Health inspection·June 13, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide the Restorative Nursing Assistant (RNA) services as ordered by the physician for two of 20 sampled residents reviewed for Range Of Motion (ROM) functions (Resident 2 and 69). This failure had the potential for decline in the resident's range of motion and mobility. Findings: 1. During a review of Resident 2's face sheet dated, 6/12/24, showed Resident 2 was admitted to the facility in 10/2020 with multiple diagnoses that included Brain Stem Stroke Syndrome (when a blood supply to the base of the brain is stopped which can potentially affect many functions in the body). During a review of Resident 2's Physical Therapy (PT) Discharge summary, dated [DATE], revealed under Assessment and Summary of Skilled Services: Prognosis to maintain Current Level of Functioning (CLOF) = Excellent with consistent staff support, excellent with participation in Restorative Nursing Program (RNP). Under Discharge Recommendations: Functional Maintenance Program/Restorative Nursing Program (FMP/RNP). During a review of Resident 2's Order Summary, dated 2/28/24, revealed RNA Program: Patient (Pt) to participate in RNP 2x/week x 90 days to address muscle weakness and lack of coordination status post (s/p) CVA with L side paresis (left side weakness). RNP to increase transfer to wheelchair (w/c) from bed, bed to w/c with two person assist and sit in w/c for at least 30 minutes. Reassess by PT/OT as necessary. During a review or Resident 2's Order Summary Report, dated 5/7/24, revealed RNA Program: Pt to participate in RNP 2x/week x 90 days to address muscle weakness and lack of coordination s/p CVA with L side paresis. Passive Range Of Motion (PROM)TO Left Upper Extremity (LUE ) 2 X A WEEK. During a review of Resident 2's care plan, dated, 2/28/24, revealed Resident 2 had ADL (Activities of Daily Living) Self Care Performance Deficit related to hemiplegia (paralysis on one side of the body). According to the care plan, one of the interventions was RNA Program: Patient (Pt) to participate in RNP 2x/week x 90 days to address muscle weakness and lack of coordination s/p CVA with L side paresis . 2. During a review of Resident 69's face sheet date, 6/12/24, showed Resident 69 was admitted to the facility in 5/22/23 with multiple diagnoses that included Hemiplegia and Hemiparesis (weakness on Page 1 of 5 055876 055876 06/13/2024 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0688 one side of the body) following cerebral infarction (stroke) affecting right dominant side and weakness. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 69's Order Summary, dated 3/19/24, revealed RNA Program: PROM to bilateral. Upper Extremity (UE) & Lower Extremity (LE) 3x/week to prevent decline in ROM & functional mobility. 3x/week every Mon, Wed, Fri for Prevent decline in ROM and functional mobility until 06/21/24. Residents Affected - Few During a review of Resident 69's PT Discharge summary, dated [DATE], revealed under Discharge Recommendations and Status: Discharge Recommendations RNA services. During a review of Resident 69's care plan, dated, 3/20/24, revealed Resident 69 had limited physical mobility r/t Hemiplegia and Hemiparesis . Furthermore, the care plan indicated one of the interventions was RNA program for PROM to strengthen muscles and increase mobility status. During a concurrent interview and record review on 6/12/24, at 12:45 p.m., with Restorative Nurse Assistant (RNA), RNA could not show evidence Resident 2 and Resident 69 received ROM exercises. During a concurrent interview and record review on 6/12/24, at 2:00 p.m., with the Director of Nursing (DON), DON stated RNP was stopped during the period Resident 2 and 69 was supposed to receive RNA services. DON verified Resident 2 and Resident 69 did not receive ROM exercises as ordered by the physician. During an interview on 6/12/24, at 2:52 p.m., with the Director Of Rehabilitation (DOR), DOR stated, all residents had the potential for decline in functioning an mobility so it was important for residents to receive ROM exercises once done with physical therapy, to maintain range of motion and prevent decline in functioning. During a review of facility's policy and procedure (P&P), titled, Restorative Nursing Program Guidelines, dated 9/2019, showed under Purpose: .This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning . Under Procedure: .I. B. Frequency of the RNA program will be determined b the medical necessity and physician order.E. A Licensed Nurse must supervise the activities in the Restorative Nursing Program .members of the nursing staff are still responsible for overall coordination and supervision of the Restorative Nursing Program. II. A Restorative Nursing Program may include: A. Passive or active range of motion exercises. 055876 Page 2 of 5 055876 06/13/2024 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to ensure there was Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure had the potential to endanger the health and safety of residents. Findings: During a concurrent interview and record review on 6/13/24 at 9:54 a.m. with Payroll (PAYROLL), payroll data was reviewed from Q3/2023 (April 1 - June 30) until Q4/2023 (July 1 - September 30). Payroll confirmed there were no RN working for the following dates: 1. For the month of April 2023: 4/23/23 2. For the month of May 2023: 5/28/23 3. For the month of June 2023: 6/25/23 4. For the month of July 2023: 7/9/23 5. For the month of August 2023: 8/27/23 6. For the month of September 2023: 9/2/23 During a concurrent interview and record review on 6/13/24 at 10:17 a.m. with Central Supply/Scheduler (CS/S), staffing schedule was reviewed. CS/S confirmed a RN was not scheduled to work on 4/23/23, 5/28/23, 6/25/23, 7/9/23, 8/27/23, 9/2/23. During an interview on 6/12/24 at 3:56 p.m., with the Director of Nursing (DON), DON stated, it was important to have RN coverage eight hours a day. DON further added, resident safety were at risk without RN available. 055876 Page 3 of 5 055876 06/13/2024 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store food in a safe and sanitary manner when: Residents Affected - Many 1. Fresh lettuce stored inside the reach-in refrigerator was exposed and had no cover 2. A plastic container bin with single packs of graham crackers had no use by date or open dates Failure to store food in accordance with facility policy and/or professional standards had the potential to not meet food service safety standards and prevent food borne illnesses for 76 residents who received food from the kitchen out of a facility census of 76. Findings: 1.During an initial kitchen tour observation and concurrent interview on 6/10/24 at 10:13 a.m., with the Dietary Supervisor (DS), the contents of Refrigerator 1, were inspected. The bottom rack had a clear storage bin with fresh lettuce inside. The lettuce was exposed and had no cover. DS stated the lettuce should be covered with a plastic wrap to keep it fresh and to make sure spills do not get in contact the lettuce. During an interview on 6/13/23 at 1:10 p.m., with the Regional Registered Dietitian (RRD), when asked what the expectation was when storing fresh produce in the refrigerator, RRD stated, it [produce] should be covered to prevent anything from spilling into it. Review of the facility's policy and procedure (P&P) titled, Food Storage - Operation Manual -Dietary Services, revision dated 7/25/19, the P&P indicated, Purpose - To establish guidelines for storing . Policy Food items will be stored . in accordance with good sanitary practice . Procedure .IX. Fresh Vegetable Storage Guidelines .E. Vegetables should be left in cartons, bags, or paper wrapping because it retards spoilage and loss of moisture . 2. During an observation and concurrent interview on 6/10/24 at 10:28 a.m., with the DS, the kitchen dry storage room was inspected. One of the storage shelving racks had a clear storage bin that contained multiple, individually packed graham crackers. The storage bin had no label and did not indicate open and use by dates for the graham crackers. DS stated the person who poured the items in the storage bin did not label and date the graham crackers. During an interview and concurrent record review on 6/13/24 at 12:40 p.m., with the DS, the facility's Dry Goods Storage Guidelines, dated 2023, was reviewed. The Dry Storage Guidelines indicated, This storage length is to be followed unless you have manufacturer's recommendation indicating otherwise . Food Item . [NAME] crackers . Unopened on shelf - 6 months, Opened on Shelf - N/A [not applicable]. DS explained that unopened on shelf referred to original packaging in box [of food item]. DS confirmed the graham crackers found in the dry storage room on 6/10/24 was in a clear storage bin and not in its original packaging in box. DS stated the graham crackers should have an open and use by dates indicated. Review of the facility's policy and procedure (P&P) titled, Food Storage - Operation Manual -Dietary Services, revision dated 7/25/19, the P&P indicated, Purpose - To establish guidelines for storing 055876 Page 4 of 5 055876 06/13/2024 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0812 . Policy - Food items will be stored . All items will be correctly labeled and dated. Procedure .XIII. Dry Storage Guidelines .H. Label and date all storage products . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 055876 Page 5 of 5