Health inspection·December 15, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plans (CP- a detailed approach to care customized to an individual resident's needs) for two of 12 sampled residents (Resident 17 and Resident 47) when: 1. Resident 17's activity care plan did not have individualized interventions. 2. Resident 47 did not have an activity [NAME] plan. These failures had the potential to prevent the residents from receiving appropriate, and individualized care and services consistent with their needs. Findings: 1. During a review of Resident 17's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 12/14/23, the AR indicated, Resident 17 was admitted from the acute care hospital on 5/3/23 to the facility, with diagnoses that included End Stage Renal Disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), Muscle Weakness, Type 2 Diabetes Mellitus (a disorder in which blood sugar or glucose levels are abnormally high), and Hyperlipidemia (high cholesterol). During a review of Resident 17's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 12/11/23, the MDS indicated Resident 17's Brief Interview for Mental Status (BIMS) score was 11 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During an interview on 12/13/23, at 9:00 a.m., with Resident 17, inside Resident 17's room. Resident 17 stated he was bored and wanting something else to do aside from watching TV. During a concurrent interview and record review on 12/13/23 at 10:01 a.m., with Licensed Vocational Nurse / Infection Preventionist (IP), Resident 17's Care Plan (CP) titled Focus: ACTIVITY CARE PLAN, dated 12/10/23 was reviewed. The CP indicated, . Will Participate and Benefit from Activities In or Out of Room of Choice and Interest . Goal The resident will maintain involvement in cognitive stimulation, social activities as desired through the next review date . Interventions/Tasks . Invite the resident to scheduled programs . Date Initiated . 12/8/23 Created by [Activity Director] . IP Page 1 of 16 055799 055799 12/15/2023 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 stated Resident 17's activity care plan was not specific to Resident 17's current needs. The IP stated Resident 17's activity care plan should include his likes and dislikes, such as watching TV shows, reading newspaper, sitting outside, or participating in activities that he's interested. During a concurrent interview and record review on 12/14/23 at 2:30 p.m., with the Activity Director (AD), Resident 17's Care Plan (CP) titled Focus: ACTIVITY CARE PLAN, dated 12/10/23 was reviewed. The AD stated Resident 17's activity care plan was not specific to Resident 17's current needs and it should. The AD stated Resident 17's activity care plan should be tailored to his interest and specific needs. During a concurrent interview and record review on 12/14/23 at 2:40 p.m., with the Director of Nursing (DON), Resident 17's CP, dated 12/10/23, was reviewed. The DON stated a resident specific care plan should have been developed to address Resident 17's activity needs and it was not done. The DON stated without a resident specific activity care plan, Resident 17 could experience depression, boredom, restlessness, or agitation. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person Centered, dated 3/22, the P&P indicated, . The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 2. During a review of Resident 47's AR dated 12/14/23, the AR indicated, Resident 47 was admitted to the facility on [DATE] with diagnoses which included recent hip joint replacement, Depression ( a condition of constant sadness and loss of interests that once brought pleasure), Dementia (decline of cognitive functions including memory) and paralytic syndrome (continual weakness to matching sides of the body) leaving resident wheelchair bound. During a review of Resident 47's MDS assessment dated [DATE], the MDS indicated Resident 47's BIMS score was 15 of 15 points which indicated Resident 47 was cognitively intact. During an interview on 12/14/23 at 11:28 a.m. with the MDS coordinator, the MDS coordinator stated Resident 47 did not have an Activity Care Plan. The MDS coordinator stated per facility policy, every resident needs an activity care plan. The MDS coordinator stated without an activity care plan, Resident 47 could become bored and depressed. During an interview on 12/14/23 at 11:35 a.m. with the Activities Director (AD), the AD stated Resident 47 did not have an Activity Care Plan. The AD stated it was her responsibility to ensure each resident has an activity care plan in place. The AD stated without an Activity Care Plan, the other staff caring for Resident 47 would not know his preferences and Resident 47 could have a poor quality of life. During an interview on 12/14/23 at 1:39 p.m. with the DON, the DON stated her expectation was for each resident in the facility to have an activity care plan. The DON stated, Residents without an activity care plan could compromise their health, and become bored and lonely. During a review of the facility's P&P titled, Care Plans, Comprehensive Person Centered, dated 3/22, the P&P indicated, . The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 055799 Page 2 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to complete an annual performance review of licensed nurses (LN) for two of nine sampled licensed nurses (Registered Nurse [RN] 1 and Infection Preventionist [IP]) when RN 1 and IP did not have annual performance evaluations and skills competencies review from 2022 to 2023. This failure had the potential to result in RN 1 and IP to not develop or maintain competencies to provide residents with needed and appropriate care and services. Findings: During an interview on 12/13/23 at 1:14 p.m., with Licensed Vocational Nurse/Infection Preventionist (IP), the IP stated she can't recall if she had her annual performance evaluation for the past 12 months. The IP stated, I am not sure. Maybe last year with the previous Director of Nursing (DON). The IP stated her role required her to be updated with new infection control regulations and best practices. The IP stated she occasionally performs medication pass and treatments. The IP stated without the annual performance evaluation, she does not have any idea if she was meeting the standards of care in the skilled nursing facility (SNF). During a concurrent interview and record review ,on 12/14/23 at 9:16 a.m., with the Director of Staff Development (DSD) and the DON, the Employee Performance Evaluations for the previous 12 months, dated 2023 was reviewed. The DSD reviewed the employee performance annual evaluations completed for the previous three years and stated RN 1 and IP did not receive their annual performance evaluations for 2022 and 2023. The DSD stated RN 1's annual performance evaluation was completed on 12/21/21 and there was no evaluation conducted for 2022 and 2023. The DSD stated the IP's annual performance evaluation was completed on 12/3/20 and there was nothing for 2021, 2022 and 2023. The DSD stated RN 1 and the IP's skills competencies should have been evaluated within the 12-month period and that did not occur. The DSD stated without the annual performance evaluations, she can't validate the skills and competency of RN 1 and IP. During an interview on 8/23/18 at 9:12 a.m., with the DON, the DON stated the annual performance evaluation of the licensed nurses was very important as it tracks the LN's progress and that did not happen. The DON stated the annual performance evaluation was one of many means to assess the type of in-services the facility should provide to the facility staff to improve the LN's knowledge and skills. The DON stated the potential outcome of not performing the LN's annual performance evaluation could be poor care and not meeting the needs of facility residents. During a review of the facility document titled, Job Description Licensed Vocational Nurse, dated 11/16, the Job Description indicated, . POSITION SUMMARY . The LVN is responsible for assisting with resident care under the medical direction and supervisor of the resident's attending physicians in order to ensure the resident remains as independent as possible . Will be in compliance with federal and state laws and regulations and community policies and procedures . During a review of the facility document titled, Job Description Registered Nurse, dated 11/16, the Job Description indicated, . POSITION SUMMARY . The RN is responsible for assisting with resident care under the medical direction and supervisor of the resident's attending physicians in order to ensure the resident remains as independent as possible . Will be in compliance with federal and state 055799 Page 3 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0726 laws and regulations and community policies and procedures . Level of Harm - Minimal harm or potential for actual harm During a review of the facility document titled, Job Description Director of Staff Development, dated 11/23, the Job Description indicated, . POSITION SUMMARY . The primary purpose of the DSD position is to plan, organize, develop, and direct all in-service educations programs throughout the facility . Conduct departmental performance evaluations in accordance with the facility's policies and procedures . Residents Affected - Some During a review of the facility document titled, Job Description Director of Nursing, dated 11/16, the Job Description indicated, . POSITION SUMMARY . To assist in the management and direction of the Nursing Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and Medical Director, to ensure that the highest degree of quality care is maintained at all times . The facility's policy and procedure for annual performance evaluation was requested but was not available. 055799 Page 4 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a performance review of a nurse aide for three of 12 sampled Certified Nursing Assistants (CNA 1, CNA 2 and CNA 3) when CNA 1, CNA 2 and CNA 3 did not have annual performance evaluations and skills competencies review within the last 12 months. Residents Affected - Some This failure had the potential to result in CNA 1, CNA 2 and CNA 3 to not develop or maintain competencies to provide residents with needed and appropriate care and services. Findings: During an interview on 12/13/23 at 1:00 p.m., with CNA 1, CNA 1 stated he could not recall if he had his annual performance evaluation for the past 12 months. CNA 1 stated the Director of Staff Development (DSD) usually schedules his annual evaluation and discuss his work performance and areas for improvement. CNA 1 stated without the annual performance evaluation he does not have any idea if he is meeting the standards of care in skilled nursing facility (SNF). During a concurrent interview and record review on 12/14/23 at 8:59 a.m., with the DSD, the Employee Performance Evaluations for the previous 12 months, dated 2023 was reviewed. The DSD reviewed the employee performance annual evaluations completed for the previous 12 months and stated CNA 1, CNA 2 and CNA 3 did not receive their annual performance evaluations for 2023. The DSD stated CNA 1's annual performance evaluation was completed on 11/20/22 and there was no evaluation conducted for 2023. The DSD stated CNA 2's annual performance evaluation was completed on 11/13/22 and there was nothing for 2023. The DSD stated CNA 3's annual performance evaluation was completed on 12/3/22 and there was nothing for 2023. The DSD stated CNA 1, CNA 2 and CNA 3 skills competencies should have been evaluated within the 12-month period and that did not occur. The DSD stated without the annual performance evaluations she can't validate the skills and competency of CNA 1, CNA 2 and CNA 3. During an interview on 8/23/18 at 2:30 p.m. with the Director of Nursing (DON), the DON stated the annual performance evaluation of the CNAs is very important as it tracks the CNA's progress and that did not happen. The DON stated the annual performance evaluation was one of many means to assess the type of in-services the facility should provide to the facility staff to improve the CNA's knowledge and skills. The DON stated the potential outcome of not performing the CNA annual performance evaluation could be poor care and not meeting the needs of facility residents. During a review of the facility document titled, Job Description Certified Nursing Assistant, dated 12/23, the Job Description indicated, . POSITION SUMMARY . Responsible for providing assistance with Activities of Daily Living and assisting with routine daily nursing care needs and services in accordance with resident's assessment and service plan . During a review of the facility document titled, Job Description Director of Staff Development, dated 11/23, the Job Description indicated, . POSITION SUMMARY . The primary purpose of the DSD position is to plan, organize, develop, and direct all in-service educations programs throughout the facility . Conduct departmental performance evaluations in accordance with the facility's policies and procedures . The facility's policy and procedure for annual performance evaluation was requested but was not 055799 Page 5 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0730 available. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055799 Page 6 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 provide pharmaceutical services on acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one of 12 sampled residents (Resident 31) when the contracted pharmacy for the facility did not deliver Resident 31's prescribed Clonazepam (a medication used to treat severe anxiety, panic disorders, and seizures) between 12/8/23 and 12/12/23. This failure resulted in Resident 31 to experience increased anxiety and restlessness which caused disturbance to other facility residents. Findings: During a review of Resident 31's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 12/14/23, the AR indicated, Resident 31 was admitted from the acute care hospital on 4/25/21 to the facility, with diagnoses that included Alzheimer's Disease (loss of memory and ability to carry simple tasks), Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Insomnia (difficulty sleeping), and Palliative Care (specialized medical care to ease symptoms without curing the underlying disease for people living with a serious illness). During a review of Resident 31's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 12/11/23, the MDS indicated Resident 31's Cognitive Skills for Daily Decision Making was severely impaired. During an observation on 12/12/23, at 10:30 a.m., in the main hallway facing the nurses station, Resident 31 was observed sitting in a geri-chair (are large padded chairs with wheeled bases, and are designed to assist seniors with limited mobility( restless and yelling incomprehensible words. A female certified nursing assisant (CNA) tried to redirect by offering fluids but was not effective. Resident 31 continued to kick his feet and yell incomprehensible words. During an observation on 12/12/23, at 2:32 p.m., in the main hallway facing the nurses station, Resident 31 was observed sitting in a geri-chair, restless and yelling incomprehensible words. A female CNA was sitting beside Resident 31 providing 1:1 care and offering redirection but was not effective. During a concurrent interview and record review on 12/12/23 at 2:25 p.m., with Licensed Vocational Nurse/Infection Preventionist (IP), Resident 31's Physician Order (PO), dated 12/8/23 was reviewed. The PO indicated, . ClonazePAM Oral tablet 0.5 milligram (mg, unit of measurement) Give 0.25 mg by mouth every 6 hours as needed for Anxiety and yelling out . Start Date 12/8/23 1345 [1:45 p.m.] . IP stated Resident 31's ClonazePAM was not delivered by the pharmacy for the last four days [12/8/23 to 12/12/23]. IP stated Resident 31 was seen by a Psychologist on 12/8/23 and he recommended to discontinue the previous anti-anxiety medication due to ineffectiveness and start on ClonazePAM. IP stated Resident 31 was restless and yelling for several days. IP stated the new medication should have been delivered within 24 hour and it was not. IP stated the pharmacy failed to deliver Resident 31's 055799 Page 7 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0755 anti-anxiety medication in a timely manner. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/12/23, at 3:00 p.m., with Resident 2, in the main hallway facing the nurses station, Resident 2 stated he was bothered by Resident 31's behavior. Resident 2 stated, He was yelling and screaming for several days and I didn't sleep at night because of the noise his making. Residents Affected - Few During a concurrent interview and record review on, 12/14/23, at 1:41 p.m., with the Director of Nursing (DON), Resident 31's PO dated 12/8/23 and Medication Administration Record (MRR) were reviewed. The PO indicated, . ClonazePAM Oral tablet 0.5 mg. Give 0.25 mg by mouth every 6 hours as needed for Anxiety and yelling out . Start Date 12/8/23 1345 [1:45 p.m.] . The DON reviewed Resident 31's MAR, dated 12/23 and stated Resident 31's ClonazePAM 0.5 mg. was unavailable and was not administered on 12/8/23, 12/9/23, 12/10/23, and 12/11/23. The DON stated the Clonazepam 0.5 mg. was first administered on 12/12/23 at 9:19 p.m The DON stated the Clonazepam was delivered to the facility on [DATE], between the hours of 7:00 p.m. and 9:00 p.m. The DON stated the Licensed Nurses should have notified the physician and pharmacy of the unavailability of ClonazePAM on 12/8/23, 12/9/23, 12/10/23, and 12/11/23 and it was not done. The DON stated the medication should have been delivered by the contracted pharmacy to the facility within 24 hours and it was not. The DON stated the goal of comfort for Resident 31 was not met due to the delay in the delivery of ClonazePAM. During a review of Resident 31's Progress Note (PN), dated 12/8/23, the PN indicated, . Psychologist visit for consultation on behaviors for Resident. He is in constant motion and yelling out constantly without any need. Recommendation were to discontinue the Lorazepam Concentrate . and start Clonazepam 0.25 mg every 6 hours as needed for behaviors, anxiety, yelling out. Continue order for 14 days then re-evaluate. Hospice to call [son], he is in agreement of order. Order entered into PCC [Electronic Health Record]. Awaiting for pharmacy to deliver . signed [DON] . During a review of Resident 31's Care plan, dated 12/8/23, the care plan indicated, . Focus: I get nervous and anxious manifested by (m/b) repetitive physical movements (kicking legs in air). Resident agitated m/b constant loud yelling . Goal: I will have less than 4 episode of anxiety . Interventions/Tasks . Referred and seen by psychologist with recommendation . Notified and updated Responsible Party of new behavior and new medication . Order ClonazePAM tablet . During a review of Pharmaceutical Services Agreement, undated, the agreement indicated, . Duties and Responsibilities of Pharmacy . 1.9 Delivery Schedule. [Pharmacy] will perform deliveries (3) times/day, 7 days a week, Monday through Sunday. [Pharmacy] will also provide emergency deliveries as requested by the Facility . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse (LVN), dated 11/16, the document indicated, . The LVN is also responsible for the delivery of medications to residents in accordance with physician's orders and the direction of Resident Services Director . During a review of Professional reference from https://www.fda.gov/drugs/special-features/why-you-need-take-your-medications-prescribed-or-instructed, titled, Why You Need to Take Your Medications as Prescribed or Instructed dated 2/16, indicated, . Sticking to your medication routine (or medication adherence) means taking your medications as prescribed - the right dose, at the right time, in the right way and frequency . not taking your medicine as prescribed by a doctor or instructed by a pharmacist could lead to your disease getting worse, hospitalization, even death . 055799 Page 8 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary medications in their treatment plan for one of 12 sampled residents (Resident 18) when Resident 18 had no appropriate indication and monitoring for the use of Atorvastatin (a medication used to lower cholesterol levels in the blood). Residents Affected - Few This failure placed Resident 18 to be at risk of being administered Atorvastatin unnecessarily which could potentially lead to constipation, muscle pain and liver damage. Findings: During a review of Resident 18's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 12/14/23, the AR indicated, Resident 18 was admitted from the acute care hospital on [DATE] to the facility, with diagnoses that included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hypertension (high blood pressure), Generalized Muscle Weakness, Myocardial Infarction (heart attack), History of Falling, and Hyperlipidemia (elevated cholesterol level). Resident 18's height was 55 inches, weight was 69 pounds, and Body Mass Index (BMI, measure of body fat) was 16 (underweight; BMI index of less than 18.5 is underweight, Normal BMI is between 18.5 to 24.9, Overweight is between 25 to 29.9). During a concurrent observation and interview, on 12/12/23, at 1:00 p.m., with Resident 18's daughter/Responsible Party (RP) in the main hallway facing the nurses station, Resident 18 was observed sleeping while sitting in a wheelchair, very thin and no muscle mass seen on both arms were observed. RP stated Resident 18 recently turned 101 [birthdate was [DATE]] and was surprised to learn that Resident 18 was prescribed and receiving Atorvastatin 40 milligram (mg, unit of measurement). RP stated her mother stopped taking Atorvastatin prior to her hospitalization. RP stated, She don't need it. My mother is [AGE] years old. During a concurrent interview and record review, on 12/13/23 at 11:18 a.m., with Licensed Vocational Nurse/Infection Preventionist (IP), Resident 18's Physician Order (PO), dated 11/6/23 and admission Record (AR), dated 12/14/23 were reviewed. The PO indicated, . Atorvastatin Calcium Oral Tablet 40 mg. Give 1 tablet by mouth at bedtime for Hyperlipidemia . IP reviewed the medical record from acute hospital and stated there was no record of Resident 18's Lipid Panel (blood test to check for cholesterol level). The IP stated Resident 18's Attending Physician ordered two blood tests on 11/8/23 and 12/12/23, but not for lipid panel. The IP stated Lipid Panel was used to determine if a resident needs to take a cholesterol lowering medication or to reduce the dosage of the current cholesterol lowering medication. The IP stated Resident 18 could potentially experience the side effects from taking Atorvastatin such as constipation, headache, diarrhea, back pain, liver, kidney and severe muscle damage. During a concurrent interview and record review, on 12/14/23, at 3:30 p.m., with the Director of Nursing (DON), Resident 18's Physician Order (PO), dated 11/6/23 and admission Record (AR), dated 12/14/23 were reviewed. The PO indicated, . Atorvastatin Calcium Oral Tablet 40 mg. Give 1 tablet by mouth at bedtime for Hyperlipidemia . The DON stated she was unable to find any Lipid Panel values from the hospital record and there was no record that a Lipid Panel was ordered by the Attending Physician since Resident 18's admission to the facility. The DON stated, If I were the physician, I will 055799 Page 9 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few order a lipid panel to check her [Resident 18] cholesterol level. The DON stated Resident 18's use of Atorvastatin could be unnecessary and could potentially cause Resident 18 to experience leg cramps, elevated enzymes (inflammation or damage to liver), and constipation. The DON stated Resident 18's BMI was 16 and considered as underweight. During a concurrent phone interview and record review on, 12/14/23, at 4:15 p.m., with the Pharmacy Consultant (PC), Resident 18's Physician Order (PO), dated 11/6/23 and admission Record (AR), dated 12/14/23 were reviewed. The PC stated there was no Lipid Panel values from the hospital record. The PC stated Resident 18 was admitted to the facility for more than a month and must have a lipid panel blood test to assist in determining if the Atorvastatin 40 mg was appropriately prescribed. The PC stated she would recommend to the Attending Physician to discontinue the Atorvastatin due to Resident 18's current age and BMI. The PC stated Resident 18 could potentially experience muscle pain and liver damage from taking Atorvastatin. During a review of the facility's Policy and Procedure (P&P) titled, Medication Therapy, dated 4/07, the P&P indicated, . 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks . 2. Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments . 055799 Page 10 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0803 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation, interview, and record review, the facility did not ensure the menu was followed for the grilled cheese offered as an alternate menu item. Residents Affected - Few This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the resident's nutritional status. The facility census was 45. Findings: During a review of the facility's Alternate Menu, the alternate menu indicated the menu items were .Lunch/Dinner Alternates: Cheese Quesadilla, Turkey sandwich with lettuce leaf and tomato slice, Grilled cheese sandwich . During an interview in the kitchen on 12/13/23 at 10:05 AM with the [NAME] (CK) 2, CK 2 was observed making two grilled cheese sandwiches on the grill station. CK 2 stated she used two slices of processed American cheese and two slices of white bread to make the grilled cheese sandwiches. CK 2 stated she did not use shredded cheese or weigh the American cheese slices, as mentioned in the grilled cheese recipe. CK 2 further stated at least three grilled cheese sandwiches are made daily at lunch and three at dinner for the alternate menu selections. During a review of the recipe titled Grilled Cheese Sandwich, the recipe indicated Ingredients: Cheese of choice: Cheddar, Monterey Jack, or combination of both sliced or shredded) Be sure to weigh cheese (in bold), wheat bread, melted margarine .*Sliced cheese may not weigh 1 oz. per slice. Make sure to weigh cheese to know how many slices equal 2 oz. If using shredded cheese, ½ cup = 2 oz. cheese. *Do not use American Cheese . During a review of the processed American cheese slices manufacturer's label, the label indicated one serving size equaled one slice of cheese and a total weight of 19 grams. The serving size provided 70 calories and 3 grams of protein per serving. Two slices of cheese weighed 38 grams and equaled 140 calories and 6 grams of protein. One ounce of cheese weighs 28 grams, so 2 oz. of cheese requires at least 3 slices of the sliced cheese. During a review of the facility document titled Nutritional Breakdown, dated Winter 2023-24, the document indicated average daily nutrient analysis for the Regular menu was 2177 calories, 98 grams of protein . The average calories for the Regular diet per daily meal would range from 500-600 calories and 26 grams of protein per meal. The Alternate menu grilled cheese sandwich prepared by CK 2 provided less than the regular diet calories and protein nutrients. During an interview on 12/13/23 at 4:48 P.M. with the Registered Dietitian (RD), the RD stated the recipes and menus have been analyzed to provide appropriate nutrients to meet the resident's needs. The RD stated it was important for the Cooks to follow the recipes as printed. During a review of the facility's policy and procedure (P&P) dated 2023, titled Menu Planning, the P&P indicated .Procedures .4. Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation . 055799 Page 11 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure food was palatable and served at an acceptable temperature to the residents in accordance with the facility policy and procedure. Residents Affected - Many This failure had the potential to affect meal and food intake which could impair the nutrition status for 45 of 45 residents who are served food from the kitchen. Findings: During the initial survey resident screening process on 12/12/23 at 9:53 a.m., multiple interviews with residents were conducted, and the residents had complaints of lack of food variety, food temperature and palatability concerns. During a test tray evaluation of the lunch meal for the Regular Diet and Pureed Diet on 12/13/23 at 12:37 p.m., an observation and interview was conducted with the FSD and the Registered Dietitian (RD). The Regular tator tots were 116 degrees fahrenheit (F-measure of temperature) and the Pureed tator tots were 118 degrees F. Both the Regular and Pureed diet tator tots were lukewarm to bland without any flavor to taste. The Pureed carrots were 116 degrees F with a gritty taste somewhat like carrots. The Pureed bread was flavorless and did not taste like bread. The FSD and RD stated the temperature and taste of the test tray food items. The RD stated it was important for the food to be flavorful and palatable so the residents will eat and enjoy it. During an interview on 12/13/23 at 4:48 p.m., with the RD, the RD stated it was important for the menu to have an adequate variety of foods to meet the residents' food preferences and choices. The RD stated the facility menu needed to be reviewed for additional food variety. During a review of the facility's policy and procedure (P&P) dated 2023, titled Meal Service, the P&P indicated .7. Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot .Recommended Temp at Delivery to Resident .milk/cold beverage less than or equal to 45 degrees F(Fahrenheit), hot entrée- less than or equal to 120 degrees F, starch - less than or equal to 120 degrees F, vegetables - less than or equal to 120 degrees F. 055799 Page 12 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food preparation tools and food storage methods, according to standards of practice and facility policy when: 1. Two cutting boards were found visibly worn with multiple tears and discolorations. 2. A case of molded onions was found on a shelf underneath the Cook's prep counter. 3. A case of Corn tortillas and a bag of Parsley did not have use by dates. These failures had the potential to expose residents to contaminants that could cause foodborne illness. The facility census was 45. Findings: During the initial kitchen tour on 12/12/23 at 9:33 a.m., observations of unsanitary and unsafe food practices and interviews with the Food and Nutrition Services Director (FSD), Registered Dietitian (RD), and [NAME] (CK) 1 were conducted. 1. A green cutting board and a red cutting board were found visibly worn with several tears, rips, discolorations, and indentations in them. CK 1 stated she used the cutting boards to chop vegetables and the red board to chop meats during food production. CK 1 did not remember when the cutting boards were last cleaned. The RD stated the worn condition of the cutting boards and stated surfaces could hold bacteria in them. According to the 2022 Federal FDA Food Code, section 4-602.11, titled Equipment Food-Contact Surfaces and Utensils, Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. Food-contact .should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces. 2. A large black rubber bin with a use-by date of 11-30-23 had 40 onions had gray, light brown and green colored substances resembling mold on them. The FSD stated the bin of onions with the mold-like substances and stated, they should have been thrown out. 3. A case with 10 bags of individually wrapped corn tortillas had a manufacturer's date of 9/17/23 and did not have a use by date. A plastic bag of parsley dated 12/8/23 was found in the reach-in refrigerator #2 without a receive or a use by date. The FSD stated the case of tortillas and the parsley did not have either a use-by date or a received date. The FSD stated she was unsure if the 12/8/23 date on the bag of parsley was the received date or use-by date. The FSD stated the case of tortillas and bag of parsley should have been properly dated according to the policy. According to the 2022 Federal FDA Food Code, section 3-501.17 (A) (B) (C) (D) indicate .the day the original container is opened in the food establishment shall be counted as Day 1 .The date marked 055799 Page 13 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises . During a review of the facility's policy and procedure (P&P) dated 2023 titled Labeling and Dating the P&P indicated .Food delivered to facility needs to be marked with a .dated .Newly marked food items will need to be .labeled with an open date and used by date that follows .storage guidelines . 055799 Page 14 of 16 055799 12/15/2023 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 Based on observation, interview and record review, the facility failed to follow CDC guidance and facility policy and procedure for the prevention of infections when the Director of Nursing (DON) did not provide evidence of vaccination and did not wear a surgical mask in accordance with written standards. Residents Affected - Few This failure resulted in the increased risk of the spread of infectious diseases. Findings: During an observation on 12/12/23 at 9:45 a.m., the DON was observed in resident care areas, conversing, and assisting residents and interacting with other staff members without a surgical mask or other facial covering over her nose or mouth. During an observation on 12/13/23 at 9 a.m., the DON was observed in resident care areas, conversing, and assisting residents and interacting with other staff members without a surgical mask or other facial covering over her nose or mouth. During an observation on 12/14/23 at 7:30 a.m., the DON was observed in resident care areas, conversing, and assisting residents and interacting with other staff members without a surgical mask or other facial covering over her nose or mouth. During a concurrent interview and record review on 12/14/23 at 8:30 a.m. with Infection Preventionist (IP), the facility Staff Vaccination Documentation (SVD), for 2023 was reviewed. The SVD included signed and dated Employee Consent/Declination of Influenza Vaccination for six staff members including the DON. The DON indicated she declined the vaccination due to a personal history of Guillain-Barré syndrome (GBS - is a rare condition in which a person's immune system attacks the peripheral nerves that branch out from the brain and spinal cord) dated 10/16/23. IP stated staff members were instructed at time of declining the vaccination that a surgical mask must be worn at all times while in the facility. IP stated DON is aware she should be wearing a surgical face mask. IP stated DON should be wearing face mask to prevent the potential transmission of infectious diseases to residents and other staff members. During a concurrent interview and record review on 12/14/23 at 1:39 p.m., with DON, the Employee Consent/Declination of Influenza Vaccination dated 10/16/23, signed by the DON was reviewed. The Employee Consent/Declination of Influenza Vaccination indicated, the DON declined to receive the Influenza Vaccination due to personal history of GBS. DON stated that was her declination and she should be wearing a face mask. DON stated it is the facility policy to have unvaccinated staff members wear a face mask during flu season. DON stated the reason for wearing a face mask is to prevent harm to the residents in the facility. During a concurrent interview and record review on 12/15/23 with Administrator (ADM), the facility's policy and procedure (P&P) titled Influenza Vaccine dated 11/2012 was reviewed. The P&P Indicated, .11. Administration of the influenza vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination . The ADM stated the DON should have worn a mask to prevent the transmission of the influenza virus. During a review of the CDC Menu of State Long-Term Care Facility Influenza Vaccination Laws dated 055799 Page 15 of 16 055799 12/15/2023 Vineyard Care Center 1090 East Dinuba Avenue Reedley, CA 93654

F 0880 Level of Harm - Minimal harm or potential for actual harm 3/6/23, the Menu of State Long-Term Care Facility Influenza Vaccination Laws indicated, . Surgical Mask Requirements The healthcare worker must wear a surgical mask during influenza (flu) season if he or she has been exempted from or declined flu vaccination . Residents Affected - Few 055799 Page 16 of 16