Health inspection·July 19, 2021

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs of the residents for three of five sampled residents (Resident 2, Resident 28 and Resident 31) when: 1. Resident 28 and 31 did not have a resident-centered care plan intervention for safe handling, humidification (process to provide moisture content to the air), and cleaning of oxygen (O2 - supplemental oxygen to supply oxygen to the lungs) therapy use; and 2. Resident 2 did not have the use of fall prevention signs implement in her room as one of the interventions to prevent falls. These failures had the potential to result in Resident 2, 28, and 31's identified care needs to go unmet. Findings: During an observation with Resident 31, on 7/13/21, at 12:19 p.m., in Resident 31's room, Resident 31 laid comfortably on the bed with O2 concentration at 4.5 liters per minute (lpm- unit per measure) via nasal cannula (a small flexible tube that contains two open prongs inside nostrils) with no date label, and no water in the unlabeled humidifier bottle (to provide moisture and prevent airways from getting too dry especially for long-term use). During an observation with Resident 31, on 7/14/21, at 1:40 p.m., in Resident 31's room, Resident 31 laid comfortably on bed with O2 concentration at 4.5 liters per minute (lpm) via nasal cannula with an unlabeled empty humidifier bottle. During a review of Resident 31's Face Sheet (resident profile information), dated 7/14/21, the face sheet indicated, Resident 31 was admitted to the facility on [DATE] with diagnoses which included, Type 2 diabetes mellitus (high blood sugar level), asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), generalized anxiety disorder (a disorder characterized by feelings of apprehension, worry, uneasiness), chronic pain and hypertension (high blood pressure). During a review of Resident's 31's Order Summary Report, dated 7/14/21, the order summary Page 1 of 40 055799 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated, oxygen at 2 lpm via nasal cannula or mask prn (as needed) for dyspnea (labored breathing). Call hospice (care for the sick or terminally ill) with titration (measure and adjust according to response) if needed. Resident 31 was transitioned (changed) from long term care to hospice on 6/28/21. During a review of Resident 28's Face Sheet, dated 7/14/21, the face sheet indicated, Resident 28 was admitted to the facility on [DATE] with diagnoses which included, morbid obesity, obstructive sleep apnea (slowed or stopped breathing), hypertension (high blood pressure), claustrophobia (extreme fear of confined places). During a review of Resident 28's Order Summary Report, dated 7/14/21, the order summary report indicated, O2 at 2 liters to 4 liters via nasal cannula or mask as needed for shortness of breath. During a concurrent observation and interview, with Licensed Vocational Nurse (LVN) 1 and Director of Staff Development (DSD), on 7/14/21, at 1:52 p.m., in Resident 31's room, LVN 1/DSD validated Resident 31's O2 had an undated nasal cannula and the unlabeled humidifier bottle had no water in it. LVN 1/DSD stated, Resident 31's humidifier was not changed and recognized the humidifier bottle was from hospice care. LVN 1 /DSD stated, the purpose of water in the humidifier was to keep resident's nose from getting dry and routine changing of the cannula will prevent build-up of bacteria, which may lead to infection. LVN 1/DSD stated, the expectation was for the licensed nurses to change the nasal cannula and humidifier bottle every Sunday night or sooner as needed. During a concurrent observation and interview, with LVN 1 /DSD, on 7/14/21, at 2:10 p.m., in Resident 28's room, LVN 1/DSD stated, Resident 28's nasal cannula and humidifier bottle were not labeled with date changed. She stated Resident 31's cannula and humidifier should had a labeled date to ensure both (cannula and humidifier bottle) were changed on a weekly basis. During a concurrent interview and record review, on 7/14/21, at 2:36 p.m., with Minimum Data Set Coordinator (MDSC), Resident 31's Care Plan and Treatment Medication Record (TAR) dated 7/14/21 was reviewed. The TAR for Resident 31 indicated, it had no respiratory care plan interventions, they had no assessments and monitoring for resident's use of oxygen, care, risks, and complications such as skin integrity issues with the long term use of nasal cannula and humidifier. MDSC stated, the admitting licensed nurse should had initiated Resident 31's care plan for oxygen use on admission from transitioned to hospice care on 6/28/21. During a concurrent interview and record review, on 7/16/21, at 1:30 p.m., with Infection Preventionist (IP), Resident 28's Clinical Records was reviewed. IP stated, Resident 28's oxygen use was ordered 4/26/21 and had no documentation in place for Resident 28's oxygen care plan interventions and monitoring [date label water change humidifier]. During an interview on 7/19/21 at 2:06 p.m., with Director of Nursing (DON), DON stated, licensed nurses should be responsible in initiating a resident's care plan on admission and the Interdisciplinary Team (IDT- a group of health care professionals with different areas of expertise who work together towards the goals of the resident) should discuss, review and revise the care plan interventions for all residents. During a review of the facility's policy and procedure titled, Oxygen Administration (via Nasal Cannula), undated, indicated, . Procedure: (for humidified oxygen): Observe for patient sensitivity to oxygen administration, such as nasal dryness, which may indicate the need for humidification 055799 Page 2 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some .Infection Prevention: Replace tubing and cannula weekly or as needed .Documentation: Date and time, method of oxygen administration and rate of flow, patient's response to oxygen therapy .as ordered . 2. During a concurrent interview and record review, on 7/15/21, at 2:04 p.m., with Infection Preventionist (IP), Resident 2's Fall Care Plan Interventions dated 6/27/21 was reviewed. The fall care plan intervention indicated, Staff to place reminders in room to call for staff when requiring assistance. The IP stated Resident 2 transferred herself to and from her wheelchair and required limited assistance. During a concurrent observation, interview, and record review, on 7/16/21 at 2:25 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 2's Care Plan for the fall, dated 6/27/21 was reviewed. The care plan indicated, place reminder signage in the room to call for staff when requiring assistance. LVN 2 observed Resident 2's room and stated there were no signs up and did not recall they had been up. LVN 2 stated, Resident 2 could read signs and the reminder could had helped prevent a fall. LVN 2 stated, the interdisciplinary team (IDT - a team of staff members who coordinate care and document communication related to resident's plan of care and treatment goals) had initiated the intervention. LVN 2 stated, usually one of the IDT members would had put up signs and communicate verbally with the nursing staff. LVN 2 stated she had not seen the updated care plan intervention to put up signs in Resident 2's room. During an interview on 7/16/21, at 3:08 p.m., with the Social Service Director (SSD), the SSD stated, the IDT discussed the intervention for the care plan and should had been communicated to the nurse. The SSD stated, signs were important to be placed in Resident 2's room since Resident 2 needed reminders to call for assistance. During an interview on 7/16/21, at 3:32 p.m., with the Minimal Data Set Coordinator (MDSC - responsible for resident comprehensive standardized assessment of resident function and health needs), the MDSC stated, the IDT updated the care plan with the new intervention. The MDSC stated, it was the usual practice of an IDT member to inform the certified nurse assistants (CNA's) and nurses to put signs in Resident 2's room. The MDSC stated, it was important to put up signs for Resident 2's safety. During an interview on 7/16/21, at 3:45 p.m., with the Director of Nurses (DON), the DON stated, signs should had been put in Resident 2's room to decrease the risk of a fall. The DON stated, After we [IDT] reviewed [the fall], we agreed on interventions then signs were to be made and put in room. I recalled we made the signs, and someone put them up .I'm shocked it's[the signs] were not there During a review of Resident 2's Long term care plan, dated 12/23/2020, the long term care plan indicated, At risk for falls related to Dx ([Diagnosis) of DM (diabetes mellitus - high blood sugar) and HTN (hypertension-high blood pressure) .Interventions .6/28/21 .Staff to place reminders in room to call for staff when requiring assistance. During a review of Resident 2's Brief Interview for Mental Status (BIMS-structured evaluation aimed at evaluating aspects of cognition in elderly residents), dated 7/1/21, the BIMS indicated, summary score 7 (significant cognitive impairment). During a review of the facility's policy and procedure titled, Care Planning Process dated 12/11/17, indicated, .The interdisciplinary team should prepare a comprehensive person centered care plan with the patient/resident and if applicable, the resident representative, to assist the 055799 Page 3 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0656 Level of Harm - Minimal harm or potential for actual harm patient/resident to reach his/her highest practicable level. The care planning process will begin upon admission to the center . 4. The care plan will be person centered and incorporate the patient/resident's goals of care and treatment. Residents Affected - Some 055799 Page 4 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status, when: Residents Affected - Some 1. The facility failed to ensure a Registered Dietitian (RD) evaluated or reassessed Resident 31's nutritional status timely, in order to recommend nutritional interventions, after an unplanned severe and continuous weight loss of 23.9% (percent) over eight months. The facility failed to intervene timely when Resident 31's weight loss began despite documented meetings acknowledging weight loss. There was no evidence demonstrating recommended interventions were implemented from 2/21 to 7/21. The was no plan of care to address the weight loss and prevent further weight loss. During the weight loss, Resident 31 also acquired a pressure ulcer to the coccyx. 2. The facility's Registered Dietitian failed to identify an unplanned severe weight loss in a timely manner or to recommend nutritional interventions for Resident 5, during which time the weight loss had continued. Resident 5 had a severe weight loss of 10 pounds (5.1%) in one week and 20 pounds (9.7%) in one month. As a result, the facility's system was not effective at ensuring the Registered Dietitian evaluated unplanned severe weight loss. The facility failed to consistently ensure that nutrition interventions to address identified nutritional concerns were implemented. These failures resulted in Resident 31 experiencing an unplanned severe weight loss of 29 pounds in eight months, which put the resident at risk for further decline in health and for Resident 5 at risk for undesirable weight loss. Findings: During a review of the facility's policy and procedure titled Weight Monitoring dated 12/31/16, indicated in order to monitor nutrition and hydration, height and weight would be obtained. It indicated weight is recorded by the nursing department upon admission, monthly and often if risk is identified. It indicated all weights will be reviewed by the Interdisciplinary team (IDT). The IDT will determine all referrals to other healthcare professionals. It indicated when weight change is significant or severe, the licensed nurse will notify the resident's physician and notify the resident's family member. It indicated the facility will have a Nutrition Risk Committee and this committee should meet regularly to determine possible reasons for weight loss and make recommendations to prevent further unplanned changes. It indicated suggested parameters for evaluating significant of unplanned and undesired weight loss: One month - 5% significant loss, greater than 5% severe loss Three month - 7.5% significant loss, greater than 7.5% severe loss Six months - 10% significant loss, greater than 10% severe loss According to the American Academy of Family Physician journal, indicated Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. (American Family Physician, February 15, 2002/Volume 65, Number 4) According to the American Academy of Family Physician journal, indicated Involuntary weight loss 055799 Page 5 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0692 Level of Harm - Actual harm Residents Affected - Some can lead to muscle wasting, .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician) According to the 2009 National Pressure Ulcer Advisory Panel [NAME] Paper, indicated Compromised nutritional status such as unintentional weight loss, undernutrition, protein energy malnutrition (PEM), and dehydration deficits are known risk factors for pressure ulcer development. (The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel [NAME] Paper, 2009) 1. During a review of Resident 31's admission Face Sheet, indicated Resident 31 was admitted to the facility on [DATE]. Resident 31's diagnoses included Type 2 Diabetes Mellitus [adult onset diabetes, when the pancreas (a large gland behind the stomach) does not produce enough insulin - a hormone that regulates the movement of sugar into your cells - and cells respond poorly to insulin and take in less sugar], Gastro-esophageal reflux disease (a condition in which acidic gastric fluid flows backward into the esophagus - connects the throat to the stomach, resulting in heartburn), generalized anxiety disorder, major depressive disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), recurrent chronic pain and unspecified dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) without behavioral disturbance to name a few. During a review of Resident 31's Minimum Data Set (MDS), a standardized assessment and care-planning tool, dated 5/28/2021, the MDS indicated Resident 31 had a BIMS (Brief Interview for Mental Status) score of 14 which indicates cognitively (thought process) intact. The MDS indicated Resident 31's Mood regarding poor appetite was present. The MDS indicated Resident 31 was not on a physician-prescribed weight loss regimen. During a review of the physician's orders dated, showed the following: 2/11/20, a regular diet; 2/11/20 Mitazapine (Remeron - medication for depression and may cause weight gain) 15 milligrams (mg) for depression 2/22/20 Remeron 15 mg for appetite 7/15/20 Remeron 7.5 mg until discontinued 7/9/21 6/14/21, a Controlled Carbohydrate Diet (CCHO - a diet for people with diabetes (disorder in which the body does not produce enough or respond normally to insulin [hormone that regulates the amount of glucose in the blood], causing blood sugar (glucose) levels to be abnormally high) to help stabilize blood glucose levels [sugar in the blood]); 6/28/21, an order to admit resident to hospice (providing care for the sick or terminally ill) with 055799 Page 6 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0692 terminal diagnosis (disease which can not be cured and likely to dead to death) Alzheimer's disease (progressive mental deterioration, due to generalized degeneration of the brain); Level of Harm - Actual harm 7/8/21, showed a regular diet; and Residents Affected - Some 7/15/21 showed regular diet, puree texture, honey thickened liquids (slightly thicker, less pourable and drizzle from a cup). During a review of Resident 31's weights and vitals summary showed: 10/1/20 - 119 pounds (lbs.) 11/2/20 - 121 lbs. 12/1/20 - 119 lbs. 1/4/21 - 115 lbs. 2/1/21 - 112 lbs. 3/2/21 - 109 lbs. 4/2/21 - 105 lbs. 5/1/21 - 104 lbs. 6/2/21 - 100 lbs. 7/1/21 - 92 lbs. Based on the weight history from 11/20-1/21 it was noted Resident 31 lost 6 pounds (4.9%), while it did not reach the threshold of significant or severe weight loss in accordance with the Weight Monitoring policy it demonstrated a pattern for concern. There was no indication the facility recognized or evaluated this weight loss pattern. Beginning in January 2021 Resident 31 consistently demonstrated significant and severe weight loss, in accordance with the Weight Monitoring policy, through multiple timeframes. A loss of 9 pounds (7.4%) from 11/20-2/1/21, 7.5% is considered significant. A weight loss of 14 pounds (11.76%) from 10/20-4/21 is considered severe. Resident 31 lost a total of Resident 31 lost a total of 29 pounds (23.9%) from 11/20-7/21. According to the Journal of the American Dietetic Association (currently called the Academy of Nutrition and Dietetics), indicated Unintended weight loss is defined as a gradual, unplanned weight loss that may occur slowly over time or have a rapid onset. In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost. (Journal of the American Dietetic Association, October 2010/Volume 110, Number 10). During a review of the facility's nutrient analysis for the menu, indicated on average the regular diet provided 2220 calories, 97 grams of protein per day. During a review of Resident 31's meal intake record from 11/20 to 12/20, Resident 31's oral intake 055799 Page 7 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0692 Level of Harm - Actual harm Residents Affected - Some had an average range from 43% to 49%. Resident 31's meal intake provided approximately on average 1021 calories and 44 grams of protein when compared to the facility menu's nutrient analysis. Resident 31's meal intake record from 1/21 to 2/21, had an average range from 48% to 51%. Resident 31's meal intake provided approximately on average 1100 calories and 48 grams of protein when compared to the facility menu's nutrient analysis. Resident 31's meal intake record from 3/21 to 4/21, average range from 54% to 61%. Resident 31's meal intake provided approximately on average 1275 calories and 56 grams of protein when compared to the facility menu's nutrient analysis. Resident 31's meal intake record from 6/21 to 7/21, average range from 21% to 39%. Resident 31's meal intake provided approximately on average 660 calories and 29 grams of protein when compared to the facility menu's nutrient analysis. During a review of Resident 31's Nutrition Note dated 2/11/21, Registered Dietitian (RD) 2 notes indicated resident expressed difficulty chewing meat, she refused alterations to the texture of the meat and requested partials for missing teeth. RD 2 indicated Resident 31's request was discussed with interdisciplinary team (IDT). There was no mention of the weight loss. There was no documentation of nutritional interventions. During a review of Resident 31's Nutrition Data note dated 2/25/21, completed by the Dietetic Service Supervisor (DSS 2), indicated Resident 31's oral intake was 65% and her weight was down by 2.6% in one (1) month, following a 5% loss in six (6) months. DSS 2 indicated she offered Resident 31 a supplement (oral nutrition supplement) due to decreased intake and that resident remains in room for all meals due to protocol for COVID-19 (a highly contagious viral lung infection) pandemic and that they will continue to monitor monthly weights and intake. While there was recognition of decreased oral intake it was not possible to determine if and when the supplement was initiated. During a review of Resident 31's Nutrition assessment dated [DATE], completed by RD 2, indicated Resident 31 estimated needs were 1300 calories and 50 grams protein, and that her intake was meeting her estimated needs. It indicated there was no significant nutrition issues, current nutrition interventions and nutrition goals were not applicable (n/a). It indicated Resident 31 had gained 7 lbs. per year, her intake averaged >25% this past week on the regular diet and no physical signs of malnutrition. It stated Resident 31 refuses a texture change and stated, I need partials. RD 2 indicated that Resident 31 was at risk for weight loss. There was no mention of the 9 lbs. (7.4%) weight loss that occurred in the previous three (3) months or the monthly 3 lbs. (2.6%) weight loss. There was no timely follow up. During a concurrent interview and review of Resident 31's clinical record with RD 1 on 7/15/21 at 11:06 AM, she stated for weights they monitor significant changes which are 5% in one month, 7.5% in three (3) months or 10% in six months for either a gain or loss but focus is on weight loss. When asked about if a resident is at 7.4% in 3 months, RD 1 stated yes we want to look at that but we aren't there yet with this group and the goal is to look at those so they do not flip over to a significant weight loss. RD 1 stated it looked like at their report that Resident 31 triggered for weight loss in April. When reviewing RD 2's Nutrition assessment dated [DATE], RD 1 acknowledged RD 2 was looking at the annual weights not what was going on currently. During a review of Resident 31's Nutrition Data note dated 5/28/21, completed by DSS 2, indicated Resident 31's weight was 104 lbs., had weight loss of 10% or more in the last six (6) months (11/20-5/21) and was not on a prescribed weight-loss regimen. It indicated Resident 31's average oral intake was 75% per day. DSS 2 indicated a supplement was offered due to decreased intake and there was noted a pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged 055799 Page 8 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0692 Level of Harm - Actual harm pressure on the skin on coccyx (base of the spinal column). DSS 2 indicated will continue to monitor monthly weights and intake. Despite a recognized severe weight loss indicated on the Weight and Vitals Summary, there was no indication Resident 31 was referred to the RD. While the note documented offering a supplement, there was no indication when and if the supplement was implemented. Residents Affected - Some Review of Resident 31's weight note dated 5/28/21, completed by the Director of Nurses (DON), indicated Resident 31 had lost 17 lbs. in six (6) months (11/20-5/21) and had been staying in her room since the pandemic. It indicated prior to pandemic resident was up and about eating snacks often, has acquired a pressure ulcer and her current intake fluctuates. It indicated will have staff encourage resident to get up in wheelchair and will add protein to her diet. While the note identified a change in eating patterns, there was no indication the facility attempted to reinstate Resident 31's snack pattern. Similarly, the DON recommended the addition of extra protein to facilitate wound healing, there was no indication of implementation. During an interview with DSS on 7/15/21 3:08 PM, while looking at computer with Resident 31's profile card to see if resident on any supplements or added protein. DSS stated the House Supplement (oral liquid supplement) three times a day (TID) changed to honey thick liquids today. DSS stated she is notified by nursing of supplement orders and nursing will write that on a paper then she would shred it. When asked how we would see if there is more protein added on the meal ticket for Resident 31, the DSS stated we would see the profile card show more protein at each meal, but she does not see anything like that. DSS stated she was not sure if it ever came by a paper document from nursing since she shreds them. DSS stated she cannot tell when house supplement was added in her computer system but getting it three times a day. There was no evidence that the recommendations from 5/28/21 were implemented. It is unclear what date the supplements were started to know how long they were in place. During a review of Resident 31's general note completed by Social Services Director (SSD) dated 5/28/21, indicated they asked Resident 31 if she was interested in being referred to the dentist for dentures. Resident 31 wanted the referral since she only had eight (8) teeth then later came back and said she did not want dentures. This was three (3) months after Resident 31 requested partial dentures to RD 2 and RD 2 stated she would request to the IDT in the Nutrition Note dated 2/11/21. During a review of Resident 31's weight note dated 6/16/21, indicated Resident 31 had an additional nine pound (7.5%) weight loss since March, on Mitazapine (Remeron - medication for depression and may cause weight gain) 7.5 milligrams and she is on a CCHO diet with an intake of 48%. It indicated to ask the Physician if they can increase Remeron, sugar free house supplements (liquid nutrition supplement) twice a day, and a multivitamin with mineral daily. It indicated to continue weekly weights. RD 1, DON, DSS present for the weight meeting. There was no evidence provided to show this recommendation was communicated to the physician. During a clinical record review of Resident 31 and concurrent interview with RD 1 on 7/15/21 at 11:06 AM, RD 1 stated we need to see if there is documentation in other binder to see if Resident 31 was put on weekly weights in May or June. During an interview with DON on 7/15/21 at 3:38 PM, DON confirmed there was no weekly weights ever taken on Resident 31 for that time. Review of Resident 31's weight note dated 7/8/21, indicated Resident 31 was admitted to hospice on 6/28/21 and she had a pressure ulcer to the coccyx. It indicated Resident 31 is down eight (8) lbs. over the last month and the oral intake has been 26% over the last week. It indicated Resident 31's weight is down 23 pounds over the last six months (1/21-7/21). The IDT recommended health shakes 055799 Page 9 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0692 (oral nutrition supplement) twice a day, multivitamin with minerals once a day, discontinue CCHO diet and to increase Remeron. DON, DSS, RD 1 and SSD present for the weight meeting. Level of Harm - Actual harm Residents Affected - Some During a review of Resident 31's Care Plans, there were only two care plans that mentioned appetite. Care Plan with focus indicated the resident felt sad and had no appetite dated 2/18/20, showed an intervention to offer me food and beverages I like initiated 2/18/20. It further showed all the interventions/tasks were initiated 2/18/20 and 2/28/20. There were no updated interventions after 2/28/20. Care Plan with focus indicated had behaviors which include episodes of depression m/b poor appetite of eating less than 50% dated 2/21/20, showed an intervention to offer me food and beverages I like initiated 5/27/20. There were no updated interventions since 5/27/20. There were no Care Plans specific to Nutrition or weight loss in the clinical record. Review of Resident 31's clinical record, indicated Resident 31 expired on 7/16/21. During an interview and concurrent review of Resident 31's clinical record with DON 7/15/21 at 4:11 PM, DON confirmed she could not find any orders for any of the recommendations made by the IDT in the clinical record. DON stated there should be an order for the house supplement in the clinical record. DON stated Resident 31 used to come to buy snacks of Cheetos and Pepsi before Covid-19 pandemic and get 5 bags of the chips at a time. DON stated prior to Covid-19 the family would also buy and bring in Cheetos, but they offered these snacks during Covid-19 but Resident 31 did not want that anymore. During a review of the facility's document titled DTH Nutrition Intervention Flow Sheet revised 1/2018, indicated if there was severe/significant weight loss or need for increased calories due to wound healing or other causes gave examples of 32 different types of interventions such as: monitoring weights weekly, involving speech therapy (evaluation of swallowing), to changing diet orders to include fortified foods (adding additional calories and/or protein to foods) and using foods first approach, adding supplements, meal time assistance, adding snacks, adding a med pass 2.0 supplement protocol (oral nutrition supplement), request psych referral and med review for depression and consider appetite stimulants. The document also indicated IDT considerations/areas to evaluate when determining root cause for weight loss or poor intake. The document listed approximately five to 10 things under each group ranging from suggestions for family, checklist for nurse, labs, food considerations, environmental considerations and a list of changes in taste/sensory, dental, feeding ability, motor agitation. 2. According to the Nutrition in Clinical Practice journal, indicated Adequate nutrients from oral intake should be demonstrated prior to discontinuing tube feeding. (Nutrition in Clinical Practice, August 2014, Volume 29, Number 4) During a review of Resident 5's admission Face Sheet, the Face Sheet indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included Gastrostomy (G-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food) and Gastrointestinal hemorrhage (Gastrointestinal (GI) bleeding is a symptom of a disorder in your digestive tract), to name a few. admission weight was 195 pounds. admission diet order was tube feeding of Jevity 1.2 (liquid nutrition) 100 milliliters (ml) for a total 1500 ml and 1800 calories. During a review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care-planning tool, dated 4/8/21, the MDS indicated Resident 5 had a BIMS (Brief Interview for Mental Status) of 13 to indicate cognitively intact (no evidence for dementia or cognitive impairment). The MDS 055799 Page 10 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0692 indicated Resident 5 was not on a physician-prescribed weight loss regimen. Level of Harm - Actual harm During a review of the physician's orders for Resident 5, dated 4/1/21 the diet was changed to a regular mechanical soft diet (soft and easy to chew). Residents Affected - Some During a review of Resident 5's Weights and Vitals Summary, showed: 3/26/21: 195 lbs. 4/2/21: 185 lbs. 4/12/21: 179 lbs. 4/19/21: 180 lbs. 4/26/21: 176 lbs. Based on the weight history, Resident 5 had 10 lbs. (5%) severe weight loss in the first week and 19 lbs. (9.74%) severe weight loss in the month (one month). During an interview with Resident 5 on 7/15/21 at 9:28 AM, Resident 5 stated he got the Gastrostomy tube (G-tube) placed at hospital since he had a GI bleed. Resident 5 stated he was told he lost weight and quite a bit of it a while back. Resident 5 stated he did not want to lose weight. He stated the SSD told him he had lost weight but no one else did. He stated his appetite is good and he doesn't have any problems with chewing or swallowing. He stated he will eat sometimes snacks at night if he wants them. When asked, Resident 5 stated no one talked to him about slowing down the Tube feeding from the tube slowly while he was starting to eat by mouth. Resident 5 stated no one talked to him about losing weight slowly/gradually. Resident 5 stated he doesn't remember the dietitian (RD) or anyone from the kitchen ever coming in to talk to him about his weight or adding anything to his meals to slow his weight loss. During a review of Resident 5's Nutrition Data dated 4/7/21, completed by DSS 2, at the time of admission indicated Resident 5 was a readmission to the facility. Resident 5 was noted to have a G-tube and receiving Jevity 1.2 100 ml which was on hold since 3/30/21. It indicated Resident 5 had swallowing and dental problems and with an average oral intake of 52%. DSS 2 indicated Resident 5's weight was 196 lbs. on 9/2/20, and when Resident 5 returned to the facility on 3/26/21 the resident was 195 lbs. and was 185 lbs at the time the note was written. The note also indicated a 10 lbs. weight loss (5.1%), which is considered severe in accordance with the Weight Monitoring policy. It indicated Resident 5 was not on a prescribed weight loss regimen. DSS 2 indicated will monitor. No interventions were done at this time. During a review of Resident 5's Nutrition Note dated 4/13/21, RD 2 indicated Resident 5 lost six (6) lbs. in one week (4/2/21-4/12/21). RD 2 indicated Resident 5 expressed difficulty eating toast, requesting softer foods like pancakes and French toast, fruit and peanut butter. RD 2 indicated food preferences were updated. RD 2 did not mention Resident 5 had lost 16 lbs. (8.2%) since admission (18 days). During a review of Resident 5's meal intake record dated 4/1/21 to 4/30/21, indicated Resident 5 on average was eating 59% of his meals. During a review of the facility's nutrient analysis for the 055799 Page 11 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0692 Level of Harm - Actual harm Residents Affected - Some menu, indicated on average the regular diet provided 2220 calories, 97 grams of protein per day. Resident 5's meal intake provided approximately on average 1300 calories and 57 grams of protein when compared to the facility menu's nutrient analysis. During a review of Resident 5's Nutrition assessment dated [DATE], RD 2 indicated Resident 5's estimated nutrition needs were 2100 calories and 80 grams protein. RD 2 indicated the total nutrition intake meets estimated nutrition needs and a Nutrition Diagnosis of Swallowing difficulty related to medical diagnosis as evidence by need for mechanically soft diet and history of G-tube. RD 2 indicated the current interventions were the mechanical soft diet and a nutrition goal to consume greater than 75% of meals. RD 2 indicated his intake fluctuated this past week and diet was appropriate. RD 2 indicated Resident 5 was at risk for weight loss, pressure injury, dehydration and nutrition needs were met. RD 2 did not acknowledge Resident 5 had 15 lbs. (7.6%) weight loss since admission (3/26-4/26/21, 27 days prior). There were no interventions at this time for his weight loss. During a concurrent interview and review of Resident 5's admission Face Sheet, Nutrition Note, Nutrition Assessment, IDT note, physician orders with RD 1 on 7/15/21 starting at 10:24 AM, RD 1 stated she would expect RD 2 would acknowledge the weight loss in that time frame and that did not happen. During an interview with RD 1 on 7/15/21 at 10:43 AM, she stated the facility may have weight meetings and could be somewhere else other than the electronic medical record. RD 1 stated the facility should schedule a weight meeting within two weeks after the weight loss occurs. RD 1 stated two weeks would be the longest window before meeting about the weight loss. RD 1 acknowledged that she could not find anything in clinical record to see that happened and she would expect interventions should be done during that window when weight loss was occurring. During an interview with DON on 7/15/21 at 4:17 PM, the DON confirmed that she could not find any interventions or other weight notes for the resident during the one-month weight loss (3/26-4/26/21). During an interview with on 7/16/21 at 11:25 AM, RD 1 stated in general the gradual slowing of the tube feeding formula (liquid nutrition), would include continuing the tube feeding in conjunction with oral intake. Once the oral intake was adequate, the tube feeding would be discontinued. 055799 Page 12 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: Residents Affected - Some 1. Controlled (drugs with high abuse potential subject to special handling, storage, disposal, and record keeping) drug accountability, when Resident 197's medication, a controlled medication was only accessible to authorized personnel 2. Provider's orders were carried out for Resident 46 These failures increased potential for drug diversion by allowing unauthorized access to Resident 197's controlled medication, and delayed the administration of medication for Resident 46. Findings: 1. During a concurrent observation and interview on 7/13/21, at 9:20 a.m. in the facility's medication room, with Licensed Vocational Nurse (LVN) 2, tramadol, a controlled medication for pain, was observed in a black bag on top of the counter. LVN 2 stated when the tramadol was discontinued for Resident 1, and acknowledged it should not have been left on the counter. LVN 2 stated, controls should not be left in bag, someone did not go through bag . control meds should be double locked in medication cards so no one but licensed nurses get to it . control was not logged in, process is to make a count sheet and count all medication that was brought in. During a review of the facility's Medication Reconciliation record for Resident 1, the Medication Reconciliation record indicated, Resident 1's provider discontinued tramadol on 7/3/21. During an interview on 7/13/21, at 2:59 p.m., with Director of Nursing (DON), DON stated the expectation for staff regarding controlled medications brought in by resident was for two nurses to count the controlled medication and document on a count sheet. If the controlled medication is discontinued, it should be handed to the DON, locked in a separate compartment and later destroyed. DON acknowledged the potential for diversion if a control medication was not counted, logged and separated locked, and easily accessible to unauthorized staff. During a review of the facility's policy and procedure (P&P) titled, Drug Disposition, the P&P indicated, Discontinued or outdated controlled drugs are to be delivered to the Director of Nursing for storage in an appropriately locked and secured storage area separated from other discontinued drugs until disposed properly according to policy. 2. During a concurrent observation and interview on 7/14/21, at 8:44 a.m., with LVN 2 during medication pass (medication administered to residents), LVN 2 stated pharmacy had delivered esomeprazole (medication for reflux) capsules instead of packets as ordered by the provider for Resident 46. LVN 2 stated she will follow up with pharmacy to deliver esomoeprazole packets as ordered by the provider. During a review of Resident 46's admission Records, dated 7/15/21, the admission Records indicated, 055799 Page 13 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 46 was admitted to the facility on [DATE] with diagnoses including Gastrostomy (surgical opening in stomach made for food). During a review of Resident 46's Order Summary Report, dated 7/15/21, the Order Summary Report indicated a provider order for esomeprazole 40 mg (milligram- unit of measure), give one packet one time a day. During a concurrent interview and record review on 7/15/21, at 10:13 a.m., with LVN 3, LVN 3 stated she did not administer esomeprazole to Resident 46, because she did not see the esomeprazole packet. LVN 3 stated LVN 2 followed up with the pharmacy; however, they did not deliver the medication during their scheduled deliveries at noon or evening. During a review of Resident 46's Progress Notes, dated 7/15/21, the Progress Notes indicated, 7/14/21 8:13 [a.m.] Phone call placed to Dr [doctor] to update on esomeprazole was sent in capsule DR [delay release] form instead of packet as ordered. MD [doctor] gave order to hold today and resume tomorrow with correct form of medication. During a review of Resident 46's Medication Administration Record (MAR), dated 7/1/21 to 7/31/21, the MAR indicated the administration time for esomeprazole was 8 a.m. 7/14/21 9:51 [a.m.] Phone call placed to [] pharmacy and will be sending medication on next pharmacy delivery. Phone call to [] r/p and updated on medication on hold until medication is delivered and gave understanding. LVN 3 acknowledged the administration time for esomeprazole was 8 a.m., and she did not follow the provider's order to resume esomeprazole in the morning of 7/15/21. During an interview on 7/15/21, at 2:35 p.m., with DON, DON acknowledged pharmacy had not delivered Resident 46's esomeprazole packets in a timely manner and LVN 3 did not administer Resident 46's medication as ordered by the provider. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, the P&P indicated, medications are administered in accordance with the written orders of the attending physician. 055799 Page 14 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a sampled resident (Resident 17) was free from an unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication when licensed nurses administered sertraline (medication for depression) without consistently doing a monthly monitoring and evaluation of resident-specific behavioral symptoms, and did not attempt non-pharmacological interventions prior to the intiation of mirtazapine (medication for depression). These failures increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: During a review of Resident 17's admission Record, dated 7/15/21, the admission Record indicated, Resident 17 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility on [DATE], whose diagnoses included depression, end stage renal disease (decrease in how kidney, a vital organ of the body works), and muscle weakness. During a review of Resident 17's Order Summary Report, dated 7/15/21, the Order Summary Report indicated a provider order for sertraline (anti-depression medication) 50 mg (milligram- unit of measure) daily for negative statements about self, complain of hopelessness related to major depressive disorder, start date 2/12/21. During a concurrent interview and record review on 7/15/21 at 10:57 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 17's Order Summary Report dated May 2021, April 2021, March 2021, and February 2021 were reviewed. LVN 3 stated licensed nurses were expected to monitor Resident 17's behavior of negative statements about self and complaints of hopelessness on the medication administration record (MAR) every shift, and the total number of behaviors were tallied at the end of each month. Resident 17's Order Summary Report dated May 2021, April 2021, March 2021, and February 2021, indicated, Resident has had _ episodes of Depression M/B [manifested by] negative statements about self, c/o [complains of] hopelessness in the last month. 2) Status of behavioral problem, incr [increase]_ Decr [decrease]_ No change_ . 3) Drug effectiveness, Yes_No_ Somewhat_. If yes, type_ Nurse_Date_.every shift. LVN 3 stated, monthly tallying is to look at trends, if notice behavior consistently through shifts, will notify doctor. LVN 3 acknowledged the total number of behaviors were not tallied at the end of May 2021, April 2021, March 2021, and February 2021, and Resident 17's behaviors of hopelessness and negative statements about self were not being consistently monitored on a monthly basis or evaluated. During a review of Resident 17's Care Plan for Depression dated 7/15/21, Resident 17's Care Plan for Depression indicated, Please tell my doctor if my symptoms are not improving to see if I need a change in my medication. During a concurrent interview and record review on 7/15/21 at 1:20 p.m., with LVN 1, Resident 17's Clinical Physician Orders on Point Click Care (PCC-electronic record system that stores clinical 055799 Page 15 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few information of residents), the Clinical Physician Orders were reviewed. LVN 1 stated, Resident 17 was initiated on mirtazapine (medication for depression) 45 mg on 5/22/19, doses were changed and mirtazapine was discontinued on 6/11/21. LVN 1 also stated Resident 17 was initiated on sertraline 50 mg on 2/28/2020, discontinued on 6/19/2020 and re-initiated on 12/2/2020. LVN 1 stated, there was no documentation in Resident 17's clinical records that indicated Resident 17 received non-pharmacological (non-drug approach) interventions prior to initiation of mirtazapine. During an interview on 7/15/21 at 1:58 p.m., with Resident 17, in Resident 17's room, Resident 17 stated, I used to be depressed but I don't feel depressed because my neighbor, we talk a lot, I talk to a lot of friends a lot, and my daughter visits me a lot. I was depressed because I thought my family didn't want to come, but now I'm understanding why. I talk to my kids every day. My daughter I talk to her every day, son calls a lot, Johnny, I talk to him every night time. During an interview on 7/15/21 at 2:09 p.m., with Director of Nursing (DON), DON stated, Nurses are expected to do monthly tallies, observe the trend to see if medication is effective . if still having issues, notify doctor . if no behaviors can ask for a GDR [graduation dose reduction of the medication] During a follow up interview on 7/15/21 at 3:58 p.m., with DON, DON stated, there was no documentation in Resident 17's clinical records that indicated Resident 17 received non-pharmacological interventions prior to initiation of mirtazapine. DON stated, We do not want to just medicate residents with unnecessary medications . interactions with other meds they are taking; she [Resident 17] is on dialysis, her kidneys are not functioning so want to give her least amount of medications but have her function well. 055799 Page 16 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications had proper storage and labeling when: a. Medication room and fridge temperature not monitored consistently; b. For Resident 1, an eye drop that required to be dated when opened, did not have an expiration date/date open sticker; c. For Resident 37, a morphine (pain medication) solution was incorrectly labeled with another resident's identifier These failures had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications, medications for Residents 1, and 37. Findings: a. During a concurrent observation and interview on 7/13/21, at 9:40 a.m., in the facility's medication room, with Licensed Vocational Nurse (LVN) 2, the temperature log for medication/vaccine refrigerator and room temperature was noted to be incomplete, with entries missing for 7/2/21 night shift; 7/4/21 pm shift; 7/6/21 am and pm shift; 7/10/21 night and am shift; 7/11/21 am and pm shift. LVN 2 acknowledged the refrigerator and room temperature log was incomplete and stated the expectation was for staff to complete the log at the beginning of each am, pm and overnight shift. During an interview on 7/13/21, at 3:02 p.m., with Director of Nursing (DON), DON stated, expectation is to keep temperature log up to date and if temperature not in range, they need to bring it up to me . if out of range, it can affect the strength of medication, medication might not be as effective. During a review of the facility's policy and procedure (P&P) titled, Drug Storage and Labeling, the P&P indicated, Drugs that are stored at room temperature will be stored in an area no warmer than 86F. Drugs stored under refrigeration will be stored between 36F [Fahrenheit-measure for temperature] & [and] 46F. b. During a concurrent observation and interview on 7/13/21, at 10:06 a.m., during medication cart check with LVN 3, a 5 ml (milliliters- unit of measure) eye drop solution for Resident 1 that required to be dated when opened was observed to not have an expiration date/date open sticker. LVN 3 acknowledged the bottle has been opened and used to administer medication to Resident 1 but was unable to determine when the bottle was opened. LVN 3 stated, No, there's no date on there, important to have a date so know when expiration . could harm resident, strength of medication can decrease. During a review of Resident 1's admission Records, dated 7/14/21, the admission Records indicated Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Medication Administration Record (MAR), dated 7/1/21 to 7/31/21, 055799 Page 17 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the MAR, indicated a provider's order for Olopatadine, instill one drop in both eyes once daily for itching eyes was administered to Resident 1 from 7/1/21 to 7/14/21. c. During a concurrent observation and interview on 7/13/21, at 10:06 a.m., during medication cart check with LVN 3, a 30 ml morphine (pain medication) solution for Resident 37 was incorrectly labeled with another resident's identifier. LVN 3 acknowledged the morphine solution was incorrectly labeled, and stated, . having two labels can cause medication to be given to incorrect resident. During a review of Resident 37's Order Summary Report, dated 7/14/21, the Order Summary Report, indicated a physician's order for morphine solution 100 mg (milligram- unit of measure) per 5 ml (millilitersunit of measure), give 0.5 ml by mouth every 6 hours as needed for pain. During an interview on 7/13/21, at 3:10 p.m. with DON, DON stated expectation for staff was to label residents' medications properly. DON stated, if not [medication] labeled, could be a potential for med error. During a review of the facility's policy and procedure (P&P) titled, Drug Storage and Labeling, the P&P indicated, Improperly labeled containers will not be allowed for use and will be returned to the pharmacy as soon as possible. 055799 Page 18 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on food services observations, staff interview and departmental document review the facility failed to ensure a Registered Dietitian and Dietetic Services Supervisor comprehensively evaluated the effectiveness of food service operations as evidenced by lapses in the delivery of services associated with meal distribution accuracy and nutritional value of menus (Cross Reference F803, F805, and F808 ), and food safety (Cross Reference F812). Failure to ensure food and nutrition services systems are accurately and effectively delivered may result in compromising the nutritional status of residents through the potential transmission of foodborne illness and incorrect plating of physician ordered therapeutic diets for the 52 residents at the facility. Findings: During the annual recertification survey from 7/13 - 7/16/21, there were multiple lapses in the delivery of food services including incorrect portion sizes, food in the improper form, not providing physician prescribed therapeutic diets and in relation to sanitation (Cross Reference F803, F805, F808, F812). During an interview on 7/13/21 at 11:22 AM, the Dietetic Services Supervisor (DSS) stated she started at facility on 5/24/21. During an interview and concurrent document review with the DSS on 7/15/21 at 8:40 AM, Resident #197's tray ticket, from 7/13/21, indicated a diet order of Regular, NAS (No Added Salt). It did not show chopped meat as prescribed by the physician. The DSS stated sometimes not everything transferred over from the clinical record to the tray card system. The DSS confirmed both systems were from the same electronic medical record system and that a couple times each week she goes through and checks the diet orders against the tray tickets to ensure accuracy. Resident 197 was admitted to the facility on [DATE], it was not clear why this tray ticket was still incorrect. During a telephone interview with RD 1 on 7/16/21 at 10:35 AM, RD 1 stated her first visit at the facility was 6/3/21 (approximately 6 weeks prior). RD 1 stated her consultant role at the facility consisted of her being at the facility 8 hours a week. She also stated her tasks, in relation to federal regulations, are to monitor food service, sanitation and departmental safety checks. RD 1 stated she has been supporting the DSS since it has been overwhelming and helping her prioritize identified issues. RD 1 stated she does sanitation audits done monthly and observes meal service during each visit but will not do a checklist every time. RD 1 stated she reviews at the steam table and looks at menus, recipes, and alternates. RD 1 stated if she sees things at that time, she will document it on her form at the end of the month. RD 1 stated the menu spreadsheet contains much detail and instructions for the menu are below, however the staff get confused. RD 1 stated the DSS and cooks are responsible for the accuracy of the menus. As part of the facility's Plan of Correction from a complaint investigated on 2/25/21, Food and Nutrition services started conducting an audit of Trayline/Meal Assembly, Meal Monitoring Checklists, as well as Kitchen and Dining Observations. 055799 Page 19 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of 11 facility documents titled Trayline/Meal Assembly Evaluation Form dated 5/31/21 - 7/12/21 and signed by the DSS, showed evaluation of multiple areas including: portion sizes served correctly, mechanical textures correct, and puree textures correct. No issues were identified with portion sizes or improper size of foods for chopped diets. Review of 31 facility documents titled DDS Meal Monitoring Checklist dated 4/5/21 to 6/25/21 completed by DSS (10 forms), RD 2 (17 forms), and DSS 3 (3 forms) showed 31 items on the checklist being evaluated related to menus and meal service. The bottom of the checklist indicated Need written plan of correction for any items marked no. Out of the 31 checklists, one audit indicated a one-time issue with Reviewed for correct preferences and accuracy of tray ticket? and one time issue with Correct dishers/scoops/utensils are being use with a written note: slotted spoons. No other issues related to portion sizes or chopped diets were identified. No written plan of correction was on the checklist for these two issues. Review of two facility documents titled Dining Observation dated 5/11/21 and 6/23/21, completed by DSS 2 and DSS 1 respectively, showed no identification of anything related to residents receiving therapeutic diets as prescribed by the physician. Review of two facility documents titled 'Kitchen Observation' dated 3/19/21, and 4/26/21, completed by RD 2, and one dated 6/23/21 completed by RD 1, showed RD 2 identified areas pertaining to dirty floor drain and prep areas not cleaned after use. Items identified did not have an action plan to address or fix the concerns. RD 1 identified bowls were being stacked wet with an action plan to purchase mesh to put down on trays. During the recertification survey it was noted the mesh was purchased and used however staff continued to stack items wet. It was also noted the floors were still dirty, cabinets, walls, drawers. No concerns relating to following menus or food not being provided in the proper form were identified. Review of the RD job description dated 10/27/15, showed the Registered Dietitian essential job duties included evaluation of food handling, sanitation, preparation, food service procedures and equipment, evaluate and provide guidance on provision of dining delivery and customer service. Review of the Manager of Dining Services (DSS) job description dated 9/27/15, signed by the DSS on 5/24/21, showed the general purpose of the position was to manage operation of the Dietary Department to including food preparation and clean-up in accordance with facility policies, physician orders, and appropriate regulations. It further included essential job duties as: ensure food is prepared per menu and recipes, monitor food production maintaining use of standardized recipes and menus while ensuring proper preparation, storage of supplies, create cleaning schedules, provide ongoing education and training to all kitchen staff, and maintain records per policy. 055799 Page 20 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed for: 1) a. 14 out of 14 residents (Residents # 6, 8, 12, 15, 16, 17, 19, 26, 38, 39, 41, 42, 45, 97) on Regular Controlled Carbohydrate diets, b. One out of one residents (Resident #1) on Small Controlled Carbohydrate diet; and 2) Three out of three residents (Residents #15, 20, 33) on Pureed diets did not receive the correct portion sizes of foods. This failure had the potential to result in not meeting the nutritional needs further compromising the medical status of the residents. Findings: 1. Review of the facility menu titled Summer Menus Cooks Spreadsheet for Week 2 Tuesday 7/13/21 indicated for the Regular and Small CCHO (Carbohydrate controlled diet -therapeutic diets designed for people with diabetes to keep the carbohydrate levels in meals evenly spaced throughout the day), the following items: Regular: Chicken with [NAME] Sauce 3 oz (ounce), 1 oz sauce, Diced Fried Potatoes #16 (#16 Scoop size= ¼ cup), Baked Fresh Zucchini 1/2 c (cup); Small: Same as above except Chicken 2 oz. During the observation of the lunch meal service starting on 7/13/21at 11:49 am: a. Resident #6, 8, 12, 15, 16, 17, 19, 26, 38, 39, 41, 42, 45, 97's trays were called, Food Service Worker 2 (FSW 2) placed a piece of chicken with sauce, #8 (1/2 cup) scoop of diced fried potatoes, and a #8 (1/2 cup) scoop of zucchini on the plates. b. Resident #1's tray was called, FSW 2 placed a piece of chicken with sauce, a #10 (3/8 cup) scoop of diced potatoes, and a #8 scoop of zucchini on the plate. Review of the lunch meal tray tickets from 7/13/21 for Residents # 6, 8, 12, 15, 16, 17, 19, 26, 38, 39, 41, 42, 45, 97 indicated under Special diets: Controlled Carbohydrate and for Resident #1 indicated under Special diets: Controlled Carbohydrate, Small Portions. During an interview with FSW 2 after the completion of the lunch meal service on 7/13/21 at 12:17 pm, FSW 2 confirmed she did not use the #16 scoop for the CCHO regular and small diets, and confirmed she used #8 scoop for regular CCHO and #10 for small CCHO for the potatoes. 2. Review of the facility menu titled Summer Menus Cooks Spreadsheet for Week 2 Tuesday 7/13/21 indicated for the puree diet the following items: Chicken with [NAME] Sauce P #8 P-sauce (Puree #8 scoop = ½ cup, Puree sauce), Diced Fried Potatoes P (Puree), and Baked Fresh Zucchini P#12 (Puree #12 scoop = 1/3 cup). 055799 Page 21 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During the observation of the lunch meal service starting on 7/13/21at 11:49 am, when Resident #15, 20, 33's tray tickets were called out for pureed diet, FSW 2 placed a #12 (1/3 cup) scoop of pureed chicken, #12 scoop (1/3 cup) of pureed zucchini and a #12 scoop (1/3 cup) of pureed diced fried potatoes on the plates. Review of the lunch meal tray tickets from 7/13/21 for Residents #15, 20, 33 indicated under Texture: Level 1 Puree. During an interview with FSW 2 in the presence of Dietary Services Supervisor (DSS) after the completion of the lunch meal service on 7/13/21 at 12:17 pm, FSW 2 confirmed that she used the #12 (1/3 cup) scoop for the puree food items. FSW 2 stated they always use #12 scoops for puree. During a concurrent interview and record review of the Summer Menus Cooks Spreadsheet for Week 2 Tuesday 7/13/21 showed a P for serving size for the potatoes. FSW 2 stated that she was not sure what scoop size that would be for the potatoes. DSS stated when there is no scoop size indicated on the menu spreadsheet then the scoop size would be the same as the regular serving size. Review of the Summer Menus Cooks Spreadsheet for Week 2 Tuesday 7/13/21 showed the Regular serving size for the Diced Fried Potatoes was a #8 scoop (1/2 cup). During a telephone interview on 7/16/21 starting at 10:32 AM with Registered Dietitian (RD 1), RD 1 stated she expects staff to follow the menus. 055799 Page 22 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review, the facility failed to ensure food was served in the proper size for five of five residents (Resident #19, 30, 38, 47, 297) on chopped meat diet when they received chicken cut in approximately 1 inch squares during the lunch meal service on 7/13/21. This failure had the potential to place residents on a chopped meat diet at an increased risk for choking. Findings: During an observation of the lunch meal service starting on 7/13/21at 11:50 am, when Resident #19, 30, 38, 47, 297's tray tickets were called out for chopped diet, Food Service Worker 2 (FSW 2) placed Chicken with [NAME] Sauce on a plate and cut it in half then in thirds with the serving tongs. Food Service Worker 1 (FSW 1) and Dietary Services Supervisor (DSS) then placed the plates on trays in the meal delivery cart for delivery. During an interview with FSW 2 on 7/13/21 at 12:17 pm once the lunch meal service was completed, FSW 1 indicated for chopped meat diets she cuts the meat in half then in thirds with whatever tool she is serving with but did not know what size to cut the meat into. During an interview on 7/14/21 at 8:48 AM with the DSS, she indicated chopped meat is described on the bottom of menu spreadsheet and meat should be cut into 1/2 inch pieces. Review of the tray tickets for Residents #19, 30, 38, 47, 297 under Texture, indicated Chopped meats. Review of the facility menu titled Summer Menus Cooks Spreadsheet for Week 2 Tuesday 7/13/21, indicated Chopped - ½ or less at the bottom. During a telephone interview on 7/16/21 starting at 10:32 AM with Registered Dietitian (RD 1), RD 1 stated she expects staff to follow the menus and that chopped meat should be cut into 1/2 inch pieces. RD 1 further indicated that an in-service on texture modification had been conducted in June. Review of facility document titled Summary Report of Meeting Types of Meeting: In-Service Dining Services Education Session conducted by RD 1 dated 6/9/21 at 1:00 pm, showed FSW 2 in attendance. Subjects covered showed Dysphagia/Mechanically Altered Diets. Review of the content of the in-service provided by the facility, showed no discussion of chopped meat diets specifically. 055799 Page 23 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review, the facility failed to ensure residents are receiving therapeutic diets as prescribed by the physician when: 1. Two residents (Resident # 2 and 40) did not receive carbohydrate controlled diets (a therapeutic diet designed for people with diabetes to keep the carbohydrate levels in meals evenly spaced throughout the day), and 2. Six resident's (Resident # 3, 9, 45, 197, 297, 298) tray tickets did not match their physician prescribed diets. This failure could result in further compromising resident medical status or unnecessarily restricting a resident's diet. Findings: 1. Review of the facility menu titled Summer Menus Cooks Spreadsheet for Week 2 Thursday 7/15/21, indicated for the Regular CCHO diet (carbohydrate controlled diet) the following items: Roast Pork Loin 3 oz (ounce), Spiced Apples 1 oz, Ranch Style Beans #12 (#12 scoop= 1/3 cup), Southern Style [NAME] Beans #12, Cornbread (2 x 2 ½ inch square) ½ serving, Vanilla Mousse No chocolate chips #12 (#12 scoop = 1/3 cup). For the Regular diet, the menu indicated Roast Pork Loin 3 oz, Spiced Apples 1 oz, Ranch Style Beans #12, Southern Style [NAME] Beans #12, Cornbread 2 x 2 ½ inch square 1 serving, Vanilla Mousse Chocolate chip garnish #12. For the mechanical soft diet, the menu indicated Roast Pork Loin Ground #10 (#10 scoop = 3/8 cup) moisten with juice, Spiced Apples 1 oz, Ranch Style Beans #12, Cornbread 2 x 2 ½ inch square blank, Vanilla Mousse Chocolate chip garnish blank. At the bottom of the menu spreadsheet, it noted If a square is blank it means you may give the item on the menu. a. During an observation of the lunch meal service on 7/15/21 starting at 11:55 am, Food Service Worker 4 (FSW 4) called Mechanical for Resident #40. FSW 2 served the same portions as other Level 3 advanced diets (diets with texture modifications for people with difficulty chewing or swallowing, often referred to as mechanical soft) being served during the same meal service. An observation of Resident #40's meal tray on the cart ready for service found vanilla mousse with chocolate chips on top. Review of the tray ticket for Resident #40 for the lunch meal on 7/15/21 indicated the diet order was Level 3 Advanced, No added salt. Review of the diet list titled Order Listing Report dated 7/15/21 showed Resident #40's diet order was Controlled Carbohydrate, NAS (no added salt) diet Mechanical soft texture, regular (thin) consistency. A review of Resident # 40's clinical record showed a physician order on 7/7/21 for a controlled carbohydrate NAS diet, mechanical soft texture regular (thin) consistency. Resident #40 was admitted to the facility on [DATE]. b. During an observation of the lunch meal service on 7/15/21 starting at 11:55 am, FSW 4 called regular for Resident #2. FSW 2 served the same portions as other regular diets being served during the 055799 Page 24 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some same meal service. During the observation, the sheet pan containing the cornbread was cut into squares that were all the same size. Review of the tray ticket for Resident #2 for the lunch meal on 7/15/21 indicated the diet order was Regular. Review of the diet list titled Order Listing Report dated 7/15/21 at 5:17 pm, showed Resident #2's diet order was Controlled Carbohydrate diet, regular texture. A review of Resident # 2's clinical record showed a physician order on 6/14/21 for a controlled carbohydrate diet, regular texture. Resident #2 was admitted to the facility on [DATE]. 2. A review of facility document titled Diet Type Report dated 7/13/21 3:11 pm showed Diet type for Resident #197 was Regular, Chopped meat. A review of Resident # 197 's clinical physician orders showed a physician order on 7/3/21 for a regular diet, chopped meat texture, regular (thin) consistency (for liquids). Resident #197 was admitted on [DATE]. A review of Resident #197's tray ticket from the breakfast, lunch, and dinner meals on 7/13/21 indicated Regular No added salt and did not indicate chopped meat texture. Review of the diet list titled Order Listing Report dated 7/15/21, showed: a. Resident # 9's diet order was Regular diet, mechanical soft texture, chop all vegetables. b. Resident # 45's diet order was Controlled carbohydrate, regular texture, regular (thin) consistency, request soups with lunch and dinner. c. Resident # 3's diet order was Regular diet, regular texture, regular (thin) consistency. d. Resident # 297's was not listed. e. Resident # 298's diet order was regular diet mechanical soft texture, thickened liquid honey consistency. Review of tray tickets for 7/15/21, showed: a. Resident #9's diet order was Level 3 advanced and did not indicate to chop all vegetables. b. Resident #45's diet order was Regular, controlled carbohydrate and did not indicate soups with lunch and dinner. c. Resident #3's diet order was regular, controlled carbohydrate. Review of Resident 3's clinical physician orders showed no record of a controlled carbohydrate diet being ordered for Resident 3. d. Resident #297's diet order was chopped meats. e. Residents #298's diet order was blank. During an interview with the Dietary Services Supervisor (DSS) at 8:40 am on 7/15/21 regarding Resident #197's tray ticket from 7/13/21 which showed Regular, NAS and did not show chopped meat as prescribed by the physician, DSS stated sometimes not everything transferred over from the clinical record to the tray card system. DSS confirmed both systems were from the same medical record system and 055799 Page 25 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that a couple times a week she goes through and checks the diet orders against the tray tickets to ensure accuracy. Resident #197 was admitted to the facility on [DATE], it was not clear why this tray ticket was still incorrect. During a telephone interview with Registered Dietitian 1 (RD 1) starting at 10:32 am on 7/16/21, she indicated the DSS and cooks are responsible for accuracy of the diets. Review of facility document titled Diet Manuals and Diet Orders undated, indicated a diet order is a prescription written by the attending physician to change a resident's diet or establish a diet. 055799 Page 26 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when: Residents Affected - Many 1. Time/Temperature Control for Safety (TCS) foods (food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation) were not properly monitored for cool down; 2. TCS foods were not properly labeled and expired items were in the refrigerator; 3. Cups for resident drinks were stored wet and stacked or wet with lids on; 4. A utensil storage drawer, cabinets, and walls were not clean; and 5. Air gaps were not present in the ice machine and food preparation sink. These failures had the potential to cause the growth of microorganisms which could cause foodborne illness or cross contaminate food (cross contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the 49 residents eating at the facility. Findings: 1. During the initial kitchen tour on 7/13/21 starting at 9:01 am, cooked pasta was in the reach in refrigerator labeled 7/12/21 and use by 7/15. During an interview with Food Service Worker 3 (FSW 3) on 7/13/21 at 2:54 pm, when asked how he monitors cool down of hot foods, FSW 3 stated he put the pork roast in freezer at 12pm when it was 120 degrees F, he checked it at 2pm and it was 70 degrees F then he will check it again at 4 pm. He wants it to be 41 degrees F at 4 pm, if not, he would by start over by reheating and cooling the roast. During an interview on 7/14/21 at 10:23 am with FSW 3, he stated the noodles were used yesterday for the lunch meal service for the renal patient. He stated the noodles are good as long as they are used between the dates on the label. A review of facility document titled Cooling Log dated July 2021 found 2 entries on the log: 7/13/21 for Pork Roast and 7/13/21 Carnitas Pork. No entry was written down for the pasta dated 7/12/21. A review of the facility policy document titled Cooling indicated any cooked potentially hazardous food will be cooled to a safe temperature in the limited time period noted and be monitored to assure the cooling process is meeting the Time/Temperature Control for Safe foods. The document also noted cooling time starts when hot food reaches 135 degrees F. A review of facility document titled Cooling Procedure indicated Potentially hazardous hot foods must be cooled from 135F to 70F in 2 hours, then cooled from 70F to 41F or less within an additional 4 hours for 6 hours total, examples are: meat, ., pasta. The document further states use cooling log to keep record steps for cooling potentially hazardous foods. 055799 Page 27 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many According to the 2017 Food and Drug Administration (FDA) Food Code, Section 3-501.14, Cooling: (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less. 2.a. During the initial kitchen tour starting on 7/13/21 at 9:01 am, the following was noted inside the reach in refrigerator near the dietary services office: *One container (46 ounces) of Moderately Thickened Lemon Flavored Water was stamped with the date 7/6/21. The container was opened and felt half full. A concurrent interview was conducted at that time with Food Service Worker 2 (FSW 2) who stated the stamp was a received dated and the container should have had an open date written on it. Review of the manufacturer's information on the side of the container indicated once opened the drink can be kept up to 7 days under refrigeration. *A container (46 ounces) of Moderately Thick Apple Juice had written dates of 7/4/21 and 7/7/21 on the top of the container. FSW 2 stated it was opened on the 7/4/21 and was to be used by the 7/7/21. Review of the manufacturer's information on the side of the container indicated once opened the drink can be kept up to 7 days under refrigeration. *Two 46 ounce containers of Moderately Thickened Cranberry Juice had a manufacturer's best buy date of 7/12/21. During the initial kitchen tour starting on 7/13/21 at 9:01 am, approximately 30 vanilla No sugar added and 1 chocolate shake were in a bin in the reach in refrigerator located in the back corner of the kitchen, labeled with the dates 7/12 and use by 8/12/21. Review of the manufacturer's information on the side of carton stated use within 14 days of defrosting. During an interview with Dietary Services Supervisor (DSS) on 7/13/21 at 3:13 pm, she stated the shakes come in frozen and once thawed, they are to be used in 14 days. DSS acknowledged the label stated good until 8/12 and stated maybe the staff who labeled the shakes incorrectly were tired and in a hurry and labeled the bin with wrong date. b. During an observation and concurrent interview on 7/14/21 at 11:16 am in the nursing Utility Room in the presence of LVN1/DSD, one container of Vanilla Med Pass 2 was in the nursing refrigerator and was opened with no date on the container. LVN 1/DSD confirmed the Vanilla Med Pass 2.0 was opened, undated, and was supposed to be dated once opened. During a telephone interview with Registered Dietitian 1 (RD 1) on 716/21 starting at 10:32 am, she stated foods should be labeled with the date opened and a use by date unless dairy which has an expiration date on it. Review of facility document titled Cold Food Storage, undated, indicated All opened container should have date opened marked to assure correct rotation. Use the following guideline for dating foods stored in the refrigerator.Thickened liquids Commercial Manufacturer's use by date or days to store after opening .Frozen Supplements Lyon's thawed Shakes 14 days. Review of facility document titled Storage of Refrigerated Foods undated indicated Monitor all items daily for expiration dates or use by dates and discard all expired/outdated items immediately. 055799 Page 28 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3. During the initial kitchen tour on 7/31/21 starting at 9:01 am, inside a closed storage cabinet were two shelves of plastic cups. There were approximately 28 cups that were wet inside and stacked in threes upside down on trays. During an interview with Food Service Worker 1 (FSW 1) on 7/13/21 at 9:21 am at the dish machine, she stated for drying equipment she would let the just washed equipment sit while she ran another load of equipment through the dishwasher, then she would remove the clean equipment and put it away. FSW 1 stated she doesn't want the equipment dripping wet when she puts it away. During an interview with Foodservice Worker 4 (FSW 4) on 7/14/21 at 9:21 am at the dish machine, she stated that when the equipment is dry you put it away and that you can see when it is dry. During an observation on 7/14/21 at 9:28 am, there were eleven stacked plastic cups and three handled cups with lids on that were wet inside stored inside the closed storage cabinet. During a concurrent interview with FSW 4, she acknowledged the cups were wet inside and then unstacked the wet cups. She stated the cups should be still drying on the tray in the cabinet and not stacked. When asked if the lids of the handled cups should be on when the cups were wet inside, she stated that is how she does it and they will still dry. FSW 4 then asked if she should put the cups and lids away separately until dried. During a telephone interview with Registered Dietitian 1 (RD 1) on 7/16/21 starting at 10:32 am, she stated any dishware should be air dried, and not with lid on which would seal in moisture. She also stated bar mesh on the trays under the cups allows for air drying if cups are inverted and not stacked. Review of facility document titled Dish Machine Use and Care, undated, indicated Allow all items to thoroughly dry before unloading and storing. Store all items completely free of moisture. Glasses should be stored unstacked but inverted. According to the 2017 Food and Drug Administration (FDA) Food Code, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: shall be air-dried . According to the FDA Food Code 2017 Annex 4-901.11 items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 4. a. During an observation of the can opener on 7/13/21 at 9:32 am in the presence of FSW 2, on the tip of blade there was black liquid substance which also ran down the shaft of the can opener. The substance could be wiped off by a paper towel. There was black substance in the teeth of the gear of the can opener and rust. During an interview with FSW 2, she stated she had been off the last two days, but the can opener should be cleaned after each use. She stated she had not used it today. FSW 2 stated she needed to clean the can opener. FSW 2 stated the rust had been there awhile. Review of facility document titled Cleaning Can Opener, undated, indicated Follow the steps below after each use to clean can openers: Step 1. Wash the handle portion (stand) of the can opener in the dish machine or pot and pan sink, 2. Sanitize and air dry, 3. Wash gears and blade with soft bristle brush if needed, 4. Wash the base with a detergent solution, using a brush and cloth; assure the shaft cavity is clean b. During an observation in the kitchen on 7/13/21at 9:34 am, the following observations were made: 055799 Page 29 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many *a drawer with serving utensils contained dirt like substance on bottom and along the edges of the drawer. When wiped, the substance came off on hand and paper towel. * The wall behind garbage can adjacent food preparation area had black spots on it. * The cabinets and ceiling above food preparation table was splattered with gray fuzzy material and the white cabinets had gray smudges around the handles. During an interview on 7/13/21at 3:04 pm, FSW 3 stated he is not responsible to clean the drawers and is not sure if someone in the morning is but he will have it cleaned tonight. During an interview on 7/13/21at 3:13 pm, DSS stated they just changed out a table and they weren't able to clean the wall yet today. She stated that the drawers should be cleaned weekly and the walls should be cleaned daily. During a telephone interview with Registered Dietitian 1 (RD 1) on 7/16/21 starting at 10:32 am, she stated cleaning walls, cabinets, and drawers is on the monthly cleaning schedule and that is a duty of the DSS to check those. Review of facility document titled Daily Cleaning Schedule, undated, indicated Walls Stoves/steamtable area, Dishwasher area and Walls, and Can Opener had been cleaned on a daily basis for the past six weeks. There was no indication that cabinets or drawers are cleaned. A document review of the 2017 Food and Drug Administration (FDA) Food Code, Section 4-602.13 states Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. It is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris (FDA Food Code, 2017 4-601.11). Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests (FDA Food Code Annex 4-602.13). 5. During an interview on 7/14/21at 8:42 am, FSW 2 stated the middle compartment of the three compartment sink is used to wash fresh fruit. During an observation in the dining room and kitchen on 7/14/21 at 2:03 pm in the presence of the Maintenance Supervisor (MS), the middle compartment of the three compartment sink was directly connected to the drain and the ice machine drain pipe was sitting directly on the floor drain grate with no gap of space. MS confirmed that the sink was directly connected and the ice machine drain pipe was touching the floor drain. According to standards of practice within the foodservice industry, an air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. (2017 FDA Food Code) 055799 Page 30 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0812 Level of Harm - Minimal harm or potential for actual harm According to the 2017 Food and Drug Administration (FDA) Food Code, Section 5-402.11 Backflow Prevention, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment or utensils are placed. Residents Affected - Many 055799 Page 31 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI, a program that enables the facility to evaluate and improve the quality of resident care and services through data collection, staff input, and other information) program failed to implement their action plans which include monitoring and sustaining the appropriate plan of actions to correct the identified quality deficiencies in accordance with their plan of correction from the last re-certification survey completed on 1/30/2020 when: 1. Quality care issues were not identified with an appropriate action plans developed to correct the identified deficient practices (cross reference F656, F801, F808, F812, F880); and 2. When four of ten interviewed facility staff were unable to identify the purpose of QAPI and current QAPI projects. These failures resulted in an ineffective QAPI program to improve quality of care for all residents in the facility. Findings: During an interview on 7/16/21, at 1:43 p.m., with Administrator (ADM) and Director of Nursing (DON), ADM stated, the current QAPI projects included call lights, bowel and bladder program (help residents manage incidence of , fall prevention, care planning, kitchen sanitation, infection control and antibiotic stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients). During an interview on 7/16/21, at 1:50 p.m., with ADM and DON, the ADM stated, she was hired in the facility last March, 2021 and was aware of the repeated identified concerns from the last recertification survey (1/30/2020) regarding care planning (cross reference F656), dietary concerns (cross reference

F801, F808, F812) , and infection control (F880). The ADM stated the facility was in the process of monitoring and working on identified concerns. During an interview on 7/16/21, at 2:02 p.m., with ADM and DON, the ADM stated, the staff were informed of the QAPI projects through departmental staff meetings. The ADM stated variance meetings (a management of significant clinical concerns on weight loss or weight gain) were conducted by the DON and Registered Dietitian (RD) every month. The DON stated, I don't have the minutes and documentation of the weight variance meetings conducted. The facility was unable to provide the monthly weight variance meetings. During an interview on 7/16/21, at 2:48 p.m., with Maintenance Supervisor (MS), the MS stated, he was not aware of any facility quality improvement projects. During an interviewmon7/16/21, at 2:51 p.m., with Director of Staff Development (DSD), the DSD stated she was not attending QAPI meetings. During an interview on 7/19/21, at 3:07 p.m., with Housekeeping Supervisor (HS), the HS was unable to identify any facility quality improvement projects. 055799 Page 32 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0867 Level of Harm - Minimal harm or potential for actual harm During an interview on 7/16/21, at 2:43 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she was unfamiliar of the QAPI and facility's current quality improvement projects. During an interview on 7/16/21, at 2:45 p.m., with CNA (5), CNA 5 was not able to identify the current facility quality improvement projects. Residents Affected - Many During a review of the facility's policy and procedure (P&P) titled, Facility Assessment dated 10/18, the P&P indicated, . the QAPI committee is responsible for reviewing the facility and resident information quarterly to determine if a facility reassessment is warranted . 055799 Page 33 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: Residents Affected - Some 2. During an observation with Resident 31, on 7/13/21, at 12:19 p.m., in Resident 31's room, Resident 31 laid comfortably on bed with O2 concentration at 4.5 liters per minute (lpm) via nasal cannula (a small flexible tube that contains two open prongs inside nostrils) with no date label, and no water on unlabeled humidifier bottle (to provide moisture and prevent airways from getting too dry especially for long-term use). During an observation with Resident 31, on 7/14/21, at 1:40 p.m., in Resident 31's room, Resident 31 laid comfortably on bed with O2 concentration at 4.5 liters per minute (lpm) via nasal cannula with unlabeled empty humidifier bottle. During a review of Resident 31's face sheet (resident profile information) indicated Resident 31 was admitted to the facility on [DATE] with diagnoses which included, Type 2 diabetes mellitus (high blood sugar level), asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing, generalized anxiety disorder (a disorder characterized by feelings of apprehension, worry, uneasiness), chronic pain and hypertension (high blood pressure). During a review of Resident's 31 order summary report dated 7/14/21, indicated oxygen at 2 lpm via nasal cannula or mask prn (as needed) for dyspnea. Call hospice (care for the sick or terminally ill) with titration (measure and adjust according to response) if needed. Resident 31 was transitioned from long term care to hospice on 6/28/21. During a review of Resident 28's face sheet (resident profile information) indicated Resident 28 was admitted to the facility on [DATE] with diagnoses which included, morbid obesity, obstructive sleep apnea (slowed or stopped breathing), hypertension (high blood pressure), claustrophobia (extreme fear of confined places). Resident 28's order summary report dated 7/14/21 indicated O2 at 2 liters to 4 liters via nasal cannula or mask as needed for shortness of breath. During a concurrent observation and interview, with Licensed Vocational Nurse 1 and Director of Staff Development (LVN 1/DSD), on 7/14/21, at 1:52 p.m., in Resident 31's room, LVN 1/DSD validated Resident 31's O2 had undated nasal cannula and the unlabeled humidifier bottle had no water on it. LVN 1/DSD stated Resident 31's humidifier was not changed and recognized the humidifier bottle was from hospice care. LVN 1 /DSD stated the purpose of water in humidifier was to keep resident's nose from getting dry and routine changing of cannula will prevent build-up of bacteria which may lead to infection. LVN 1/DSD stated the expectation was for the licensed nurses to change the nasal cannula and humidifier bottle every Sunday night or sooner as needed. During a concurrent observation and interview, with LVN 1 /DSD, on 7/14/21, at 2:10 p.m., in Resident 28's room, LVN 1/DSD stated Resident 28's nasal cannula and humidifier bottle were not labeled with date changed. She stated Resident 31's cannula and humidifier should have a labeled date to ensure both (cannula and humidifier bottle) were changed on weekly basis. During a concurrent interview and record review, on 7/14/21, at 2:36 p.m., Minimum Data Set Coordinator (MDSC) reviewed Resident 31's care plan and treatment medication record (TAR) and indicated 055799 Page 34 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 31 did not have respiratory care plan interventions and there were no assessments and monitoring for resident's use of oxygen and care, risks, and complications such as skin integrity issues with the long term use of nasal cannula and humidifier. MDSC stated the admitting licensed nurse should have initiated Resident 31's care plan for oxygen use on admission from transitioned to hospice care on 6/28/21. During a concurrent interview and record review, with Infection Preventionist (IP), on 7/16/21, at 1:30 p.m., IP reviewed Resident 28's clinical records and stated, Resident 28's oxygen use was ordered 4/26/21 and there were no documentation in place for Resident 28's oxygen care plan interventions and monitoring [date label water change humidifier]. During an interview with Director of Nursing (DON), on 07/19/21, at 2:06 p.m., DON stated licensed nurses should be responsible in initiating a resident's care plan on admission and the Interdisciplinary Team (IDT) should discuss, review and revise the care plan interventions for all residents. During a review of the undated facility's policy and procedure titled, Oxygen Administration (via Nasal Cannula), indicated, . Procedure: (for humidified oxygen): Observe for patient sensitivity to oxygen administration, such as nasal dryness, which may indicate the need for humidification .Infection Prevention: Replace tubing and cannula weekly or as needed .Documentation: Date and time, method of oxygen administration and rate of flow, patient's response to oxygen therapy .as ordered . During a review of the facility's policy and procedure titled, Infection Prevention and Control Program dated 10/18, indicated, .6. Policies and procedures (1) Updating or supplementing policies and procedures as needed . 11. Prevention of Infection .(1) identifying possible infections or potential complications of existing infections (2) insttuting measures to avoid complications or dissemination. During a review of prefessional reference found at https://www.verywellhealth.com/nasal-cannulas-914867 dated 8/5/2020, indicated, .One side effect of using a nasal cannula is ensuing nasal dryness, which is fairly common as cold, dry oxygen is streamed into your nostrils. However, some oxygen units come equipped with warming humidifiers, or these may be available as a separate attachment. Warm, moist air combats the effects of dryness . While generally regarded as safe, there are several risks to consider before using any form of supplemental oxygen. Namely, long-term use has been linked to lung damage, eye damage (resulting from pressure buildup), and a condition called pulmonary oxygen toxicity, in which too much oxygen exists in the body and may result in damage to airways . Most manufacturers advise that patients change their nasal cannulas once a week for regular daily use . You can prolong the life of your cannula by taking proper care of it and washing it regularly. The biggest danger in not doing so is a buildup of bacteria, which may lead to infection. Based on observation, interview, and record review, the facility failed to implement and maintain an infection control procedures when: 1. Licensed Vocational Nurse (LVN) 2 failed to observe infection control measures by failing to properly disinfect resident's glucometer for one randomly selected resident (Resident 41) according to manufacturer's specifications 2. two (Resident 28 and Resident 31) of four sampled residents' nasal cannula and humidifier container of oxygen therapy (also called supplemetal oxygen) were not changed and not labeled with date changed in accordance to facility's policies and procedures. 055799 Page 35 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0880 Level of Harm - Minimal harm or potential for actual harm These deficient practices had the potential for the development and the spread of infection to all residents, and for Resident 28, and Resident 31's nasal cannula build up of bacteria which could lead to infections and result in adverse reactions on Resident 28 and 31's respiratory treatments. Findings: Residents Affected - Some 1. During a review of Resident 41's admission Records, dated 7/15/21, the admission Records indicated Resident 41 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, diabetes, and presence of a cardiac pacemaker. During a review of Resident 41's Order Summary Report, dated 7/15/21, the Order Summary Report, indicated a provider order for blood glucose check before meals and at bedtime, starting 6/25/21. During an observation on 7/14/21 at 11:20 a.m., during the medication pass observation, LVN 2 was observed using a glucometer to check Resident 41's concentration of blood glucose. LVN 2 was observed wiping the glucometer with bleach disposable wipes for approximately 12 seconds, then placing the glucometer on medication cart. During an interview on 7/14/21 at 2:26 p.m., with LVN 2, LVN 2 stated she had cleaned the glucometer and used it to check blood glucose for the next resident. When asked what the dwell time was (the time the glucometer was to be in contact with the bleach disposable wipes), LVN 2 stated, I wiped the glucometer .no, I don't know what dwell time is. During an interview on 7/14/21 at 2:38 p.m., with Infection Control Preventionist (IP), IP stated after the glucometer was cleaned, the expectation was for staff to leave the glucometer in the bleach wipes for 5 minutes to make sure all blood borne pathogens are killed. IP stated, not cleaning [glucometer] correctly can cause cross contamination and spread infections. During an interview on 7/15/21, at 2:25 p.m., with Director of Nursing (DON), DON acknowledged LVN 2 did not follow the manufacturer's guidelines for disinfecting the glucometer after use. DON stated it was important to wrap the glucometer in bleach wipes to keep it wet and to leave it for appropriate dwell time to prevent blood borne pathogen infections. During a review of the facility's policy and procedure (P&P) titled, Cleaning Glucometers, the P&P indicated, Starting from the top, wipre around side of glucometer, finish where started. Discard used bleach wipe. Place clean bleach wipe on clean surface and place glucometer on top of wipe. Wrap entire glucometer and let sit for 5 minutes. During a review of the manufacturer's instructions for dwell time for the bleach wipes provided by the facility, the manufacturer's instructions indicated, bacteridal [bacteria killing], fungicidal [fungus killing], tuberculocidal [tuberculosis killing], and virucidal [virus killing] in 4 minutes. 055799 Page 36 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, the facility failed to maintain an essential equipment in a safe operating condition when one of two laundry washer (washer 1) had unreadable water temperature control to detect and measure recommended water temperature for laundry process of soiled resident's linens and clothes. Residents Affected - Many This failure had the potential for residents to be exposed to unclean linens and microorganisms (bacteria, viruses, and fungi). Findings: During a concurrent observation and interview, on 7/15/21, at 8:45 a.m., with Housekeeper (HK) 2, in the laundry room, the two washers (washer 1 and 2) were running in washing and rinsing cycle with loads of linens. The washer 1 temperature screen was not readable to detect the water temperature in ongoing wash cycle mode. HK 2 stated, The machine [washer 1] is off. We [laundry staff] can't read the temperature of [washer 1]. It's been like this [washer 1] for a month. We can still use it [washer 1]. HK 2 stated, the defective temperature control of washer 1 had been reported to their office (outside source). During a concurrent interview and record, on 7/15/21, at 8:45 a.m., with HK 2, the facility's Water temperature log, dated June 1 - July 14, 2021 was reviewed. The temperature log indicated, there were water temperature readings written on washer 1 ranging from 161 F (Fahrenheit, unit of measure) to 169 F. HK 2 stated, We are still using washer 1 because it has the same water temperature with washer 2. The same water running and coming out from the same boiler (fuel container for heating water). During a concurrent interview and record review, on 7/15/21, at 1:46 p.m., with Maintenance Supervisor (MS), the facility's Maintenance binder (reporting system for defective items or equipment) was reviewed. MS was unable to find the report for washer 1's temperature reading control. MS stated, he was responsible for the maintenance of equipment in the facility which included the washer and dryer. MS stated, he was unaware washer 1's temperature reading control was defective and it should had been documented and reported in the maintenance binder. During an interview on 7/19/21, at 10:26 a.m., with ADM, ADM stated, the facility had no policies and procedures for building maintenance and repairs of the facility. During a review of facility's (outside source) titled, Operation Manual dated 1/16, indicated, .Operations: Description of steps in the laundry process .3) WASHING SOILED LINEN . Once the laundry is sorted into Whites . The wash cycle has one purpose; to get the linens clean. There are, however, several factors below that impact your ability to get linens clean . C. The temperature of the water used in the wash cycle . C. Usually high-water temperatures produce the best wash results . During a review of the facility Job Description titled, Specialist Maintenance dated 2/21/14, the job description indicated, Specialist Maintenance 1 .Assist in ensuring the building(s), equipment and utilities are maintained in good working order and grounds are properly maintained in accordance with company policies .Make rounds, assess, and make minor repairs. Assist with large repairs. Conduct preventative maintenance as assigned . 055799 Page 37 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, and staff interviews, the facility failed to provide a safe, sanitary, comfortable working environment for residents, staff, and the public when: Residents Affected - Many 1. the kitchen's temperature readings exceeded 83 °F (Fahrenheit [temperature measure). This failure resulted in an unsuitable working environment for kitchen staff. 2. a rubber strip across doorway of a resident room came loose when it was walked on. This failure had the potential to cause tripping and injury to a resident, staff, or the public. 3. the paint from the walls of the laundry room, inlcuding above the laundry sink was peeling. The laundry sink, faucet, faucet handles, and surfaces of the sink were stained with grime (dirt ingrained on the surface). Findings: 1. During an observation on 7/13/21 at 11:27 AM, the Surveyor Thermometer in kitchen by stove across from tray line area showed 88.7 °F. During an observation on 7/13/21 at 11:31 AM, the Surveyor Thermometer showed 120 °F at stove in the kitchen. During an observation on 7/13/21 at 11:43 AM, in front of stove on steam table the surveyor thermometer showed 98.1°F. During an observation on 7/13/21 at 3:00 PM, the surveyor Thermometer in kitchen on table where steam table located showed 98.2 °F. During an interview with Food Service Worker (FSW) 3 on 7/13/21 at 3:04 PM, he stated that the kitchen has been very hot but last week they changed out the AC unit in the window on the back side of the kitchen last week and it works better than the other one but it is still hot in the kitchen. The AC unit in the window showed it was set to 65 °F. When asked if it would go lower, he stated he did not know. Stated the main AC in the kitchen was shut off because it was blowing dust into the kitchen from the vents. The Surveyor felt AC vents on ceiling and there was no air coming out. During an observation on 7/14/21 at 8:46 AM, the Surveyor Thermometer near steam table by coffee maker showed 85.3 °F. During an observation on 7/14/21 at 10:20 AM, the Surveyor Thermometer near the steam table showed 89.9 °F. During an interview on 7/14/21 at 10:23 AM, FSW 3 and the Dietetic Service Supervisor (DSS) were stating it was hot in the kitchen. During an observation on 7/14/21 at 11:59 AM, the Surveyor Thermometer near the steam table and coffee machine showed it was 91.8°F. 055799 Page 38 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0921 Level of Harm - Minimal harm or potential for actual harm During an observation on 7/14/21 at 2:11 PM, the Surveyor Thermometer on table near coffee machine steam table showed 88.8°F. During an observation on 7/14/21 at 2:17 PM, the Surveyor Thermometer in back of kitchen near AC window unit showed it was 83.1°F. Residents Affected - Many During an observation on 7/14/21 at 4:34 PM, the Surveyor Thermometer showed it was 91.4 °F in the kitchen. During an observation of lunch meal service on 7/15/21 at 11:37 PM and 11:40 AM, the Surveyor Thermometer showed 91 °F in kitchen by steam table (Trayline). During an observation at 7/15/21 at 3:24 PM, the Surveyor Thermometer showed it was 93.6 °F. During a concurrent observation and interview with the Maintenance Supervisor (MS) on 7/15/21 at 3:42 PM, MS stated last week, maybe on Friday they got new AC unit for window in the kitchen. MS confirmed it was warm in the kitchen. MS stated he was not sure if the new AC unit helped the warmth in the kitchen and that kitchen staff would have to tell him since he doesn't work in the kitchen. MS stated there was an evaporator cooler/swamp cooler in kitchen but there is AC in the rest of the building and dining room that is attached. The Maintenance thermometer showed at the swamp cooler it was 94 °F and then another swamp cooler vent in window, his thermometer shower it was 81-83 °F. MS stated they had a policy on temperatures for resident rooms and would get a copy of that. During an interview with MS on 7/16/21 at 11:53 AM, MS stated the facility did not have a policy on room temperatures but stated rooms should be within 72-82F. During a review of facility policy and procedure titled, Test and log temperatures dated 4/29/21, indicated, . All buildings are required to maintain an ambient temperature throughout resident and patient areas in a temperature range of 71 to 81 degrees Fahrenheit or at a more restrictive range required by state or local requirements . According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Ventilation Section 6-304.11 Mechanical, indicated If necessary to keep rooms free of excessive heat, steam, condensation, vapors, obnoxious odors, smoke, and fumes, mechanical ventilation of sufficient capacity shall be provided. 3. During a concurrent observation and interview, with HK 2, on 7/15/21, at 9:05 a.m., in laundry room, the paint was peeling from the walls of the laundry room, including above laundry sink (area where staff used to wash hands). The laundry sink (above and under), faucet, faucet handles, surfaces of the sink, and surfaces of the back area of washer 1 and 2 were stained with yellowish to brownish colored adhered to surfaces. HK 2 validated the findings. During an interview with MS, on 7/15/21, at 1:46 p.m., MS stated the walls of the laundry room above the laundry sink should be repainted to avoid flaking and to maintain sanitation and cleanliness of the laundry room. During a review of the facility Job Description, 2/21/2014, indicated, Specialist Maintenance 1 .Assist in ensuring the building(s), equipment and utilities are maintained in good working order and grounds are properly maintained in accordance with company policies .Make rounds, assess, and make 055799 Page 39 of 40 055799 07/19/2021 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0921 minor repairs. Assist with large repairs. Conduct preventative maintenance as assigned . Level of Harm - Minimal harm or potential for actual harm 2. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3, on 7/15/21, at 11:41 a.m., LVN 3 observed the rubber strip came loose at one end when it was walked on. LVN 3 observed the strip curled away approximately six inches from joining the carpet and tile inside a Resident room. LVN 3 put the strip back in place and stated, Someone could get injured by tripping over it. I will tell maintenance. Residents Affected - Many During a concurrent observation and interview with the Maintenance Supervisor (MS), on 7/15/21, at 11:53 a.m., the MS stated he did not know the rubber strip was loose. The MS stated, You [HFEN] are the first to notice it. The MS was at the resident room and glued down the loose rubber strip. During an interview with the Housekeeper (HK) 2, on 7/15/2, at 11:46 a.m., HK 2 stated she had seen the rubber strip loose the day before when a bed was pushed into the resident room. HK 2 stated the loose rubber strip was a hazard and could cause someone to trip and fall. HK 2 stated, I should have let maintenance know and put it in the maintenance log book. During an interview with the Housekeeping Supervisor (HS), 7/15/21, at 1:33 p.m., the HS stated the housekeepers would go to the MS to inform him of repairs that were needed. The HS stated, Someone could trip over [the loose rubber strip]. It [loose rubber strip] should be written in the log and told to the maintenance man. During an interview with the Administrator (ADM), on 7/19/21, at 10:26 a.m., the ADM stated the facility had no policies and procedures for building maintenance and repairs of the facility. 055799 Page 40 of 40