Health inspection·November 17, 2022

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for one of two sampled residents (Resident 2), the facility failed to provide devices to ensure Resident 2's activities of daily living (ADL) did not diminish when Resident 2 was not provided with an assistive device to stay upright during meals. Residents Affected - Few This failure resulted in Resident 2's inability to feed self independently and had the potential to result in decreased oral intake. Findings: Review of Resident 2's Face Sheet indicated Resident 2 had been known to the facility since 1/20/21 with diagnoses that included acute transverse demyelinating disease (inflammation of both sides of the spinal cord) of the central nervous system, spinal stenosis (narrowing of the spinal canal which then puts pressure on the spinal cord) of the cervical (neck) region, and need for assistance with personal care. Review of Resident 2's comprehensive Minimum Data Set (assessment tool used to direct resident care) assessment dated [DATE] indicated Resident 2 required staff supervision for set up help with meals (if a resident is provided with devices necessary to perform the ADL independently) and extensive staff assist for bed mobility (staff providing weight-bearing support; bed mobility is how one positions body while in bed). Review of Resident 2's bed mobility care plan effective 4/16/21 indicated to use pillows and foam wedges to maintain position while in bed. During an observation on 11/14/22 at 10:04 a.m., Resident 2 was eating breakfast while in bed. Resident 2 leaned to the right side, completely pinning the right hand under the right shoulder. There was one small pillow on the right side of the bed and no foam wedges. Resident 2's breakfast tray was on the over-bed table and placed higher than Resident 2's eye level. A small pillow was on the right side of the bed. Resident 2 attempted to pick up a cup of tea from the tray with the left hand but struggled and spilled the tea all over the tray. Resident 2 stated not knowing why the staff would not help her. There was no staff present in the room. During an interview with Certified Nurse Assistant (CNA) 2 on 11/14/22 at 10:25 a.m., CNA 2 stated the tray was set up and checked on Resident 2 once in a while. CNA 2 also stated, Resident 2 had the tendency to lean towards the right side and a pillow was placed to prevent that. Page 1 of 9 056096 056096 11/17/2022 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0676 Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Rehabilitation (DOR) on 11/16/22 at 2:27 p.m., DOR stated while Resident 2 is in bed, the most important thing was correct positioning, with support on both sides to maintain an upright position, and position the over-bed table at the right height where Resident 2 could see the tray. DOR also stated Resident 2 would be re-evaluated to see if a wedge would be ordered and staff training would be provided. Residents Affected - Few 056096 Page 2 of 9 056096 11/17/2022 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, for one of five (Resident 259) sampled residents reviewed for unnecessary medications, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan when the physician was not notified as ordered when Resident 259's blood sugar level exceeded 400 milligrams per deciliter (mg/dL). Residents Affected - Some This failure increased the risk for Resident 259 of developing complications related to severely elevated blood glucose levels, like diabetic ketoacidosis (life-threatening complication of diabetes when the build-up of acids in the body occurs when the blood sugar is too high for too long) or coma. Findings: Review of Resident 259's Face Sheet indicated Resident 259 was admitted to the facility with diagnoses that included diabetes mellitus with hyperglycemia (condition of uncontrolled, elevated blood glucose levels). Review of Resident 259's Physician's Orders dated 7/2/22 indicated to administer insulin (treats diabetes) lispro per sliding scale ( insulin dosage varies based on blood glucose level) before every meal and to notify the physician if the blood glucose was higher than 400 mg/dL. Review of Resident 259's undated, insulin use care plan indicated staff were to monitor the blood sugar as ordered by provider and to report to the physician signs of hyperglycemia (high blood sugar). During an interview and concurrent review of Resident 2's clinical records with the Director of Nursing (DON), on 11/16/22 at 9:03 a.m., DON stated, Resident 259 was sent to the hospital on 8/27/22 for hyperglycemia and fainting and returned to the facility with instructions to adjust the insulin dose. Further record review with DON of the physician order dated 9/7/22 indicated an order for admelog (treats diabetes) insulin lispro per sliding scale and to notify physician if blood sugar level was more than 400 mg/dL. DON stated, on 9/7/22 and 9/8/22, Resident 259's clinical record indicated physician was notified of the blood sugar result higher than 400 mg/dL and extra insulin was administered. DON stated in October 2022, Resident 259's clinical record indicated staff had notified the physician of Resident 259's high blood sugar level two times on 10/1/22 and 10/26/22. Review of Resident 259's Medication Administration Record (MAR) for October 2022 indicated Resident 259's blood sugar exceeded 400 mg/dL 28 times. MAR for November 2022 indicated Resident 259's blood sugar level exceeded 400 mg/dL 18 times. DON stated the clinical record indicated the physician notification occurred four times on 11/1/22, 11/5/22, 11/13/22 and 11/15/22. Further review of Resident 259's MAR for November 2022 indicated the following; - 11/10/22, Resident 259's blood sugar reading was 481 mg/dL at 6:30 a.m The clinical record did not indicate the physician was notified, until a few hours later at 11:30 a.m. On the same day, Resident 259's blood sugar remained elevated at 485 mg/dL. - 11/12/22, Resident 259's blood sugar reading was 463 mg/dL at 6:30 a.m., and at 11:30 a.m., the blood sugar reading was 590 mg/dL. 056096 Page 3 of 9 056096 11/17/2022 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0684 Level of Harm - Minimal harm or potential for actual harm - On 11/14/22, Resident 259's blood sugar reading was 560 mg/dL at 6:30 a.m., later at 11:30 a.m., Resident 259's blood sugar was 581 mg/dL. On the above dates, the clinical record did not reflect the physician was notified by licensed staff about the high blood sugar levels as ordered. Residents Affected - Some 056096 Page 4 of 9 056096 11/17/2022 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interviews and record review, the facility failed to ensure the Consultant Pharmacist's (CP) monthly Medication Regimen Review (MRR) reported a medication irregularity for two (Residents 18 and 27) sampled residents. For Resident 18, CP did not address the duration for the administration of Macrobid (antibiotic medication) for the prevention of Urinary Tract Infection (UTI). For Resident 27, the duration of Keflex (antibiotic) for UTI was not identiied for more than one year. These deficient practices had the potential for residents to receive unnecessary drugs and future antibiotic resistant infections due to prolong use Findings: Review of the physician order dated 8/16/22 indicated Resident 18 was to receive Macrobid 100 mg (milligram) capsule every morning for UTI prophylaxis, indefinite. Review of Resident 18's Medication Administration Record (MAR) for October 1 through November 16, 2022, indicated Resident 18 was administered Macrobid 100 mg capsule by mouth every morning as ordered by the physician. During an interview on 11/17/22 at 8:08 a.m., the Director of Nursing (DON) stated she had not received CP's recommendations for Resident 18's use of Macrobid for the prevention of UTI indefinite. During an interview on 11/17/22 at 9:17a.m., CP stated she did not address the duration for Resident 18's administration of Macrobid 100 mg capsule every morning for the prevention of UTI, or report any irregularities to DON and Resident 18's physician. Review of the Nitrofurantoin (Macrobid) literature, revised April 2022, indicated using antibiotics when it is not needed can cause it to not work for future infections. According to the pharmacy professional reference resource, Lexicomp for Macrobid indicated the optimal duration has not been established; duration ranges from 3 to 12 months, with periodic reassessment (Ref). Prolonged use (>6 months) of Macrobid has been associated with diffuse interstitial pneumonitis (inflammation of the lining of the lung) and/or pulmonary fibrosis, chronic hepatitis (liver inflammation), and the development of neuropathy (nerve pain). The facility's policy and procedure titled, Consultant Pharmacist Services Provider Requirement dated 10/07, indicated, The consultant pharmacist, or designee, provides pharmaceutical care services including Medication Regimen Reviews (MRR) for each resident at least monthly, or more frequently under certain conditions, incorporating the federally mandated standards of care in addition to other applicable professional standards. During a review of Resident 27's active physician orders for November 2022, indicated an order start date of 06/28/21 for Keflex (antibiotic), indicated for UTI prophylaxis (action taken to prevent disease). During an interview on 11/17/ 22, at 10:00 a.m., CP stated, she did not send monthly recommendations for Resident 27's prophylactic antibiotic use to the physician. CP acknowledged no recommendation 056096 Page 5 of 9 056096 11/17/2022 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to verify the duration of Resident 27's Keflex and that long-term antibiotic usage should be evaluated every six months. CP also stated the risk of long-term antibiotic usage for Resident 27 was to have another form of infection. During an interview on 11/17/22, at 11:07 a.m., DON stated, the facility should have verified with the physician the duration of Resident 27's Keflex because the resident has been on the antibiotic since last year. DON further stated the risk of long-term antibiotic usage could result in another form of infection that is resistant to antibiotics. During a review of Resident 27's laboratory tests indicated Resident 27's urinalysis (test to also detect urine infection) was last done on 7/12/21. During a review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Services Provider Requirements, dated 10/07 indicated to, Communicate to the responsible prescriber and the director of nursing potential or actual problems detected and other findings related to medication therapy orders at least monthly. Communicate recommendations for changes in medication therapy and the monitoring of medication therapy. 056096 Page 6 of 9 056096 11/17/2022 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

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, interviews, and record review, the facility failed to follow proper sanitation and food storage practices when: Residents Affected - Some - The High temperature dishwasher was not within the required temperature range - Kitchen floor tiles had brownish residual discoloration, - Two food steamers had brownish food debris on the bottom shelf and around the steamer areas - Bowl of lettuce, bowl of tomatoes in refrigerator were not labeled or dated - Two opened milk cartons in the walk in refrigerator were not label or dated - Bowl of sliced ham in the refrigerator had use by date 11/10/22 -Two food mixers had brownish discoloration and debris around the edges - Plate covers were faded and discolored - Three compartment sink air gap drain area had yellow residue - Ice machine cover had debris and crumbs - Ice machine air-gap drain area with yellowish residual - [NAME] trays with thick blackish brown crusts around the edges - Double door panel to the kitchen/dumpster area with black discoloration on the surface These deficient practices had the potential to result in foodborne illness. Findings: During the initial tour of the kitchen on 11/14/22 at 9:15 a.m., accompanied by the Chef (CF1) and Registered Dietician (RD), the following were observed: High temperature dishwasher was not within the required temperature range, Kitchen floor tiles had brownish residual discoloration, two food steamers with brownish food debris on bottom shelve and around the steamer areas Bowl of lettuce , bowl of tomatoes in refrigerator not label or dated, two opened Milk cartons in walk in refrigerator not label or dated, bowl of sliced ham in refrigerator with use by date 11/10/22, two food mixer with brownish discoloration and debris around the edges, plate covers with faded discolored appearance, 3 compartment sink air gap drain area with yellowish residual, Ice machine air-gap drain area with yellowish residual. Ice machine cover with debris and crumbs, cooking trays with thick blackish brown crusts around the edges, double door panel to the kitchen/dumpster area with blackish discoloration on the surface. During an observation on 11/14/22 at 10:49 a.m., in the presence of CF1 and RD, the high 056096 Page 7 of 9 056096 11/17/2022 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some temperature dishwasher was operated to wash dishes. The final rinse temperature was at 60 degrees Fahrenheit (F). RD operated the dishwasher three times and the final rinse temperature gauge was at 60 (degrees F). During an interview on 11/14/22 at 10:54 a.m., RD stated the dishwasher had to be run three times for the temperature to be at the required range. RD operated the dishwasher several times and the final rinse temperature gauge was at 60 degrees F. During an interview on 11/15/22 at 8:56 a.m., RD stated a work order was placed for the contractor to visit and check the dishwasher temperature gauge for proper functioning. During an interview on 11/15/22 at 11:55 a.m., the Executive Chef (EC) stated he was aware the dishwasher temperature gauges was not at the required range when the heat booster was not operated at the same time. EC stated the dietary staff needs to use the heat booster when operating the dishwasher for the temperature to reach the required final rinse temperature. EC further stated the staff assigned to clean and sanitize the dishwasher and floor were out on family leave vacation. EC said staff needed to be trained to start the heat booster with the dishwasher. The Dishwasher Installation & Operation Manual indicated the Final rinse temperature and flow pressure gauges are accurate only when a rack enters the final rinse area and water is flowing. Acceptable temperature range is 180 - 195 degrees Fahrenheit and pressure should be 20 psi (pounds per square inch). The facility's policy and procedure titled, Sanitation and Infection Prevention Control, revised 1/21' reflected, Assigns daily cleaning responsibilities in each position workflow. 056096 Page 8 of 9 056096 11/17/2022 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

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 ensure appropriate use of antibiotic (medication for infection) for one of five residents reviewed (Resident 27) when they did not monitor appropriate use and improved outcomes. Residents Affected - Few This failure had the potential for Resident 27 to take unnecessary antibiotics which could lead to antibiotic resistance. Findings: During a concurrent interview and record review, on 11/16/22 at 10:43 a.m., with the Infection Preventionist (IP), Resident 27's Physician Order Sheet (POS), dated November 2022 was reviewed. The POS indicated an order start date of 06/28/21, for Keflex (an antibiotic), indicated for urinary tract infection (UTI) prophylaxis (action taken to prevent disease). IP stated, there was no documentation on the POS dated November 2022 that indicated Resident 27's Keflex had a stop date. During an interview and concurrent record review, on 11/16/22 at 10:43 a.m., IP stated she could only find documentation that their antibiotic stewardship for Resident 27 was done in February, May and November of 2022. IP stated she could not find the antibiotic stewardship documentation that was done for Resident 27 on the other months of 2022. During a review of Resident 27's laboratory tests indicated Resident 27's urinalysis (test that can also detect urine infection or evaluate antibiotic effectiveness), was last done on 7/12/21. During an interview on 11/17/22, at 11:07 a.m., with the Director of Nursing (DON), DON stated, the facility should have followed up about the stop date for Resident 27's Keflex because the resident has been on the antibiotic since last year. DON stated the risk of long-term antibiotic usage is for Resident 27 to acquire another form of infection that is resistant to antibiotics. Review of the facility's policy and procedure titled, Antibiotic Stewardship, revised December 2016 indicated, If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the . duration of treatment: stop and start date or number of days of therapy . 056096 Page 9 of 9