Health inspection·April 26, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube, a tube inserted through abdomen that delivers enteral feeding formula and hydration directly to the stomach) was implemented for one of two sampled residents with G-tube (Resident 37), when: 1) The G-tube pump (a machine which helps to deliver the enteral formula to the resident), was off and 1500 cc (cc - unit of volume) of Glucerna (enteral feeding formula) 1.2 cal [calories] was left in the bottle. This failure resulted in Resident 37 not receiving the calculated amount of enteral feeding formula for the day, as per physician's orders. 2) The order for Glucerna 1.2 cal was not transcribed (written) accurately onto the physician's orders (It was ordered via oral route of administration on April 1, 2024, instead of via G-tube). This failure has the potential for Resident 37 to receive the enteral feeding formula via the wrong administration route. Findings: 1) During a review of Resident 37's Face sheet (demographic data sheet), Resident 37 was admitted to the facility on [DATE], with the diagnoses of hemiplegia (paralysis of one side of the body), aphasia (a language disorder that affect a person's ability to communicate) and dysphagia (difficulty swallowing). During a review of Resident 37's physician orders, dated April 1, 2024, Physician order indicated, Glucerna 1.2 Cal 0.06 gram (gram- unit of weight measurement)1.2 kcal (Kilocalories) /mL(mL - milliliter, unit of measurement) oral liquid ,70 mL /hr (hour) . Notes: 70 ml/hr x (times) 22hrs to provide 1848 calories and 92 gram protein, to equal 1540cc. Off @1000 on@1200. During an observation on April 25, 2024, at 9:45 AM in Resident 37's room, Resident 37 was lying in bed with the head of the bed elevated. Resident 37's G-tube was connected to the pump. The G-tube pump was turned off. A bottle of Glucerna 1.2 cal was hanging from the pole, the bottle was dated April 25, 2024, the bottle label indicated Start time 2:00AM . Rate 70ml/hr. During an observation and interview on April 25, 2024, at 9:55 AM with Licensed Vocational Nurse 2 Page 1 of 11 055914 055914 04/26/2024 Plymouth Village 819 Salem Drive Redlands, CA 92373

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (LVN 2) in Resident 37's room, LVN 2 stated, I never calculate the feeding formula. I just do only visual checks if the bottle has enough. LVN 2 further stated, the formula was supposed to be stopped at 10:00 AM according to doctor's order, but I turned it off at 8:00 AM for his morning routine. During a concurrent observation and interview on April 25, 2024, at 10:50 AM with the Director of Nursing (DON), the DON inspected the G-tube bottle of Glucerna 1.2 cal on hanging in the pole. The DON stated the bottle has a remaining amount of 1500mL. The DON further stated, I agree that there is a discrepancy of more than 300 ml of formula which was supposed to be infused to the resident (Resident 37) by this time. During a concurrent interview and record review on April 26, 2024, at 10:30 AM with the DON, the facility's policy and procedure (P&P) titled, Enteral Nutrition, dated January 2024, was reviewed. The P&P indicated, . Nursing . Administer and document enteral nutrition per community protocol. The DON stated, The policy was not followed as there was a discrepancy in formula amount delivered. 2) During a concurrent Interview and record review on April 25, 2024, at 9:50 AM with LVN 2, LVN 2 reviewed Resident 37's physician orders, dated April 1, 2024, it indicated, Glucerna 1.2 Cal 0.06 gram-1.2 kcal/mL oral liquid, 70 cc/hr Oral. LVN 2 stated, it was the first time she noticed the order was written incorrectly (via oral route administration). During a concurrent interview and record review on April 25, 2024, at 11:00 AM with the DON, the DON reviewed Resident 37's physician's orders dated April 1, 2024. The order indicated Resident 37 to receive Glucerna 1.2 Cal 0.06 gram-1.2 kcal/ml oral liquid, 70 cc/hr via oral route. The DON stated, it was a mistake, the correct route should be via G-tube (enteral). During a concurrent interview and record review on April 26, 2024, at 10:33 AM with the DON, the facility's policy and procedure (P&P) titled, Enteral tube feeding via Continuous pump, dated November 2018, was reviewed. The P&P indicated, General Guidelines . 3. Check the enteral nutrition label against the order before administration . Check the following information: d. Route of delivery . The DON stated, the policy was not followed as the Route was wrong. 055914 Page 2 of 11 055914 04/26/2024 Plymouth Village 819 Salem Drive Redlands, CA 92373

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 implement a process to routinely evaluate contracted nursing staff on their skill levels (range of tasks and duties to be performed) and develop individualized competency-based training (a process to acquire skills and knowledge to be able to perform a task to a specified standard) for 10 of 10 contracted staff (one Licensed Vocational Nurse [LVN 1], and nine Certified Nursing Assistants [CNA 1, 2, 3, 4, 5, 6, 7, 8 and 9]). This failure had the potential to compromise the services and types of care necessary to safely meet the resident's needs. Findings: During an interview and record review on April 25, 2024, at 2:30 PM, with the Director of Nursing (DON), the DON reviewed the document titled, Orientation Checklist dated March 20, 2020, the checklist indicated, Skills-C.N.A . Ambulation . Bed making .Body Mechanics . Position in Bed .Charting and Reporting .Bladder Training . Foley Catheter Cares . Vital Signs . The DON stated the facility used the checklist for contracted nursing staff. DON was not able to provide documented evidence of the Orientation Checklist for LVN 1, CNA 1 and 2 to demonstrate that each of the contracted nursing staff have been validated for their skills. The DON stated she is not able to provide a documented competency checklist for any contracted staff that have been assigned to the facility today. During a concurrent interview and record review on April 25, 2024, at 2:49 PM, with the Director of Staffing Development (DSD), in the presence of the DON, the electronic files from Clipboard Health (staffing record) were reviewed. The DSD stated there were three (3) contracted nursing staff currently working at the facility (LVN 1, CNA 1 and 2). The DSD stated, the ,facility uses a buddy system for the contracted CNA's to validate their competencies and skills. The DSD further stated, the contracted RN's (Registered Nurses) and LVN's are assigned to a core staff member to be supervised throughout their shift. Both, the DON and DSD were not able to provide documented evidence of the competencies or skills set checklist for the contracted nursing staff were completed and reviewed. During a review of the staffing assignment for the month of April 2024, contracted nursing staff worked in the facility for the following dates, shifts, and assignments: 1. LVN 1 - April 25, 2024, 7:00 AM - 3:00 PM Shift, as a treatment nurse 2. CNA 1 - April 25, 2024, 7:00 AM - 3:00 PM Shift, Rooms 31A - 34A 3. CNA 2 - April 25, 2024, 7:00 AM - 3:00 PM Shift, Rooms 40A - 43B 4. CNA 3 - April 22, 2024, 3:00 PM - 11:00 PM Shift, Rooms 44A - 47B, 40A & 40B 5. CNA 4 - April 21, 2024, 11:00 PM - 7:00 AM Shift, Rooms 30 - 37B 6. CNA 5 - April 21, 2024, 11:00 PM - 7:00 AM Shift, Rooms 40 - 47B 7. CNA 6 - April 19, 2024, 3:00 AM - 11:00 PM Shift, Rooms 20A - 22B, 30A & 30B 055914 Page 3 of 11 055914 04/26/2024 Plymouth Village 819 Salem Drive Redlands, CA 92373

F 0726 8. CNA 7 - April 15, 2024, 7:00 AM - 3:00 PM Shift, Rooms 44A - 47B Level of Harm - Minimal harm or potential for actual harm 9. CNA 8 - April 7, 2024, 11:00 PM - 7:00 AM Shift, Rooms 30A - 37 10. CNA 8 - April 5, 2024, 11:00 PM - 7:00 AM Shift, Rooms 30A - 37B Residents Affected - Many 11. CNA 9 - April 1, 2024, 7:00 AM - 3:00 PM Shift, Rooms 40A - 43A During a concurrent interview and record review on April 26, 2024, at 8:26 AM, with the DSD, the DSD reviewed the electronic files from Clipboard Health, for CNA 3, 4, 5, 6, 7, 8 and 9. The DSD stated , there was no documented Orientation Checklist on file for CNA 3, 4, 5, 6, 7, 8 and 9. During an interview on April 26, 2024, at 10:02 AM with CNA 2, CNA 2 stated, during her first day of work, she was oriented to fire exits, rooms and resident assignments. CNA 2 further stated, she does not recall any checklist that was signed or given to her during her orientation. When asked ,if the facility provided any written documentation on completing competency training, she stated she does not recall any checklist that was signed or given to her during her orientation. During an interview with the DON on April 25, 2024, at 4:40 PM, the DON was not able to provide a policy and procedure regarding contracted nursing staff to validate their competencies and skills. The DON stated, We do not have any policy and procedure for contracted staff. 055914 Page 4 of 11 055914 04/26/2024 Plymouth Village 819 Salem Drive Redlands, CA 92373

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. Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (narcotic medications that are controlled by the government because it may be abused or cause addiction) for one of two medication carts (Front Hall medication cart), with seven missing signatures for narcotics count. This failure had the potential for drug diversion (Illegal distribution of controlled drugs for any illicit use) of controlled medications by the staff. Findings: During concurrent interview and record review on April 24, 2024, at 6:30 AM, with the Director of Nursing (DON), the DON reviewed the Front Hall medication cart's narcotics shift count verification signature log (a form used by facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses), dated March 2024 and April 2024. The log indicated the following: a. On March 20, 2024, missing signatures on the night shift (NOC) from Signature 1 (incoming nurse) and Signature 2 (outgoing nurse). b. On March 26, 2024, missing signature on NOC shift from Signature 1. c. On April 21, 2024, missing signatures on day shift from Signature 1 and Signature 2. d. On April 23, 2024, missing signatures on NOC from Signature 1 and Signature 2. The DON acknowledged the missing signatures for the above dates. The DON further stated her expectation is for licensed nurses to count at the beginning and end of shift and sign the sheet. I am not sure what happened. During interview on April 26, 2024, at 8:39, AM with Licensed Vocational Nurse (LVN 2), LVN 2 stated, We count narcotics together with incoming and outgoing nurse and we sign the sheet. LVN 2 further stated, I forgot to sign the narcotics sheet count verification signature log. It is simply a mistake. LVN 2 stated, We are responsible to count and sign at the beginning and end of each shift. During concurrent interview and record review on April 26, 2024 at 11:05 AM, with the DON, the facility's provided policy and procedure (P&P), titled Controlled Substances, revised November 2022, was reviewed. The P&P indicated, Dispensing and Reconciling Controlled Substances 3, Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4, The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing . The DON stated, the licensed nurses have been educated to sign the shift confirmation for narcotics counts and it is expected that all licensed nurses count and verify at each shift. 055914 Page 5 of 11 055914 04/26/2024 Plymouth Village 819 Salem Drive Redlands, CA 92373

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 drugs and biologicals were labeled in accordance with currently accepted professional principles for one of one resident (Resident 247) when a bubble pack (a card that packages doses of medications within plastic bubbles organized by day and time of the day) containing morphine (medication used to treat pain) had no expiration date ( a date that indicates when medicine is no longer effective) written in the label. This failure had the potential to result in staff administering an expired medication to Resident 247 which can alter the efficacy (ability to produce desired effects) of the medications and reduce its therapeutic effectiveness. Findings: During a concurrent observation and interview on [DATE], at 6:15 AM, with the Director of Nursing (DON), the medication storage Cart 1 located at the front hallway, was inspected. A bubble pack containing Resident 247's Rx# (prescription number) 159536, Morphine Sulfate (MS), 15 milligrams (mg -a unit of measure), tablet (TAB) #10, dated [DATE], was inspected. The bubble pack contained 15 half tablets of morphine; the label did not have an expiration date. The DON stated, it is received by Registered Nurse (RN), RN verifies the medication with label and gets recorded on the narcotic log. The DON further stated, I know this one does not have an expiration date, but we can use all medications within one year of the order date. During a further interview on [DATE], at 7:54 AM with the DON, the DON stated, Unfortunately, we don't have the one-year use policy. I am going to check with our pharmacy consultant. During a telephone interview on [DATE], at 9:35 AM with the Pharmacy Consultant (PC), the PC stated he was not aware of Resident 247's Rx# 159536, MS 15 mg, TAB #10, order date [DATE]), had no expiration date. The PC further indicated, the standard for pharmacy is, for medications to have a label with an expiration date either written by hands or generated by computer. A review of the facility's policy and procedures (P&P) by [name of the pharmacy] policies and procedures titled, Medication Storage and Labeling,[ Undated], indicated, . All prescription medications used in the facility must have a pharmacy label that includes the following information: Expiration date of the effectiveness of the drug dispensed, . State of California Business & Professions Code, Chapter 9, Division 2, 4076 # 9, it indicated, the expiration date of the effectiveness of the drug dispensed. 055914 Page 6 of 11 055914 04/26/2024 Plymouth Village 819 Salem Drive Redlands, CA 92373

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 store food by methods that conserve nutritive value, flavor, and appearance, when four bags of raw chicken had freezer burn (frozen foods are exposed to cold, dry air, which causes them to dehydrate as the outer layers lose moisture. One of the most commonly recognized signs of freezer burn is the formation of ice crystals on the outside of food, making it appear frost bitten). This had the potential for the chicken to not be palatable when cooked and served to 40 of 41 medically compromised residents who received food from the kitchen. Residents Affected - Many Findings: During an observation on April 22, 2024 at 9:00 a.m., inside the walk-in freezer, there were four bags of frozen chicken that had ice build-up and the bags had a lot of air that was keeping the bags expanded. During an interview with the Food Service Director on April 24, 2024, at 12:03 p.m., She stated that no food in the freezer should have any ice build-up or freezer burn. During a review of the facility policy titled Production, Purchasing, Storage, dated January 2023, indicated, All food, non-food items and supplies use in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. 055914 Page 7 of 11 055914 04/26/2024 Plymouth Village 819 Salem Drive Redlands, CA 92373

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 maintain a sanitary kitchen when: 1. Floors under equipment in multiple areas of the kitchen had a build up of black grime, old food, crumbs, and trash, this had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted. 2. Two convection (fans to circulate air around food to create an evenly heated environment) ovens, two ranges, a grill top, a food warmer box (appliance that holds already cooked foods at ideal temperatures until they are ready to be served) and 4 waffle irons, had a buildup of black grime, and yellow crusted grime. This had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted. 3. Two buckets used as funnels to drain cooking liquid from a large steam kettle (used to cook large quantities of liquid-based foods) were crusted with old food. This had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted. These failures had the potential to cause food borne illness to 40 of 41 medically compromised residents who received food from the kitchen. Findings: 1. During an observation on April 22, 2024, at 8:41 a.m. in the kitchen, there was a build-up of crumbs under the stainless-steel counter-top and behind and under the industrial mixer. under the reach-in refrigerator and freezer there was a build-up of trash and crumbs. During an observation in the dry storage area on April 22, 2024, at 8:45 a.m., there was food crumbs, liquid spills and a tomato that had fallen on the floor and turned moldy (type of fungus that causes food spoilage) under the shelves on the floor. During an observation in the walk-in refrigerator on April 22, 2024, at 8:55 a.m., there was food and trash and spills under the shelves on the floor. During an observation in the walk-in freezer on April 22, 2024, at 9:00 a.m., there was old food and trash on the floor under the shelves. During an observation in the mop closet on April 22, 2024, at 9:04 a.m., there was crumbs and trash on the floor. During an observation and concurrent interview with the Executive Chef, on April 22, 2024, at 9:09 a.m., at the front cooking line the floors under the equipment and under the stainless-steel countertop had a build-up of old food and trash. The Executive chef stated that the floor under the equipment should be clean. During an interview with the Food Service Director on April 24, 2024, at 12:03 p.m., She stated that the floor underneath equipment should be kept clean and there shouldn't be any old food on the 055914 Page 8 of 11 055914 04/26/2024 Plymouth Village 819 Salem Drive Redlands, CA 92373

F 0812 floor. She stated that they would need to add those areas that were identified to their cleaning list. Level of Harm - Minimal harm or potential for actual harm During a review of the facility policy titled Sanitation and Infection Prevention/Control, dated January 2024, indicated Nonfood contact surfaces of equipment .shall be cleaned as often as is necessary. Kitchen floors will be swept and mopped at a minimum daily or as needed. Residents Affected - Many During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated C) Nonfood- contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. Section 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 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. 2. During an observation in the kitchen on April 22, 2024, at 8:41 a.m., the convection oven near the handwashing sink had black grime build-up and the inside of the doors had yellow crusted build-up. During an observation in the kitchen on April 22, 2024, at 9:09 a.m., the convection oven near the steam kettle was crusted with black grime and had yellow build-up on the inside of the doors. During an observation in the kitchen on April 22, 2024, at 9:12 a.m., two range ovens had black grime build-up and food crumbs inside the ovens. Next to the ovens was a rack with storing waffle irons that had food crumbs, grease, and a white powdery substance. The grill next to the rack, used to grill hamburgers, was crusted with black grime and the stainless steel was crusted with black grime. During an interview with the Food Service Director, on April 24, 24, at 12:03 p.m., she stated the equipment should be kept clean and should be added to their cleaning list for deep cleaning. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-Contact Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, 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. 3. During an observation in the kitchen on April 22, 2024, at 9:06 a.m., under the grill top near the steam kettle there were two white buckets that were being used as funnels to drain water from the steam kettle into the floor drain so that water does not go all over the floor. The buckets were crusted with old food. During an interview with the Food Service Director, on April 24, 24, at 12:03 p.m., she stated the buckets being used as funnels should be kept clean, should have no food in them. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-Contact 055914 Page 9 of 11 055914 04/26/2024 Plymouth Village 819 Salem Drive Redlands, CA 92373

F 0812 Level of Harm - Minimal harm or potential for actual harm Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, 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. Residents Affected - Many 055914 Page 10 of 11 055914 04/26/2024 Plymouth Village 819 Salem Drive Redlands, CA 92373

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 maintain a sanitary and safe medication storage in one of two medication carts (a cart used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment) when the hearing aids (a small device that fits in or on the ear, worn by a partially deaf person to amplify sound) for four of four residents (Resident 39, 29, 13 and 25) were found inside a medication cart's narcotic drawer. Residents Affected - Few This failure had the potential for cross contamination and infection (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and jeopardize the health and safety of (Resident 39, 29, 13 and 25). Findings: During a concurrent observation and interview on April 24, 2024, at 5:40 AM, with the Director of Nursing (DON), the DON reviewed the Front Hall medication cart. The DON opened the narcotic drawer inside the medication cart. The narcotic drawer contained two small black cases, one small gray case and two clear specimen containers. The DON stated, the three cases and the two specimen containers, contained resident's hearing aids. The DON further stated, They are not new hearing aids. The DON stated, the residents give their hearing aids to the nurse in the evening to keep it locked. When the residents ask for it, the nurse takes out the case from the narcotics drawer, removes the hearing aid from the case and gives the hearing aid to the residents. During observation on April 24, 2024 at 6:10 AM, in the hallway, Resident 39 asked the Licensed Vocational Nurse (LVN 3), for his hearing aid. LVN 3, opened the narcotic drawer pulled out one black case from the narcotic drawer and removed the hearing aid. LVN 3 proceed to give the hearing aids to the Resident 39, without using gloves. LVN 3 stated, I only hand it to the residents out of the box. I don't clean it. During an interview on April 26, 2024, at 8:00 AM, with the DON. The DON stated, Unfortunately, we don't have a policy to store hearing aids inside narcotics drawer. During a concurrent interview and observation on April 26, 2024, at 8:28 AM with the Infection Preventionist (IP) and LVN 2, the LVN 2, opened the narcotic drawer inside the Front Hall medication cart. The IP counted two small black cases, one small gray case and two clear specimen containers containing hearing aids. The IP was not able to provide a policy regarding storage of resident's hearing aids. The IP stated, there is no policy regarding storage of hearing aids. 055914 Page 11 of 11