Health inspection·November 17, 2023

F 0583 Keep residents' personal and medical records private and confidential. 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, the facility failed to maintain the resident's right to privacy and confidentiality of personal and medical records for two residents out of a census of 83 residents when computer screens showed a resident's photo and confidential personal and medical information were left unsecured. Residents Affected - Few These failures had the potential to result in unauthorized access of residents' personal and medical information. Findings: 1. During an observation on 11/14/23, at 7:41 a.m., the computer screen on medication cart 2, located in River Road hallway, had a picture of a resident, resident's name, and a list of the resident's medications displayed. Medication cart 2 was left unattended with the computer screen facing towards the hall. During an interview on 11/14/23, at 7:47 a.m., with Licensed Nurse 3 (LN 3), LN 3 confirmed the computer screen on medication cart 2 displayed personal resident information and was accessible [to anyone walking down the hall]. LN 3 stated she should have closed the computer screen when she walked away from the medication cart. During an interview on 11/14/23, at 8:46 a.m., with the Assistant Director of Nursing (ADON), the ADON indicated it was not acceptable to leave the medication cart unattended with personal resident information displayed .the expectation was for staff to turn off the computer screen or have the privacy screen on when they walked away from the cart to prevent unauthorized viewing. 2. During an observation on 11/15/23 at 3:40 p.m. at Station 1&2, in front of room [ROOM NUMBER] and room [ROOM NUMBER], a computer attached to medication cart 2 with screen showing a resident's photo, complete name, medical record number, current room and bed number, gender, date of birth , age, attending physician, and other pertinent personal and medical information was left unattended facing the hallway. Two residents and two facility staff were observed passing by the medication cart. During a concurrent observation and interview on 11/15/23 at 3:45 p.m. with LN 9 at Station 1&2, in front of room [ROOM NUMBER] and room [ROOM NUMBER], LN 9 was observed going back to the medication cart 2 and started working on the computer. LN 9 confirmed the observation that the computer attached to medication cart 2 with screen showing a resident's photo and pertinent personal and medical information was left unattended and was facing the hallway. LN 9 stated he should have closed the computer screen before moving away. LN 9 further stated, .It's [leaving resident's personal and medical Page 1 of 35 056243 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few records unattended] a HIPAA (Health Insurance Portability and Accountability Act- a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed) violation .the personal information of the residents should not be accessible to unauthorized staff or other residents. During an interview on 11/16/23 at 9:17 a.m. with the ADON, the ADON stated she expects staff to protect and keep residents' information private. The ADON further started, Residents personal and medical information should remain private per HIPAA .If the nurse is away, the records [personal and medical records] should not be seen by other residents or other unauthorized staff .the computer screen should be closed or should be in privacy mode. A review of the facility's policy and procedure (P&P) titled, Protected Health Information (PHI), Management and protection, revised 4/2022, indicated, 1. It is the responsibility of personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure. A review of the facility's P&P titled, Administering Medications, revised 4/2021, indicated, .Access to resident personal and medical records will be limited to authorized staff. 056243 Page 2 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 15 was admitted to the facility June 2023 with diagnoses which included chronic pulmonary disease (group of diseases that cause airflow blockage and breathing problems), high blood pressure (force of blood flowing through blood vessels is consistently too high) and shortness of breath. A review of Resident 15's most recent MDS indicated Resident 15's BIMS (a brief interview for mental status) was 15, indicating Resident 15 was cognitively intact. During a review of Resident 15's MDS, dated [DATE], indicated Resident 15 was a smoker. During a concurrent interview and record review on 11/16/23, at 1:30 p.m., the ADON confirmed there was no smoking care plan for Resident 15. The ADON stated there should be a care plan based on the smoking assessment. The ADON stated, I will be honest there is no smoking care plan for this resident and there should be one. During a review of the facility's policy and procedure (P&P) titled, Care Planning - Interdisciplinary Team, revised 1/11, the P&P indicated, 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment .2. The care plan is based on the resident's comprehensive assessment . 2. Resident 60 was admitted to the facility November 2023 with multiple diagnoses which included end stage renal disease (late stage of long-term kidney disease) and dependence on renal dialysis. A review of Resident 60's Minimum Data Set (MDS, an assessment tool) dated 11/8/23, indicated, Resident 60 was receiving dialysis while a resident. During an interview on 11/14/23, at 8:51 a.m., with LN 1, LN 1 stated Resident 60 left the facility for dialysis treatment three times a week. During a concurrent interview and record review on 11/15/23, at 2:59 p.m., with the ADON, the ADON stated Resident 60 was admitted to the facility receiving dialysis treatment. A review of Resident 60's clinical records with the ADON, the ADON confirmed there was no care plan for Resident 60's dialysis treatments. The ADON stated the resident should have been care planned for dialysis and it was the responsibility of the Supervisor to create the care plan on admission. The ADON stated, care plans are not where we want them to be, we are working on them. Based on interview and record review, the facility failed to develop and implement comprehensive care plans for three out of 19 sampled residents (Resident 73, Resident 60, and Resident 15), when: 1. No care plan was developed or implemented for Resident 73's peripherally inserted central catheter (PICC) line (a tube inserted into a vein in the arm to access large veins near the heart for medications, liquid nutrition, and drawing blood); 2. No care plan was developed or implemented for Resident 60's renal dialysis (treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to); and 3. No smoking care plan was developed for Resident 15. 056243 Page 3 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few These failures had the potential to result in residents not attaining their highest practicable physical, mental, and psychosocial well-being. Findings: 1. During a review of Resident 73's medical record, the record indicated Resident 73 was admitted in the Fall of 2023 with diagnoses that included severe sepsis (the body's extreme response to infection), open wound on right hip, idiopathic aseptic necrosis (death of bone tissue due to a lack of blood supply) of right femur, infection, and inflammatory reaction due to right hip prosthesis (an artificial body part), cellulitis (deep infection of the skin caused by bacteria) of right lower limb, and chronic osteomyelitis (bone infection). During a review of facility record titled, PICC Insertion Record, dated 10/13/23, the record indicated Resident 73's PICC line was inserted on 10/13/23. During a concurrent interview and record review on 11/15/23 at 11:59 a.m., with Licensed Nurse (LN 7), LN 7 confirmed there was no care plan regarding PICC Line. LN 7 stated, I'm not sure if we should have a care plan for that. That would be a question for the ADON (Assistant Director of Nursing) .care plan is a guide to anyone providing care and it lists your nursing diagnoses and interventions and goals. During a concurrent interview and record review on 11/15/23 at 12:02 p.m., with the ADON, the ADON stated, I don't see a PICC line care plan, we should have a care plan for that. There should be one in. There are IV medication orders and PICC line monitoring but there was no care plan, we will improve on that. 056243 Page 4 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain an acceptable parameter of nutritional status when one out of 19 sampled residents (Resident 90) lost 11.1% of his body weight over an 18-day period. Residents Affected - Few This failure placed Resident 90 at risk for potential muscle loss, increasing his susceptibility to infection and delayed wound healing. Findings: Resident 90 was admitted to the facility October 2023 with multiple diagnoses which included pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (near base of the spine), pressure ulcer of right heel, and dysphagia (difficulty swallowing). During a review of Resident 90's Weights and Vitals Summary, between 10/25/2023 and 11/12/2023, the Weights and Vitals Summary indicated, Resident 90 weighed 153 pounds (a measure of weight) on 10/25/2023 and 136 pounds on 11/12/2023. This loss of 17 pounds was 11.1% of his body weight over an 18-day timespan. During an interview on 11/15/23, at 10:11 a.m., with the Registered Dietician (RD), RD stated she would implement interventions for a resident who has had a five pound or greater weight change. The RD confirmed she was aware of Resident 90's 17 pound weight loss and stated no interventions for his weight loss had been put in place. The RD stated she does not know if the physician had been notified. During an interview on 11/15/23, at 10:36 a.m., with Licensed Nurse 5 (LN 5), LN 5 stated there were no weight monitoring orders for Resident 90. During an interview on 11/15/23, at 11:46 a.m., with Restorative Nursing Assistant 1 (RNA 1), RNA 1 stated it was the RNAs' responsibility to weigh residents monthly or as ordered. RNA 1 stated the resident would be weighed twice to ensure accuracy and notify nursing staff of weight changes of five pounds or greater. During an interview on 11/15/23, at 11:54 a.m., with LN 1, LN 1 stated the expectation was for nurses to notify the physician for weight changes of five pounds or greater and to document when the physician was notified. During a concurrent interview and record review on 11/15/23, at 12:17 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that the expectation was for the RD to notify the physician of weight changes of five pounds or greater and for the nursing staff to notify the physician of a change of condition including weight loss. A review of Resident 90's Progress Notes, with the ADON, the ADON confirmed there was no documentation showing the physician was notified of Resident 90's significant weight loss and there were no orders for addressing weight loss. The ADON stated, physician should have been notified. The ADON acknowledged not notifying the physician had put Resident 90 at risk for malnutrition and continued weight loss. During a review of Resident 90's care plan, dated on 11/2/23, indicated, Monitor for .change in 056243 Page 5 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few condition which may contribute to risk of malnutrition, notify physician .monitor for signs of malnutrition .and notify physician if observed. During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, revised May 2023, the P&P indicated, .notify the resident's Attending Physician/physician on call .when there has been a .significant change in the resident's physical/emotional/mental condition . During a review of the facility's P&P titled, Weight Assessment and Intervention, reviewed 2023, the P&P indicated, 1 month - 5% weight loss is significant .Physician/nurse practitioner/physician assistant and the multidisciplinary team will identify conditions or medications that may be causing .weight loss or increasing the risk of weight loss. 056243 Page 6 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

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 ensure proper storage, handling, and labeling of respiratory care equipment consistent with the facility's policy and procedures (P&P) for three out of 19 sampled residents when: Residents Affected - Some 1. Resident 294's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was left wrapped around Resident 294's bed rail while not being used and was not labeled with the date it was first used; 2. Resident 47's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mouthpiece and tubing was left on top of the nebulizer machine after use and was not labeled with the date it was initially used; 3. Resident 15's nasal cannula was not placed in an infection control pouch and observed touching the floor when oxygen was not in use. These failures had the potential to result in unsafe and unsanitary delivery of oxygen to Resident 294 and Resident 15, and aerosol medication to Resident 47. Findings: 1. A review of Resident 294's clinical record indicated Resident 294 was admitted Spring of 2023 and had diagnoses that included congestive heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of your body) and shortness of breath. A review of Resident 294's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 9/22/23, indicated Resident 294 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 294 had intact cognition. A review of Resident 294's MDS Health Conditions, dated 9/22/23, indicated Resident 294 had shortness of breath or trouble breathing with exertion such as walking, bathing, and transferring, and when lying flat. A review of Resident 294's MDS Special Treatments, Procedures, and Programs, dated 9/22/23, indicated Resident 294 had oxygen therapy while she is a resident in the facility. During a concurrent observation and interview on 11/13/23 at 8:50 a.m. with Resident 294 in Resident 294's room, Resident 294's nasal cannula was observed wrapped around the bed rail of Resident 294's bed while not being used. Resident 294's nasal cannula was also not labeled with the date of when it was first used. Resident 294 confirmed the observation. Resident 294 stated the last time she used her oxygen and nasal cannula was last night and she could not remember when the last time it was changed. During a concurrent observation and interview on 11/13/23 at 8:54 a.m. with Certified Nurse Assistant (CNA) 2 in Resident 294's room, CNA 2 confirmed that Resident 294's nasal cannula was left wrapped around Resident 294's bed rails while not in use and was not labeled with the date it was first used. CNA 2 stated the nasal cannula should be put inside a bag when not being used. CNA 2 further stated, .It [nasal cannula] should be labeled with the date it was first used because its only good for a certain amount of time .If it's not labeled, then we don't know how long it has been used or when to change it It's a risk for contamination and spread of infection. A review of Resident 294's active physicians' order, dated 10/12/22, indicated, O2 [oxygen] @ [at] 056243 Page 7 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0695 Level of Harm - Minimal harm or potential for actual harm 2L/min [2 liters per minute- unit of measurement for oxygen administration] via NC [nasal cannula] PRN [Pro Re Nata- as needed] for SOB [shortness of breath] every shift. A review of Resident 294's active physicians' order, dated 1/16/23, indicated, Change Nasal Cannula. every day shift every Wed [Wednesday] AND as needed. Residents Affected - Some During an interview on 11/16/23 at 9:17 a.m., with the Assistant Director of Nursing (ADON), the ADON stated oxygen tubing and nasal cannula should always be placed inside a bag when not being used and should always be dated of when it was first used. The ADON further stated, .the risk [if nasal cannula is not properly stored and labeled] are infection control issues .we will not be able to track how long has it been used and when to change it .the nasal cannula will be exposed to germs which could lead to respiratory problems . A review of the facility's P&P titled, Respiratory Therapy including Oxygen Labeling, revised 11/2021, indicated, .Infection Control Considerations Related to Oxygen Administration .3. Change the oxygen cannula and tubing every seven (7) days, or as needed. 4. Keep the oxygen cannula and tubing used PRN in infection control pouches when not in use . 2. A review of Resident 47's clinical record indicated Resident 47 was admitted Winter of 2023 and had diagnoses that included congestive heart failure, chronic obstructive pulmonary disease (a group of diseases that causes airflow blockage and breathing-related problems), and atelectasis (the collapse of a part or of all part of a lung causing blockage of airflow). A review of Resident 47's MDS Cognitive Patterns, dated 9/5/23, indicated Resident 47 had a BIMS score of 15 out of 15 which indicated Resident 47 had intact cognition. A review of Resident 47's MDS Health Conditions, dated 9/22/23, indicated Resident 294 had shortness of breath or trouble breathing when lying flat. During a concurrent observation and interview on 11/13/23 at 9:29 a.m., with Resident 47 in Resident 47's room, Resident 47's nebulizer mouthpiece and tubing was observed left on top of the nebulizer machine which was placed on top of Resident 47's nightstand. Resident 47's nebulizer mouthpiece and tubing were also observed not labeled with the date it was initially used. Resident 47 confirmed the observation. Resident 47 stated he used the nebulizer yesterday and he does not think they had been putting it inside a bag after use. Resident 47 further stated, .I've been using it for at least 2 months, and I don't think they ever changed it . During a concurrent observation and interview on 11/13/23 at 9:33 a.m., with Licensed Nurse (LN) 6 in Resident 47's room, LN 6 confirmed that Resident 47's nebulizer mouthpiece and tubing was left on top of the nebulizer machine after use and was not labeled with the date it was initially used. LN 6 stated the nebulizer mouthpiece and tubing should be placed in an antimicrobial bag after use and should be labeled with the date it was initially used. LN 6 further stated, the risk [if the nebulizer mouthpiece and tubing was not stored and labeled properly] is that it can get confused with other residents tubing .It's a risk for growing of bacteria, cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), and we would not know when it was first used and when to change it . A review of Resident 47's active physicians' order, dated 10/24/23, indicated, Albuterol Sulfate Inhalation Nebulization Solution [a liquid medicine used to prevent and treat difficulty breathing, shortness of breath, coughing, and chest tightness caused by lung diseases which is administered via nebulizer] (2.5 MG [milligrams- unit of measurement/3ML [milliliters- unit of measurement]) .3 ml inhale orally via nebulizer every 8 hours as needed for SOB [shortness of breath] and wheezing [a 056243 Page 8 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0695 high-pitched whistling sound during breathing indicative of airway obstruction] . Level of Harm - Minimal harm or potential for actual harm During an interview on 11/16/23 at 9:17 a.m., with the ADON, the ADON stated she expects nebulizer mouthpiece and tubing to be also treated like the other respiratory care equipment. The ADON further stated, .I expect it [nebulizer mouthpiece and tubing] to be clean, as clean as possible .it should also be bagged after use to prevent exposure to germs and be labelled with the date it was first used so we know when to change it .if not, it could lead to complications and possible respiratory problems . Residents Affected - Some A review of the facility's P&P titled, Respiratory Therapy including Oxygen Labeling, revised 11/2021, indicated, .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 1. Mouthpiece to be stored in infection control pouch when not in use. 2. Discard the administration set-up every seven (7) days. 3. During a review of Resident 15's clinical record, the record indicated Resident 15 was admitted to the facility in June of 2023 with multiple diagnoses which included chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), anxiety disorder (significant and uncontrollable feelings of anxiety and fear), post-traumatic stress disorder (difficulty recovering after experiencing or witnessing a terrifying event), and shortness of breath. A BIMS, dated 10/18/23 indicated, Resident 15 was cognitively intact. During a review of Resident 15's physician order, dated 7/20/23, the order indicated, Oxygen @ [at] 2-4 liters/min [minute] via nasal cannula for respiratory comfort . During an observation on 11/13/23 at 10:45 a.m., in Resident 15's room, oxygen was observed turned on while not in use, set to 2 liters per minute, and the nasal cannula tubing was observed touching the floor. During a concurrent observation and interview on 11/13/23 at 11:05 a.m., with LN 6, LN 6 stated Resident 15 uses oxygen as needed. LN 6 confirmed that oxygen was turned on and the nasal canula tubing was on the floor. LN 6 was observed asking Resident 15 if the oxygen was needed and Resident 15 said no. LN 6 was observed turning off the oxygen and placing the nasal canula in the black pouch. LN 6 stated, It should not touch the floor, germs and bacteria on the floor are introduced to his nose and cause illness, if it touched the floor, we need to change it. During an interview on 11/14/23 at 10:25 a.m., with the Infection Preventionist (IP), the IP stated, Nasal cannula should be placed in black pouch when not in use. When asked about the cannula touching the floor, the IP stated, Change it immediately and label it with date. It can cause respiratory infection, hypoxia. During an interview on 11/15/23 at 1:12 p.m., with the ADON, when asked about the expectation on the nasal cannula touching the floor, the ADON stated, We are going to change it right away. Supposed to be in the bag and the oxygen turned off. That's very germy. It might touch the floor if not in the pouch. During a review of the facility's P&P titled, Respiratory Therapy including Oxygen Labeling, dated 11/21, the P&P indicated, Infection Control Considerations Related to Oxygen Administration .4. Keep the oxygen cannula and tubing used PRN in infection control pouches when not in use . 056243 Page 9 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to document the opening of an Emergency kit ([E-Kit], a limited supply of medications in the facility to use during an emergency or after-hours) for a census of 83 residents. This failure had the potential to delay the replacement of the E-Kit and contribute to decreased availability of medications in an emergency. Findings: During a concurrent observation and interview on 11/13/23, at 9:57 a.m., with the Assistant Director of Nursing (ADON) in the Medication Storage Room, E-Kit 13 was observed to have been opened. The ADON stated she did not know when the E-Kit 13 was opened and therefore did not know when the E-Kit 13 should have been replaced. The ADON confirmed the opening of the E-Kit 13 was not logged in the E-Kit log book. The ADON stated all medication bottles were present in the E-Kit but acknowledged the E-Kit should be replaced within 72 hours after opening. During a review of the facility's policy and procedure (P&P) titled, Emergency Kits, dated 12/22, the P&P indicated, .opened kits are replaced with sealed kits within 72 hours of opening. 056243 Page 10 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

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 had a 6.25% error rate when two medication errors out of 32 opportunities were observed during a medication pass for two of seven residents (Resident 50 and Resident 46). Residents Affected - Some This failure resulted in medications not given in accordance with the prescriber's orders, which resulted in residents not receiving the intended therapeutic effect of the medications. Findings: During a medication pass observation on 11/14/23, at 7:44 a.m., with Licensed Nurse 3 (LN 3), LN 3 prepared seven medications for Resident 50 including one tablet docusate sodium (medication to treat constipation) 100 milligrams (mg, a unit of measurement). During a review of Resident 50's Order Summary Report, dated 11/14/23, indicated, Resident 50 had an order for Colace Capsule 100mg (Docusate Sodium) Give 200 mg by mouth one time a day for bowel regularity. During a medication pass observation on 11/14/23, at 8:26 a.m., with LN 3, LN 3 prepared nine medications for Resident 46 including one tablet famotidine (medication to decrease the production of stomach acid) 40 mg. Pharmacy label on the medication package indicated, take 1 tablet by mouth daily 30 min [minutes] before food for r/t [related to] acid suppression. During an interview on 11/14/23, at 8:33 a.m., with Resident 46 and her son, both stated Resident 46 had breakfast one hour ago and confirmed breakfast was delivered daily between 7 a.m. and 7:30 a.m. During a review of Resident 46's Medication Administration Record (MAR), dated 11/1/23 to 11/30/23, the MAR indicated, Resident 46 was administered famotidine 40 mg daily at 8 a.m. (after breakfast) from 11/1/23 to 11/15/23. During an interview on 11/14/23, at 10:41 a.m., with LN 3, LN 3 confirmed the order for docusate sodium for Resident 50 indicated 200 mg and she should have given him two tablets of the medication. LN 3 stated breakfast was served between 7 a.m. and 7:30 a.m. and Resident 46 should have had her famotidine before she ate breakfast. LN 3 stated, need to follow the instructions on the label. During an interview on 11/15/23, at 12:17 p.m., with the Assistant Director of Nursing (ADON), the ADON stated nursing staff were expected to follow the prescriber's order and to follow the instructions on the medication pharmacy label. The ADON confirmed nursing staff were able to call the pharmacy if they had any questions. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised April 2021, the P&P indicated, Medications are administered in accordance with prescriber orders .medications are administered within .prescribed time, unless otherwise specified (for example, before or after meal orders). 056243 Page 11 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide dental services to one out of 19 sampled residents (Resident 23) when Resident 23 did not have any evaluation of dental needs. Residents Affected - Few This failure had the potential to result in the facility to not be aware of Resident 23's dental needs and Resident 23 not provided with appropriate and adequate dental/oral care. Findings: A review of Resident 23's clinical record indicated Resident 23 was admitted Spring of 2022 and had diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system and parts of the body controlled by the nerves, often including tremors, stiffness or slowing of movement), dysphagia (swallowing difficulties), and depression. A review of Resident 23's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 9/8/23, indicated Resident 23 had short-term and long-term memory problems, and severely impaired cognitive skills for daily decision making. During a concurrent observation and interview on 11/13/23 at 10:18 a.m. with Resident 23 in Resident 23's room, Resident 23 was observed to have no top teeth and a few yellowish natural bottom teeth. Resident 23 was not wearing dentures. Resident 23 stated that sometimes he would have a hard time chewing his food so he would just not eat it. During an interview on 11/14/23 at 10:58 a.m. with the Social Services Director (SSD), the SSD stated the facility had an in-house dentist that attends to residents as needed for dental issues. The SSD also stated she had never been alerted in the past or had seen a note that Resident 23 had any dental concerns, so he was never referred to the dentist. The SSD further stated that every resident should be evaluated initially for dental needs, even if the resident did not have dental concerns, because it is part of the resident's initial assessment. The initial evaluation of Resident 23's dental needs was requested. During a concurrent interview and record review on 11/14/23 at 2:15 p.m. with the SSD, Resident 23's clinical records were reviewed. The SSD stated she was not able to locate any initial or annual dental assessment record for Resident 23 which would mean that the initial evaluation of Resident 23's dental needs was not done. The SSD further stated if the initial evaluation of a resident's dental needs was not done, the resident would not be provided with adequate dental/oral care. During an interview on 11/16/23 at 9:17 a.m. with the Assistant Director of Nursing (ADON), the ADON stated, .All residents should receive initial dental assessment .The risk [if residents had no initial evaluation for dental needs] is that we would not know the residents' baseline dental status and if there's anything wrong. A review of Resident 23's active physician's order, dated 10/31/22, indicated, Consult - Dental For Oral Hygiene With Follow-up And Treatment As Indicated. A review of Resident 23's speech therapy evaluation, dated 6/17/23, the oral peripheral exam section indicated, General, Facial and Dentition = Edentulous [lacking teeth] . 056243 Page 12 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 23's physician's progress note, dated 6/28/23, indicated, ENMT [Ear, Nose, Mouth, and Throat]: Lips, Teeth, and Gums: poor dentition. A review of the facility's policy and procedure, P&P titled, Dental Care, revised 4/2021, indicated, Each resident will receive appropriate dental care . 4. Our facility's routine dental care includes, but is not limited to: a. An initial evaluation of the resident's dental needs . 056243 Page 13 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) met the state's education qualification requirements, as required per federal regulations, to be the DM to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the full time Registered Dietitian (RD) provided frequently scheduled consultation to the DM to include overseeing food safety and sanitation, food preparation, meal service and food storage. As a result, there were lapses in the delivery of food and nutrition services associated with meal distribution accuracy (Cross Reference F803), and safe food handling and sanitation (Cross Reference F812), which lacked the benefit of a qualified Food and Nutrition Services Director (DM) responsible for the day-to-day food service operation for the skilled nursing facility. In addition, the facility lacked the benefit of the expertise of RD input when there was not sufficient oversight over the food service operations via frequently scheduled consultation to the DM by the RD, when the job description of the RD was essentially based on clinical nutrition. There was a total of 81 out of 83 residents receiving meals from the facility kitchen. Findings: During the annual recertification survey from 11/13 to 11/16, 2023, multiple issues surrounding the delivery of dietetic services were identified: 1. Meal distribution accuracy - the menu/recipes/meal spreadsheets were not followed, and the portion size of food items and fortification for the therapeutic diets were not served correctly, and 2. Safe food handling and sanitation: a. Improper labeling and dating for the food items in dry storage and walk-in refrigerator; b. Improper storage of opened packages of food items in dry storage and walk-in refrigerator; c. Ice machine in the kitchen was not clean with orange slimy and black substances were found in the ice maker (upper machinery unit); d. Lack of thawing process system (items were found in walk-in refrigerator): 1. The thawing meats had no date to show when they could be used and when they should be discarded, and 2. A box of cartons of supplement drinks (nutrition drinks provide additional nutrients and are perishable) were not dated to show when they would be used or discarded. e. Four individual ice cream cups were found in the reach-in refrigerator; f. Several various sizes of metal pans and dishes were found stacked and stored wet at the ready-to-use storage areas; 056243 Page 14 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many g. Dietary Aide (DA) 1, was in dishwasher position, was not able to demonstrate and verbalized the process of manual dishwashing by the three-compartment sink, and h. [NAME] (Cook 1) was not able to verbalize the cooling down process of cooked (hot) food. During an initial kitchen tour and concurrent interview with the Dietary Manager (DM) on 11/13/23, at 8:35 a.m., DM stated he had no credential (not a DSS (Dietary Service Supervisor) nor CDM (Certified Dietary Manager), and stated he was still waiting to be approved from the administration to start the class of CDM. DM stated he worked at the dietary manager position for two years and before he worked as dietary assistance and dietary aide since 2021. DM stated his role was to manage the kitchen, staff, ordering, visiting residents to get their food preferences. He stated the facility had a full-time Registered Dietitian (RD) for doing assessments for the residents. During an interview with the RD on 11/13/23, at 12:48 p.m., RD stated she was a full-time in-house (not contracted) RD and worked in facility from Monday to Friday. She stated she was responsible to do monthly kitchen sanitation audits and monthly in-services for the kitchen staff. RD stated she was not overseeing day-to-day operation of the kitchen. She stated her overall workload for the facility was 10 percent for the foodservice work and 90 percent for the clinical work. She stated she would do all the assessments which included new admission, annual, quarterly, and significant changes, and she also completed the MDS (minimum data set - a standardized assessment tool that measure health status in nursing home residents). She stated she was responsible to attend the IDT (interdisciplinary team-development of professional plan to coordinate and deliver personalized health care for the residents) meeting and monitored and documented on weight status of the residents (weekly and monthly). During a follow up interview with the RD on 11/15/23, at 11:25 a.m., RD stated she had been told her primary focus was clinical nutrition and resident nutrition care upon hire. She stated she was not doing any day-to-day foodservice operation, and she did not have time for it because she had a lot to do in the clinical nutrition and visiting/interviewing residents. During an interview with the Administrator (ADM) on 11/15/23, at 2:51 p.m., ADM acknowledged the DM was not qualified for the DM position per federal/state regulation, and the full-time RD was not overseeing day-to-day foodservice operation. ADM stated the company was working on putting the DM on the CDM program. It was noted the DM was not qualified on the last annual recertification on 2022, and the POC (Plan of Correction) stated DM would start the CDM program on June 2022 and would be complete by June 2023. ADM stated he was not aware of it because he had not started working in the facility at that time. He stated the RD was new and still trying her best. He stated he would ask the RD to be more involved in the foodservice since she was the only qualified person. A review of the employee file for the DM, it indicated his hire date was on 10/22/21, and he got promoted to the DM position on 5/1/22. There was no competency or performance evaluation in file. His employee file had a California State Food Handling Training certificate, but no other credentials or certificates. A review of an employee file for the RD, it indicated her hire date on 2/20/23, and had a CDR (Commission of Dietetics Registration - a credentialing agency for the Academy of Nutrition and 056243 Page 15 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0801 Dietetics) credential. There was no competency or performance evaluation in file. Level of Harm - Minimal harm or potential for actual harm A review of an undated facility organizational chart, it indicated the DM position was responsible for the dietary department, managing the dietary staff, and reporting to the ADM. The RD position was not responsible for the dietary department and did not manage the dietary staff. The RD also reported to the ADM. Residents Affected - Many A review of facility policy and procedure, titled Personnel Management, dated 2023, it indicated, .A qualified FNS (Food and Nutrition Services) Director (same as Dietary Manager-DM) .is responsible for the total operation of the FNS Department. All FNS is performed under their direction .If a person is not a Registered Dietitian, they must meet the Federal and State Law and receive regular consultation from a RD or have met equivalent requirements. A review of facility job description, titled Job Description: Dietary Supervisor (same as DM), dated 9/2016, it indicated, .Purpose: this position must provide supervision for the Dietary Department, ensuring quality food. The Dietary Supervisor will direct and assist the preparation and service of regular meals and therapeutic diets, order food and supplies, maintain area and equipment in sanitary condition, and assure the smooth operation with other nursing facilities department .Duties: .Direct and participate in food preparation and service of food that is safe .to meet each resident's needs in accordance with physicians order in compliance with approved menu .Assures that proper storage is available, and that handling of food and supplies complies with current state and federal guidelines .Maintain kitchen and food storage area in a safe, orderly, clean and sanitary manner .Check trays for accuracy before they are delivered .Plan and presents in-service education programs for the Dietary Department . Qualification .must be a graduate of an approved dietary manager's course that meet the state and federal care regulations . A review of the state's qualifying pathways to be a dietary manager as listed in the Health and Safety Code (H & SC) 1265.4, 72035. Dietetic Service Supervisor. Dietetic service supervisor means a person who has completed the training requirements specified in section 1265.4(b) of the Health and Safety Code. A review of facility job description, titled Job Description: Registered Dietitian, dated 9/2017, it indicated, .Purpose: Complete nutrition initial, quarterly, annual, and significant change reviews on residents according to federal and state guidelines. Assist in coordination of nutrition care services with Dietary Supervisor. Complete nutritional reviews monthly on high risk residents (significant weight loss/gain, pressure ulcer, hemodialysis, and tube fed) .Supervisory Requirement: Assists with the overall supervision and management of the dietary staff . 056243 Page 16 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when: Residents Affected - Some 1. One Dietary Aide (DA 1) was unable to demonstrate and verbalize the process of manual dishwashing by using a three-compartment sink (cross refer to F812, number 8), and 2. One [NAME] (Cook 1) was: a. unable to verbalize the proper cool down procedure for the cooked meats (cross refer to F812, number 9), and b. unable to follow a recipe or menu when preparing food for the lunch meal on 11/14/23 (cross refer to

F803, number 5). These failures had the potential to place 81 out of 83 highly susceptible residents who received food from the kitchen at risk for food-borne illness. Findings: 1. During an interview on 11/13/23, at 9:50 a.m., DA 1 stated she never performed the manual dishwashing with the three-compartment sink. She stated the process was washing, rinsing, and sanitizing, but was not able to verbalize the water temperature of the process for washing, rinsing, and sanitizing. She stated she would immerse the dishes after washing and rinsing in the sanitizing solution for five to 10 minutes. DA 1 added to check the sanitizing solution concentration by using the test strip and it should be 200 ppm (parts per million, a unit to measure the sanitizing solution concentration). During an interview with the Registered Dietitian (RD) on 11/15/23, at 11:25 a.m., she stated the dietary aides who were in dishwasher positions should know the process of the manual dishwashing with the three-compartment sink in case the dishwashing machine was not working or there was a power outage. During an interview with the DM on 11/15/23, at 12:43 p.m., he explained how to read the facility documents, Verification of Job Competency Demonstration completed for the kitchen staff. He stated if he marked a D (Demonstration) or V (Verbal) next to the skill tasks that meant the staff was competent to those tasks. A review of competency audit of DA 1, titled Verification of Job Competency Demonstration, Employee Name: [DA 1's name], completed by the year of 2023 and evaluated by DM, showed DA 1 was not competent to the knowledge of emergency dish washing (three-compartment sink dishwashing) policy and when to use it. A review of a facility document, titled Food and Nutrition Services In-Service: 3-Compartment Sink, was done on 8/21/23 and completed by unknown person (not DM nor RD), the attendance sheet did not indicate DA 1 attended. 056243 Page 17 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of department policy and procedure, titled 3-Compartment Procedure for Manual Dishwashing, dated 2023, it indicated, .The first compartment is for washing. Fill .with detergent .and hot water (110 degrees - 120 degrees F) .The second compartment is for rinsing .with clean, clear hot water, (110-120 degrees F) .The third compartment is for sanitizing. Fill .with .sanitizer. Test the concentration with the appropriate test strip, which is dipped in the sanitizer solution 10 seconds before reading .must read 150-400 ppm. Immerse all washed items for 60 seconds (one minute) . 2. a. During an interview with [NAME] 1 regarding cooling down process of cooked (hot) food on 11/14/23, at 9:20 a.m., she stated she did not follow the cool down process for cooked food and sometimes they kept leftover food. [NAME] 1 explained the cooling down procedure. She stated she would put the cooked food in the other pan and put in the refrigerator, then she would check if the temperature reached at 40 degrees Fahrenheit (F) in two hours. [NAME] 1 stated she did not remember the proper process of cooked food cooling down and had the training or in-service a long time ago. During an interview with the RD on 11/15/23, at 11:25 a.m., she stated the [NAME] should have knowledge of the cooling down process of cooked food and it was food safety. A review of departmental policy and procedure, titled Cooling and Reheating Potentially Hazardous Foods, dated 3/2013, it indicated, Cooked potentially hazardous foods shall be cooled and reheated in a method to ensure food safety .when potentially hazardous cooked food will not be served right away it must be cooled as quickly as possible .The Two-Stage Method .cool cooked food from 140 degrees F to 70 degrees F within two hours .then cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours .During the cooling process .measure the internal temperature of the food .note menu item, date, time, temperature and cook's initials on the Cool Down Log . b. During an observation of the preparation for pureed food, for the lunch meal on 11/14/23 and a concurrent interview conducted with [NAME] 1 on 11/14/23, at 11:30 a.m. Upon observation, it was noted the puree recipes (Vegetables, Meats, Starch) were on the prep table. [NAME] 1 stated she would prepare six servings of puree food. [NAME] 1 started to make puree rice, she scooped six servings of rice into the blender and added warm milk without measurement and started to blend. [NAME] 1 stated she was looking for the texture of pudding. Then she scooped six servings of carrots in the blender and added two cups of chicken broth to blend for puree carrots. She stated she was looking for the texture of mashed potatoes. Next, she put six pieces of (three oz.) fish fillets and added one and a quarter (1 ¼) cups of broth in the blender and blended to make puree fish. Then she added half of one-third (1/3) cup (approximately 2.5 tablespoons (Tbsp.) of food thickener. Observed [NAME] 1 did not read the puree recipes when preparing the puree foods. A concurrent review of undated recipes, titled Recipe: Puree Starch (Rice, Pasta, Potatoes), it showed making six servings of rice should add three-quarter (¾) to one and a half (1½) cups of warm milk. Recipe: Puree Vegetables, it showed making six servings of vegetable (carrot) should add two Tbsp. to 1/3 cup of warm milk or broth. During an interview with the DM on 11/14/23, at 1:16 p.m., he stated the staff and the cook needed to follow the menu and spreadsheet to give the right portion size and correct food items for the diet as ordered. During an interview with the RD on 11/15/23, at 11:25 a.m., she stated [NAME] 1 needed to follow the recipes, if not it may affect the nutritive values, textures, and taste of the puree foods. 056243 Page 18 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of facility document titled, Job Description: FNS (Food and Nutrition Services) Director, dated 2023, showed, .follow prepared menus and portion control guides .the preparation and service of all food and ensures that approved menus and accompanying recipes are followed . A review of facility document, titled Job description: Cook, dated 2023, it indicated a [NAME] should have, .ability to accurately measure food ingredients and portions .knowledge of basic principles of quantity food cooking and equipment use . A review of competency audit of [NAME] 1, titled Verification of Job Competency Demonstration, Employee Name: [Cook 1's name], completed by the year of 2023 and evaluated by DM, it showed [NAME] 1 was competent to the knowledges of Use of recipes, spread sheets .The danger zone temperature range and its importance .Leftovers usage and storage .reheating .Proper use of Cool Down Log . A review of departmental document, titled Food and Nutrition Services In-Service, Topic: Sanitization and Hot Food cool down process, completed on 9/23/23 and was given by a person (not DM nor RD). It showed [NAME] 1 attended the in-service. The in-service material/lesson plan did not include anything about Cool Down process of hot (cooked) food. 056243 Page 19 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0803 Level of Harm - Minimal harm or potential for actual harm 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 ensure the menu was followed for a therapeutic diet during the lunch meals on 11/14/23 when: Residents Affected - Some 1. 10 residents (Resident 2, 8, 20, 33, 35, 36, 43, 56, 59, and 295) who were on diets without fortification (addition to meats or vegetables to increase calories and/or protein) received fortified (butter) carrots; 2. 10 residents (Resident 7, 10, 18, 35, 43, 45, 56, 57, 63, and 80) who were with diets such as Heart Healthy/Cardiac (diet for people to manage heart disease) and (2-2.5 g (gram) Na (sodium=salt), and Low fat/low cholesterol (diet for people to control fat and cholesterol intake from food) received tartar sauce instead of a lemon wedge; 3. One resident (Resident 2) with CCHO diet (carbohydrate control diet to manage people's blood sugar level for diabetes) with small portion received three ounces (oz.) fish, a wheat roll, and margarine instead of two oz. of fish, no roll, and no margarine; 4. One resident (Resident 4) with a Renal diet (a diet for people to manage chronic kidney disease) received no dessert and should receive sherbet as dessert, and 5. One [NAME] (Cook 1) did not follow the recipe when preparing pureed foods for the lunch meal on 11/14/23. These failures had the potential to result in compromising the medical and nutrition status of those 18 residents. Findings: 1. During an observation of a lunch meal service on 11/14/23 beginning at 12:00 p.m., it was noted 10 residents (Resident 2, 8, 20, 33, 35, 36, 43, 56, 59, and 295) received fortified (added with two oz. melt butter) diced carrots. A concurrent review of the facility diet list (a list shows resident's ordered diet), indicated those residents were not on fortified diets. During an interview with [NAME] 1 on 11/14/23, at 12:03 p.m., [NAME] 1 stated she was not aware that she poured the melted butter on those plates and Oh, that's right, only the Residents with a fortified diet would get butter on the carrots. During an interview with the Dietary Manager (DM) on 11/14/23, at 1:16 p.m., he acknowledged 10 residents received fortified carrots with their diets without fortification ordered. During an interview with the Registered Dietitian (RD) on 11/15/23, at 11:25 a.m., she stated the fortified carrots should not be given to the residents with diets without fortified orders. 2. During an interview with the DM on 11/14/23, at 11:16 a.m., he confirmed that a heart healthy/cardiac diet order was equivalent to a low fat/low cholesterol diet. During an observation of the lunch meal service on 11/14/23, beginning at 12:00 p.m., it was noted 056243 Page 20 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0803 Level of Harm - Minimal harm or potential for actual harm there were 10 residents (Resident 7, 10, 18, 35, 43, 45, 56, 57, 63, and 80) with diets (2-2.5 g Na, Heart Healthy/Cardiac, or low fat/low cholesterol) who received tartar sauce. A concurrent review of undated facility document, titled Fall Menus, it indicated the diets of 2g Na, low fat/low cholesterol, or heart healthy/cardiac should receive a lemon wedge instead of tartar sauce. Residents Affected - Some During an interview with DM on 11/14/23, at 1:16 p.m., he acknowledged those residents received tartar sauce instead of lemon wedges as stated in the menu/spreadsheet. During an interview and concurrent review of the Fall Menu with the RD on 11/15/23, at 11:25 a.m., she confirmed those residents with diets (2-2.5 g Na, Heart healthy/cardiac, or low fat/low cholesterol) should receive lemon wedges with the fish fillets. 3. During an observation of the lunch meal service on 11/14/23, beginning at 12:00 p.m., it was noted that Resident 2 with a CCHO diet with small portion received three oz. of fish fillet, a wheat roll, and one teaspoon of margarine. A concurrent review of undated facility document, titled Fall Menu, it indicated CCHO diet with small portion should receive two oz. of fish fillet, no wheat roll, and no margarine. During an interview with [NAME] 1 on 11/14/23, at 12:03 a.m., she confirmed that all the fish fillets that she prepared were three oz. During an interview with DM on 11/14/23, at 1:16 a.m., he acknowledged Resident 2 with CCHO diet with small portion received three oz. of fish fillet, a wheat roll, and margarine instead of two oz. of fish fillet, no roll, and no margarine. During an interview and concurrent review of the Fall Menu with the RD on 11/15/23, at 11:25 a.m., she confirmed Resident 2 with a CCHO diet with small portions should receive two oz. of fish fillet, no wheat roll, and no margarine. 4. During an observation of the lunch meal service on 11/14/23, beginning at 12:00 p.m., it was noted Resident 4 with a renal diet did not receive dessert. A concurrent review of an undated facility document, titled Fall Menu, it indicated the renal diet should receive sherbet as dessert. During an interview with the DM on 11/14/23, at 1:16 p.m., he acknowledged Resident 4 had a renal diet but did not receive dessert. During an interview and concurrent review of the Fall Menu with the RD on 11/15/23, at 11:25 a.m., she confirmed a renal diet should receive sherbet for dessert. 5. During an interview with [NAME] 1 and a concurrent observation of the preparation of the pureed food for the lunch meal on 11/14/23, at 11:30 a.m. [NAME] 1 started to make the puree food items, and it was noted the puree recipes (Vegetables, Meats, Starch) were on the prep table. [NAME] 1 stated she would prepare six servings of puree food. [NAME] 1 started to make the pureed rice, she scooped six servings of rice into the blender and added warm milk without measurement and started to blend. 056243 Page 21 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [NAME] 1 stated she was looked for the texture of pudding. Then she scooped six servings of diced carrots in the blender and added two cups of chicken broth to blend. She stated she was looking for the texture of mashed potatos. Next, she put six pieces of fish fillets (three oz.) and added one and a quarter (1 ¼) cups of broth in the blender and blended. Then she added half of one-third (1/3) cup (approximately 2.5 tablespoons (Tbsp.) of food thickener powder. [NAME] 1 was observed to not read the puree recipes when she prepared the pureed foods. A concurrent review of undated recipes, titled Recipe: Puree Starch (Rice, Pasta, Potatoes), it showed making six servings of rice should add three-quarter (¾) to one and a half (1½) cups of warm milk. Recipe: Puree Vegetables, it showed making six servings of vegetable (carrot) should add two Tbsp. to 1/3 cup of warm milk or broth. During an interview with the DM on 11/14/23, at 1:16 p.m., he stated the staff and the cook needed to follow the menu and spreadsheet to give the right portion size and correct food items for the diet as ordered. During an interview with RD on 11/15/23, at 11:25 a.m., she stated the kitchen staff should follow the menu, spreadsheet, and tray ticket to provide the correct meal and therapeutic diets to the residents. If not, the residents may be over- or under- nutrition. The RD also stated [NAME] 1 needed to follow the recipes, to ensure the correct nutritive values, textures, and taste of the pureed foods. A review of facility document titled, Job Description: FNS (Food and Nutrition Services) Director, dated 2023, showed, .follow prepared menus and portion control guides .the preparation and service of all food and ensures that approved menus and accompanying recipes are followed . 056243 Page 22 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate assistive drinking equipment to one out of 19 sampled residents (Resident 23) when Resident 23 was not provided a specialized drinking cup during the 11/14/23 breakfast meal. Residents Affected - Few This failure had the potential to result in Resident 23 not being able to safely drink and potential for hydration problems. Findings: A review of Resident 23's clinical record indicated Resident 23 was admitted Spring of 2022 and had diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system and parts of the body controlled by the nerves, often including tremors involuntary quivering movement, stiffness or slowing of movement), dysphagia (swallowing difficulties), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and depression. A review of Resident 23's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 9/8/23, indicated Resident 23 had short-term and long-term memory problem, and severely impaired cognitive skills for daily decision making. A review of Resident 23's MDS Functional Status, dated 9/8/23, indicated Resident 23 needed supervision while eating with one-person physical assistance. During a concurrent observation and interview on 11/14/23 at 8:39 a.m. with Resident 23 in Resident 23's room, Resident 23 was observed almost done eating his breakfast meal. Resident 23 was also observed to have shaky hands. On the corners of Resident 23's meal tray were beverages which included a cup of milk in a regular 8 fl oz. (fluid ounce- unit of measurement) drinking cup which was still full, a cup of bright yellow beverage in a regular 4 fl oz. drinking cup with plastic lid still on, a cup of water in a regular 8 fl oz. drinking cup with plastic lid still on, and a mug of dark brown beverage in a regular 8 fl oz. plastic mug which was filled half way. Resident 23 stated it was hard for him to hold the regular cups because his hands get shaky, and he would like to have a better cup which he could hold more steady. A review of Resident 23's breakfast meal ticket, dated 11/14/23, indicated, .Adap. Equip. [adaptive equipment- any tool, device, utensil, or machine that is used to help with any task associated with daily living]: .Sippy Cup [a specialized drinking cup designed to be held more steady in several ways for people with tremors or reduced coordination] . During a concurrent observation and interview on 11/14/23 at 8:42 a.m. with Certified Nurse Assistant (CNA) 3 in Resident 23's room, CNA 3 confirmed that Resident 23 was not provided with sippy cups. CNA 3 stated Resident 23 sometimes had tremors on both hands which usually occurred in the morning. CNA 3 further stated, .He [Resident 23] needs those sippy cups so he can hold and safely drink his drinks. During an interview on 11/15/23 at 9:43 a.m. with the Registered Dietician (RD), the RD stated, .He [Resident 23] has Parkinson's so his hands were shaky .The sippy cup is generally for his shaking so he won't spill what he is drinking .If it [sippy cup] is in the meal ticket, it should always be provided to the resident every meal . The RD further stated, .the risk [if the sippy cup was not 056243 Page 23 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0810 provided] is he would not be able to drink enough and could have potential dehydration problem. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/15/23 at 9:54 a.m. with the Speech-Language Pathologist (SLP), the SLP stated, .It [sippy cup] needs to be provided to him [Resident 23] .it [sippy cup] can control the flow of drink into his [Resident 23] mouth so to avoid fluid aspiration [fluid entering a person's airway and eventually the lungs by accident]. Residents Affected - Few A review of Resident 23's occupational therapy Discharge summary, dated [DATE], indicated, Patient will improve ability to safely and efficiently perform eating tasks with Supervision or Touching Assistance with use of 2-handled mug [sippy cup] and weighted spoon to ensure adequate nutrition and hydration and to facilitate ability to live in environment with least amount of supervision and assistance. A review of Resident 23's nurse's progress note, dated 10/24/23, indicated, Family of [name of Resident 23] .called stating she is concerned [name of Resident 23] is dehydrated and that she has discussed this with the Charge Nurse who put him on charting for 3 days, for monitoring and encouraging fluid intake. A review of Resident 23's nurse's progress note, dated 10/24/23, indicated, Encouraging fluids for 3 days r/t [related to] resident being dehydrated . During an interview on 11/16/23 at 9:17 a.m. with the Assistant Director of Nursing (ADON), the ADON stated she would expect the staff to always check and provide all the adaptive equipment a resident needs during every meal. The ADON further stated, .if it [sippy cup] is ordered, then it should be followed .This [sippy cup not being provided] could affect the way the resident drinks. It could cause spillage of the drink, difficulty drinking, and potential for hydration problems. A review of Resident 23's care plan, dated 11/1/22, indicated, The resident has dehydration or potential fluid deficit . A review of Resident 23's care plan intervention, dated 11/2/22, indicated, [Provide] Adaptive devices as recommended by therapy or MD [doctor of medicine]. Monitor for safe use. Monitor/document to ensure appropriate use of safety/assistive devices. A review of the facility's policy and procedure titled, Assistance with Meals, revised 7/2021, indicated, Residents Who May Benefit from Assistive Devices: 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as .specialized cups. 056243 Page 24 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

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 prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: Residents Affected - Many 1. Food items with missing or incorrect labeling and dating were found in dry storage and walk-in refrigerator; 2. Food items with opened packages were found not covered properly to prevent cross contamination in dry storage and walk-in refrigerator; 3. Ice machine was not clean; 4. Thawing meats found in the walk-in refrigerator were not dated to show when they were to be used or discarded; 5. A box of supplement shakes (nutrition drinks provide additional nutrients and are perishable) were not dated to show when they were to be used or discarded in the walk-in refrigerator; 6. Four individual ice cream cups were found in the reach-in refrigerator and were soft to touch; 7. Several various sizes of metal pans and dishes were found stacked and stored wet at the ready-to-use storage areas; 8. One dishwasher (Dietary Aide) (DA 1) was not able to demonstrate and verbalized the process of manual dishwashing by the three-compartment sink, and 9. One [NAME] (Cook 1) was not able to verbalize the cooling down process of cooked (hot) food. These failures had potential to cause food-borne illness in a highly susceptible population of 81 out of 83 residents who received food from the kitchen. Findings: 1. During an initial kitchen tour on 11/13/23, at 10:01 a.m. and 10:35 a.m., there were the following food items found opened and had no or improper labeling (stickers on the packages indicating opened date and used by date): In the walk-in refrigerator: -two bags of yellow shredded cheese (no used by date) -a bag of diced hard boiled eggs (no opened date and used by date) -a bag of Swiss cheese (no opened date and used by date) In dry storage: 056243 Page 25 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0812 -six bags of dry pasta (no opened date and used by date) Level of Harm - Minimal harm or potential for actual harm -a bag of croutons (no used by date) Residents Affected - Many During an interview with the Dietary Manager (DM) on 11/13/23, at 10:15 a.m. and 10:45 a.m., he confirmed and stated the opened food items should be labeled with the opened date and used by date. During an interview with the Registered Dietitian (RD) on 11/15/23, at 11:25 a.m., she stated the food item packages were opened should be labeled with opened and used by dates. A review of departmental policy and procedure, titled Labeling and Dating of Foods, dated 2023, indicated Newly opened food items will need to be closed and labeled with an open date and used by date that follows the various storage guidelines . 2. During an initial kitchen tour on 11/13/23, at 10:01 a.m. and 10:35 a.m., there were the following food items found opened and not securely or improperly covered: In the walk-in refrigerator: -a big of Swiss cheese (closed with a paper clip) -a big of diced hard boiled eggs (closed with a paper clip) In the dry storage: -6 bags of dry pasta (were not covered securely) -a bag of croutons (used a rubber band to close the package opening) -a box of hot wheat cereal and a box of cream of rice (were in the ziplock bags individually but not zipped) -a bag of white cake mixed powder (closed with a paper clip) During an interview with DM on 11/13/23, at 10:15 a.m. and 10:45 a.m., he confirmed and stated the opened food items should be stored in a bag or container that could closed securely to prevent pests and rodents. DM stated the use of paper clips to close the opened packages was not acceptable. During an interview with the RD on 11/15/23, at 11:25 a.m., she stated the opened food items should be stored in an enclosed bag or container and sealed tightly. A review of departmental policy and procedure, titled Storage of Food and Supplies, dated 2023, it indicated .Dry food items which have been opened, such as .biscuit mix, pancake mix, dry cereal .noodles, etc., will be tightly closed . 3. During an inspection of the ice machine in the kitchen on 11/13/23, at 8:41 a.m., the Maintenance Supervisor (MS) removed the ice machine's top access panel to reveal the water curtain (a white plastic cover to prevent the ice from shooting out and direct the ice back into the ice storage bin). Upon the water curtain dissembled, there was orangish/pink slimy substances found inside part of the 056243 Page 26 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many curtain and could be wiped off with paper towel. There were orangish/pink slimy substances found at the opening of the ice chute (the passage through which ice falls into the ice storage bin) and could be easily wiped off with paper towel. There were significant black substances on the left and right panels of the ice evaporator unit (a unit that makes cold liquid flow into the evaporator and freeze to make ice). A concurrent interview with the MS, he confirmed and agreed the substances were found. He stated the maintenance department was responsible for the deep cleaning (clean and sanitize the machinery part of the machine and the ice storage bin) monthly. MS stated he would dissemble the part apart to clean, scrub, and sanitize. Also, he would clean and sanitize the ice storage bin. MS stated his last deep clean of the ice machine and ice storage bin was on 10/16/23. He stated the facility hired the outside vendor to run the chemical (cleaner and sanitizer solutions) for the cleaning and sanitizing cycles and changed the water filter together annually. During an interview with RD on 11/15/23, at 11:25 a.m., she stated the ice machine should have regular maintenance, cleaning and sanitizing to keep it clean because ice was food and needed to be in a safe environment. A review of the facility document, titled [Outside Vendor Company Name] Invoice, dated 12/8/2022, it showed maintenance service completed and the water filter was changed on 12/8/2022. It also had a description on the invoice stated the ice machine was leaking. A review of the ice machine manual, titled, [Manufacturer's brand] Instruction Manual, dated 4/16/2019, it indicated, .Maintenance .Maintenance Schedule .More Frequent maintenance may be required depending on water quality, the appliance's environment, and local sanitation regulations .The icemaker must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may require in some water conditions . According to 2022 FDA (Food and Drug Administration) Food Code, on section 4-602.11 Equipment Food-Contact Surface and Utensils, it stated equipment like ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residue that may contribute to an accumulation of microorganisms (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae). 4. During an initial kitchen tour on 11/13/23, at 9:50 a.m., and a concurrent interview with the DM, there were thawing meats observed on the bottom shelf of the storage rack in the walk-in refrigerator without a pull-out date (date for when pulled out from the freezer and placed in the refrigerator to thaw) and used by date: -a half loaf of ham -a box of turkey breast -a tray of five loaves of pork loins -a box of beef roast -a tray of seven packs of turkey deli meat 056243 Page 27 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The interview with the DM, he stated the thawed meats should have a label of pull-out date from the freezer and the used by date. The DM stated the kitchen had a system for thawing meats, but the staff did not date the meats and they needed an in-service. During an interview with the RD on 11/15/23, at 11:25 a.m., she stated the staff should put the date when they pulled out the meats from the freezer and the used by date. The RD added, the dates would easily identify when the thawing meats were pulled and when to be used. If not, the thawing meats may pass the used by date and not safe to use. A review of departmental policy and procedure, titled Procedure for Refrigerated Storage, dated 2023, it indicated, .Frozen food should be left in a refrigerator to thaw. Once thawed, uncooked meat is to be used with 2 days. The exception is cured meats, which are to be used within 5 days .Dating the packages or containers will facilitate this practice . 5. During an observation of the walk-in refrigerator on 11/13/23, at 10:27 a.m., there was a box that contained cartons of supplement drinks that did not have the date they were pulled out from the freezer or a use by date after being thawed. A concurrent review of the supplement shake's storage instruction, which was printed on the carton with the DM, it showed the shakes had to be stored frozen and once thawed in the refrigerator the shakes had to be used within 14 days. A concurrent interview with the DM, he stated he could not determine when the kitchen staff started thawing the shakes because they had no dates on them. He stated he was not aware the instructions indicated the shakes needed to be used by 14 days after being thawed. The DM agreed that the kitchen did not have a system to track the shakes and the staff should be trained about the tracking system with the pull-out date and used by date. During an interview with RD on 11/15/23, at 11:25 a.m., she stated the staff should put the pull-out date when they pulled out the supplement shakes from the freezer and the shakes had 14 days to store in the refrigerator for use after thawed. RD stated if the staff did not have a system for storage and handling the shakes, they could not track when they pulled them out, and when they could be used by. She added it could be food safety issue if the shakes still in use when they passed the 14 days of use. A review of departmental policy and procedure, titled Procedure for Refrigerated Storage, dated 2023, it indicated, .Supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator. Follow the manufacturer's recommendation (specifications) for shelf life . 6. During an initial kitchen tour on 11/13/23, at 9:30 a.m., there were four individual ice cream cups found in the reach-in refrigerator with internal temperature of 36 degrees Fahrenheits (F) that were soft to touch. A concurrent confirmation with the RD, she stated the ice cream should not be stored in the refrigerator and should be stored in the freezer. During an interview with the DM on 11/13/23, at 10:55 a.m., he stated ice cream should be stored in the freezer and not in the refrigerator, and the ice cream should be solid and not soft to touch. He stated the soft ice cream should be discarded. 056243 Page 28 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many A review of departmental policy and procedure, titled Procedure for Freezer Storage, dated 2023, it indicated, .Frozen food should be maintained at a temperature of zero-degree F or lower .Freezer Storage Guidelines .All foods which need to be kept in the freezer can be stored frozen .item: .ice cream . 7. During an observation on the initial tour in the kitchen, and concurrent interview with the DM on 11/13/23, at 9:13 a.m. there were the following items found stacked and stored wet in the ready-to-use storage areas: -six of full sheet metal trays -one insulated cover (food cover to maintain freshness and temperature) -one insulated base (food cover base to hold the food plate to help hold the temperature) -11 of one-sixth (1/6) sheet metal pans -four of one-fourth (1/4) sheet metal pans -four of one-half (1/2) sheet metal pans -five of full sheet metal pans The DM confirmed the metal pans were wet and stacked on top of each other. He stated all dishes/pots/pans should be completely dry before they were stored away. The DM stated dishes needed to be dry because the moisture from the wetness would promote bacteria. During an interview with the RD on 11/15/23, at 11:25 a.m., she stated the dishes/pots/pans should be completely dry before stored away and should not be wet because the moisture could promote bacteria growth. A review of an undated departmental policy and procedure, titled Dish Washing, it indicated, .Dishes are to be air dried in racks before stacking and storing . According to 2022 FDA Food Code, under section 4-901.11 Equipment and Utensils, Air-Drying Required, it stated, .Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow . 8. During the kitchen tour and a concurrent interview with a Dietary Aide (DA 1) regarding the manual dishware washing by the three-compartment sink was conducted on 11/13/23, at 9:50 a.m. The DA 1 stated she never performed the manual dishware washing with the three-compartment sink. She explained the process and stated there were sinks for washing, rinsing, and sanitizing. The DA 1 did not know what the water temperature of washing and rinsing should be, and the temperature of the sanitizing solution. She stated after washing and rinsing, she would immerse the dishes in the sanitizing solution for five to 10 minutes, and then air dried. She stated she would use the test strips to check the sanitizing solution and it should be at 200 ppm (parts per million, a unit to measure the solution concentration). 056243 Page 29 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with the RD on 11/15/23, at 11:25 a.m., she stated the dietary aide who worked in a dishwashing position should have knowledge about manual dishwashing with a three-compartment sink in case the dishwashing machine was not working or there was a power outage. A review of department policy and procedure, titled 3-Compartment Procedure for Manual Dishwashing, dated 2023, it indicated, .The first compartment is for washing. Fill .with detergent .and hot water (110 degrees - 120 degrees F) .The second compartment is for rinsing .with clean, clear hot water, (110-120 degrees F) .The third compartment is for sanitizing. Fill .with .sanitizer. Test the concentration with the appropriate test strip, which is dipped in the sanitizer solution 10 seconds before reading .must read 150-400 ppm. Immerse all washed items for 60 seconds (one minute) . 9. During the follow up kitchen tour and concurrent interview regarding cooling down process of cooked (hot) food on 11/14/23, at 9:20 a.m. [NAME] 1 stated she did not do cool down for cooked food but sometimes they kept leftover food. She stated she would put the food in another pan and put in the refrigerator, and then checked if the temperature reached at 40 degrees F in two hours. [NAME] 1 stated she did not remember the proper process of cooked food cooling down and had the training or in-service a long time ago. During an interview with the RD on 11/15/23, at 11:25 a.m., she stated the [NAME] should have knowledge of the cool down process of cooked food. A review of departmental policy and procedure, titled Cooling and Reheating Potentially Hazardous Foods, dated 3/2013, it indicated, Cooked potentially hazardous foods shall be cooled and reheated in a method to ensure food safety .when potentially hazardous cooked food will not be served right away it must be cooled as quickly as possible .The Two-Stage Method .cool cooked food from 140 degrees F to 70 degrees F within two hours .then cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours .During the cooling process .measure the internal temperature of the food .note menu item, date, time, temperature and cook's initials on the Cool Down Log . 056243 Page 30 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to provide a clean environment for the residents and visitors when one out of four garbage disposal bins, located outside by the kitchen, was overflowing with bags of trash and was not securely closed. Residents Affected - Many This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During an initial tour observation of the kitchen and a concurrent interview with the Registered Dietitian (RD), on November 13, 2023, at 10:32 a.m., one dumpster garbage bin located just outside the facility kitchen was not securely closed by the lid, and there were bags of trash that were overflowing on top of the bin. In addition, the lid was deformed (bent) which prevented it to completely closed. The RD confirmed and stated the trash should not be overflowing and the lid should completely closed. A review of undated facility policy and procedure, titled Miscellaneous Areas: Garbage and Trash, it stated, .All Food waste must be placed in sealed containers .The trash collection area is a potential feeding ground for vermin and rodents .if a commercial rubbish service is used, arrangements must be made for periodic exchange of trash bins . According to Federal Food Code 2022, section 5-501.15 Outside Receptacles, it indicated the receptacles (containers) and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment must be designed and constructed to have tight-fitting lids, doors, or covers. 056243 Page 31 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0880 Provide and implement an infection prevention and control program. 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, the facility failed to follow and maintain an effective infection prevention and control program for a census of 83 residents when: Residents Affected - Some 1. A facility staff entered a room requiring use of an N95 mask (a type of mask that filters up to 95% of particles in the air), face shield, gown, and gloves wearing only a surgical mask (a type of mask that protects the mouth and nose from splashes, sprays, and large droplets that may include microorganisms) and gloves; 2. A shared glucometer (a device which measures blood sugar using blood from the fingertip) was not cleaned and sanitized after use for resident care and before storage; and, 3. A peripherally inserted central catheter (PICC) Line (a tube inserted into a vein in the arm to access large veins near the heart for medications, liquid nutrition, and drawing blood) did not indicate a date when the dressing was last changed for Resident 73. These failures resulted in increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential for spread of germs, and may cause infection among residents, staff, and visitors. Findings: 1. During an interview on 11/13/23 at 8:54 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated the resident in room [ROOM NUMBER] bed B tested positive for COVID-19 (a highly contagious respiratory illness). During an observation on 11/14/23 at 10:10 a.m., room [ROOM NUMBER] had a red STOP sign posted on top of the room number sign which indicated, PLEASE FOLLOW CDC [Centers for Disease Control and Prevention] DONNING AND DOFFING [putting on and removing an item of clothing] PPE SEQUENCE .THIS ROOM REQUIRES N95 & FACE SHIELD. 1. SWITCH TO N95 AND FACE SHIELD PRIOR TO ENTRY. 2. REMOVE N95 AND FACE SHIELD AND DISCARD UPON EXIT . Below the room number sign was also a signage which indicated, SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE) . 1. GOWN . 2. MASK OR RESPIRATOR . 3. GOGGLES OR FACE SHIELD . 4. GLOVES . Licensed Nurse (LN) 3 was observed entering room [ROOM NUMBER] wearing a surgical mask and gloves. During a concurrent observation and interview on 11/14/23 at 10:13 a.m. with Licensed Nurse (LN) 3 in front of room [ROOM NUMBER], LN 3 confirmed that she entered room [ROOM NUMBER] and performed direct care to a resident in the room wearing only a surgical mask and gloves. LN 3 stated she is aware that a resident in room [ROOM NUMBER] tested positive for COVID19 and she knows about the sign posted by the door. LN 3 further stated, I'm sorry, I did not realize .We should always wear N95, face shield, gown-up and gloves before entering the room, and I did not .It's [not wearing required PPE] a risk for us and the residents, I could get covid and spread covid to others . During an interview on 11/15/23 at 1:12 p.m. with the Infection Preventionist (IP), the IP stated when a resident in a room tested positive for COVID-19, they would put the room under airborne precautions (used for patients known or suspected to be infected with pathogens transmitted by the airborne route) and post signage by the door to alert staff. The IP also stated she would expect everyone 056243 Page 32 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some entering the room to follow the signage posted and to wear the proper PPE required before entering the room. The IP further stated, .It would be a risk of contaminating self and other resident if they're not wearing the required PPE .it could lead to possible spread of infection. During an interview on 11/16/23 at 9:17 a.m. with the Assistant Director of Nursing (ADON), the ADON stated she expects the staff to be aware and to know what to do before entering a room. The ADON also stated staff should always wear the required PPE when entering a room and performing direct care to either of the residents in the room. The ADON further stated, . [if staff are not wearing required PPE] they could spread infection, cross-contamination, spread the germs and putting other residents or staff at risk. A review of the facility's policy and procedure (P&P) titled, Isolation- Categories of Transmission-Based Precaution, revised 10/2018, indicated, Airborne Precautions. 1. Airborne precautions are indicated when an individual is infected with a pathogen that is very small and can be transmitted long distance through the air . 3. Any individual who enters the room of a resident placed on airborne precautions must wear approved respiratory protection. 2. During an observation on 11/14/23 at 10:10 a.m., LN 3 was observed checking a resident's blood sugar using a glucometer which was shared between residents. LN 3 used a lancet (a sharp piercing device) to pierce the resident's finger to get blood and then applied the blood to the test strip that was attached to the glucometer. LN 3 then exited the room, discarded the used lancet and test strip, put the glucometer back in a blue open container together with a canister of test strips and multiple lancets, and stored it in the bottom left drawer of medication cart 2. The bottom left drawer of medication cart 2 contained multiple resident's personal medication inhalers, multiple shared equipment, and care supplies. During a concurrent observation and interview on 11/14/23 at 10:13 a.m. with LN 3, LN 3 confirmed that she did not clean and sanitized the used glucometer before putting it back in the container and storing it in the medication cart. LN 3 stated, oh, I did not wipe it, grabbed the glucometer back from the container, started wiping the glucometer's outer surface with an alcohol prep pad (pads used to clean the skin prior to bandaging, wiping off surfaces like desks, sinks and counters, and cleaning hands) for less than 10 seconds and placed it on top of medication cart 2. LN 3 then stated, .I know at some facilities, they use an alcohol wipe for cleaning it [glucometer]. LN 3 further stated it would be a risk for spread of infection and cross-contamination if a glucometer is not cleaned after use and before storage. During an interview on 11/15/23 at 1:12 p.m. with the IP, the IP stated she expects glucometer to be cleaned after every use and staff should follow the facility's policy and the manufacturer's instructions on cleaning the glucometer. The IP further stated, They [staff] should always clean shared apparatus [glucometer] with bleach wipes for 3 minutes .They need to make sure it remains wet with the solution for 3 minutes . During an interview on 11/16/23 at 9:17 a.m. with the ADON, the ADON stated glucometers should always be wiped down with bleach and should remain wet for three minutes until dry. The ADON further stated, .glucometers should always be cleaned and sanitized in between residents, before and after use, and before putting it away .The risk [if shared equipment is not cleaned and sanitized properly] is contamination of other supplies and medications in the cart, and blood borne pathogens can spread. A review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items, Surfaces 056243 Page 33 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0880 Level of Harm - Minimal harm or potential for actual harm and Equipment, revised 10/2021, indicated, .b. Semi-critical items consist of items that may come in contact with mucous membrane or non-intact skin .Such devices should be free from all microorganisms . d. Reusable items, including environmental surfaces will be cleaned and/or disinfected between residents . 4. Reusable resident care equipment will be decontaminated between residents according to manufacturers' instructions. Residents Affected - Some A review of the glucometer manufacturer's instruction with brand name, EVENCARE G3 BLOOD GLUCOSE MONITORING SYSTEM, undated, the section on Cleaning and Disinfecting Procedures for the Meter indicated, The EVENCARE G3 Meter should be cleaned and disinfected between each patient .The following products have been approved for cleaning and disinfecting the EVENCARE G3 meter: .Clorox Healthcare Bleach Germicidal and Disinfectant Wipes . A review of the label of the facility's preferred anti-microbial wipe called, Clorox Healthcare Bleach Germicidal and Disinfectant Wipes, indicated .TO CLEAN AND DISINFECT .SURFACES: wipe surface to be disinfected .surface to remain visibly wet for the contact time .let stand for 3 minutes . 3. During a review of Resident 73's medical record, the record indicated Resident 73 was admitted in the Fall of 2023 with diagnoses that included severe sepsis (the body's extreme response to infection), open wound on right hip, idiopathic aseptic necrosis (death of bone tissue due to a lack of blood supply) of right femur, infection, and inflammatory reaction due to right hip prosthesis (an artificial body part), cellulitis (deep infection of the skin caused by bacteria) of right lower limb, and chronic osteomyelitis (bone infection). During a review of facility record titled, PICC Insertion Record, dated 10/13/23, the record indicated Resident 73's PICC line was inserted on 10/13/23. During a concurrent observation and interview on 11/13/23 at 10:45 a.m. in Resident 73's room, the PICC line was observed without a written date to indicate when the dressing was changed. Resident 73 confirmed there was no date on the dressing. During an interview on 11/13/23 at 10:16 a.m. with LN 8, LN 8 confirmed there was no date on the dressing. LN 8 stated it is expected to have a date for infection control purposes. LN 8 stated, We don't know when it was changed. During an interview on 11/13/23 at 10:30 a.m. with LN 7, LN 7 stated PICC line dressings are to be changed every seven days and as needed. LN 7 confirmed the dressing was not dated and stated it should be dated. LN 7 stated there was a potential for infection if the dressing was not dated and staff did not know when to change the dressing. During an interview on 11/14/23 at 10:20 a.m. with the IP, the IP stated dressings should be changed every seven days using sterile dressing and should be labeled with initials and date. The IP stated, If there is no date on it, they should change it. During an interview on 11/15/23 at 1:06 p.m. with the ADON, the ADON stated dressings should be changed once a week by a registered nurse (RN), dated and documented. The ADON stated the date of the dressing should be on the site and it should have been changed again when there was no date. The ADON stated the dressing needed to be changed right away and [RNs] should not just base it on the date of the Electronic Medication Administration Record (E-MAR). The ADON stated, It needs to be done for infection control and to check for proper placement. We don't want infection at the site. 056243 Page 34 of 35 056243 11/17/2023 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 73's medical record, the medical record indicated there were no care plans developed regarding care of PICC line. During a review of the facility's P&P titled Central Venous Catheter/Peripherally Inserted Central Catheter Dressing Changes, revised 4/21, the P&P indicated, Procedure to apply sterile dressing .6. Apply sterile transparent dressing (with or without gauze) to area .Label with initials, date and time. 056243 Page 35 of 35