face sheet (contains demographic information), the document indicated Resident 40 was admitted on [DATE], with a diagnoses of dementia (group of diseases with symptoms, which affect the way people think and interact with each other), osteoporosis (density and quality of bone are reduced and became fragile). During a review of Resident 40's influenza and pneumonia vaccination informed consent form, it was noted that the form was left blank in the section where the facility was to list the resident's name or the resident representative's name. During a concurrent interview and record review with the DSD, on May 29, 2019, at 7:18 AM, the DSD stated prior to obtaining a consent form the resident or the resident representative, the facility's form should be filled with appropriate resident name, or the responsible resident representative's name, whomever gave the consent. The DSD further reviewed Resident 40's Influenza vaccination informed consent and the Pneumococcal vaccination informed consent and verified the forms were left blank. During a concurrent interview and record review with the DON on May 31, 2019, at 9:42 AM, the DON reviewed Resident 40's clinical record for influenza and pneumonia vaccination consent form was supposed to be filled out with the resident and the resident representative name. The facility Policy and Procedure titled, Completion and Correction, Medical Records Manual-General, revised January 2012, indicated, Purpose: To ensure that medical records are complete and accurate. Policy: The facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. III. Entries will be complete, legible, descriptive and accurate . 2. During a review of the clinical record for Resident 12 the flu and pneumonia consent form did not include the resident's name. During an interview with DSD, on May 29, 2019 at 7:38 AM, the DSD stated that the forms have missing information. During an interview with a LVN 7, on May 29, 2019 at 12:07 PM, she confirmed that the consent forms should have the resident's name. During an interview with DON, on May 30, 2019 at 11:19 AM, she stated the name of the resident was not on the forms, without proper labeling the forms could get lost and the facility did not follow policy and procedure by placing a resident identifier. The facility Policy and Procedure titled, Completion & Correction, Medical Records Manual-General revised January 2012, indicated, purpose: To ensure that medical records are complete and accurate. Policy: The facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation . III. Entries will be complete, legible, descriptive and accurate . 055693 Page 12 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Based on interview and record review, the facility failed to ensure accurate documentation for four of 14 residents reviewed for comprehensive care plan, post fall assessment, and consent forms (Residents 12, 24, and 40) when: 1.Resident 24's medical record did not have documentation of a post fall assessment after Resident 24 experienced an unwitnessed fall on April 23, 2019. 2.Resident 12 did not have a complete and accurate documentation for the influenza (flu a contagious respiratory virus) and pneumonia (is an infection in one or both of the lungs) consent forms. 3. Resident 40 did not have a complete and accurate documentation for the influenza and pneumonia consent forms. These failures had the potential to cause inadequate management of Residents 12, 24, and 40's medical condition, placing their health and safety at risk. Findings: 1.During an interview with Resident 24 on May 28, 2019 at 10:51 AM, she stated that she fell about a month ago in her room. During a record review on the Resident 24's face sheet (contains demographic information) indicated that Resident 24 was readmitted [DATE] with diagnoses which included: difficulty in walking, muscle weakness (generalized), unspecified psychosis **not due to substance or known physiological conditions. During further record review of Resident 24's nursing progress notes dated April 24, 2019, indicated, a conversation between staff and the resident discussing the incident when Resident 24 was found on the floor in her room on April 23, 2019. The doctor and the responsible party were notified. During an interview and concurrent record review with the Director of Nursing (DON) on May 31, 2019 at 11:25 AM, the DON stated that an Interdisciplinary Team (IDT-group of healthcare professionals) meeting should have met to assess the cause of the fall. During an interview with a Licensed Vocational Nurse 1(LVN 1) on May 31, 2019 at 11:30 AM, LVN 1 stated that a possible significant change should have been documented and the IDT should have met. During an interview with the Director of Staff Development (DSD) on May 31, 2019 at 11:37 AM, she stated that the IDT should meet and review the care plan and update it, as necessary, and ensure the post fall assessment has been completed on residents after a resident experiences a fall. The DSD stated that a post fall assessment packet was not completed for Resident 24 and that the IDT meeting did not meet after her unwitnessed fall on April 23, 2019, as evidenced by non-documentation of a meeting being held. She also stated that Resident 24's comprehensive care plan was not revised or updated. A review of the facility's policy and procedures titled, Fall Management Program, dated as revised November 7, 2016 indicated, .II. A. Following each resident fall, the Licensed Nurse will perform a Post-Fall Assessment utilizing FA - 01 - Form A - Post-Fall Assessment, and update, initiate or revise a Plan of Care 055693 Page 13 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0842 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedures titled, Comprehensive Person-Centered Care Planning, revised November 2018 indicated, .IV .c the comprehensive care plan will also be reviewed and revised at the following times: .i. Onset of new problem; ii. Change of condition Residents Affected - Few 055693 Page 14 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow the infection control and prevention program when two staff (a certified nurse aide - CNA and a housekeeper - HSK) did not perform hand washing. This failure had the potential of transmission of infection to vulnerable residents whose conditions were already compromised. Residents Affected - Few Findings: During an observation on May 28, 2019 at 11:30 AM, Certified Nurse Assistant 1 (CNA 1) was carrying a bag of trash from a resident room and dispensed the trash in the trash bin at hallway. The CNA 1 was not wearing gloves at that time and then she headed to the exit door passed the dining room area without washing or sanitizing her hands. During an interview with the CNA 1 on May 28, 2019 at 12:48 PM, she stated she missed washing her hands after she bagged the trash and after throwing it in the trash bin. During an observation on May 29, 2019 at 6:10 AM, a HSK 1 was carrying the trash bag coming out of the residents' room, not wearing gloves, then picked up a pair of gloves that fell on the floor. The HSK 1 proceeded to throw the trash in the housekeeping cart trash bin. The HSK 1 entered another resident's room and picked up a bag full of trash, then removed the trash at the side of the medication cart, and then threw the bags in to the trash bin. During the handling of the trash HSK 1 was not wearing gloves and she did not perform hand washing. During an interview with the HSK 1 on May 29, 2019, at 6:15 AM, the HSK 1 stated she washed her hands one time in a resident bathroom. She further stated she did not wash her hands in the other resident room since the bathroom was occupied. She stated she did not wear gloves when she picked up the trash and did not use any hand sanitizer. During an interview with the Maintenance Supervisor (MS) on May 05/29/19 at 12:22 PM, he stated the expectation was for the housekeeper to wash hands after picking up and removing gloves, and after picking up and throwing trash in to the trash bins. During an interview with the Director of Staff Development and Infection Control Nurse(DSD/ICP) on May 30, 2019 at 9:45 AM, she stated all staff were to follow hand hygiene as part of infection control program. A review of the facility policy and procedure titled, Hand Hygiene, revised February 1, 2013 indicated, Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: Facility staff follow the hand hygiene procedures to prevent the spread of infections to other staff, residents, and visitors. IV. Wash hands with soap and water when soiled with visible dirt or debris. B. Alcohol-based hand hygiene products can and should be used to decontaminate hands: i. Immediately upon entering a resident occupied area (single or multiple room, procedure or, treatment) regardless of glove use. ii. Immediately upon exiting a resident occupied area (before exiting into a common area such as corridor regardless of glove use. 055693 Page 15 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to have documentation of screening and eligibility for one of 14 sampled residents (Resident 403) to receive the influenza (flu) vaccine (protect against infection by the flu virus). Residents Affected - Few This failure had the potential for Resident 403 to not be protected from the influenza virus by not being provided the opportunity to receive the vaccine if he chose to receive it. Findings: During an interview on May 30, 2019 at 10:43 AM, Licensed Vocational Nurse (LVN 5) confirmed that Resident 403 had not been screened for the flu vaccine. He stated the policy is that they are supposed to ask the resident on admission if they are alert and oriented if they would like the flu vaccine and fill out the form. If the resident is not alert, they are supposed to contact the resident representative. During an interview on May 30, 2019 at 2:50 PM, the Director of Nursing (DON) stated that the standard is for all newly admitted residents to be screened for flu and pneumonia vaccine (to protect against the pneumonia bacteria that is an infection of the lungs). During an interview on May 31, 2019 at 9:06 AM, Director of Staff Development/Infection Control Nurse (DSD/ICP) confirmed that no flu vaccine screening was done for resident 403. The DSD/ICP stated that the flu vaccine screening/consent is included in the admissions packet. During a review of the facility policy titled, Influenza Prevention and Control dated July 14, 2017, the policy indicated that, The resident's medical record includes documentation that indicates, at a minimum, the following: That the resident or the resident's legal representative was provided education regarding the benefits and potential side effects of the influenza vaccine and the resident was given a copy of IC-14-Form A-Influenza Vaccination and that the resident either received the influenza vaccine or did not receive it or refused. 055693 Page 16 of 17 055693 05/31/2019 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to meet the required square footage (sq./ft.) for nine rooms (Rooms 26,27,28,29,30,31,32,33, and 34.) This failure had the potential to limit freedom of movement and affect the health and safety of nine residents who resides in these rooms. Findings: During an observation and interview with the Maintenance Supervisor (MS) on May 30, 2019, at 10:50 AM, nine rooms were measured and found to be less than the required 80 sq. ft. per resident as follows: 1.Room. 26 (three beds) = 21.2-inch Length(L) x 11 inches Width (W) =77.73 sq. ft. per resident. 2.Room. 27 (three beds) = 21 L x 11 W =77 sq. ft. per resident. 3.Room. 28 (three beds) =21 x 11.2 W =78.4 sq. ft. per resident. 4.room [ROOM NUMBER] (three beds) = 22 L x 11W = 80.6 sq. ft. per resident. 5.room [ROOM NUMBER] (three beds) = 21 L x 10. 11 W =70.7 sq. ft. per resident. 6.room [ROOM NUMBER](three beds) =21.2 L x 10.11 W = 71.4 sq. ft. per resident. 7.room [ROOM NUMBER] (three beds) = 21.1 L x 11 W = 77.36 sq. ft. per resident. 8.Room. 33 (three beds) = 21.1 L x 11.3 W = 79.4 sq. ft. per resident. 9.Room. 34 (three beds) = 21 L x 11 W = 77 sq. ft. per resident. During a survey conducted on May 28, 2019, through May 31,2019, all residents in the above listed rooms were observed to utilize the space available. There were no complaints verbalized by the residents residing in the rooms regarding the sizes. 055693 Page 17 of 17