Health inspection·June 7, 2019

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review, the facility failed to ensure residents were provided with comfortable sound levels for three of three sampled residents (Resident 15, 13 and 20) when: Resident 17's television (TV) sound was so loud, it was heard in the hallways and adjacent rooms and disrupted Resident 15,13 and 20. This failure violated the residents' rights to a comfortable and homelike environment that would respect the residents' dignity, privacy and well-being. Findings: During an observation in the facility hallway on 6/3/19, at 9:30 a.m., a very high volume of sound came from a TV inside Resident 17's room. Resident 15 who tried to form words to speak was unable to (non-verbal) do so. She immediately signaled and pointed to her ears and Resident 17's TV. Resident 17 held her TV remote control while she watched the TV show in a loud volume. During an interview with Resident 17, on 6/3/19, at 11 a.m., in her room. Resident 17 stated she could not hear well, which caused her to increase the TV volume. Resident 17 stated the staff knew she could not hear well and needed the TV volume to be loud enough for her to hear. During an interview with Resident 20, on 6/6/19, at 10:01 a.m., he stated he could hear the loud volume of TV sound coming from a room in Station I hallway. The loud sound was heard through out the day and it became really annoying during the night. During an interview with Resident 13, on 6/6/19, at 10:15 a.m., she stated she was completely bothered by the loud volume of the TV sound from across her room. Resident 13 stated she told staff about the loud TV volume from across her room bothered her. She stated the volume went down for a while but would later the loud TV volume would come back again. She stated she told the former Director of Nursing about this but nothing was done. Resident 13 stated she deserved a quiet and private environment paid for by her insurance and instead she was bombarded with blasting TV shows and news sounds. Resident 13 stated,It was a torture. Resident 13 stated she could not leave her bed and she needed quiet time for her to meditate. During a concurrent observation and joint interview with Resident 15 and the Director of Nursing (DON) on 6/6/19, at 10:35 a.m., the DON stated Resident 15 was non verbal and was able to answer to yes and no questions by raising her left and right arm. The DON stated Resident 15 would answer yes by raising her left arm and would answer no by raising her right arm. Resident 15 was asked if Resident 17's TV volume was loud and bothersom. Resident 15 raised her left arm and validated the loud Page 1 of 21 055935 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0584 volume from Resident 17's TV was bothersome to her. Level of Harm - Minimal harm or potential for actual harm During an interview with the Administrator (ADM), on 6/5/19, at 10:20 a.m., the ADM stated the previous Social Service Director (SSD) informed him about Resident 17's loud TV volume and her non compliance in lowering the TV volume. The ADM stated nothing was done to address the loud TV volume and he should have done something about addressing the loud noise. The ADM stated an interdisciplinary team (group of health care providers from different fields who worked together to provide best care) meeting could have been held to find out interventions to address the problem with the loud TV volume. The ADM stated the residents should have been provided with a comfortable sound level and were not. Residents Affected - Some The facility's policy and procedure titled,Quality of Life - Homelike Environment dated 2018, indicated, Residents are provided with a safe, clean, comfortable and homelike environment . The facility's policy and procedure titled Quality of Life- Accommodation of Needs dated 1/18, indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being . 055935 Page 2 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to operationalize their policy and procedure to investigate abuse when Residents Affected - Few the Director of Nursing (DON) and the Administrator (ADM) did not conduct an investigation after one of three sampled residents (Resident 23) engaged in disruptive yelling and abusive verbal behavior toward Resident's 13 and 26. This failure resulted in the missed opportunity to provide Resident 13 and Resident 26 emotional support and counseling during and after the investigation, as needed. This failure had the potential for all allegations of abuse to continue. Findings: During a telephone interview with Certified Nursing Assistant (CNA) 3, on 6/4/19, at 8:08 a.m., she stated she was on duty on 5/23/19, at 10 p.m. and assigned to a 1:1 (a caregiver assigned to one resident only) with Resident 23. CNA 3 stated Resident 23 had been restless and agitated and therefore required the 1:1 to keep him safe. CNA 3 stated Resident 23 woke up got out of bed on the night shift of 5/23/19. CNA 3 stated Resident 23 was restless and paced back and forth in the room. CNA 3 stated she opened the door to Resident 23's room and shouted for help. CNA 3 stated there was a change of shift going on and no one came to help. CNA 3 stated she tried to calm Resident 23 down by offering him a sandwich. CNA 3 stated Resident 23 did not accept her redirection and became angry with her attempt to calm him down. CNA 3 stated Resident 23 grabbed the sandwich, threw it at CNA 3 which hit on her left shoulder. Resident 23 then, in an agitated manner, rummaged through the briefs and linens in his closet. CNA 3 stated she persuaded Resident 23 to lie in bed but Resident 23 yelled, No, No, No. Resident 23 climbed on to his bed, standing tall and came down towards CNA 3 very fast pushing her on the wall and grabbed her by the neck and attempted to choke her. CNA 3 stated she attempted to release herself from Resident 23, when CNA 4 opened the door to the room. CNA 3 stated this was when Resident 23 ran out of the room toward the hallway disruptively screaming out. CNA 3 stated Resident 23 entered room [ROOM NUMBER] and hovered over Resident 26 who was lying in bed; he hit Resident 26's bedrails and yelled at Resident 26 and told him to get up. CNA 3 stated Resident 26 was non-verbal and woke up wide-eyed with a terrified look on his face. CNA 3 stated staff attempted to redirect Resident 23 without effective results. Resident 23 continued with his agitated behavior and disruptive yelling. Resident 23 entered another room this time cursing at Resident 13. CNA 3 stated both residents began to yell at each other and were verbally abusive during the encounter. CNA 3 stated Resident 13 attempted to defend herself and yelled and cursed at Resident 23 which in turn caused Resident 23 to continue with his agitated behavior. During a telephone interview with CNA 4, on 6/4/19, at 9 a.m., she validated Resident 23 went to Resident 26 and 13 's room and dirsupted their environment. CNA 4 stated Resident 23 cursed at Resident 13. During an interview with Resident 13, on 6/4/19, at 10:12 a.m., she stated Resident 23 entered her room that night shift of [5/23/19], she became terrified and told him to get out of her room, yelling for help. Resident 13 stated she engaged in a verbal confrontation with Resident 23 in an attempt to protect herself. Resident 13 stated she was cursed at by Resident 23 and she cursed at Resident 23 in return. 055935 Page 3 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a joint interview with the DON, the ADM, and the Director of Clinical Services (DOC), on 6/4/19, at 3:16 p.m., the DON stated when Resident 23 attempted to strangle CNA 3, they did not know about the interaction and the incident between Resident 23, 26, and 13 that took place on the night shift of 5/23/19. During a telephone interview with CNA 3, on 6/4/19, at 4 p.m., she stated she made a written statement dated 5/24/19, at 9:30 a.m., and submitted it to the Director of Staff Development (DSD). CNA 3 stated she was reading the copy of the written statement she submitted to the DSD, and described how Resident 23 went in and out of Resident 26's room aggravating the resident then went to Resident 13's room and engaged in verbally heated exchanges with each other. CNA 3 stated she did not file a State of California (SOC) 341 (document used by healthcare providers to report all forms of abuse and neglect) to report the verbal abuse she witnessed between the residents. During an interview with the DSD, on 6/4/19, at 4:30 p.m., she stated she did not receive the written statement from CNA 3 informing her about Resident 23's behavior the night shift of 5/23/19. During an interview with Licensed Vocational Nurse (LVN) 4, on 6/5/19, at 9:45 a.m., she stated LVN 1 reported to her about Resident 23's attempt to strangle a CNA and Resident 23 running into Resident 26's room. During a telephone interview with the Ombudsman (OMB) 2, on 6/6/19, at 1:30 p.m., she stated the DSD called her on 5/24/19 and informed her Resident 23 tried to choke a staff member on Thursday night 5/23/19. OMB 2 stated the DSD informed her about Resident 23 entering into other resident rooms and shook the bedrails. During a review of Resident 23's nurse's notes dated 5/24/19, at 11:50 p.m., indicated, At the beginning of the shift, [Resident 23] was observed sleeping in his room. During report approximately [11:30 p.m.,] [Resident 23] woke up and was yelling continuously. [Resident 23] came out of his room and began yelling and wandering up and down hallways from Station 1 to Station 2. [Resident 23] began reaching out towards staff .[Resident 23] was walking getting increasingly agitated and yelling louder. When at Station 1 [Resident 23] tried going to several rooms and ran after another resident into the room . During a review of Resident 23's progress notes dated 5/24/19, at 10:02 a.m., indicated,Late Entry - As per NOC (night), resident was yelling, hitting, trying to leave facility and attempted to strangle a cna (certified nursing assistant). Resident had his hands around cna's neck which left finger marks. The Director of Nursing (DON) notified and called MD (physician) . at 7:00 am and get the order to send resident out. During a review of Resident 23's progress notes documented by LVN 3 dated 5/25/19, at 7:30 p.m., indicated, At around 6:45 p.m. heard [Resident 23] yelling at CNA staff in his room .two CNA's were attempting to change resident's soiled clothing and resident was yelling, and pushing both CNA and attempting to bite CNA staff also . called MD and notified him of the incident . got telephone order to transfer resident to an acute hospital due to resident's aggressive behavior .also telephoned . police department . During a review of Resident 23's face sheet (a document with background information) dated 6/4/19, indicated Resident 23 had the following diagnosis: Alzheimer's disease (a progressive brain disease affecting long and short term memory), Picks disease (a brain disease similar to Alzheimer's 055935 Page 4 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0607 affecting memory, mood and behavior), aphasia (loss of ability to understand or express speech). Level of Harm - Minimal harm or potential for actual harm The facility's policy and procedure titled, Abuse Prevention Program dated 1/18, indicated, Our resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment involuntary seclusion, verbal, mental sexual of physical abuse . Residents Affected - Few 055935 Page 5 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the abuse prohibition policy and procedure for two of two residents (Resident 26 and 13) when Certified Nursing Assistant (CNA) 3, CNA 4, CNA 5, Licensed Vocational Nurse (LVN 1), Director of Staff Development (DSD), Director of Nursing (DON) and Administrator (ADM) failed to report an incident of verbal abuse from Resident 23 toward Resident 26 and 13 in accordance with the State law. These failures subjected the staff and the residents' safety at risk and had the potential for these incidents to continue endangering the well-being of the residents. Findings: During a telephone interview with Certified Nursing Assistant (CNA) 3, on 6/4/19, at 8:08 a.m., she stated she was on duty on 5/23/19, at 10 p.m. and assigned to a 1:1 (a caregiver assigned to one resident only) with Resident 23. CNA 3 stated Resident 23 had been restless and agitated and therefore required the 1:1 to keep him safe. CNA 3 stated Resident 23 woke up got out of bed on the night shift of 5/23/19. CNA 3 stated Resident 23 was restless and paced back and forth in the room. CNA 3 stated she opened the door to Resident 23's room and shouted for help. CNA 3 stated there was a change of shift going on and no one came to help. CNA 3 stated she tried to calm Resident 23 down by offering him a sandwich. CNA 3 stated Resident 23 did not accept her redirection and became angry with her attempt to calm him down. CNA 3 stated Resident 23 grabbed the sandwich, threw it at CNA 3 which hit on her left shoulder. Resident 23 then, in an agitated manner, rummaged through the briefs and linens in his closet. CNA 3 stated she persuaded Resident 23 to lie in bed but Resident 23 yelled, No, No, No. Resident 23 climbed on to his bed, standing tall and came down towards CNA 3 very fast pushing her on the wall and grabbed her by the neck and attempted to choke her. CNA 3 stated she attempted to release herself from Resident 23, when CNA 4 opened the door to the room. CNA 3 stated this was when Resident 23 ran out of the room toward the hallway disruptively screaming out. CNA 3 stated Resident 23 entered room [ROOM NUMBER] and hovered over Resident 26 who was lying in bed; he hit Resident 26's bedrails and yelled at Resident 26 and told him to get up. CNA 3 stated Resident 26 was non-verbal and woke up wide-eyed with a terrified look on his face. CNA 3 stated staff attempted to redirect Resident 23 without effective results. Resident 23 continued with his agitated behavior and disruptive yelling. Resident 23 entered another room this time cursing at Resident 13. CNA 3 stated both residents began to yell at each other and were verbally abusive during the encounter. CNA 3 stated Resident 13 attempted to defend herself and yelled and cursed at Resident 23 which in turn caused Resident 23 to continue with his agitated behavior. During a telephone interview with CNA 4, on 6/4/19, at 9 a.m., she validated Resident 23 went to Resident 26 and 13 's room and disruptive their environment. CNA 4 stated Resident 23 cursed at Resident 13. CNA 4 stated she was a mandated reporter and did not file an SOC 341 (document used by healthcare workers to report abuse). During an interview with Resident 13, on 6/4/19, at 10:12 a.m., she stated Resident 23 entered her room that night shift of [5/23/19], she became terrified and she told him to get out of her room and she yelled for help. Resident 13 stated she engaged in a verbal confrontation with Resident 23 in an attempt to protect herself. Resident 13 stated she was cursed at by Resident 23 and she cursed at Resident 23 in return. 055935 Page 6 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a telephone interview with CNA 4 on 6/4/19, at 9 a.m., she validated Resident 23 went to Resident 26 and 13 's room. During interview with Resident 13 in her room on 6/4/19, at 10:12 a.m., she stated Resident 23 entered her room that night. Resident 13 stated she became terrified and told Resident 23 to get out of her room and yelled for help. Resident 13 stated she engaged in a verbal confrontation with Resident 23 in an attempt to protect herself. During a joint interview with the DON, the ADM and the Director of Clinical Services (DOC), on 6/4/19, at 3:16 p.m., the DON stated when Resident 23 strangled CNA 3, they did not report the incident of abuse because they did not know about the incident between Resident 23, 26, and 13 that took place on the night of 5/23/19. During a telephone interview with CNA 3, on 6/4/19 at 4 p.m. she stated she made a written statement dated 5/24/19 at 9:30 a.m. and had submitted this to the DSD CNA 3 stated she was reading the copy of the written statement she submitted to the DSD, and described how Resident 26 went in and out of Resident 23's room aggravating the resident then went to Resident 13 and traded verbal abuse with each other. CNA 3 stated she knew she was a mandated reporter and reported this incident through a written statement to the DSD before she left for the hospital for treatment. CNA 3 stated she did not report it to other agencies and did not complete the State of California SOC 341 which she should have as a mandated reporter. During an interview with the DSD on 6/4/19 at 4:30 p.m., she stated she did not receive any written statement from CNA 3 about the incident of strangling and Resident 23 going on and out of the resident's room. During a telephone interview with LVN 1, on 6/5/19 at 7:55 a.m., she stated she was a mandated reporter but she was not sure if she had to report a resident to a staff abuse. LVN 1 stated she did not report the verbal abusive encounter that she witnessed between Residents 13, 23, and 26 the night shift of 5/23/19. During an interview with LVN 4, on 6/5/19, at 9:45 a.m. she stated during shift change report LVN 1 reported to her about Resident 23's behavior of aggression and his attempt to strangle a CNA. LVN 4 stated she was made aware of Resident 23's abusive and threatening behavior toward Resident 13 and 26. She stated she knew of her obligation to report all forms of abuse and she did not file an abuse report. During a joint interview with the Corporate [NAME] President, DON, Director of Clinical Services (DOC) and Ombudsman (OMB) 1, on 6/5/19, at 2:22 p.m., the DON stated the staff were aware of the incident and were expected to complete an abuse report by filing an SOC 341 as soon as possible. During a telephone interview with OMB 2, on 6/6/19, at 1:30 p.m., she stated the DSD called her on 5/24/19, and informed her Resident 23 tried to choke a staff member on Thursday night 5/23/19. OMB 2 stated the DSD informed her Resident 23 entered other resident rooms and shaken the bedrails. During an interview with the DSD, on 5/6/19, at 1:45 p.m., she stated all staff were mandated reporters and the CNAs and LVNs who were involved in the incident of 5/23/19 should have reported the incident and completed an SOC 341 form. The DSD stated the form SOC 341 was available anywhere at the 055935 Page 7 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0609 facility. The DSD stated she did not make sure the SOC 341 was filed. Level of Harm - Minimal harm or potential for actual harm The facility's policy and procedure titled, Abuse Prevention Program dated 1/18 indicated, Process; as part of the resident abuse prevention, the administrator will .7. Investigate and report any allegation of abuse within time frames as required by the federal requirement . Residents Affected - Few The facility's policy and procedure titled, Policy: Reporting Suspicion of Crime dated 1/18 indicated, The Administrator, Director of Nursing or any designated individual will report (within the required time frame) any reasonable suspicion of a crime against a resident to the State Survey agency and local law enforcement agency .Process: . 4. The timing of reporting will be based on the events that cause the suspicion and will be as follows: . 4 b. If the event does not result in serious bodily injury, the suspicion will be reported not more than 24 hours after the individual first suspects that a crime has occurred . 5. if multiple individuals intend to report the same incident, these individuals may file a single report to the state Survey Agency as long as the report contains information about the suspected crime from each covered individual's perspective and the report includes each covered individual's name. 6. Additional Information or suspicion that are formed after the report is made made be included as a supplement to the report. The supplement will include the names of individuals reporting a suspicion, as well as the date and time that they became aware of the incident. 7. No report that has already been submitted (single or multiple person) will preclude an individual from reporting his or her suspicion independently, in his or her own words. 8. Employees (covered individuals or not) are encouraged to report any reasonable suspicion of a crime and will be protected against retaliation for their reporting . The facility's policy and procedure titled, Abuse Investigation and Reporting dated 2/18, indicated, All reports of resident abuse . shall be promptly reported to local, state and federal agencies . Reporting 1. All alleged violations involving abuse . will be reported by the facility administrator, or his/her designee, to the following persons or agencies: f. The State licensing/certification agency responsible for surveying/ licensing the facility . 055935 Page 8 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure residents' Minimum Data Set (MDS) (an assessment of memory, recall and functional abilities) assessment accurately reflected the residents functional status for three of three sampled residents (Resident 17, 30 and 33) when: Residents Affected - Some 1. Resident 17's hard of hearing status was not coded in the MDS assessment. 2. Resident 30's dialysis (filters a patient's blood to remove excess water and waste products when the kidneys are damaged, dysfunctional, or missing) treatment was not coded in the MDS assessment. 3. Resident 33 ate by mouth and the MDS assessment coding indicated nasogastric feeding or percutaneous endoscopic Gastrostomy (PEG-tube) (tube inserted by was of the nose or stomach for administration of nutrition, fluids and/or medications) instead. These failures had the potential for the residents' needs to be unmet. Findings: During an observation on 6/3/19, at 9:30 a.m., the TV volume inside Resident 17's room was heard from the hallway outside of her room. During an interview with Resident 17, on 6/3/19, at 11 a.m., Resident 17 stated she could not hear well and the facility staff knew she could not hear well. During a review of the clinical record for Resident 17, the MDS assessment dated [DATE], indicated Resident 17 had adequate hearing and had no difficulty hearing normal conversation, social interaction, listening to TV . During a concurrent interview and record review with the Social Service Director (SSD), on 6/5/19, at 10:08 a.m., she stated the MDS assessment on Resident 17's hearing was not accurate. The SSD stated the ADM knew Resident 17 was hard of hearing. During an interview with the ADM, on 6/5/19, at 10:20 a.m., the ADM stated the previous SSD informed him Resident 17 could not hear the TV unless the volume was loud. The ADM stated Resident 17 had a hearing problem and the hearing assessment was inaccurate. 2. During an observation and interview with Resident 33, on 6/5/19, at 9 a.m., the resident had a arteriovenous (AV) fistula (an access point for the dialysis) on his left forearm. During a review of Resident 33's clinical record the physician's order dated 6/19, indicated, Dialysis treatment . on Tuesdays, Thursdays and Saturdays . Resident 33's MDS assessment dated [DATE], indicated Resident 33 was not on dialysis. During a concurrent interview and record review with the Director of Nursing (DON), on 6/7/19, at 11 a.m., she stated Resident 33 was on dialysis and her MDS assessment was inaccurate. 3. During a lunch observation in Resident 30's room on 6/3/19, at 11:59 a.m., Resident 30 ate by 055935 Page 9 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0641 mouth and was fed by a staff. Resident 30's meal ticket indicated, Regular Puree, Fortified [diet]. Level of Harm - Minimal harm or potential for actual harm During a review Resident 30's clinical record, the physician orders dated 6/19, indicated,Dietary- DietRegular diet: Puree texture. Regular liquids consistency . Resident 30's, MDS dated [DATE], indicated Resident 30 was tube fed and had a nasogastric or abdominal PEG-tube. Residents Affected - Some During a concurrent observation and interview of Resident 30, on 6/7/19, at 9:30 a.m. with the Director of Staff Development (DSD), the inspection of Resident 30's abdominal area indicated Resident 30 had no feeding tube. The DSD stated Resident 30's MDS assessment was inaccurate. During an interview with the Certified Dietary Manager (CDM) on 6/7/19, at 2 p.m., the CDM stated Resident 30 was on a pureed diet and had no feeding tube. The CDM stated Resident 30's MDS assessment was inaccurate. The facility's policy and procedure titled, MDS Accuracy dated 4/05, indicated, The accuracy of the MDS is checked to assure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and are knowledgeable of the resident's status, needs, strengths, and areas of potential or actual decline . 055935 Page 10 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and record review, the facility failed to ensure residents were assisted in gaining access to hearing services for one of three sampled residents (Resident 17). Residents Affected - Few This failure resulted in not meeting Resident 17's functional hearing needs necessary to improve her quality of life. Findings: During an observation on 6/3/19, at 9:30 a.m., the TV volume inside Resident 17's room was heard from the hallway outside of her room. During an interview with Resident 17, on 6/3/19, at 11 a.m., in her room. Resident 17 stated she could not hear well, which caused her to increase the TV volume. Resident 17 stated the staff knew she could not hear well and needed the TV volume to be loud enough for her to hear. During a concurrent interview and record review with the Social Service Director (SSD), on 6/6/19, at 3 p.m., she was unable to find documented evidence of a hearing consult scheduled for Resident 17. The SSD stated Resident 17's hearing needs were not met and should have been followed up by scheduling a consultation with an audiologist. The facility's policy and procedure titled, Referrals, Social Services dated 1/18 indicated Social Services personnel shall coordinate most resident referrals with outside agencies. Policy Interpretation and Implementation . 6. Social service will help arrange transportation to outside agencies, clinic appointments, etc. as appropriate. 055935 Page 11 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and record review, the facility failed to ensure one of three sample residents (Resident 27) received routine dental care when a follow-up with dental recommendations for Resident 27 to have an upper partial denture fitting was not done. Residents Affected - Few This failure resulted in Resident 27 feeling embarrassed and inability to eat regular textured food. Findings: During a concurrent observation and interview with Resident 27, on 6/3/19, at 9:45 a.m., Resident 27 had no front upper teeth and interfered with her speech. Resident 27 stated she had a partial upper denture before and had lost it. During an observation and interview of Resident 27, on 6/6/19, at 4:45 p.m., Resident 27 stated she would be able to eat regular food and would be able to smile if she had a new denture plate. Resident 27 stated she was known for her smile and felt embarrassed to smile. During a review of the clinical record for Resident 27's, the dental notes dated 5/13/19, indicated Resident 27 had under gone a dental evaluation with X-ray. The recommendation indicated a referral to a prosthetic dentist (a person who restores /reconstructs intra-oral defects such as missing teeth). During an interview with the Social Service Director (SSD), on 6/7/19, at 4:54 p.m., she stated Resident 27's referral to a prosthetic dentist should have been followed up as soon as possible and was not. The facility's policy and procedure titled, Referrals, Social Services dated 1/18 indicated, Social Services personnel shall coordinate most resident referrals with outside agencies. Policy Interpretation and Implementation . 6. Social service will help arrange transportation to outside agencies, clinic appointments, etc. as appropriate. 055935 Page 12 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide one of three sampled residents (Resident 21) with eating equipment necessary to facilitate drinking and reduce fluid spillage when two nosey cups (designed with a cut out on the non-drinking side enabling tilting without interference by the nose) were not included in Resident 21's lunch tray. Residents Affected - Few This failure had the potential for Resident 21's fluids to spill and difficulty to drink fluids. Findings: During a lunch observation of Resident 21, on 6/3/19, at 11:50 a.m., Resident 21 lunch tray consisted of a pureed diet served in separate bowls, one four ounce (oz) glass of juice and one four oz glass of water. Resident 21 ate her pureed food from the separate bowls while a Certified Nursing Assistant (CNA) 1 supervised. Resident 21's meal ticket indicated, Serve food in bowls and 2 nosey cups. During an interview with CNA 1 and CNA 2, on 6/3/19, at 12 p.m., both CNA's stated Resident 21's lunch tray should have included 2 nosey cups for Resident 21's use. CNA 2 stated anyone of them could have transferred the water and the juice in the nosey cups if they were provided to prevent fluid spillage when Resident 21 drank. During an interview with the Head [NAME] (HC), on 6/4/19, at 11:00 a.m., the HC stated she forgot to include the two nosey cups in Resident 21's lunch tray on 6/3/19. During an interview with the Certified Dietary Manager, on 6/6/19, at 3 p.m., she stated the nosey cups for Resident 21 should have been included in her meal tray. The facility's policy and procedure titled, Resident Nutrition Services dated 1/18, indicated PROCESS . 3. Nursing personnel will provide assistance with eating and ensure that assuasive devices are available to residents as needed . 055935 Page 13 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

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 ensure the chemical sanitizing solution used for dishes, utensils and kitchen working surfaces met the recommended sanitation concentration when expired chemical test strips were used. This practice failed to ensure the required level of sanitation was followed and placed the residents and staff of the facility at risk for food borne illness. Findings: During a concurrent observation and interview with [NAME] 1, on 6/3/19, at 8:15 a.m., [NAME] 1 took a test strip to test the sanitizing solution in a red bucket. [NAME] 1 stated the solution in the red bucket was used to sanitize the countertops of the kitchen. The Quaternary Sanitizer (a form of disinfectant) (QT) test strip used by [NAME] 1 indicated an expiration date of 2/2019. During a concurrent observation and interview with [NAME] 1, on 6/3/19, at 8:20 a.m., [NAME] 1 took the chlorine test paper to verify the sanitation solution for the dishwasher. The container for the chlorine test paper indicated an expiration date of 5/19. [NAME] 1 stated the test strip she used to test the sanitation solution in the red bucket was already expired and was expired for more than three months. [NAME] 1 stated the chlorine test paper to test the sanitation of the dishes was also expired for three days. [NAME] 1 stated she did not know the test strips had an expiration date. [NAME] 1 stated she did not know she was using expired test strips. [NAME] 1 stated if the test strips were already expired, then the test result would not be right. During an interview with the facility's contracted dietary hygienist (DH) representative, on 6/3/19, at 10:10 a.m., he stated his company was the supplier of the test strips. The DH stated he called the manufacturer of the sanitizing strips, and was informed the company would stand by the expiration date of the test strips. During an interview with the Registered Dietician (RD), on 6/5/19, at 3:43 p.m., she stated the test strips used to verify the chemical concentration would not be accurate when used after their expiration date. The facility's undated policy and procedure titled, Inservice: Cleaning and Sanitizing Dishes, Utensils, Pots and Pans indicated, Note: Chlorine and Quat Test Strips may have expiration dated, Please check before using. During a review of the professional reference retrieved from https://www.microessentiallab.com/help.aspx dated 6/11/19, indicated, The shelf life of Hydrion pH (chemistry) paper is 3 years from the date of manufacture. The color chart is marked with the expiration and lot number for that specific roll. Our PH paper will remain accurate until the expiration date listed. 055935 Page 14 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to conduct a facility wide assessment specific to the facility needs when the facility assessment did not include a water management plan. This practice failed to establish an individualized facility assessment to meet the requirement for a water management plan which had the potential for waterborne bacteria exposure to the residents including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by bacterium known as legionella, most people get legionnaires' disease from inhaling the bacteria in showers, water faucets, water fountain) in an event of an outbreak. Findings: During an interview with the Administrator (ADM), on 6/5/19, at 9:30 a.m., he stated he was aware of the facility's requirement to establish a water management plan issued by the Centers of Medicare and Medical Services (CMS) in September 17, 2018. The ADM stated the requirement indicated all healthcare facilities were required to develop a plan for water management in an effort to reduce the risk of growth and spread of waterborne bacteria. The ADM stated he did not develop the water management plan. During a concurrent interview and record review with the ADM on 6/5/19 at 9:30 a.m., the facility document titled, Facility Assessment Tool dated May, 2019, did not include information regarding the facility's need for a water management program. The ADM stated the water management program was not developed and should have been in their facility risk assessment. Professional references CMS Quality, Safety & Oversight (QSO) letter dated and revised 7/6/18, indicated, Expectations for Healthcare Facilities: CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1) Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens .could grow and spread in the facilitywater system. 2) Develops and implements a water management program that considers the [American Society of Heating, Refrigeration and Air-Conditioning] ASHRAE industry standard and the [Centers for Disease Control] CDC tool kit. 3) Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are maintained. 4) Maintains compliance with other applicable Federal, State and local requirements. 055935 Page 15 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

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 failed to have an effective Quality Assurance and Performance Improvement (QAPI) program that had a data driven approach to maintain safety and quality when the facility's QAPI program did not develop and implement a water management program as part of the infection Control Program. These failure resulted in the facility not having a program in place to reduce the risk of waterborne illnesses including Legionella (a severe form of pneumonia) (lung inflammation usually caused by infection, caused by a bacterrium known as legionella, most people get legionnaires'disease from inhaling the bacteria in showers, water faucets, water fountain). Findings: During an interview with the Maintenance Supervisor (MS), on 6/5/19, at 9:15 a.m., the MS stated he was not aware of the water management plan for Legionella and did not know what Legionella was. During a concurrent interview and facility document review with the Administrator (ADM), on 6/6/19, at 11 a.m., he stated he was aware of the facility's requirement to establish a water management plan issued by the Centers of Medicare and Medical Services (CMS) in September 17, 2018. The ADM stated the facility did not discuss the need to develop a water management program during the QAPI meeting. The ADM stated he did not have any information regarding the facility's need for water management program in the facility QAPI. The ADM stated, he had not developed and implemented a water management plan. Review of Professional references, CMS Quality, Safety & Oversight (QSO) letter dated and revised 7/6/18, indicated, Expectations for Healthcare Facilities: CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1) Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens .could grow and spread in the facilitywater system. 2) Develops and implements a water management program that considers the [American Society of Heating, Refrigeration and Air-Conditioning] ASHRAE industry standard and the [Centers for Disease Control] CDC tool kit. 3) Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are maintained. 4) Maintains compliance with other applicable Federal, State and local requirements. 055935 Page 16 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

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 an effective infection prevention and control program when: Residents Affected - Many 1. The facility water management plan was not created or implemented to reduce the risk of Legionella (waterborne bacteria which can cause life threatening pneumonia) (a lung infection) and other waterborne pathogens (germs that cause disease) in accordance with Centers for Medicare and Medicaid Services (CMS). These failures placed the residents at risk for cross contamination, infection and had the potential for not identifying the risk of waterborne illnesses such as Legionella. 2. The Infection Surveillance Logs (to track residents with infections) was not completed in accordance with the facility policy and procedure titled, Infection Control Plan. These failures had the potential to result in an ineffective infection surveillance program which could potentially lead to undetected infection outbreaks, unnecessary antibiotic use and place residents at risk to develop antibiotic resistance. Findings: 1. During an interview with the Maintenance Supervisor (MS), on 6/5/19, at 9:15 a.m.,the MS stated he was not aware of the water management plan to reduce the risk of Legionella and other water borne bacteria. During an interview with the Administrator (ADM), on 6/5/19, at 9:30 a.m., he stated he was aware of the facility's requirement to establish a water management plan issued by the Centers of Medicare and Medical Services (CMS) in September 17, 2018. The ADM stated the requirement indicated all healthcare facilities were required to develop a plan for water management in efforts to reduce the risk of growth and spread of waterborne bacteria. The ADM stated he did not have any information regarding the facility's need for a water management program in the facility quality assurance program and in the facility assessment tool. The ADM stated, he had not developeded a water management plan. During an interview the Director of Staff Development (DSD), on 6/5/19, at 1:30 p.m., she stated she was not aware of the water management plan to reduce the risk of Legionella. Professional references CMS Quality, Safety & Oversight (QSO) letter dated and revised 7/6/18, indicated, Expectations for Healthcare Facilities: CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1) Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens .could grow and spread in the facility water system. 2) Develops and implements a water management program that considers the [American Society of Heating, Refrigeration and Air-Conditioning] ASHRAE industry standard and the [Centers for Disease Control] CDC tool kit. 3) Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are maintained. 4) Maintains compliance with other applicable Federal, State and local requirements. 055935 Page 17 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2. During a concurrent interview and record review with the Director of Development (DSD) on 6/4/19, at 10:05 a.m., the DSD stated she was responsible for the facility's Infection Prevention and Control Program. The DSD stated she did not have the infection surveillance (a system designed to identify, record and track incidents of infections or possible communicable diseases) logs for the months of December 2018 through the month of July 2019. The DSD stated she was unaware of the requirement to document infection surveillance information. The DSD stated, I use the McGreer Criteria (clinical guidance on evaluating and managing infections, tools used to determine minimum criteria for infection symptoms prior to the start of antibiotics) and print the list of residents on antibiotic therapy every month. During an interview with the Director of Nursing (DON), on 6/5/19, at 1:16 p.m., she stated the DSD was in charge of the facility's Infection Control Program and needed to document the infection surveillance. The DON stated the infection surveillance log was important in order to track and identify any trends on the facility's infections and if interventions were effective to prevent re-occurrence of infections. Review of the facility policy and procedure titled, Infection Control Plan undated, indicated, .Objectives .maintain accurate records of nosocomial (facility acquired infection) infections, infection controls measure and surveillance . Review of the facility document titled, Infection Control Plan undated, indicated Position Description .Administrative .5. Provides monthly summary of surveillance sheets (Monthly Infection Reports) . 055935 Page 18 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation and interview, during the annual recertifiction survey period of 6/3/19 to 6/7/19, the facility failed to provide the minimum of at least 80 square feet per resident in multiple residents rooms (Rooms 1, 2, 3, 4, 5, 6, 11, 12, 13, 14, 15, 16, 17 and 18). This failure had the potential for residents to not have reasonable privacy or adequate space. Findings: During an environmental tour with the Maintenance Supervisor (MS), on 6/5/19, at 10:30 a.m., the inspection indicated the following rooms did not meet the minimum square footage as required by regulation. However, variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. These rooms were as follows: Room number (#) Square feet #Residents 1 140 2 2 140 2 3 140 2 4 140 2 5 210 3 6 210 3 11 140 2 12 140 2 13 210 3 14 210 3 15 140 2 16 140 2 17 148 2 055935 Page 19 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0912 18 168 2 Level of Harm - Potential for minimal harm Recommend waiver be continue in effect. ______________________________________ Signature of Administrator Residents Affected - Some ______________________________________ Signature of HFEN 055935 Page 20 of 21 055935 06/07/2019 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, and interview, the facility failed to assure full visual privacy for one of 23 sampled residents (Resident 7) when Resident's 7's cubicle curtain (material suspended from the ceiling to circle around the bed to provide privacy during resident personal care) was removed and not replaced. Residents Affected - Few This failure had the potential for Resident 7 to receive personal care with out being afforded privacy. Findings: During a medication pass observation and interview with Licensed Vocational Nurse (LVN ) 2 on 6/4/19, at 8:30 a.m., LVN 2 tried to pull the curtain from the middle of the room. The curtain did not provide full circle privacy around Resident 7's bed. LVN 2 stated Resident 7 could not speak. LVN 2 stated the privacy curtain was missing for Resident 7. LVN 2 stated the hooks for the curtains were hanging in the curtain rail and the housekeepers were responsible for the replacement of the privacy curtain after their removal. During an interview with the Housekeeper/Laundry staff, on 6/5/19, at 4:17 p.m., stated she was responsible to check privacy curtains were in place for each resident and did not do so. Review of the facility document titled, Washing & Drying Cubicle Curtains dated April 2005 indicated, . Procedure:1 Identify cubicle curtains that need washing and take them down from their hangers .4. Air dry cubicle curtains in dryer for 3 to 5 minutes .5. Remove promptly from dyer and re-hang curtains . 055935 Page 21 of 21