Health inspection·June 10, 2021

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure one (Resident 6) of two sampled residents needs were accommodated when administrator (Adm) told him he was not allowed to smoke. Residents Affected - Few This failure caused Resident 6 psychological distress. Findings: During a concurrent observation and interviews on 6/8/21, at 11:36 a.m., with Resident 44 and Resident 6 were on the back patio, Resident 44 was seen smoking and Resident 6 was not. Resident 44 stated he often assists Resident 6 to smoke, but the Adm told Resident 6 he was not allowed to smoke. Resident 6 stated the Adm told him recently he was not allowed to smoke even though he has been smoking at the facility with assistance. Resident 6 further stated he had not smoked all day and felt stressed out that he was not allowed to smoke any longer. During an interview on 6/8/21, at 11:59 a.m., with Adm, Adm stated Resident 6 does not qualify to smoke. Adm further stated Minimum Data Set (MDS - a screening and assessment tool of health status) coordinator completed a safe smoking assessment on Resident 6 and added to the care plan. During a concurrent interview and record review, on 6/8/21, at 12:45 p.m., with MDS, Resident 6's Smoking - Safety Screen (SSS), dated 4/22/21 was reviewed. MDS read from the SSS which indicated, Resident 6 requires one-on-one assistance from staff to smoke, and, safe to smoke with one-on-one assistance. During a review of Resident 6's Care Plan, dated 6/7/21, the Care Plan indicated, Resident 6 is a smoker and requires one-on-one assistance with smoking. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy - Residents, dated 7/2017, the P&P indicated, Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Page 1 of 22 055715 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on the observation, interview and record review the facility failed to provide a homelike environment when three (Resident 36, 51 and Resident 255) of five sample residents were complaining about the noise level at night. This failure had the potential to result in Resident 36 and 255 inability to sleep and feeling tired. Findings: During an observation on 06/07/21, at 9:40 a.m.,. a beeping noise was heard from the call light of Resident 51's room number and was ongoing until 3:30 p.m. same day. During an interview with the Director of Nursing ( DON) on 06/07/21, at 3:20 p.m., DON stated the call light had been broken since 6/6/21 on the night shift. DON stated they had called the company to fix the call light on 6/7/21. During an interview with Resident 35 on 06/07/21, at 10:32 a.m., Resident 35 stated There was so much noise at night. Resident 35 stated she was not able to sleep because of a beeping noise and residents yelling. During an interview with Resident 255 on 06/07/21, at 11:28 a.m., Resident 255 stated She was not able to sleep at nighttime because the place was so noisy. Resident 255 stated she was able to hear other residents yelling and talking load and the beeping noise. During a review of the facility's policy and procedure Quality of Life . revised 5/2017, it indicated . 2. The facility staff and management shall maximize, to the extent possible . i. Comfortable noise level . 055715 Page 2 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, interviews and record review, the facility failed to follow its Grievances/Complaint policy and procedure to make prompt efforts to resolve a complaint for one (Resident 40) of 15 sampled residents when the facility did not follow up and resolve Resident 40's concerns regarding cold food. This deficient practice had the potential to cause emotional distress. Findings: During an observation on 6/08/21, at 8:08 a.m., breakfast tray for Resident 40 was on the bedside table containing eggs, waffles and harsh browns. During an interview on 6/8/21, at 8:08 a.m., Resident 40 stated that breakfast was always cold. Resident 40 stated the harsh browns was very hard, dry and cold. Resident 40 stated he had complained to the staff about the cold food ,but it continued to be served cold. During an interview with Dietary Supervisor (DS) on 6/09/21, at 2:38 p.m., DS stated Resident 40 had concerns about cold food. DS stated Resident 40 complained to her about cold food and she warmed his food as needed. DS stated she had no documentation regarding resident concerns and could not provide her follow up documentation. During an interview with the Administrator (Admin) on 6/10/21, at 8:57 a.m., Admin stated she was not aware of Resident 40's concerns regarding cold food. Admin stated a grievance /concerns form must be completed to allow follow up with concerns. The facility's policy and procedures titled, Grievance/Complaint, dated 9/1/2008 indicated; Purpose is to facilitate prompt resolution of complaints or grievances for residents and /or their representative. 055715 Page 3 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide necessary treatment and services to promote healing and prevent infection for one (Resident 51) of six sample residents when the facility staff did not provide the wound treatment on multiple shifts for Resident 51's multiple wounds. Residents Affected - Some This deficient practice could result in worsening of Resident 51's existing pressure ulcers. Findings: Review of the facility admission Record, dated 5/17/21, indicated Resident 51 was admitted to the facility with multiple diagnosis including sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body ' s response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). During a review of the Treatment Administration Record from 5/1/21 through 5/31/21 the following treatment were not provided: a. The treatment to the wound on the coccyx area to apply collagen powder and cover with foam dressing was not provided on 5/22/21 during the day shift b. The treatment to the wound on the left knee to apply triad and to cover with foam dressing was not provided on 5/18/21, 5/20, 5/24, 5/26, 5/28 and 5/30/21. c. The treatment to the wound on the left ischium (part of the hip bone) to apply santyl (an ointment to remove dead tissue from the wound) and cover with calcium alginate (a type of dressing) and foam dressing was not provided on 5/22/21 and 5/25/21. d. The treatment to the wound on the left foot to apply wound gel and to cover with foam dressing was not provided on 5/22/21 and 5/25/21. e. The treatment to the bilateral heels to apply A&D ointment was not provided on the evening shift of 5/31/21 and on the night shift on 5/25/21, 5/26, 5/27, 5/28, 5/29, 5/30 and 5/31/21 f. The treatment to the coccyx/buttocks area to apply moisture barrier cream was not provided on the evening shift of 5/31/21 and on the night shift on 5/25/21, 5/26, 5/27, 5/28, 5/29, 5/30 and 5/31/21 During a review of the Treatment Administration Record from 6/1/21 through 6/30/21 the following treatment were not provided: a. The treatment to the bilateral heels to apply A&D ointment was not provided on the evening shift of 6/1/21, 6/6 and 6/7/21 and on the night shift on 6/1/21, 6/2, 6/3, 6/4, 6/6, 6/7 and 6/8/21 b. The treatment to the coccyx/buttocks area to apply moisture barrier cream was not provided on the evening shift of 6/1/21, 6/6 and 6/7/21 and on the night shift on 6/1/21, 6/2, 6/3, 6/4, 6/6, 6/7 and 6/8/21 055715 Page 4 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0686 Level of Harm - Minimal harm or potential for actual harm During an interview with the (Director of Nursing) DON on 06/10/21, at 8:43 a.m., DON stated she talked to the nurses who were assigned to Resident 51's wound care and they confirmed that they did not do the wound treatments on multiple shifts for Resident 51. DON stated if staff do not provide the wound care as ordered, the wounds could get worse or Resident 51 could developed new wounds and other complications. Residents Affected - Some During an interview with Licensed Vocational Nurse (LVN) 2 on 06/10/21, at 11:29 a.m., LVN 2 stated Resident 51 refused to have the treatment on those shifts that she was assigned to did the wound care LVN 2 stated she forgot to documented Resident 51 refused treatments. LVN2 stated she did not report to anyone that Resident 51 had refused treatment. LVN 2 was not able to show any documents that Resident 51 refused the treatments on those shifts. During a review of the facility's policy and procedure Wound Care revised October 2010 indicated . Documentation . The following information should be recorded in the resident's medical record . 9. If the resident refused the treatment and the reasons why . reporting 1. Notify the supervisor if the resident refuses the wound care . 055715 Page 5 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interviews and record review the facility failed to ensure one (Resident 3) of six sampled residents received treatement to prevent further decline of range of motion when restorative nursing exercise was not provided as ordered by the physician. This deficient practice had the potential for Resident 3's range of motion to further decline. Findings: During a review of the Minimal Data Set (MDS-an assessment screening tool used to guide care), dated 5/28/21, indicated: Resident 3 had functional limited range of motion on one side of the upper and lower extremities. Resident 3 required 2-person physical assistance with movement to and from lying positron, turns side-to-side, movement to or from bed, chair and wheelchair. Resident 3's diagnosis included hemiplegia (paralysis of one side of the body). During a review of Resident 3's physician orders dated 11/27/20, it indicated Resident 3 was prescribed restorative nursing exercise three times a week for twelve weeks for upper/lower extremities, range of motion for contractor management. During a review of Resident 3's care plan initiated on 1/22/21, it indicated Resident 3 was ordered restorative nursing services three times a week for 12 weeks. During an interview with Restorative Nursing Assistant (RNA) on 6/08/21, at 11:15 a.m., RNA stated Resident 3 had not received restorative exercises for over a month because he had refused. RNA stated he did not document Resident 3's refusal anywhere. During an interview with DON on 6/08/21, at 12:14 p.m., DON stated physical therapy evaluation (PT) was scheduled but was declined due to payment status. DON could not provide documentation to support Resident 3's refusal and scheduled PT that was declined. The facility's policy and procedures, titled Restorative Nursing Services, revised 7/2017 indicated; Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 055715 Page 6 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

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. 2. During a concurrent observation and interview on 6/8/21, at 12:20 p.m., with the Director of Nursing (DON), in the Medication Storage Room, an uncapped and undated multi-dose vial (MDV) of Aplisol (used in skin tests to help diagnose tuberculosis) was found in the refrigerator. During an observation, on 6/8/21, at 12:30 p.m., with the DON, the uncapped and undated MDV of Aplisol was compared side-by-side to the capped MDV of Aplisol. The fluid level was lower in the uncapped and unlabeled MDV compared to the capped MDV, which indicated the vial had been opened. During an interview on 6/9/21, at 4 p.m., the DON stated she cannot find a facility policy and procedure for dating opening MDV. During a review of the Centers for Disease Control (CDC) Injection safety, dated 6/2019, it indicated If a multi-dose (vial) has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Based on observations, interviews and record review the facility failed to follow it's policy and procedure for labeling and storing all drugs in a locked compartments when; 1. Multiple medications were kept on Resident 40's bedside window. 2. Multiple dose of medication vials were opened, undated and stored in medications storage room refrigerator. These deficient practices had the potential to cause unauthorized access, medication errors and the administration of outdated medications. Findings: During an observation on 6/08/21, at 8:08 a.m., one tube of hydrophilic (wound dressing cream), one tube of Nystop cream and one bottle of 3 % hydrogen peroxide was stored on Resident 40's bedside window. During an interview on 6/8/21, at 8:08 a.m., Resident 40 stated the medications were kept at his bedside window because when he needed the cream and called for assistance no one showed up. During an observation and concurrent interview on 6/08/21, at 8:20 a.m., Licensed Vocational Nurse (LVN1) stated the medications at Resident 40's bed side are for wound care and should be stored in the treatment carts. During a review of the facility's policy and procedures, titled Storage of Medications, revised 4/2007, it indicated Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medication shall be assigned to an individual cubicle, drawer. or cart holding area to prevent the possibility of mixing medications of several residents. 055715 Page 7 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview and facility document review, the facility failed to: 1. Ensure the Registered Dietitian (RD) supported the Dietary Supervisor (DS) in maintaining a clean and safe kitchen environment; 2. Ensure the Dietary Supervisor (DS) maintained a clean kitchen and clean equipment on a day-to-day basis; and 3. Involve the RD in the quality assurance and performance improvement (QAPI; a data driven and proactive approach to quality improvement), when food and nutrition services was involved. This failure had the potential for contamination of food leading to foodborne illness for a highly susceptible population of 56 residents who received food from the kitchen out of a facility census of 57. Findings: 1. During the Federal Recertification Survey from 6/7/21-6/10/21, multiple issues were identified inside the kitchen including cleanliness of the environment such as a significant amount of residue, dirt, and/or dust on windows, window screens, window shade, walls, vents, window air-conditioner unit, on the inside surface of cabinets holding clean cooking utensils, food carts, light switch and light switch covers, and imbedded residue in cracked floor tiles. In addition, it was identified that drywall was damaged throughout the kitchen, caulking along wall seems were crumbling, cabinet doors were worn with exposed particle board, and a drawer front surface was cracked. In an interview on 6/8/21, at 9:25 a.m., the RD stated she conducted a monthly sanitation and food safety check. She said she did not report on her monthly inspection the following: the vent located above a reach-in freezer which she confirmed was covered with black residue and the surrounding wall and ceiling had black residue on the surface fanning out from the vent, the light switch and cover by the back door with imbedded black residue which she stated was dirty and dusty, the large support pole by the back door which she confirmed had dried orange drip marks covering a large portion of the surface, broken floor tiles with imbedded black residue, multiple windows in the food preparation area she confirmed had residue and dust around the perimeters and along the window ledge, the window blind she confirmed was dirty and had black residue on the surface but she stated never looked at the blind before, the window air/conditioner which she stated was dirty and covered with dust, the surface of the cabinet next to the stove which held cooking utensils such as pans, had a black residue on the linoleum that covered the shelf surface. She stated it was just scuffed until the residue scraped off onto a paper towel, then she confirmed the shelf was dirty. She also stated she did not report wood cabinets located under a preparation table with the bottom of the outer wood surface worn and cracked exposing particle board. She stated ideally the cabinets should be replaced. She stated she did not report the tall open tray carts which she confirmed had a build-up of thick black residue at the base above all the wheels, and the utility cart with food stored on top which she confirmed had imbedded black residue and stated it was dirty. Review of the last 3 kitchen audits completed by the RD titled Sanitation and Food Safety Checklist dated 3/24/21, 4/30/21, and 5/28/21 showed areas on the report for the RD to assess for cleanliness 055715 Page 8 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and condition included but not limited to: all floors, storage devices for dishware, air-cooling system, ceiling vents, all painted surfaces, all windows and doors. Review of the job description titled Consultant Dietitian with a revised date of 2019, showed the RD was responsible for supporting the Food and Nutrition Services Director in maintaining department standards of food service storage, preparation, safety, and delivery to residents. In addition, conducts food safety and sanitation inspections with recommendations for items not meeting standards. Review of the document titled Sanitation dated 2018, showed all equipment shall be maintained as necessary and kept in working order. Also, all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 2. During the Federal Recertification Survey from 6/7/21-6/10/21 multiple issues were identified inside the kitchen including cleanliness of the environment such as a significant amount of residue, dirt, and/or dust on windows, window screens, window shade, walls, vents, window air-conditioner unit, on the inside surface of cabinets holding clean cooking utensils, food carts, light switch and light switch covers, and imbedded residue in cracked floor tiles. In addition, it was identified that drywall was damaged throughout the kitchen, caulking along wall seems were crumbling, cabinet doors were worn with exposed particle board, and a drawer front surface was cracked. In an interview on 6/8/2,1 at 9:25 a.m., the DS stated she did not know who was responsible for cleaning the support structure which was a cylindrical support structure from floor to ceiling of at least 10 inches in diameter. It had a rough, painted surface. The surface had orange drip marks on a large portion of the surface. She said the kitchen staff should be responsible for cleaning it and it needed to be cleaned. The DS also stated maintenance was responsible for cleaning a vent located above a reach-in refrigerator. The vent surface was covered with a thick, black, residue. The residue also fanned out on the surrounding wall and ceiling. The DS confirmed the vent and the surrounding area was very dusty and dirty. She said maintenance did not do rounds in the kitchen on a regular basis to check for things that had to be cleaned or fixed. In order for maintenance to clean or fix anything, she had to write it in her logbook, which maintenance checked daily. In an interview and observation on 6/8/21, at 9:49 a.m., the DS stated a kitchen staff cleaned floor by mopping but the maintenance staff was responsible for deep cleaning things that kitchen staff could not do. An observation of the window air conditioner located in a food preparation area had a fuzzy, gray matter on the surface of accordion plastic that connected the air conditioner to the window. She stated maintenance was responsible for cleaning the air conditioner. She said the air conditioner was used every day and stated it was dusty and dirty but did not have it in her logbook for maintenance to clean. On 6/8/21, at 10:31 a.m., in an interview with DS and Dietary Aide 2, DS confirmed 2 tall, metal resident meal tray carts were dirty. An observation showed the area at the base above the wheels of the cart had a thick layer of a thick black residue. DS wiped the black residue with a towel and a black residue came off onto a towel. She stated DA 2 was responsible for cleaning the carts. DA 2 confirmed he cleaned the carts by wiping them down with sanitizer after trays were delivered, but he did not clean the bases to try to remove the built-up residue. In an interview and observation with the Maintenance Supervisor (MS) on 6/9/21, at 10:29 a.m., he stated he did not clean anything in the kitchen, and he was not responsible for cleaning vents. He 055715 Page 9 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated he did clean the window screens once a month but from standing outside of the kitchen and hosing them off. MS confirmed the cabinets located under a food preparation table had a surface that was coming off and exposing the underneath particle board. He said it was not in good condition, so it had to be repaired. He also stated a drawer under the preparation table was cracked and had to be replaced. He said he was not aware of these things since they were not reported to him in the logbook. MS also stated he was not responsible for cleaning the window air conditioner. In an interview with the Administrator on 6/9/21, at 3:10 p.m., she stated the janitor was to make sure every aspect of the kitchen was clean. She stated the janitor went into the kitchen one time per week, early in the morning, and did a deep cleaning. She stated he did things such as scrub and buff the floors. She stated the janitor was also responsible for keeping the baseboards clean. The Administrator stated MS was in charge of cleaning the air conditioner and changing the air conditioner filters in the kitchen. In an interview on 6/9/21, at 4 p.m., Housekeeper 1 (HK1) stated he worked at the facility for 20 years and there was no deep cleaning done in the kitchen by housekeeping staff. He stated housekeeping staff was not allowed in the kitchen to clean. He said the one housekeeping staff that did deep cleaning in the kitchen left working for the facility about 8 years ago. Review of the undated facility cleaning schedule titled Janitor did not showed public bathrooms were cleaned but did not show other areas within the kitchen were cleaned. Review of the undated facility daily work schedule titled Housekeeping did not show any areas in the kitchen were cleaned. In an interview on 6/10/21, at 8:42 a.m., DS stated she did not always check to see that staff cleaned areas they were responsible for on the cleaning schedule. She stated she was too busy. Review of the document titled Dietary aid/Tuesday 11:00 - 2:00 pm Cleaning Schedule dated 1/5/2021 showed wipe windows on the schedule. Review of the job description titled FNS [Food and Nutrition Supervisor] dated 2018, showed the DS was responsible for maintaining cleanliness of kitchen equipment. Review of the document titled Sanitation dated 2018, showed all equipment shall be maintained as necessary and kept in working order. Also, all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 3. An observation during the initial tour of the kitchen on 6/7/21, at 10:20 a.m., showed tile baseboards throughout the kitchen were missing or coming away from the wall. Where there was missing baseboard, the drywall was missing or not intact. (Refer to F-812) In addition, a large mixer with a bowl was observed. The inside surface of the bowl had a dark residue that covered the bottom surface. In an interview on 6/7/21, at 10:30 a.m., the Dietary Supervisor (DS) stated the residue in the bowl was not removeable and she did not know what it was. She said it had to be replaced and it was in this condition for 6 years. In an interview with the RD on 6/8/21, at 9:25 a.m., she stated she reported baseboards in 055715 Page 10 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0801 Level of Harm - Minimal harm or potential for actual harm disrepair on a regular basis on her monthly inspection report. She also stated she noticed the mixer bowl was in bad condition a couple of years ago and reported it consistently on the inspection report. In a concurrent interview with the Maintenance Supervisor (MS) on 6/8/21, at 9:25 a.m., he stated he was not aware the baseboards were missing and coming off the wall because he did not see the RD reports. Residents Affected - Some Review of the last 3 kitchen audits completed by the RD titled Sanitation and Food Safety Checklist with a revised date of 2019, showed the RD documented the mixing bowl needed to be replaced on 3/24/21, 4/30/2, and 5/28/21. The report also indicated tiles on baseboard falling off on 4/30/21 and 5/28/21. In an interview on 6/9/2,1 at 10:29 a.m., the RD stated her monthly kitchen inspection reports were given to the Administrator, the DS, and the Director of Nursing (DON). She stated she did not take part in the QAPI program and did not know if any kitchen projects were in QAPI. The DS stated the baseboards and mixer were reported in QAPI. In an interview on 6/9/21, at 3:10 p.m., the Administrator (ADM) stated she kept the RD sanitation reports in a binder and usually took care of issues right away. She stated the mixer and baseboards were addressed in QAPI. ADM did not answer when she was asked why the mixing bowl was still in the kitchen if it was not useable. She stated it did not matter if it was in there because the mixer did not work. She stated in QAPI the first priority was giving the facility a face lift. She said in QAPI patient care items and infection control were next on the priority list. She did not consider the mixing bowl and the damaged baseboards a part of infection control. In an interview on 6/9/2, at 4:15 p.m., the RD and DS stated the mixer was plugged in and did work as far as they knew. In an interview and observation with the Administrator on 6/10/21, at 9:55 a.m., the Administrator reviewed her QAPI notes form April 21 showing sideboards were noted to be repaired by the remodeling team by July 2021. She stated sideboards meant baseboards. There was no additional information or documentation to show a plan for fixing the baseboards. The Administrator was not able to show a QAPI plan that was systematic, comprehensive, and data-driven. She stated the baseboards were not in the May 28 QAPI notes. She confirmed the RD was not a part of QAPI. She said there was no documentation 055715 Page 11 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and facility document review, the facility failed to ensure competency of staff in the functions of the food and nutrition service when: Residents Affected - Some 1. [NAME] 2 did not follow and properly document cooldown procedures for a time temperature control for safety (TCS) food (food that is more likely to grow harmful bacteria if not stored appropriately leading to foodborne illness); 2. [NAME] 1 did not appropriately demonstrate how to check the quaternary ammonia strength to clean food contact and nonfood-contact surfaces; 3. [NAME] 1 did not follow the menu for residents on a renal diet; and 4. Dietary Assistant 2 (DA2) did not appropriately demonstrate how to check the chlorine strength for the dish machine. This lack of competency by kitchen staff had the potential to result in contamination of food leading to foodborne illness as well as residents receiving different nutrients as indicated on the planned menu. Findings: 1. An observation during the initial kitchen tour on 6/7/21, at 10:30 a.m., showed a plastic bag filled with cooked white rice. The plastic bag was dated 6/6/21. During a review of the Cool Down Log binder, it did not show any cool down entries for food for the month of June. There was one entry for cooling of rice on 3/6/21. This entry showed the first temperature was taken at 11 a.m. and was 140 degrees Fahrenheit (F). The next temperature was taken at 2 p.m. and was 48 degrees F. This was 3 hours between taking the first and second temperature. The instructions on the cool down log showed a two-step cool down process. The first step was to take the temperature of a food 2 hours or less after the food dropped to 140 degrees F. to ensure the food was 70 degrees F or less. During an interview on 6/9/21, at 2:25 p.m., the Registered Dietitian (RD) confirmed there was no entry for rice on 6/6/21 but there should be if cooked rice was observed in the refrigerator dated 6/6/21. She stated the entry for rice cool down dated 3/6/21 was not documented appropriately to show safe cool down. She said the second temperature should have been recorded after 2 hours at 1 pm to ensure the food was cooled appropriately. During an interview with [NAME] 2 on 6/10/21, at 9:11 a.m., she stated the entry dated 3/6/21 was the entry for the cool down of the rice cooled on 6/6/21. She stated she made a mistake when she wrote the date. She also stated the process for cooling food involved checking the temperature of the food every 2 hours to make sure it was cooling properly. She stated her first entry showed she checked the rice at 11 am and again at 2 pm. She stated the time between 11 a.m. and 2 p.m. was 2 hours so the rice was cooled appropriately 2. During an observation and interview with [NAME] 1 and the RD on 6/8/21, at 10:35 a.m., [NAME] 1 055715 Page 12 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated she was responsible for checking the quaternary ammonium solution (quat) strength for the red buckets used to clean food contact and nonfood-contact surface areas. She demonstrated how she tested the strength of the solution by filling a red bucket with quat and dipped a quat test strip in the solution for 4 seconds. When the surveyor asked how long she was supposed to hold the test strip in the solution, she stated 10 seconds. She tested again with a new strip and counted to ten out loud very fast. Again, she held the strip in the solution for 4 seconds. The RD confirmed she did not hold the test strip in the solution for 10 seconds. The strip turned a very dark green and when [NAME] 1 compared the strip to the color chart located on in the test strip container, she stated the color of the strip showed the concentration of the quat solution was 200 parts per million (ppm). The color chart showed 200 ppm was a mustard yellow color. The color of the strip was observed by 2 surveyors and both surveyors concluded in comparison to the color chart, the strip showed the strength of the solution was between 300 to 400 ppm. The RD also agreed the strip compared to the color chart was more than 200 ppm. Review of the quat test strip instructions located inside the container of the quat strips showed to immerse for 10 seconds . 3. During an an observation during trayline food service on 6/8/21, at 12 p.m., showed [NAME] 1 plated white rice on trays for residents whose tray tickets showed they were prescribed a renal diet. Review of the Cook's spreadsheet titled Summer Menus Week 1 Tuesday used for lunch on 6/8/21, showed renal diets received wheat pasta with margarine. During an concurrent interview with [NAME] 1, the RD, and DS on 6/8/2,1 at 12 p.m., [NAME] 1 stated she made a mistake and did not cook pasta to serve to residents on a renal diet. DS stated there was pasta available, so the reason for [NAME] 1 not making pasta was not because they ran out. DS stated residents did not like whole wheat pasta. The RD stated [NAME] 1 did not ask her if she could substitute rice for pasta because the cooks knew that rice could be a substitute for pasta if needed. She stated in this case, the residents on a renal diet should have received wheat pasta since they had it in stock. She stated she knew that residents did not like whole wheat pasta, but they accepted regular wheat pasta. 4. In an observation and interview with the RD and DA2 on 6/8/21 at 10:40 a.m., DA2 stated he was responsible for checking dish machine sanitizer strength. He demonstrated how he checked the strength by running a metal bowl through a cycle. When it was finished, he placed a chlorine test strip on the surface of a metal bowl. The test strip turned a dark purple color. He compared the strip to the color chart located in the test strip container and stated it showed the strength of the chlorine sanitizer was 200 ppm and it should be between 100 to 200 ppm. He stated 50 ppm was not okay. The RD stated the chlorine sanitizer strength for the dish machine should be 50 to 100 ppm. Review of the Dish Machine Temperature Log dated 2020 showed in the instruction the chlorine should be 50 to 100 ppm. 055715 Page 13 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and facility document review, the facility failed to serve two residents (Resident 51 and 49) of 57 sampled residents diets prescribed by a physician. Residents Affected - Many This failure had the potential for two residents, Resident 51 and 49, to receive inadequate calories and/or nutrients contraindicated for a prescribed diet leading to nutritional related health issues. Findings: 1. An observation of trayline food service on 6/8/21, at 12 p.m., showed resident [NAME] 1 placed a scoop of mashed potatoes on a plate for resident 51's lunch. An observation of the tray ticket for Resident 51 located on his tray showed he was on a Regular, Controlled Carbohydrate (a diet typically prescribed to diabetics), Renal (a diet typically prescribed to a person with kidney disease), Thin Liquids. During a review of the Cook's Spreadsheet titled Summer Menus Week 1 Tuesday and used for lunch on 6/8/21, showed residents on a renal diet received wheat pasta with margarine instead of mashed potatoes which was served to regular diets. In a concurrent interview with [NAME] 1, the Registered Dietitian (RD) and the Dietary Supervisor (DS), on 6/8/21, at 12 p.m., the RD confirmed Resident 51 should have not received mashed potatoes because he was on a renal diet. The RD stated the diet for resident 51 was recently changed to Renal. DS stated [NAME] 1 was familiar with all the resident diets, so she did not read all the meal tickets and she missed the new diet change written on the Resident's meal ticket. Review of the Diet Manual For Long Term Care and Residential Facilities 2020 reviewed and signed by the RD on 1/8/21, gave a description of a Renal diet which indicated, this diet is usually ordered when a patient is in renal failure, receiving dialysis, or has elevated serum potassium. Potassium content of the diet is controlled to prevent hyperkalemia (elevated blood potassium). An example of a menu for a Renal diet was given and indicated to avoid potatoes. In an interview with RD on 6/9/21, at 12:25 p.m., the RD stated the diet order for Resident 51 was changed on Monday 6/7/21. She said the cook should have looked at the entire tray ticket during trayline. She stated the kitchen did not get the communication slip from the Director of Nursing (DON) that alerted the kitchen of a new diet. She stated the original communication slip was placed in the resident's chart and the carbon copy was given to the kitchen. In an interview with DS on 6/10/21, at 8:42 a.m., DS stated cooks should look at the tickets when serving food on trayline. She stated sometimes, but not all the time, there was a kitchen staff to help the cook read the trayline tickets and make sure the food on the tray was correct for the prescribed diet. In an interview with RD on 6/10/21, at 9:11 a.m., the RD stated she recommended Resident 51's diet change to a Renal diet based on his lab results. Review of Resident the Nutrition/Dietary note dated 6/4/21, showed the RD stated Given recent lab 055715 Page 14 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many results with elevated BUN (Blood urea nitrogen; a test used to measure the amount of nitrogen in the blood), Cr (Creatinine; a waste product removed from the body by the kidneys), and K+ (Potassium), recommend to change diet to Renal, CCHO, regular texture . During a review of the facility's policy and procedure (P&P) titled, Diet Orders, dated 2018, the P&P indicated, Policy diet orders as prescribed by the physician will be provided by the food and nutrition services department. Nursing will send a Diet Order Communication slip to the Food and Nutrition Services department. The FNS Director or cook in charge will make or adjust the diet profile and tray card as prescribed Any discrepancy in the diet order slip will be clarified by the FNS Director or cook in charge with nursing. During a concurrent interview and record review on 6/10/19 at 12:54 p.m., with DON, Resident 51's Status Report, dated 6/7/21, signed by DON, was reviewed. The status report showed a change to renal diet for Resident 51. DON stated this report is used to communicate diet change orders between nursing and dietary staff. DON stated she gave a dietary staff member the yellow carbon copy but could not remember which staff member. During a review of the facility's Food and Nutrition Services (FNS) director job description, titled Job Description, Position FNS Director, dated 2018, the document indicated, [FNS] is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed. In addition, the document indicated, [FNS is to] check trays to ensure diets are served as ordered. During a review of the facility's policy and procedure (P&P) titled, Diet Orders, dated 2018, the P&P indicated, Policy diet orders as prescribed by the physician will be provided by the food and nutrition services department. 2. During a concurrent observation and interview on 6/8/21, at 12:40 p.m., with CK 1, RD and DS, the preparation of Resident 49's lunch tray was observed. CK 1 plated mashed potatoes, gravy, shredded beef and spinach. CK 1 placed the plate on Resident 49's meal tray for delivery to Resident 49. The diet order card dated 6/8/21, on Resident 49's tray indicated , Diet order: Mech Soft (easy to chew and swallow food texture), Controlled Carbohydrate, Fortified Diet (foods with additional nutrients added), Thin liquids. CK 1 stated she fortified the meal with melted butter. Melted butter was not observed on Resident 49's meal. RD and DS confirmed residents with a fortified diet should have a scoop of melted butter added to the meal and the butter on Resident 49's meal was missed. During a review of Resident 49's Diet Type Report, dated 6/10/21, the report indicated Resident 49 was on a fortified diet. During a review of the facility's fortified diet menu, titled, Weekly Guideline for Summer 2021 - Week 1, undated, the document indicated for fortified Tuesday lunch, Potatoes: ½ ounce melted margarine. Vegetables ½ ounce melted margarine. During an interview with RD, on 6/9/121, at 12:25 p.m., RD stated CK 1 should have followed the fortified spreadsheet to know what to provide on trayline. She stated Resident 49 was initially placed on a fortified diet due to being underweight and not eating very well. It was recommended for Resident 49 to stay on a fortified diet to maintain weight. 055715 Page 15 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's Food and Nutrition Services (FNS) director job description, titled Job Description, Position FNS Director, dated 2018, the document indicated, [FNS] is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed. In addition, the document indicated, [FNS is to] check trays to ensure diets are served as ordered. During a review of the facility's policy and procedure (P&P) titled, Diet Orders, dated 2018, the P&P indicated, Policy diet orders as prescribed by the physician will be provided by the food and nutrition services department. 055715 Page 16 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 facility record review, the facility failed to store food, brought into the facility by visitors, safely for residents. The facility also failed to have a policy to show food would be stored safely for residents upon request. Residents Affected - Many This failure had the potential for decreased food intake by residents who preferred to eat food brought in from outside sources for 56 residents who were able to eat food by mouth out of a facility census of 57. Findings: Review of the undated facility policy and procedure titled Food For Residents From Outside Sources showed food brought in from outside sources for the resident would first be shown to the charge nurse for approval to ensure the food was within the diet order parameters. The nurse would consult with the Food and Nutrition Supervisor (FNS) or the consultant dietitian as needed. Prepared or perishable food must be consumed within one hour of receiving . Unused food would be disposed of immediately thereafter. An observation on 6/8/21 at 2:30 p.m. showed a carton of individual yogurt containers with room [ROOM NUMBER] E and Resident 22's name written on the carton located in a staff refrigerator. There was also a plastic bag with 25 C written on the bag. Inside the bag was a store-bought fruit salad in a plastic container. The fruit salad consisted of cut watermelon, cut cantaloupe, cut honey dew, cut pineapple, and grapes. There was no thermometer in the refrigerator to determine the internal ambient temperature of the refrigerator. In a concurrent interview on 6/8/21 at 2:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated staff were not allowed to store food for residents brought in from visitors. She said there was no refrigerator to store this type of food. She confirmed the food labeled with resident names and room numbers were residents at the facility. In an interview on 6/8/21 at 2:30 p.m., the Director of Nursing (DON) stated there was not a refrigerator to store food for residents brought in by visitors. She stated she worked at the facility for 5 months and never went upstairs to look in the staff break room refrigerator. She said food brought in from outside was not allowed but sometimes if a resident did not eat well it was allowed. She stated food was not allowed from outside because of concern with infection control as well as the possible contraindication with physician diet orders. She said she encouraged families to not bring in food for residents. The DON looked in the staff refrigerator and confirmed there was food inside labeled with resident name and room numbers. She stated the refrigerator was supposed to be only for staff food. She said nursing was not trained on storing food safely in refrigerators for residents. She said she did not know the appropriate storage temperature for refrigerated foods. The DON confirmed there was no thermometer in the staff refrigerator. A concurrent observation on 6/8/21 at 2:30 p.m., showed the temperature of the melon in the fruit salad was 44 degrees Fahrenheit when measured with a calibrated digital thermometer. In an interview on 6/8/21 at 2:54 p.m., Certified Nursing Assistant 3 (CNA 3) stated she was caring for resident 255 that day. She stated when she came in for her shift that morning the resident had 055715 Page 17 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many food brought in by visitors at her bedside. CNA 3 stated there were 2 plastic containers of fruit salad and a vegetable platter. She labeled the bag that contained a fruit salad with the resident's room number and placed it in the staff refrigerator at 7:30 a.m. that morning. She left one fruit salad and the vegetable platter at the resident's bedside. She stated she did not know anything about safe food storage temperatures. An observation and interview with resident 255 at 3 p.m., showed she had a vegetable platter and a plastic container of fruit salad. The fruit salad was half full. The resident stated a family member brought the food in for yesterday evening. She said she wanted to keep the fruit salad at her bedside and eat some more of it. In an interview on 6/9/21 at 12:25 p.m., the RD stated no outside food was allowed for residents as long as she was the RD for the facility which was 5 years. She stated she was not aware of any training for nursing about safe food storage. She said yogurt should not be in the refrigerator if the refrigerator is not being monitored for temperatures. She also stated cut melon is a potentially hazardous (time temperature control for safety food; food that has an increased potential to grow bacteria if it is not stored safely.) According to the 2017 Federal Food Code, Time/Temperature Control for Safety Food is to be held at 41 degrees F or less when time is not used as a control. 055715 Page 18 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 4. During a review of the employee symptoms screening log in the presence of the Director of Nursing (DON), three staff members CNA 4, 5 and 6 were not screened for COVID-19 symptoms on Sunday 6/6/21 prior to providing care for residents. Residents Affected - Some During an interview on 6/09/21, at 8:54 a.m., the DON stated screening logs are checked by the Medical Record Designee (MRD) who is responsible for collecting the forms. During an interview on 6/09/21, at 8:47 a.m., MRD stated she only collects and keep the screening logs. MRD stated I do not verify for accuracy. During an interview on 6/09/21, at 10:11 a.m., the Administrator (Admin) stated she was responsible for verifying that all staff are screened for COVID-19 symptoms prior to proving residents care. The facility's policy and procedures, titled, COVID-19: Clinical Protocol undated, indicated All staff will be required to answer screening questionnaire and have their temperature checked before the beginning of each shift or start of work. Based on observation, interview and record review the facility failed to provide a safe and sanitary environment for four (Residents 21, 26, 36, and 255) of 57 sampled residents, as evidenced by: 1) Nurse did not disinfect and clean BP cuff between using the BP cuff on residents 26, 36, 255 2) Nurses did not follow manufacturer's directions for SaniWipe use on medication baskets 3) Certified Nursing Assistant did not perform hand hygiene after doffing gloves and assisting a resident 4) The facility did not screen staff members for COVID-19 symptoms on 6/6/21 prior to providing care for the residents. . These failures had the potential to result in cross contamination and infection. Findings: 1. During an observation on 6/8/21, at 8:35 am., Registered Nurse (RN)2 removed wrist blood pressure (BP) cuff from his own wrist and placed it directly on the left wrist of Resident 255. After measuring Resident 255 BP. RN 2 removed the BP cuff from Resident 255's wrist and placed it back on his wrist. The BP cuff was not cleaned or disinfected prior to or after use with Resident 255. During an observation on 6/8/21, at 8:50 a.m., RN 2 removed wrist BP cuff from his own wrist and placed it directly on the left wrist of Resident 36. The BP cuff was not cleaned or disinfected prior to or after use with Resident 36. During an observation on 6/8/21, at 9:10 a.m., RN 2 removed wrist BP cuff from his own wrist and placed it directly on the left wrist of Resident 26. The BP cuff was not cleaned or disinfected prior 055715 Page 19 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0880 to or after use with Resident 26. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/10/21, at 7:30 a.m., with RN 2, RN 2 stated the wrist BP cuff is from his personal home, and that he cleaned the wrist BP cuff after his shift and not between residents. RN 2 stated if a resident was on isolation he would clean between residents but not if the residents are not on isolation. RN 2 stated he was unsure if the facility had a policy that stated he needed to clean the BP cuff between resident use. Residents Affected - Some During an interview on 6/10/21, at 8 a.m., with the DON, the DON stated BP cuffs are to be cleaned between resident use to maintain infection control. During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 7/2014, it indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard, and Reusable items are cleaned disinfected or sterilized between residents. 2. During an observation on 6/8/21, at 8:45 a.m. and 9:05 a.m., Registered Nurse (RN) 2 wiped the medication basket on the medication cart using Sani-Cloths, and immediately used the basket During an observation on 6/8/21, at 9:45 a.m. and 10:10 a.m., Licensed Vocational Nurse (LVN) 2 wiped the medication basket on the medication cart using Sani-Cloths, and immediately used the basket. During an concurrent observation and interview on 6/10/21, at 7:30 a.m. RN 2 stated he didn't look at the Sani-Cloth germicidal disposable wipe container regarding the wet time or kill time. RN 2 stated he had not read the Sani-Wipe guidelines. During a review of the Sani-Wipe germicidal disposable wipe container on 6/9/21, at 8:10 a.m., it indicated to Allow surface to remain wet for three (3) minutes. Let air dry and Bactericidal, tuberculosis, virucidal in 3 minutes. During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Environmental Surfaces, dated June 2009, indicated Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions and By law, all applicable label instructions on EPA-registered products must be followed. 3. During an observation on 6/7/21, at 10:45 a.m., in Resident 5's room, Certified Nursing Assistant (CNA)1 touched the bedside commode (BSC), it's lid, seat and handles, that was located at the foot of Resident 5's bed. After CNA1 touched the BSC she doffed her gloves, then placed Resident 21's cup on the bedside table. CNA1 did not perform hand hygiene (HH) after she doffed her gloves. During an interview on 6/7/21, at 10:50 a.m., with CNA 1, CNA 1 stated that she should have sanitized her hands after she doffed her gloves, and before she helped Resident 21. During a review of handwashing in-services, dated 12/14/20 and 10/29/20, CNA 1 was signed-in at both in-services. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, 055715 Page 20 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0880 Level of Harm - Minimal harm or potential for actual harm dated August 2015, indicated This facility considers hand hygiene the primary means to prevent the spread of infections, and Use an alcohol-based hand rub . or alternatively soap . and water for the following situations:. After contact with blood or bodily fluids; l. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident;. After removing gloves and Hand Hygiene is the final step after removing and disposing of personal protective equipment. Residents Affected - Some 055715 Page 21 of 22 055715 06/10/2021 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0912 Level of Harm - Minimal harm or potential for actual harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation and interview, the facility had seven resident's rooms (Rooms A, B, C, D, E, F, G and H) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. Residents Affected - Few This deficient practice had the potential to result inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 6/7/21, at 10:00 a.m.,. the following rooms and corresponding square footage per bed were identified: Room number A and B has three beds, total SQF is 235.30 and SQF per bed is 78.42. Room number C has five beds and total SQF is 463.33 and SQF per bed is 97.41. Room number D, E, F and G has six beds, total SQF is 465.60 and SQF per bed is 77.59. Room number H has five beds and total SQF is 406.28 and SQF per bed is 86.43. During random observation of care and services from 6/7/21 to 6/10/21 there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident's care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns the eight rooms. Granting of room size waiver recommended. 055715 Page 22 of 22