Health inspection·April 22, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a baseline care plan for one of three sampled residents (Resident 73), when Resident 73 was admitted with hearing aids and the facility did not establish a care plan with interventions to address Resident 73's hearing needs. This failure had the potential to result in Resident 73 not having her hearing needs met. Findings: During a concurrent observation and interview on 4/18/22, at 3:19 p.m., with Resident 73, in Resident 73's room, Resident 73 was awake in her bed. Resident 73 had a hearing aid to her left ear and without a hearing aid to the right ear. Resident 73 stated her right hearing aid was missing. Resident 73 stated she kept her hearing aids in a pink box in her room. During a review of Resident 73's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 4/6/22, the MDS assessment indicated, Resident 73 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation, and memory recall) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 73 had no cognitive impairment. During a concurrent interview and record review, on 4/19/22, at 9:19 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 73's .Resident's Personal Items dated 3/30/22 was reviewed. The Personal Items indicated, . 3/30/22 . hearings aids [with] bag . LVN 2 stated Resident 73 wore hearings aids. During an interview on 4/20/22, at 9:41 a.m., with Certified Nursing Assistant (CNA) 9, CNA 9 stated 4/20/22 was the first time she cared for Resident 73. CNA 9 stated she was not aware Resident 73 wore hearing aids. During an interview on 4/20/22, at 3:15 p.m , with LVN 1, LVN 1 stated she was aware Resident 73 wore hearing aids. LVN 1 stated when a resident was admitted with hearing aids, a care plan should be developed for the hearing aids. LVN 1 stated a care plan for Resident 73's hearing aids was developed on 4/20/22. LVN 1 stated Resident 73's care plan for hearing aids should have been developed upon admission on [DATE]. LVN 1 stated it was important to have a care plan in place in case the hearing aids went missing. LVN 1 stated the care plan needed to indicate the reasons why Resident 73 wore hearing aids. During a review of Resident 73's .Resident's Personal Items, dated 3/30/22, the Resident's Personal Page 1 of 36 055955 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0655 Items indicated, Resident 73 was admitted with black Hearing Aids [with] bag. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated, .8. The Comprehensive, person-centered care plan will . Incorporate identified problem areas .; Incorporate risk factors associated with identified problems . Aid in preventing or reducing decline in the resident's functional status and or functional levels . The comprehensive, person-centered care plan is developed within (7) days of the completion of the required comprehensive assessment (MDS) . Residents Affected - Few 055955 Page 2 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop a comprehensive care plan with measurable objectives and timeframes for one of 19 sampled residents (Resident 52), when Resident 52 required oxygen at night and a care plan was not developed to address Resident 52's respiratory needs. This failure had the potential for Resident 52's respiratory needs to be not met, which could lead to respiratory issues and/or death. Findings: During a review of Resident 52's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 7/2/21 .Chronic Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing) . During a review of Resident 52's Order Summary Report (OS), dated 7/9/21, the OS indicated, .Oxygen at 2L/min (liters per minute- unit of measurement) via nasal cannula (device used to deliver supplemental oxygen or increased airflow to a person) at bedtime for shortness of breath (SOB) . During a concurrent interview and record review on 4/20/22, at 2:19 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 52's Care Plan was reviewed. LVN 1 stated Resident 52 used oxygen at night for SOB. LVN 1 stated there was no care plan indicating interventions for oxygen use. LVN 1 stated there needed to be a care plan for oxygen use to identify goals and interventions Resident 52 may need to maintain normal oxygen levels. During an interview on 4/20/22, at 2:48 p.m., with the Director of Nursing (DON), the DON stated care plans for oxygen dictate what problems nurses could anticipate with oxygen and how to resolve those issues. The DON stated an oxygen care plan could assist nurses, and therapists in determining the oxygen levels Resident 52 could tolerate. The DON stated there should have been an oxygen care plan in place for Resident 52 to identify goals for respiratory status. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plans, dated December 2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 055955 Page 3 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality when: Residents Affected - Some 1. The facility's pain assessment tool for cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) residents, Pain Assessment in Advanced Dementia (impairment of at least two brain functions, such as memory loss and judgment) (PAINAD), was not used for one of 22 sampled residents (Resident 67). This failure had the potential to result in Resident 67's pain going unnoticed and untreated, which could delay healing time, disturb sleep and activity patterns, reduce function, and reduce quality of life. 2. One of four sampled licensed nurses (Registered Nurse [RN] 1) administered two medications crushed together in Resident 63's gastrostomy tube (G-tube- a tube surgically inserted through the abdominal wall that brings nutrition directly to the stomach) at the same time, against the facility's policy and procedure (P&P) titled, Medication Administration Enteral Tubes. This failure had the potential to result in Resident 63 to experience drug interactions when mixed and clogging of the G-tube. 3. Licensed Vocational Nurse (LVN) 1 did not follow physician's orders for two of three sampled residents (Resident 73 and Resident 76) when the apical pulse (AP-the pulse site over the apex [pointed end] of the heart and is the most accurate, non-invasive way of assessing cardiac health) was not checked prior to administering a medication. This failure had the potential to result in Resident 73 and Resident 76 to experience adverse effects of the medication, such as bradycardia (slow heart rate) and cardiac arrest (when the heart stops). 4. Three of four licensed nurses (LVN 3, LVN 5 and RN 1) failed to lock the medication cart when it was out of sight, per the facility's P&P titled, Administering Medications. This failure had the potential for staff or residents to access an medications from the unlocked medication cart. 5. Licensed nurses did not follow the physician's order for one of 22 sampled residents (Resident 45), when Resident 45 had a meal intake of 50% or less, and the facility did not administer Resident 45's tube feeding formula. This failure resulted in Resident 45 to not receive her tube feeding formula on 4/1/22, 4/4/22 and 4/16/22, and had the potential for Resident 45 to not receive adequate nutrition. Findings: 1. During a review of Resident 67's pain assessments dated 4/1/22 through 4/20/22, ordered for every shift, Resident 67's pain assessments indicated, Resident 67 had zero pain every shift from 4/1/22 through the morning of 4/18/22 and then was documented as a pain of six out of 10 on a numeric 055955 Page 4 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0658 scale. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/20/22, at 11:41 a.m., with LVN 8, LVN 8 stated Resident 67 was alert, but could not communicate her needs. LVN 8 stated Resident 67 spoke mostly Armenian, very little English, and was sometimes non-responsive. LVN 8 stated she used the FACES scale (self-report measure of pain intensity using pictures of faces) to assess Resident 67's pain but documented it as assessing the pain on a Numeric scale (self-reported measure of pain intensity using numbers 0-10) by accident. LVN 8 was unable to explain how to properly use the FACES scale. LVN 8 stated she associated the look on Resident 67's face to the faces on the scale. LVN 8 stated Resident 67 was resting in bed, so she documented a zero for pain. Residents Affected - Some During an interview on 4/20/22, at 2:30 p.m., with RN 2, RN 2 stated she was new and on orientation with RN 3 and they took care of Resident 67 on 4/18/22. RN 2 stated she assessed Resident 67's pain, Resident 67 was grimacing, so she documented a pain of six out of 10 on the numeric scale. During a concurrent interview and record review on 4/20/22, at 2:30 p.m., with RN 3, Resident 67's pain assessment scale was reviewed. RN 3 stated Resident 67 was fine on 4/18/22, was sitting up in chair, and visiting with her son. RN 3 validated Resident 67's pain assessment was documented as six out of 10 on a numeric scale. RN 3 stated Resident 67 could sometimes communicate in English if she was in pain. RN 3 stated she used the FACES scale to assess Resident 67's pain. RN 3 stated it was important to use the same pain assessment scale/tool each time a resident's pain was assessed to ensure proper pain management. During a concurrent observation and interview on 4/20/22, at 2:50 p.m., with the Assistant Director of Nursing (ADON), Resident 67 was observed in activities. The ADON stated Resident 67 could verbalize her pain on a numeric scale. The ADON asked Resident 67 if she was having any pain. Resident 67 did not answer intelligibly. The ADON stated, she thought Resident 67 might have said no, but nurses should be using the FACES scale to assess Resident 67's pain and not the numeric scale. During a concurrent observation and interview on 4/20/22, at 2:53 p.m., with LVN 6 and the ADON, the documentation of a pain assessment in the electronic medical record (EMR) was reviewed. LVN 6 stated the PAINAD assessment tool needed to be used on non-verbal, confused, and residents with dementia. LVN 6 demonstrated how to document with the PAINAD scale in the EMR. LVN 6 stated the numeric and PAINAD pain scales were the only two pain assessment scales to choose from when documenting pain. During an interview on 4/20/22, at 3:17 p.m., with the Director of Nursing (DON), the DON stated, if a resident was unable to speak or not able to understand a question, the nurses should use the FACES/grimace scale to monitor pain. During an interview on 4/21/22, at 8:25 a.m., with LVN 7, LVN 7 stated Resident 67 could verbalize her pain on a numeric scale, most times for LVN 7. LVN 7 was unable to describe how to use the PAINAD assessment tool or who it was appropriate to use it on. During a review of the facility's P&P titled, Pain - Clinical Protocol, revised March 2018, the P&P indicated, Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident' cognitive level. During a review of the professional reference of Wong-Baker FACES Foundation the FACES Pain Rating Scale, indicated, This self-assessment tool must be understood by the patient, so they are able to 055955 Page 5 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some choose the face that best illustrates the physical pain they are experiencing. It is not a tool to be used by a third person, parents, healthcare professionals, or caregivers, to assess the patient's pain. There are other tools for those purposes. During a review of the professional reference of The Hartford Institute for Geriatric Nursing the article titled, Assessing Pain in Older Adults with Dementia, dated 2018, indicated, Pain in older adults is very often undertreated .Changes in a patient's ability to communicate verbally present special challenges in treating pain .Untreated pain in cognitively impaired older adults can delay healing, disturb sleep and activity patterns, reduce function, reduce quality of life, and prolong hospitalization .The PAINAD scale is reported to have moderate to high concurrent validity .The use of a standardized pain assessment tool is important in measuring pain. It enables health care providers to document their assessment, measure change in pain, evaluate treatment effectiveness, and communicate to other health care providers, the patient, and the family. 2. During a review of Resident 63's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/21/22, the AR indicated, admission Date 7/18/18 .Diagnosis Information . Pneumonia (lung inflammation caused by bacterial or viral infection) . Dysphagia (difficulty swallowing) . Unspecified Dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) . Neuroleptic Induced Parkinsonism (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) . During a review of Resident 63's Order Summary Report (OS), dated 4/21/22, the OS indicated, .May crush or pull apart medications unless contraindicated . carbidopa-levodopa (medication used to treat Parkinson's Disease) Tablet 25-100 mg (milligrams- unit of measurement) give 1 tablet via (by) G-tube every 6 hours for Dx: Parkinson Disease . hydrocodone-acetaminophen (medication used to treat moderate to severe pain) Tablet 10-325 mg Give 1 tablet via G-tube every 6 hours related to OTHER CHRONIC PAIN . During an observation on 4/20/22, at 12:54 p.m., RN 1, prepared Resident 63's medication and enteral feeding. RN 1 crushed Resident 63's hydrocodone-acetaminophen tablet and poured the crushed pill into a medication cup. RN 1 crushed Resident 63's carbidopa-levodopa tablet and poured it into the same cup with the hydrocodone-acetaminophen. RN 1 poured water into the medication cup and mixed it. RN 1 opened the end of Resident 63's G-tube and inserted the tip of the syringe. RN 1 poured the water mixed with two medications into the syringe and allowed the medications to drain into the G-tube by gravity. LVN 5 stated there were two medications mixed in the medication cup and administered at the same time. LVN 5 stated medications should always be administered separately in G-tubes because medication interactions and clogging the G-tube from too much of the crushed medication at the same time. During an interview on 4/21/22, at 12:29 p.m., with the DON, the DON stated when G-tubes were clogged it was usually from ineffective administration of medication. During a review of the facility's P&P titled Medication Administration Enteral Tubes, dated 2007, the P&P indicated, .Policy . The nursing care center assures the safe and effective administration of enteral formulas and medications . 10. Crushed medications are not mixed together. The powder from each medication is mixed with water before administration. The souffle cup (measurement cups that are used for dispensing medications) is rinsed with water to get all of the medication contained within the cup to facilitate the ordered dose . 12. Each medication is administered separately to avoid 055955 Page 6 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0658 interaction and clumping. The enteral tubing is flushed with water between each medication . Level of Harm - Minimal harm or potential for actual harm During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19052281/, titled Medication administration through enteral feeding tubes, undated, the professional reference indicated, .Purpose: An overview of enteral feeding tubes, drug administration techniques . Summary: Enteral (passing through the intestine through an artificial opening) nutrition through a feeding tube is the preferred method of nutrition support in patients who have a functioning gastrointestinal tract (organs that food and liquids travel through when they are swallowed, digested, absorbed) but who are unable to be fed orally. This method of delivering nutrition is also commonly used for administering medications when patients cannot swallow safely. However, several issues must be considered with concurrent administration of oral medications and enteral formulas. Incorrect administration methods may result in clogged feeding tubes, decreased drug efficacy, increased adverse effects, or drug-formula incompatibilities . Liquid medications, particularly elixirs and suspensions, are preferred for enteral administration . Before solid dosage forms are administered through the feeding tube, it should be determined if the medications are suitable for manipulation, such as crushing a tablet or opening a capsule . Residents Affected - Some 3. During a review of Resident 73's AR, dated 4/21/22, the AR indicated, admission Date 3/30/22 .Diagnosis Information . Cerebral Infarction (a stroke-the result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) . Hypertensive Chronic Kidney Disease (high blood pressure caused by the narrowing of your arteries that carry blood to your kidneys) . Unspecified Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) . During a review of Resident 73's OS, dated 4/21/22, the OS indicated, . Metoprolol Tartrate (medication to lower blood pressure) Tablet 25 MG Give 1 tablet by mouth two times a day related to HYPERTENSIVE CHRONIC KIDNEY DISEASE . (Hold for SBP [systolic blood pressure-(the first number) - indicates how much pressure your blood is exerting against your artery walls when the heart beats] <(less than) 100 or Apical Pulse <60) . During an observation on 4/20/22, at 4:15 p.m., with LVN 1, LVN 1 was at the doorway of Resident 73's room with the medication cart. LVN 1 reviewed a sheet with vital signs on it. LVN 1 stated the CNAs checked the resident's vital signs (VS-clinical measurements that include heart rate, respiration rate, temperature, oxygen level, and blood pressure that indicate the status of the body's vital functions) around 3 p.m. LVN 1 stated she would use the vital signs taken by the CNA to determine if a resident's VS met the parameters to administer blood pressure medications. LVN 1 stated the physician's order indicated if Resident 73's systolic blood pressure (SBP) was below 100, or apical pulse (AP) was less than 60 beats per minute (BPM), Resident 73's metoprolol would not be given. LVN 1 took a blood pressure cuff and stethoscope into Resident 73's room. LVN 1 checked Resident 73's blood pressure and stated it was 128/70. LVN 1 turned and walked through the doorway of Resident 73's room to administer the medication to Resident 73 and was stopped. LVN 1 stated she forgot to check Resident 73's AP. LVN 1 stated if she would have administered the metoprolol to Resident 73 without the AP checked, Resident 73's heart would slow down more, which could affect her circulation, and could cause the resident to pass out (become unconscious). During a review of Resident 76's AR, dated 4/21/22, the AR indicated, admission Date 3/31/22 .Diagnosis Information . Fracture of Left Pubis (broken pelvis) . Type 2 Diabetes Mellitus (impairment in the way the body regulates and uses sugar (glucose) as a fuel) . Chronic Kidney Disease . Hypertensive Heart and Chronic Kidney Disease (high blood pressure caused by the narrowing of your arteries 055955 Page 7 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0658 that carry blood to your kidneys) . Level of Harm - Minimal harm or potential for actual harm During a review of Resident 76's OS, dated 4/21/22, the OS indicated, . Carvedilol Tablet [medication to lower blood pressure] Tablet 12.5 MG Give 1 tablet by mouth two times a day related to HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE . (Hold for SBP <100 or Apical Pulse <60) . Residents Affected - Some During an observation on 4/20/22, at 4:42 p.m., with LVN 1, LVN 1 was at the medication cart outside of Resident 76's doorway. LVN 1 stated Resident 76 was due to receive carvedilol (medication used to lower blood pressure) and the physician ordered VS parameters was to hold the medication if SBP was less than 100 or the AP was less than 60. LVN 1 stated around 3 p.m., the CNAs would check the VS of residents she needed to pass medication to and turn them in to her. LVN 1 stated it had been approximately an hour and a half since the CNA checked Resident 76's VS. LVN 1 stated the VS could change within that amount of time and stated, oh, maybe I better check them [VS] again. During a concurrent interview on 4/20/22, at 4:53 p.m., with Resident 76 and LVN 1, Resident 76 stated when CNAs checked her pulse, she would hold up my wrist and the CNAs check my pulse, they don't listen to my heart. LVN 1 stated the physician order was to hold if the resident's apical pulse was less than 60. LVN 1 stated Resident 76's physician ordered parameters were not followed because the CNAs checked a peripheral pulse (pulses that are palpable at the hand) instead of an apical pulse. LVN 1 stated it was important to check an apical pulse when she administered anti-hypertensives because the AP was more accurate. During an interview on 4/21/22, at 12:29 p.m., with the DON, the DON stated when a nurse administered medications, and an apical pulse was required, the nurse should check the apical pulse themselves. The DON stated the apical pulse should be taken when the nurse gave the medication for an accurate and current reading. During a review of the facility's P&P titled, Administering Medications, dated April 2019, the P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders . 11. The following information is checked/verified for each resident prior to administering medications . b. Vital signs, if necessary . During a review of the professional reference titled Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1 The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan . 4. During an observation on 4/19/22, at 11:11 a.m., LVN 3 prepared Resident 71's medication, walked into Resident 71's room and pulled the privacy curtain closed. The medication cart was left unlocked by LVN 3 while she was in Resident 71's room. During an interview on 4/19/22, at 11:27 a.m., with LVN 3, LVN 3 stated the medication cart must be 055955 Page 8 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some locked anytime it was out of her sight. LVN 3 stated leaving the medication cart unlocked was a safety issue for the residents because they could access other medications in the cart and could cause adverse side effects if they ingested other's medications. During a concurrent observation and interview on 4/20/22, at 12:44 p.m., with LVN 5 and RN 1, LVN 5 and RN 1 entered Resident 53's room and closed the privacy curtain. The medication cart was left unlocked at the doorway and out of the nurse's eyesight. LVN 5 stated when she returned to the cart, she saw it was left unlocked and stated she should have locked it. LVN 5 stated an unlocked cart was a risk to the residents and anybody could take medication from an unlocked cart. During an interview on 4/21/22, at 12:29 p.m. with the DON, the DON stated her expectation was for the nurses to lock the medication cart any time it was out of their eyesight. The DON stated it was a standard of practice to lock the medication cart when unattended. The DON stated there were many people in the hallway and drugs could easily be diverted from an unlocked medication cart. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed . 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . The cart must be clearly visible to the personnel administering medications . During a professional reference review retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/lewingroup titled, CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services Long-Term Care Pharmacy Primer, dated December 30, 2004, the professional reference review indicated, .C. Administration of Medications by Nursing Facility Personnel . Nursing facility personnel administer medications pursuant to the prescription order. The personnel designated to administer medications must be trained by the nursing facility . Medication Carts. Medication carts are most often provided by the LTCP. The carts contain locked, non-removable drawers for each resident's medications . Medication carts must be supervised at all times by the nurse administering medications. When medication carts are not in use, they must be stored in a designated locked area with all drawers locked .5. During an interview on 4/18/22, at 11:48 a.m. with Family Member (FM), FM stated Resident 45 had been at the facility since November 2020. FM stated Resident 45 had a g-tube. FM stated when Resident 45 consumed less than 50% of the meal by mouth, Resident 45 was given the tube feeding formula. During a review of Resident 45's Order Summary Report (OS), dated 2/16/22, the OS indicated, [brand name (tube feeding formula)] three times a day for Supplement (Administer 8 [ounces- units of measurement] [237 milliliters- units of measurement] via [gastrointestinal tube] if resident eats [less than] 50% (Administer at [8 a.m., 1 p.m. and 6 p.m.]-Start date-2/16/2022. During a concurrent interview and record review on 4/21/22, at 9:25 a.m., with the Registered Dietician (RD), Resident 45's Medication Administration Record (MAR), dated April 2022 was reviewed. The MAR indicated: On 4/1/22, at 8 a.m., Licensed Nurse (LN) documented Resident 45 was not administered tube feeding formula when she ate 0% of her meal. On 4/4/22, at 1 p.m. and 6 p.m., LN documented Resident 45 was not administered tube feeding formula when she ate 25% of her meal. 055955 Page 9 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 4/16/22, at 1 p.m., LN documented Resident 45 was not administered tube feeding formula when she ate 25% of her meal. The RD validated on Resident 45's MAR there were four instances in the month of April where Resident 45 ate less than 50% of her meals and was not administered the tube feeding formula. The RD validated the dates were 4/1/22, twice on 4/4/22 and 4/16/22. The RD stated Resident 45 should have been given the tube feeding formula. The RD stated she did not know why the physician's order was not followed. The RD stated the licensed nurses should know why the tube feeding formula was not administered. During a concurrent interview and record review on 4/21/22, at 12:23 p.m., with LVN 5, Resident 45's MAR, dated April 2022 was reviewed. The MAR indicated, Resident 45 did not receive the tube feeding formula on 4/1/22, twice on 4/4/22 or 4/16/22, after eating less than 50% of her meal. LVN 3 validated on 4/1/22, twice on 4/4/22, and 4/16/22 Resident 45 was not given tube feeding formula when she should have received it for eating less than 50% of her meal. LVN 3 stated Resident 45 had the potential to lose weight and needed the tube feeding formula for nutrition. During a concurrent interview and record review, on 4/21/22, at 3:02 p.m., with the DON, Resident 45's MAR, dated April 2022 was reviewed. The MAR indicated, Resident 45 did not receive the tube feeding formula on 4/1/22, twice on 4/4/22 and 4/16/22 after eating less than 50% of her meal. The DON stated the physician's order was to administer the tube feeding formula when Resident 45 ate less than 50% of meals. The DON stated the physician's order was not followed on 4/1/22, twice on 4/4/22 and 4/16/22. The DON stated the licensed nurses should have documented in the progress notes the reason why the tube feeding formula was not administered. The DON stated the licensed nurses should have notified the physician and Resident 45's family. The DON stated there was no documentation from the licensed nurses as to why the physician's order for the tube feeding formula was not given to Resident 45 on 4/1/22, twice on 4/4/22 and 4/16/22. The DON stated the tube feeding formula was ordered to maintain her weight and nutrition due to her weight loss. The DON stated Resident 45 had the potential for further weight loss if the tube feeding formula not administered. During a review of Resident 45's MAR, dated April 2022, the MAR indicated, on 4/1/22 at 8 a.m. LN documented Resident 45 was not administered tube feeding formula when she ate 0% of her meal. The MAR indicated, on 4/4/22, at 1 p.m. and 6 p.m. LN documented Resident 45 was not administered tube feeding formula when she ate 25% of her meal. The MAR indicated, on 4/16/22, at 1 p.m. LN documented Resident 45 was not administered tube feeding formula when she ate 25% of her meal. During a review of the professional reference titled, Lippincott Manual of Nursing Practice 11th edition dated 2020, page 15 indicated, . Standards of Practice . General Principles . 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable . b. These standards provide patients with a means of measuring the quality of care they receive . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: . follow physician orders . document appropriate information in the medical record . and follow physician's orders . Failure to implement a physician's . order properly . 055955 Page 10 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure two out of three sampled residents (Resident 55 and Resident 44) with an indwelling urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder) received appropriate care when: 1. Resident 55's indwelling urinary catheter had sediment (substances present in urine) trapped in the tubing and the physician was not notified; and 2. Resident 44's indwelling urinary catheter bag was partially folded and placed sideways in the catheter bag (bag used to cover the urinary catheter bag for privacy), preventing the free flow of urine. These failures placed Residents 55 and 44 at risk for urinary tract infections (infection in any part of the urinary system, the kidneys, bladder, or urethra). Findings: 1. During a review of Resident 55's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 3/15/22 .Diagnosis Information . Other Pulmonary Embolism (blood clot in the lungs) .Neuromuscular Dysfunction of Bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems) . Urinary Tract Infection . Encounter for fitting and Adjustment of Urinary Device (drain urine via tubing attached to a bag ) . During a review of Resident 55's Order Summary Report (OS), dated 4/20/22, the OS indicated, .Change Foley Catheter . draining to gravity as needed for infection, obstruction or closed system is compromised related to NEUROMUSCULAR DYSFUNCTION OF BLADDER . During a concurrent observation and interview on 4/18/22, at 2:11 p.m., with Certified Nursing Assistant (CNA) 1, Resident 55's indwelling urinary catheter hung in a bag on the bedrail and had a large amount of sediment in the tubing. CNA 1 stated Resident 55 did not drink water often and the sediment was normal for her. During a concurrent observation and interview on 4/19/22, at 2:56 p.m., with Licensed Vocational Nurse (LVN) 4, Resident 55's indwelling urinary catheter tubing had a large amount of sediment. LVN 4 stated the buildup of white sediment in the tubing was not normal. During a concurrent interview and record review on 4/19/22, at 3:03 p.m., with LVN 4, Resident 55's physician orders and progress notes were reviewed. LVN 4 stated she was unable to locate documentation Resident 55's physician had been notified about the sediment in her urine. LVN 4 stated urine should be clear and Resident 55's urine should be checked for an infection. During a concurrent observation, interview, and record review on 4/21/22, at 8:47 a.m., with LVN 3, Resident 55's indwelling urinary catheter was observed. LVN 3 stated the night nurse changed the indwelling urinary catheter bag once a week and would date the bag when it was changed. LVN 3 donned (put on) gloves and picked up Resident 55's indwelling catheter bag. LVN 3 stated she was unable to 055955 Page 11 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0690 Level of Harm - Minimal harm or potential for actual harm locate a date on the bag. LVN 3 stated Resident 55's urine had an abnormal appearance and the sediment in the tubing could cause the urine to flow back into the bladder. LVN 3 reviewed Resident 55's electronic medical record and stated Resident 55 had a urinalysis (test of urine used to detect a wide range of disorders, such as urinary tract infections, kidney disease and diabetes) on 2/27/22 and it indicated she had a urinary tract infection. Residents Affected - Few During an interview on 4/21/22, at 12:08 p.m., with the Director of Nursing (DON), the DON stated when an indwelling urinary catheter had a large amount of sediment, the bag should be changed and reported to the physician. The DON stated the bag should be dated when it was changed. The DON reviewed the photo of Resident 55's indwelling urinary catheter tubing and stated the physician should have been notified for further follow up. The DON stated the risk of sediment buildup in the urinary catheter tubing would be that the resident could become septic (life-threatening condition in which the body is fighting a severe infection that has spread via the bloodstream). During a record review Resident 55's care plan, untitled and undated, the care plan indicated, .Problem . Foley Catheter . draining to gravity r/t (related to) Neurogenic bladder . Goal . The resident will show no s/sx (signs and symptoms) of Urinary infection . Monitor/record/report to MD for s/sx UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness . foul smelling urine . During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated September 2014, the P&P indicated, .The purpose of this procedure is to prevent catheter-associated urinary tract infections . Complications . 1. Observe the resident for complications associated with urinary catheters . b. Check the urine for unusual appearance (i.e., color, blood, etc.) . e. Observe for other signs and symptoms of urinary tract infection or . Report findings to the physician or supervisors immediately . Documentation . The following information should be recorded in the resident's medical record: .4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor . 2. During a review of Resident 44's AR, dated 4/20/22, the AR indicated, admission Date 3/3/22 .Diagnosis Information . Pneumonia (lung inflammation caused by bacterial or viral infection) . Neuromuscular Dysfunction of Bladder . Urinary Tract Infection . Encounter for fitting and Adjustment of Urinary Device . During a review of Resident 44's OS, dated 4/20/22, the OS indicated, .Change Foley Catheter .draining to gravity as needed for infection, obstruction or closed system is compromised related to NEUROMUSCULAR DYSFUNCTION OF BLADDER . During an observation on 4/19/22, at 2:38 p.m., at Resident 44's bedside, Resident 44's indwelling urinary catheter bag was folded over on itself and placed in the bag sideways. During a concurrent observation and interview on 4/19/22, at 2:42 p.m., with CNA 1, Resident 44's catheter bag was observed halfway in the dignity bag. CNA 1 stated Resident 44's indwelling urinary catheter bag was crunched and put in the bag. CNA 1 stated the catheter bag should be hung on the bedframe hanging down so the urine could flow freely through the tubing. CNA 1 took Resident 44's indwelling urinary catheter bag out of the bag. CNA 1 stated the position the indwelling urinary catheter bag was in, would have prevented it from draining correctly. During an interview on 4/19/22, at 3:09 p.m., with LVN 4, LVN 4 viewed a photo of Resident 44's 055955 Page 12 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few catheter bag and stated, the catheter bag should not be put in the bag sideways. LVN 4 stated the bag was folded over and the tube would not flow straight into the bag. LVN 4 stated the bag should have hung freely so it could drain correctly. LVN 4 stated if the urine were to back up into the bladder, it could cause an infection or kidney failure (condition in which the kidneys lose the ability to remove waste). During an interview on 4/21/22, at 12:08 p.m., with the DON, the DON viewed the photo of Resident 44's catheter bag in the bag and stated, the catheter bag was scrunched up in the picture and the urine would not flow out properly. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated September 2014, the P&P indicated, .The purpose of this procedure is to prevent catheter-associated urinary tract infections . Maintaining Unobstructed Urine Flow . 1. Check the resident frequently to be sure he or she is not lying on the catheter and keep the catheter and tubing free of kink . 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent that urine in the tubing and drainage bag from flowing back into the urinary bladder . 055955 Page 13 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide respiratory (network of organs and tissues that help you breathe) care and services in accordance with professional standards of practice for four of five sampled residents (Residents 25, 39, 52, and 55) when: Residents Affected - Some 1. Resident 25 had a humidifier (a container with sterile water used to prevent dry airway when breathing oxygen) with an outdated label (3/9/22); 2. Resident 39 had a humidifier with an outdated label (4/7/22); 3. Resident 52 had a humidifier with an outdated label (4/10/22); 4. Resident 55's oxygen humidifier and tubing were not dated; and 5. A non-licensed staff member (Central Supply [CS]) routinely changed residents' oxygen humidifiers and tubing, against the facility's policy and procedure titled, Oxygen Concentrator. These failures resulted in a non-licensed staff to perform duties they were not supposed to perform and had the potential for contamination of oxygen equipment for Residents 25, 39, 52, 55 that could lead to illness, or even death. Findings: 1. During a review of Resident 25's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 12/19/20 .Diagnosis Information . Chronic Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing) . During a review of Resident 25's Order Summary Report (OS), dated 12/19/20, the OS indicated, .Oxygen at 2L/min (liters per minute- units of measurement) via nasal cannula (device used to deliver oxygen that is placed in a resident's nose) as needed for Shortness of Breath related to COPD . During an observation on 4/18/22, at 10:39 a.m., in Resident 25's room, there was an oxygen concentrator (a medical device that gives extra oxygen) near Resident 25's bed, with a date written on the humidifier of 3/9/22. During an interview on 4/19/22, at 3:11 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated the humidifier and tubing needed to be changed every 24 to 72 hours. LVN 4 stated if the humidifier and tubing were not changed frequently enough, it could cause a respiratory infection. During a review of the facility's P&P titled, Oxygen Concentrator dated 12/30/2021, the P&P indicated, .5. Care of the Concentrator .c .i .Change oxygen tubing and mask/cannula weekly and as needed .ii. Change humidifier bottle when empty, every seventy-two hours . 2. During a review of Resident 39's AR dated 4/20/22, the AR indicated, admission Date 11/13/19 .Diagnosis Information . Pulmonary Fibrosis (PF-lung disease that occurs when lung tissue becomes damaged and scarred) . 055955 Page 14 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 39's OS, dated 11/14/19, the OS indicated, .Oxygen at 2L/min via nasal cannula every shift for Shortness of Breath . During an observation on 4/18/22, at 10:23 a.m., in Resident 39's room, there was an oxygen concentrator near Resident 39's bed with a date written on the humidifier of 4/7/22. Resident 39 was using the oxygen via nasal cannula. During an interview on 4/19/22, at 3:11 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated the humidifier and tubing needed to be changed every 24 to 72 hours. LVN 4 stated if the humidifier and tubing were not changed frequently enough, it could cause a respiratory infection. During a review of the facility's P&P titled, Oxygen Concentrator dated 12/30/2021, the P&P indicated, .5. Care of the Concentrator .c .i .Change oxygen tubing and mask/cannula weekly and as needed .ii. Change humidifier bottle when empty, every seventy-two hours . 3. During a review of Resident 52's AR, dated 4/20/22, the AR indicated, admission Date 7/2/21 .COPD . During a review of Resident 52's Order Summary Report (OS), dated 7/9/21, the OS indicated, .Oxygen at 2L/min via nasal cannula at bedtime for shortness of breath (SOB) . During a review of Resident 52's Minimum Data Set Section C Cognitive Patterns (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs), dated 3/14/22, the MDS indicated, .BIMS (Brief Interview for Mental Status) Summary Score .15 [indicating normal level of cognition] . During a concurrent observation and interview on 4/18/22, at 10:43 a.m., with Resident 52, Resident 52 had an oxygen concentrator near her bed with a date written on the humidifier of 4/10/22. Resident 52 stated she did not know when the humidifier had been changed, nor did she know how often it should have been changed. During an interview on 4/18/22, at 11:06 a.m., with LVN 2, LVN 2 stated the Department of Transportation (DT) staff was responsible for changing out the oxygen tubing and humidifier once a week. LVN 2 stated the nurses would only change out the tubing and humidifier if they were to become soiled or dislodged. During an interview on 4/19/22, at 3:11 p.m., with LVN 4, LVN 4 stated the humidifier and tubing needed to be changed every 24 to 72 hours. LVN 4 stated if the humidifier and tubing were not changed frequently enough, it could cause a respiratory infection. During a review of the facility's P&P titled, Oxygen Concentrator dated 12/30/2021, the P&P indicated, .5. Care of the Concentrator .c .i .Change oxygen tubing and mask/cannula weekly and as needed .ii. Change humidifier bottle when empty, every seventy-two hours . 4. During a review of Resident 55's AR, dated 4/20/22, the AR indicated, admission Date 3/15/22 .Diagnosis Information . Other Pulmonary Embolism (blood clot in the lungs) . Shortness of Breath . During a review of Resident 55's OS, dated 4/20/22, the OS indicated, .Oxygen at 2L/min via nasal cannula every shift related to SHORTNESS OF BREATH . 055955 Page 15 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 4/18/22, at 2:30 p.m., with Certified Nursing Assistant (CNA) 1, Resident 55 was lying in bed with oxygen tubing on and an oxygen concentrator at bedside. The oxygen concentrator's humidifier and tubing were undated. CNA 1 stated the tubing and humidifier should have been dated. CNA 1 stated she was unable to tell when the humidifier and tubing were changed, and she did not know when they were due for replacement. CNA 1 stated the date was used to determine when it would need to be replaced. CNA 1 stated if they were not replaced timely, it could cause a bacterial infection (organisms that cause illness) and the residents could become very sick. CNA 1 stated Department of Transportation (DT) was responsible to change the humidifier and tubing. During an interview on 4/19/22, at 3:11 p.m., with LVN 4, LVN 4 stated the oxygen humidifier and tubing should be dated otherwise there was no way to know when it needed to be changed. LVN 4 stated the humidifier and tubing needed to be changed every 24 to 72 hours. LVN 4 stated if the humidifier and tubing were not changed frequently enough, it could cause a respiratory infection. During an interview on 4/20/22, at 11:09 a.m., with LVN 3, LVN 3 stated the oxygen humidifiers and tubing were changed daily. LVN 3 stated DT checked the oxygen concentrators daily, and would let her know which humidifiers and tubing were due to be changed. 5. During a concurrent interview and record review on 4/20/22, at 11:25 a.m., with the CS, the facility's P&P titled, Oxygen Concentrator dated 12/30/21 was review. The CS stated she followed the facility's policy and replaced the humidifiers and tubing every 72 hours. The CS stated she would date the humidifier but did not date the tubing. The facility's P&P titled, Oxygen Concentrator, dated 12/30/21, indicated, .The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators . 5. Care of the Concentrator . c. Nurse responsibilities: i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. ii. Change humidifier bottle when empty, every seventy-two hours, or as recommended by the manufacturer . The CS stated she performed the humidifier bottle and tubing changes herself. The CS stated DT trained her to set up the oxygen concentrators, change the humidifier bottles and tubing before he changed job positions. The CS stated she was not aware the P&P indicated only the nurses were responsible for the humidifier and tubing change. During a concurrent interview and record review at 4/20/22, at 11:41 with the Director of Nurses (DON), the facility's P&P titled, Oxygen Concentrator, dated 12/30/21 was reviewed. The facility's P&P indicated, .The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators . 5. Care of the Concentrator . c. Nurse responsibilities: i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. ii. Change humidifier bottle when empty, every seventy-two hours, or as recommended by the manufacturer . The DON stated the way the P&P was written, it indicated the nurses were responsible to change the humidifiers and tubing. The DON stated the P&P should include the CS since she was trained and responsible to perform the humidifier and tubing changes. The DON stated according to the P&P, the CS should not change the humidifiers and tubing. 055955 Page 16 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 25), that received dialysis (treatment that uses the blood stream to filter out wastes in the body for people whose kidneys are failing) treatments, received ongoing assessments, when the facility did not perform post (after) dialysis assessments (includes vital signs [clinical measurements including heart rate, temperature, respiration rate and blood pressure that indicate the state of a resident's essential body functions], access site [used for connecting to a machine that filters blood during treatment] assessment, and condition of resident) three out of five days (4/8/22, 4/11/22, 4/13/22). Residents Affected - Few This failure resulted in incomplete assessments for Resident 25 and had the potential for the facility to not recognize dialysis related complications (low blood pressure, fluid overload, blood clots, muscle cramps, access site infection, and itchy skin) for Resident 25, that could lead to harm or death. Findings: During a review of Resident 25's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 12/19/20 .Diagnosis Information .End Stage Renal Disease (ESRD-medical condition in which a person's kidneys stop functioning on a permanent basis and needing long-term dialysis) . During a review of Resident 25's Order Summary Report (OS), dated 12/19/20, the OS indicated, Dialysis at [name of dialysis clinic] one time every Mon, Wed, Fri . During a review of Resident 25's SNF (Skilled Nursing Facility)/Dialysis Communication Form, dated 4/8/22, the form indicated, . Dialysis Assessment After Return to [name of facility] .General Comments on Resident Overall Condition [all entries blank] .Vascular Access Site (site on body where a device is used to remove the resident's blood so that it could be filtered during dialysis treatment) [all entries blank] . During a review of Resident 25's SNF/Dialysis Communication Form, dated 4/11/22, the form indicated, . Dialysis Assessment After Return to [name of facility] .[vital signs] .[all entries blank] General Comments on Resident Overall Condition [all entries blank] .Vascular Access Site [all entries blank] . During a review of Resident 25's SNF (Skilled Nursing Facility)/Dialysis Communication Form, dated 4/13/22, the form indicated, . Dialysis Assessment After Return to [name of facility] .General Comments on Resident Overall Condition [all entries blank] .Vascular Access Site [all entries blank] . During an interview on 4/19/22, at 2:38 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 25's vital signs and condition needed to be assessed by a nurse before every dialysis appointment and after returning to the facility from dialysis. LVN 1 stated all findings should have been documented in the SNF/Dialysis Communication Form. LVN 1 stated there was missing documentation on the dialysis communication forms for the dates of 4/8/22, 4/11/22, and 4/13/22. LVN 1 stated all forms should have been completed to ensure Resident 25 was stable and to monitor any abnormalities such as a low blood pressure and follow up with the physician if any findings could cause Resident 25 055955 Page 17 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0698 harm. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/20/22, at 12 p.m., with the Director of Nursing (DON), the DON stated nurses should have assessed Resident 25 before and after dialysis appointments and completed the SNF/Dialysis Communication Forms to ensure Resident 25's safety. Residents Affected - Few During a review of the facility policy and procedure (P&P) titled, Care of a Resident with End-Stage Renal Disease (ESRD), dated September 2010, the P&P indicated, .2. Education and training of staff includes .b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis . During a review of the facility P&P titled, Charting and Documentation, dated July 2017, the P&P indicated, .2. The following information is to be documented in the resident medical record a. Objective observations .d. Changes in the resident's condition .7. Documentation of procedures and treatments will include care-specific details, including .c. The assessment data and/or any unusual findings obtained during the procedure/treatment . 055955 Page 18 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

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 ensure 20 of 22 licensed nursing staff (LN) possessed the competencies required to provide for residents' needs, when annual competency evaluations were not documented as completed in 2021. This failure had the potential for staff to not possess the appropriate skills and competencies to assure residents' safety and provide appropriate care. Findings: During a concurrent interview and record review on 4/21/22, at 2:25 p.m., with Accounts Payable (AP), employee files and staffing schedules were reviewed for compliance with staffing regulations. The AP validated orientation check off lists were kept in the employee files, but there were no recent annual competencies to be found in three of three sampled nursing staff files (Licensed Vocational Nurse [LVN] 7, LVN 8, and Registered Nurse [RN] 3. LVN 7's employee file indicated, LVN 7 started working at the facility on 2/10/2022. The orientation check off was completed and competencies were checked on abuse and reporting abuse. No other competency was in the file. LVN 8's employee file indicated, LVN 8 started working at the facility on 3/2/22. The orientation check off was completed and competencies were checked on abuse and reporting abuse. No other competency was in the file. RN 3's employee file indicated, RN 3 worked at the facility since 4/6/2005. Individual competencies checked for 2021 included Medication Administration, Hand Hygiene, and Wound Care. Annual competency checks for 2014, 2016, 2019, and 2020 were in the file. No annual competency for 2021 was in RN 3's employee file. During an interview on 4/21/22, at 3:02 p.m., with the Assistant Director of Nursing (ADON), the Director of Staff Development (DSD), and the Interim Director of Staff Development (IDSD), the DSD stated, nursing staff have orientation with the ADON, Director of Nursing (DON), or shift leads, and the former DON or ADON checked annual competencies for nursing staff. The ADON stated she had not completed any competencies for nursing staff since the former DON left, but the former DON checked annual competencies for nursing staff before then. During an interview on 4/21/22, at 3:57 p.m., with the ADON, the ADON stated the previous DON had worked on the 2021 nursing competencies, but the ADON did not know where she had kept them. The ADON stated she had not given any in services (education or training) or checked any competencies for LNs since starting with the facility. During a concurrent interview and record review on 4/21/22, at 4:02 p.m., with the DSD, the yearly in-service binders for LNs was reviewed. The DSD validated seven of 22 LNs completed the Medication Administration competency for 2021, five of 22 LNs completed the Wound Care competency for 2021, 12 of 22 LNs completed the Hand Hygiene competency for 2021, one of 22 nurses completed the Nephrostomy (artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system) Competency for 2021, and one of 22 nurses completed the Suprapubic (drains urine from the bladder; it is inserted into your bladder through a small hole in the belly) Competency for 2021. During a concurrent interview and record review on 4/21/22, at 4:24 p.m., with the ADON, the yearly in-service binders for LNs were reviewed. The ADON stated the binder being reviewed was the only 055955 Page 19 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nurse competency binder she could find. The ADON validated there were only two completed annual competency evaluations completed for LNs in 2021. The ADON stated the competency binder for LNs was not complete for 2021 and needed to be kept complete and current to keep track of the competencies and ensure all nursing staff were competent in their practices. During a review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, revised October 2017, the P&P indicated, .licensed nurses .will: participate in a facility-specific, competency-based staff development and training program; and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care .The following factors are considered in the creation of the competency-based staff development and training program .A method to track, assess, plan, implement and evaluate the effectiveness of training .The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population .Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment .Inquiries concerning staff competency evaluations should be referred to the Director of Nursing Services or to the Personnel Director. During a review of the facility's P&P titled, On-the-job Training, revised January 2008, the P&P indicated, .Department directors will be responsible for on-the-job training to assure that our established training schedules are followed .All training programs and classes attended by an employee shall be entered on his/her Employee Training Attendance Record. Training records will be filed in the employee's personnel file or may be maintained by the department supervisor. 055955 Page 20 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement an annual gradual dose reduction (GDR-tapering of a medication dosage to determine if symptoms, conditions, or risks can be managed by a lower dose or it can be discontinued) of antipsychotic medication (medication for the treatment of psychosis [involves a loss of contact with reality and can feature hallucinations and delusions]) in accordance with the facility policy and procedure titled Medication Monitoring Medication Management, dated 2007, for one of five sampled residents (Resident 70) when Resident 70 was prescribed and administered an antipsychotic medication and the previous effort to conduct a GDR was 2/20/21. There were no documented clinical contraindications (specific situation in which a drug, procedure, or surgery should not be used because it may be harmful to the person) related to the antipsychotic to not conduct the GDR. This failure had the potential to result in Resident 70 receiving unnecessary antipsychotic medications. Findings: During a review of Resident 70's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/20/22, the AR indicated, admission Date 1/12/20 .Diagnosis Information . Type 2 Diabetes Mellitus (impairment in the way the body regulates and uses sugar as fuel) . Alzheimer's Disease (brain disorder that slowly destroys memory and thinking) . Unspecified Psychosis . Major Depressive Disorder (persistently depressed mood) . During a review of Resident 70's Order Summary Report (OS), dated 4/21/22, the OS indicated, .Monitor behavior for episodes of striking out during essential care every shift related to UNSPECIFIED PSYCHOSIS . [brand name of antipsychotic] 100 mg (milligrams- unit of measurement) (quetiapine fumarate) Give tablet by mouth every 12 hours related to Unspecified Psychosis . During a concurrent interview and record review on 4/20/22, at 3:29 p.m., with Licensed Vocational Nurse (LVN) 6, Resident 70's behaviors documented on the Medication Administration Record (MAR- legal record of the drugs administered to a patient at a facility by a health care professional) was reviewed. LVN 6 stated Resident 70 had a history of behaviors such as striking out and attempting to go outside. LVN 6 reviewed Resident 70's behaviors documented on the MAR and stated Resident 70 had 20 behaviors in April 2022. LVN 6 stated the specific behaviors should be addressed in Resident 5's progress notes, but was unable to locate progress notes which addressed the behaviors. During an interview on 4/21/22, at 11:10 a.m., with Social Service Supervisor (SSS), the SSS stated the interdisciplinary committee met for each resident monthly and would review the residents on psychotropic medications annually to consider a GDR. The SSS stated the committee would complete a Psychotrophic [sic] Drug Regimen Review note and send recommendations to the resident's physician for follow up. During a concurrent interview and record review on 4/21/22, at 11:23 a.m., with the SSS, Resident 70's note titled Psychotrophic Drug Regimen Review, dated 2/10/21, was reviewed. The note indicated .Pharmacy review .GDR of [brand name of previous antipsychotic] 5mg 1 tab (tablet) PO (by mouth) QD 055955 Page 21 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (every day) for psychosis m/b (manifested by) agitation and striking out . is contraindicated at this time due to risk of potential emotional distress & harm to self or others . signed by the IDT members. The note indicated, . Other Drugs attempted in the past with poor response . yes, I agree (see new order) [left blank] . yes, but I wish to modify (see new order [left blank] . No, I disagree (List Risk vs. [versus] benefits) [left blank] . signed by Resident 70's physician. The SSS stated the IDT determined a GDR was not appropriate for Resident 70 because of his behavior history. The SSS stated he was unable to locate a more current Psychotrophic Drug Regimen Review note. During an interview on 4/21/22, at 11:37 a.m., with the Pharmacist (PHM), the PHM stated for Resident 70, the facility attempted a GDR approximately a year ago. The PHM stated she did not have Resident 70's information with her, so she was unsure of the dates and what Resident 70's behaviors were. The PHM stated after the GDR, Resident 70 fell more frequently and the physician ordered to increase the [antipsychotic] medication to the previous dosage. During an interview on 4/21/22, at 12:44 p.m., with the Director of Nursing (DON), the DON stated the IDT met monthly and would review the residents on psychotropic medications for GDR annually. During an interview on 4/21/22, at 2:34 p.m., with the SSS, the SSS stated GDRs were important because antipsychotic medication should be used at the lowest dose to prevent side effects and any risks to the resident. During a concurrent interview and record review on 4/21/22, at 3 p.m., with the SSS, Resident 70's electronic medical record was reviewed. The SSS looked through Residents 70's notes and stated Resident 70's last GDR was on 12/6/19. During a review of a professional reference found at https://www.umassmed.edu/globalassets/[NAME]-primary-care-institute/iadapt_toolkit_printingfull_final_10.04.12.pdf, titled, Caring for Residents with Dementia: A Guide for Behavior Management and Evidence-Based Medication Use, dated July 2012, pages 40-43, the reference indicated, . Atypical antipsychotic medications are not FDA-approved for behavior management in elderly people with dementia . Atypical antipsychotics have serious side effects . Appropriate indications include . Aggressive behavior (resident is a danger to self and/or others) . Hallucinations or delusions (if these behaviors cause impairment in functional capacity) . For all persons receiving an antipsychotic (regardless of indication) . Reassess the need for therapy . Attempt taper to minimal effective dose . Include resident centered behavioral management . Inappropriate Use of Antipsychotics . Verbally Aggressive/Threatening . Combative . Substantial Difficulty Receiving care . Hallucinations Not Impairing Functional Capacity . Delusions Not Impairing Functional Capacity . Hitting/Striking out . The patient has one of the following diagnosis . Atypical Psychosis . Delusional Disorder . Acute Psychotic episodes . Specific behaviors which cause the resident to present a danger to themselves or others . Continuous crying out, screaming, yelling, or pacing if these specific behaviors cause an impairment in functional capacity . Psychotic symptoms (hallucinations, paranoia, delusions) . During a review of the facility's policy and procedure titled, Medication Monitoring Medication Management, dated 2007, the P&P indicated, . In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences . 1. Antipsychotics . d. Inadequate Indications . In many situations, antipsychotic medications are not indicated . f. Dosage . Doses for acute indications . may differ from those used for long-term treatment, but should be the lowest possible to achieve the desired therapeutic effects . Tapering of a medication dose/gradual dose reduction (GDR) . after the first year, a GDR must be attempted annually . 055955 Page 22 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the facility's medication error rate did not exceed five percent, when two of 25 medication administration opportunities observed were not administered in accordance with facility policy and procedure (P&P) and standards of practice. Residents Affected - Few This failure resulted in a medication error rate of 8% (percent- unit of measurement) and placed Resident 63 at risk for drug interaction and clumping of medications, which could result in plugging of the gastrostomy tube (G-tube- a tube surgically inserted through the abdominal wall that brings nutrition directly to the stomach) and prevent Resident 63 from getting the full therapeutic effect of all administered medications and nutrition. Findings: During a review of Resident 63's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/21/22, the AR indicated, admission Date 7/18/18 .Diagnosis Information . Pneumonia (lung inflammation caused by bacterial or viral infection) . Dysphagia (difficulty swallowing) . Unspecified Dementia (the loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) . Neuroleptic Induced Parkinsonism (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) . During a review of Resident 63's Order Summary Report (OS), dated 4/21/22, the OS indicated, .May crush or pull apart medications unless contraindicated . Carbidopa-Levodopa (medication used to treat Parkinson's Disease) Tablet 25-100 mg (milligrams- units of measurement) give 1 tablet via (by) G-tube every 6 hours for Dx (diagnosis): Parkinson Disease . Hydrocodone-Acetaminophen (medication used to treat moderate to severe pain) Tablet 10-325 mg Give 1 tablet via G-tube every 6 hours related to OTHER CHRONIC PAIN . During an observation on 4/20/22, at 12:54 p.m., Registered Nurse (RN) 1 in orientation with Licensed Vocational Nurse (LVN) 5, prepared Resident 63's medication and enteral (tube feeding) feeding. RN 1 crushed Resident 63's hydrocodone-acetaminophen tablet and poured the crushed pill into a medication cup. RN 1 crushed Resident 63's carbidopa-levodopa tablet and poured it into the same cup with the hydrocodone-acetaminophen. RN 1 poured water into the medication cup and mixed it. RN 1 opened the end of Resident 63's G-tube and inserted the tip of the syringe without the stopper. RN 1 poured the water mixed with two medications into the syringe and allowed the medications to drain into the G-tube tube by gravity. LVN 5 stated there were two medications mixed in the medication cup and administered at the same time. LVN 5 stated medications should always be administered separately in G-tubes because if there were problems with a medication you would not know which medication caused it. LVN 5 stated there was a risk of clogging the G-tube from too much of the crushed medication at the same time. During an interview on 4/21/22, at 12:29 p.m., with the Director of Nursing (DON), the DON stated when G-tubes were clogged, it was usually from ineffective administration of medication. During a review of the facility's policy and procedure (P&P) titled Medication Administration Enteral Tubes, dated 2007, the P&P indicated, .Policy . The nursing care center assures the safe and effective administration of enteral formulas and medications . 10. Crushed medications are not mixed 055955 Page 23 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few together. The powder from each medication is mixed with water before administration. The souffle cup is rinsed with water to get all of the medication contained within the cup to facilitate the ordered dose . 12. Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with water between each medication to avoid physical interactions . During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19052281/, titled Medication administration through enteral feeding tubes, undated, the professional reference indicated, .Purpose: An overview of enteral feeding tubes, drug administration techniques . Summary: Enteral nutrition through a feeding tube is the preferred method of nutrition support in patients who have a functioning gastrointestinal tract but who are unable to be fed orally. This method of delivering nutrition is also commonly used for administering medications when patients cannot swallow safely. However, several issues must be considered with concurrent administration of oral medications and enteral formulas. Incorrect administration methods may result in clogged feeding tubes, decreased drug efficacy, increased adverse effects, or drug-formula incompatibilities . Liquid medications, particularly elixirs and suspensions, are preferred for enteral administration . Before solid dosage forms are administered through the feeding tube, it should be determined if the medications are suitable for manipulation, such as crushing a tablet or opening a capsule . 055955 Page 24 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 failed to follow one of five sampled residents' (Resident 16) food preferences and dislikes, when Resident 16 received canned fruit instead of the preference for fresh fruit on her meal tray for lunch on 4/18/22. This failure had the potential to result in decreased food consumption for Resident 16. Findings: During a concurrent observation and interview on 4/18/22, at 11:36 a.m., with Resident 16, in Resident 16's room, Resident 16 stated she received canned fruit and not fresh fruit. Resident 16's lunch tray was observed to have a container of canned chopped peaches. Residents 16's meal tray had a tray ticket that did not indicate likes or dislikes for fruit. During an interview on 4/19/22, at 9:29 a.m., with Resident 16, Resident 16 stated she received canned fruit on her meal tray. Resident 16 stated the canned fruit was not appealing. During a concurrent observation and interview on 4/20/22, at 12:27 p.m., with Resident 16, in Resident 16's room, Resident 16 stated most of her meals came with fruit, but it was canned fruit. Resident 16 stated she told someone (Registered Dietician [RD]) in the food services department her food likes and dislikes. Resident 16 stated she was visited by the food services department once a month. Resident 16 stated when she received canned fruit, she would notify the staff she did not like the canned fruit. Residents 16's meal tray had a tray ticket that did not indicate likes or dislikes for fruit. During a review of Resident 16's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 4/13/22, the MDS assessment indicated Resident 16 was cognitively intact with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During an interview on 4/21/22, at 10:24 a.m., with the RD, the RD stated she or the Dietary Supervisor talked to the residents about their food preferences as often as needed. The RD stated she was familiar with Resident 16. The RD stated she would make the Certified Dietary Manager (CDM) aware of resident preferences. The RD stated the CDM had access to update preferences on resident tray tickets. During a concurrent interview and record review, on 4/21/22, at 2:12 p.m., with the RD, Resident 16's Nutrition/Dietary Department Note (NDDN), dated 1/7/22, 2/12/22, and 2/22/22 were reviewed. The NDDN, dated 1/7/22 indicated, .RD visited resident .has food preference of fruits, will communicate with kitchen . The NDDN dated 2/13/22, indicated, .Resident states likes to snack in the day and would like it scheduled in the day-prefers fresh fruit . The NDDN dated 2/22/22, indicated .Resident preferences updated-fresh fruit only . The RD stated she informed the CDM of Resident 16's preferences. The RD stated it was important to honor Resident 16's preferences to maintain a homelike environment and uphold Resident 16's resident rights. During a concurrent interview and record review on 4/21/22, at 2:24 p.m., with the CDM, the CDM 055955 Page 25 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0803 Level of Harm - Minimal harm or potential for actual harm stated she was notified by the RD that Resident 16 wanted fresh fruit. The CDM validated that on 4/18/22, Resident 16 received canned fruit for lunch. The CDM reviewed Resident 16's tray card dated 4/20/22 and verified Resident 16's preferences were not listed on the tray card. The CDM stated she would be honoring Resident 16's preference by indicating the preference on the tray card and ensuring that fresh fruit was on Resident 16's tray. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Nutrition Care, dated 2018, the P&P indicated, .Resident/Patient Food Preferences .1. The resident/patient food preferences should be updated and placed on the profile card/tray card as needed . 055955 Page 26 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

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 ensure food was stored and prepared in accordance with professional standards, when: Residents Affected - Some 1. The mechanical soft (chopped to make the food soft and easy to eat) salad located on the lunch assembly line was 56 degrees Fahrenheit (F- scale used to measure temperature) (acceptable temperature is below 41 degrees F) when measured with a food thermometer. This failure had the potential to place residents at risk for complications from foodborne illness (sickness caused by bacteria, viruses, parasites, or toxins). 2. Individually wrapped cookies and crackers were stored in three easily accessible snack bins. The individually wrapped cookies and crackers and the bins were not labeled with a use-by date. This failure had the potential for residents to consume foods that may have been compromised (quality and taste) and for residents to have a decrease in their nutritional intake. Findings: 1. During a concurrent observation and interview on 4/18/22, at 11:27 a.m., with the Certified Dietary Manager (CDM), the tray line assembly for lunch preparation was measured with a food thermometer. The mechanical soft salad was in a cup, over ice. The salad's temperature was measured with the food thermometer, and thermometer indicated 56 degrees F. The CDM stated, the serving temperature of the mechanical soft salad should be 41 degrees or less to minimize foodborne illness. During a concurrent interview and record review on 4/18/22, at 11:30 a.m., with the CDM, the facility document titled, Food: Temperature Log, dated April 18, 2022 was reviewed. The Food Temperature Log indicated, Suggested serving temperature .Cold food maximum 40 degrees F. Record. The Food Temperature log dated 4/18/22 for lunch meal service did not contain a temperature collected for the salad. The CDM stated the cooking staff did not check the temperature on the vegetables (salad). During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2018, the P&P indicated, .Policy: Employees will prepare food in a clean and safe manner to protect residents/patients and staff from foodborne illness .Procedures .12. Prepared food will be stored at proper temperature until serving time. Temperature forms will be utilized .c. Cold foods at less than or equal to 41 degrees F . During a review of the professional reference retrieved from https://www.fda.gov/regulatory-information/search-fda-guidance-documents/guidance-industry-guide-minimize-microbial-fo titled, Guidance for Industry: Guide to Minimize Microbial Food Safety Hazards of Fresh-cut Fruits and Vegetables, dated February 2008, the professional reference indicated, Processing fresh produce into fresh-cut products increases the risk of bacterial growth and contamination by breaking the natural exterior barrier of the produce (Ref. 6).The release of plant cellular fluids when produce is chopped or shredded provides a nutritive medium in which pathogens, if present, can survive or grow (Ref. 6). Thus, if pathogens are present when the surface integrity of the fruit or vegetable is broken, pathogen growth can occur and contamination may spread. The processing of fresh produce without proper sanitation procedures in the processing environment increases 055955 Page 27 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the potential for contamination by pathogens (see Appendix B, Foodborne Pathogens Associated with Fresh Fruits and Vegetables.) .The potential for pathogens to survive or grow is increased by the high moisture and nutrient content of fresh-cut fruits and vegetables, the absence of a lethal process (e.g., heat) during production to eliminate pathogens, and the potential for temperature abuse during processing, storage, transport, and retail display (Ref. 6). Importantly, however, fresh-cut produce processing has the capability to reduce the risk of contamination by placing the preparation of fresh-cut produce in a controlled, sanitary facility . During a professional reference review of the Food Code - U.S. (United States) Food & Drug Administration 2017, dated 2017, the professional referenced indicated, .Historical Record of Cold Holding Temperature Provisions .41&deg;F became the standard for cold holding . 2. During a concurrent observation and interview on 4/20/22, at 2:25 p.m., with the CDM, a bin stored individually wrapped graham crackers [brand name] (removed from its original packaging) and did not contain a label with a used by date. Two bins with individually wrapped cookies and chips [brand names] did not contain a used by date (removed from its original packaging) in the facility's kitchen pantry. The individually wrapped snacks did not contain a manufacturer's used by date as they were removed from the original packaging. The CDM stated there should have been an opened date and use by date on a label, on each snack bin, to ensure the snacks were within the recommended manufacturer's guideline to ensure the nutritional value, taste, and quality of the snacks During a concurrent interview and record review of the facility's P&P titled, Sanitation and Infection Control Subject: Canned and Dry Goods Storage, dated 2018, the P&P indicated, .All open food items will have an open date and use-by-date per manufacturer's guidelines. During a review of the professional reference retrieved from https://www.fda.gov/consumers/consumer-updates/are-you-storing-food-safely titled, Are You Storing Food Safely? Storing food properly can help prevent foodborne illnesses. Here are tips for safely storing food in your refrigerator, freezer, and cupboards, dated 2/9/21, the professional reference review indicated, Check expiration dates. A 'use by' date means that the manufacturer recommends using the product by this date for the best flavor or quality. The date is not a food safety date. At some point after the use-by date, a product may change in taste, color, texture, or nutrient content, but, the product may be wholesome and safe long after that date. If you're not sure or if the food looks questionable, throw it out . 055955 Page 28 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. During an observation on 4/19/22, at 11:08 a.m., with LVN 3, LVN 3 prepared Resident 69's medication for administration. LVN 3 touched the medication cart and did not perform hand hygiene before she prepared the medication. Residents Affected - Some During an observation on 4/19/22, at 11:11 a.m., with LVN 3, LVN 3 did not perform hand hygiene before she prepared Resident 71's medication and donned (put on) gloves. LVN 3 entered Resident 71's room and administered Resident 71 oral medication and eye drops with the same gloves on. LVN 3 did not perform hand hygiene between the oral medication and eye drops. LVN 3 did not clean her hands after she removed the gloves. During an interview on 4/19/22, at 11:27 a.m., with LVN 3, LVN 3 stated hand hygiene must be performed before medication administration to prevent illness. LVN 3 stated she should have washed her hands before and after Resident 71's eye drops. LVN 3 stated she did not want bacteria to enter Resident 71's eyes and cause an eye infection. During an observation on 4/20/22, at 4:15 p.m., with LVN 1, LVN 1 pushed the medication cart to Resident 428's room. LVN 1 did not perform hand hygiene and prepared Resident 428's medication. During an interview on 4/21/22, at 12:29 p.m., with the Director of Nursing (DON), the DON stated all nurses needed to Gel [hand sanitizer to kill bacteria and viruses] in and gel out when they prepared and administered medication. The DON stated if the hand gel was not easily accessed, the expectation would be for the nurses to wash their hands in the room before and after they prepared and administered the medication. The DON stated her expectation was the nurse to have washed their hands before and after they administered eye drops. During a review of the facility's P&P titled, Administering Medications, dated April 2019, the P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed . 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves .) for the administration of medications, as applicable . Based on observation, interviews, and record review, the facility failed to maintain an effective infection prevention and control program to prevent the development and transmission of communicable disease and infections when: 1. One of five sampled residents' (Resident 68) nasal cannula (device used to deliver oxygen that is placed in a resident's nose) was observed on the floor in Resident 68's room. This failure had the potential to result in transmission of organisms (germs) from the floor, onto the nasal cannula and to Resident 68. 2. Two of four Licensed Nurses (Licensed Vocation Nurse [LVN] 1 and LVN 3) failed to perform hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizer) prior to the administration of medications for three of 11 residents (Residents 69, 71 and 428). This failure had the potential to expose Residents 69, 71, and 428 to communicable diseases. 055955 Page 29 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0880 Findings: Level of Harm - Minimal harm or potential for actual harm 1. During an observation on 4/18/22, at 10:28 a.m., in Resident 68's room, a nasal cannula was attached to an oxygen concentrator (medical device that gives extra oxygen). The nasal cannula was on the floor, next to Resident 68's bed. There was no plastic bag available to store the nasal cannula. Residents Affected - Some During a concurrent observation and interview on 4/18/22, at 10:40 a.m., with LVN 2, in Resident 68's room, LVN 2 stated there should have been a plastic bag on the oxygen concentrator to store the nasal cannula. LVN 2 validated the nasal cannula was on the floor. LVN 2 stated the nasal cannula should be stored in bag to keep it from getting contaminated with germs from the floor. LVN 2 stated the nasal cannula belonged to Resident 68. During a concurrent interview and record review, on 4/20/22, at 10:21 a.m., with the Infection Preventionist (IP), the facility's policy and procedure, titled, Oxygen Concentrator, dated 2022, was reviewed. The IP stated there should be a disposable bag on the oxygen concentrator and the nasal cannula tubing coiled up and stored in the bag. The IP stated the nasal cannula tubing should not be on the floor. The IP stated if the nasal cannula tubing from the floor was placed back on a resident, it could potentially introduce a pathogen (germ) into their nose, mouth or around their face, and there was a potential for infection. During a review of the facility's policy and procedure (P&P) titled, Oxygen Concentrator, dated 2022, the P&P indicated, .4. Use of the concentrator: . l. Keep delivery devices covered in a plastic bag when not in use . During a professional reference review retrieved from https://www.cdc.gov/infectioncontrol/spread/index.html, titled How Infections Spread, dated January 7, 2016, the professional reference indicated, .An infection occurs when germs enter the body, increase in number, and cause a reaction of the body. Three things are necessary for an infection to occur: Source: Places where infectious agents (germs) live (e.g., sinks, surfaces, human skin) Susceptible (vulnerable) Person with a way for germs to enter the body Transmission: a way germs are moved to the susceptible person . Transmission refers to the way germs are moved to the susceptible person . Germs don't move themselves. Germs depend on people, the environment, and/or medical equipment to move in healthcare settings. A Source is an infectious agent or germ and refers to a virus, bacteria, or other microbe. In healthcare settings, germs are found in many places. People are one source of germs including . Germs are also found in the healthcare environment. Examples of environmental sources of germs include: Dry surfaces in patient care areas (e.g., bed rails, medical equipment, countertops, and tables) Wet surfaces, moist environments, and biofilms (e.g., cooling towers, faucets and sinks, and equipment such as ventilators) . 055955 Page 30 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to have an infection prevention and control program that included an antibiotic stewardship program that ensured residents who required antibiotics were prescribed the appropriate antibiotic, when the Infection Preventionist (IP) was unaware one of 21 sampled residents (Resident 67) who tested positive for extended spectrum beta-lactamase (ESBL- enzymes produced by a variety of gram negative bacteria with an increased resistance [not easily killed by] to commonly used antibiotics) and the physician was not notified of the lab results, and the resident was treated with an antibiotic her infection was resistant to. Residents Affected - Many This failure had the potential for Resident 67's infection to not be treated with the appropriate medication and placed Resident 67 at risk to become septic (an infection spread throughout the body) and experience worsening of the infection. Findings: During a concurrent interview and record review, on 4/19/22, at 2:39 p.m., with the IP, the facility's antibiotic stewardship program was reviewed. The IP stated, part of the antibiotic stewardship program was to do daily audits of antibiotics ordered and laboratory tests, track residents on antibiotics, review culture and sensitivity (C&S- a test to determine what antibiotics will destroy the bacteria causing the infection) if it was ordered, and compare the antibiotic ordered to the C&S. The IP reviewed the antibiotic stewardship notebook and stated, Resident 67's information was placed in the notebook in February 2022. The IP validated the notebook indicated Resident 67 had a urinary tract infection (UTI- common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract) from a bacterium that tested positive for ESBL, the C&S was collected, and Resident 67 was put on the antibiotic, ciprofloxacin. During a concurrent interview and record review, on 4/21/22, at 8:41 a.m., with Licensed Vocational Nurse (LVN) 7, Resident 67's electronic and paper charts were reviewed. LVN 7 stated Resident 67 exhibited some symptoms of a UTI on 1/30/22 and had a urine sample sent off to test for infection. LVN 7 stated there was a nurses' note in Resident 67's electronic chart dated 2/1/22 that indicated, Resident 67's Medical Doctor (MD) 1 had been paged regarding Resident 67's lab results and MD 1 called back with orders to start Resident 67 on ciprofloxacin. LVN 7 stated there was a lab report in Resident 67's paper chart that indicated Resident 67, was ESBL positive and the bacteria responsible for her infection was resistant to ciprofloxacin. LVN 7 validated the handwritten note on the lab report indicating MD 1 was not made aware of the C&S until 2/15/22. LVN 7 stated, there was no documentation in Resident 67's electronic chart indicating MD 1 had been notified of the C&S. During an interview on 4/21/22, at 9 a.m., with the Administrator (ADM), the ADM stated he did not know what the process was for notifying the MD of lab results for antibiotic stewardship. During a concurrent interview and record review on 4/21/22, at 9:02 a.m., with the IP, the IP stated he was not aware Resident 67's C&S results because the results were received so late. The IP stated tracking lab reports was part of his job, but he was not responsible for it. The IP stated, Determining the proper antibiotic is not my job to determine but if the bacteria is not sensitive to the antibiotic the resident was on, he would tell the MD. The IP validated Resident 67's bacteria was resistant to ciprofloxacin, and Resident 67 was not given another antibiotic or a repeat urine test to ensure the UTI had been cured. The IP stated the risk in prescribing an antibiotic that a bacteria is resistant to, would be the infection not being treated and turning into septic infection and risk 055955 Page 31 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many for interfacility transmission. The IP stated he was not sure if there was a policy and procedure (P&P) on notifying the MD of lab results and was not sure what the policy was for notifying the MD was, if there was one. The IP found the P&P titled, Culture Tests, revised January 2012, which indicated, IP and the Infection Control Committee (ICC) will review all cultures. The IP stated, he was not currently doing this practice [reviewing cultures] and had not reviewed Resident 67's C&S and was unaware the results came back so late. The IP stated Resident 67 did not have a follow up urine test or have any other antibiotics prescribed after the ciprofloxacin. The IP stated the facility did not follow the facility's P&P. During an interview on 4/21/22, at 9:22 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the nurses were responsible for checking residents' C&S when it came back and making sure the bacteria was sensitive (could be killed by) to the antibiotic the resident was prescribed. The ADON stated, she was on the ICC and the ICC did not review cultures. The ADON stated, she was unsure who was responsible for tracking C&S and making sure the residents were on the correct medication. The ADON stated the risk of not having the resident on the correct antibiotic would be residents becoming septic and dying. During a phone interview on 4/21/22, at 9:43 a.m., with MD 1, MD 1 stated he was very familiar with Resident 67 and did not recall receiving results of Resident 67's C&S. MD 1 stated if he had received Resident 67's C&S results, he would have run a repeat urine test and changed the antibiotic if the resident was still having symptoms. MD 1 stated he was going to order a follow up urine test for Resident 67 immediately. During an interview on 4/21/22, at 11:26 a.m., with the Director of Nursing (DON), the DON stated, she was not involved in antibiotic stewardship. The DON stated the IP brought recommendations during care plan and IDT meetings. The DON stated she believed the P&P made sure the IP was doing his job of tracking and reporting on antibiotics. The DON stated the risk for not being prescribed the correct antibiotic for an infection was that the infection would continue until it was septic and could possibly kill the resident. During a review of the facility's P&P titled, Culture Tests, revised January 2012, the P&P indicated, .Should the Attending Physician order cultures, they shall be obtained and completed as soon as practical. As test results shall be reported to the physician as soon as the results are obtained .Completed culture reports shall be reviewed by the Infection Preventionist and the Infection Control Committee and filed in accordance with established recordkeeping requirements . During a review of the facility's P&P titled, Test Results, revised April 2007, the P&P indicated, .The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results . During a review of the facility's P&P titled, Antibiotic Stewardship, revised December 2016, the P&P indicated, .The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents .When a C&S is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued .Appropriate i indications for use of antibiotics include: .Pathogen susceptibility, based on C&S, to antimicrobial (or therapy begun while culture is pending) .As part of the facility antibiotic Stewardship Program, all clinical infection treated with antibiotics will undergo review by the Infection Preventionist, or designee .The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific 055955 Page 32 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many situation that are not consistent with the appropriate use of antibiotics. Therapy may require further review and possible changes if: 1) The organism is not susceptible to antibiotic chosen .at the conclusion of the review, the provider will be notified of the review findings .The DON will monitor individual resident antibiotic regimens, including: a. Reviewing clinical documentation supporting antibiotic orders .The IP will audit and the DON will provide feedback to providers on antibiotic prescribing practices .The IP will monitor over time and report to the IPCC .Antibiotic susceptibility patterns . 055955 Page 33 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to ensure each resident was offered the influenza (viral infection that attacks the respiratory system - your nose, throat and lungs) vaccine annually, when one of five sampled residents (Resident 64), was last offered the influenza vaccine in 2013, and no further education, offering, or declination (refusal) was obtained. Residents Affected - Few This failure resulted in Resident 64 and/or their responsible parties (a person other than the resident, designated to make health care decisions on behalf of the resident), who had previously refused the vaccine, to not receive education and be offered the vaccine annually. Findings: During an interview on 4/19/22, at 9:03 a.m., with the Infection Preventionist (IP), the IP stated, he had worked at facility since 2017 as a nurse and had been the facility's IP since February 2020. During a review of Resident 64's Influenza Immunization Informed Consent, dated 10/21/13, the Influenza Immunization Informed Consent indicated Resident 64 had not been offered nor declined the influenza vaccination since 2013. Resident 64's electronic medical record (EMR) indicated, no record of vaccination history for COVID-19 (communicable, respiratory disease that can cause severe illness in some people), influenza or pneumococcal (infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus), vaccinations or refusals of the offered vaccines. During a concurrent interview and record review, on 4/20/22, at 9:52 a.m., with the IP, Resident 64's Influenza Immunization Informed Consents were reviewed. The IP stated, if a resident had a declination of the immunization on file, the declination was valid for the entire time of the resident's stay. The IP stated if a resident's mental status changed and the resident required a responsible party to make decisions, the RP would be offered the education and decide if the resident should receive the vaccine and the consent would be updated. The IP stated Resident 64 was not her own responsible party. The IP searched Resident 64's charts and stated there was no additional information documented for Resident 64's influenza refusal since 2013. During a review of the facility's policy and procedure titled, Influenza Vaccine, dated October 2019, the policy and procedure indicated, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza .6. A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record . 055955 Page 34 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0888 Ensure staff are vaccinated for COVID-19 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 implement and ensure their policy and procedure (P&P) titled, Mandatory COVID-19 (communicable, respiratory disease that can cause severe illness in some people) Employee Vaccination Policy was followed, when the facility did not follow their process for granting non-medical exemptions, four of 19 staff members were inaccurately documented as having a non-medical exemption, and one nursing student was marked as having a non-medical exemption, without documentation of the exemption. Residents Affected - Some This failure resulted in 93.8% (percent- unit of measurement) of staff being vaccinated for COVID-19, which placed residents at risk of being exposed and contracting COVID-19 from staff. Findings: During a concurrent interview and record review, on [DATE], at 9:44 a.m., with the Infection Preventionist (IP), the facility's COVID-19 staff Vaccination Status for Providers, updated [DATE], and proof of employee granted exemptions, were reviewed. The IP stated the facility accepted both Request for a Religious Exemption to the COVID-19 Vaccination Requirement and Declination of COVID-19 Vaccination forms for vaccine exemptions. The IP stated there were five Request for a Religious Exemption to the COVID-19 Vaccination Requirement on file, but only one of the five staff members had answered the three questions on the exemption request form. The IP stated the facility had not required staff to answer the questions on the form because of employee rights, and the facility had no process of validating an employees' religious exemption request. During a concurrent interview and record review, on [DATE], at 10:13 a.m., with the IP, the facility's P&P titled Mandatory COVID-19 Employee Vaccination Policy, dated [DATE], was reviewed. The IP validated the P&P indicated employees needed to submit a Religious Accommodate Request Form and describe the basis for their religious belief to be eligible for a religious belief exemption. The IP stated the facility was not following the P&P. During a concurrent interview and record review, on [DATE], at 3:16 p.m., with the IP, the facility's staff immunization tracker titled, COVID-19 staff Vaccination Status for Providers, updated [DATE], and proof of employee granted exemptions, were reviewed. The IP validated there were 17 employees with granted (approved) non-medical exemptions (GN) and two employees with pending non-medical exemption (PN) on the tracker. The IP stated Housekeeping (HK) 1 received her first COVID-19 vaccination on [DATE], but was listed as GN. HK 1 had filled out a Request for a Religious Exception to the COVID-19 Vaccination Requirement, did not answer the questions, but wrote in at the bottom of the form, I haven't gotten it done yet but I'm planning on getting it soon. But it's against my religious reasons. HK 1's COVID-19 vaccination card was reviewed, the card indicated HK 1 received her fist dose of [name of COVID-19 vaccine] on [DATE]. The IP indicated he had not updated the vaccination tracker yet. The IP stated Medical Record Assistant (MRA) 1 was also listed as GN but had a temporary delay with a medical note and no Declination or Exemption request filed. The IP stated he should have marked MRA 1 as having a temporary delay on the tracker. The IP validated there were ten other staff members marked as GN who only had a vaccination declination on file. The IP stated four of the five Request for a Religious Exception to the COVID-19 Requirement forms submitted did not have the questions answered for religious exception. The IP stated, Nursing Student (NS) 1 had not been into the facility yet and he had no documentation for her vaccine or exemption but had put her on the tracker as GN while he waited for the information. The IP stated, he had no paperwork for the two staff listed 055955 Page 35 of 36 055955 04/22/2022 California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727

F 0888 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as PN. The IP stated the information on the tracker was incorrect. The IP stated he did not know who granted the exemptions or what the process was to determine if the exemptions were granted or not. During an interview on [DATE], at 11:47 a.m., with the Director of Nursing (DON), the DON stated she did not know what the process was for COVID-19 vaccination exemptions at the facility. The DON stated staff vaccination status should be maintained accurately. During a review of the facility's form titled, Request for a Religious Exception to the COVID-19 Vaccination Requirement, [undated], the form indicated, .All requests for a religious exception will be evaluated on an individual bases .Questions: 1. Please describe the nature of your objection to the COVID-19 vaccination requirement. 2. Would complying with the COVID-19 vaccination requirement substantially burden your religious exercise or conflict with your sincerely held religious beliefs, practices, or observances? If so, please explain how. 3. Please provide an additional information that you think may be helpful in reviewing your request. For example: How long you have held the religious belief underlying your objection; Whether your religious objection is to the use of all vaccines, COVID-19 vaccines, a specific type of COVID-19 vaccine or some other subset of vaccines; Whether you have received vaccines as an adult against any other diseases (such as a flu vaccine or a tetanus vaccine) . During a review of the facility's P&P titled Mandatory COVID-19 Employee Vaccination Policy, dated [DATE], the P&P indicted, .The policy is intended to safeguard the health of our employees and their families; our clients and visitors; and the community at large from COVID-19 .All staff are to be fully vaccinated or submit a valid exemption no later than [DATE] .Before the stated deadlines to be vaccinated have expired, employees will be required to provide either proof of vaccination or an approved reasonable accommodation to be exempted from the requirements .To be eligible for a Religious Beliefs exemption, the employee must submit a Religious Accommodate Request Form, signed by the employee, describing the basis for their religious belief. Additional documentation or evidence may be required .Employees who do not qualify for an exemption who nonetheless refuse get a vaccination will be separated from employment at [facility name] .If the worker is exempt, [facility name] must maintain all exemption forms . 055955 Page 36 of 36