Health inspection·August 1, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment when: 1. A room housing two residents (Resident 15 and Resident 36), had overflowing bins of trash and soiled linens, from which strong, offensive, and fetid smells originated. In this same room dry, urine-appearing (yellow) stains were observed on the floor. 2. Hallway carpets were soiled, stained, and appeared unvacuumed, 3. Three resident rooms had sticky floors (Rooms 107, 113 and 136) and dirty fall mats (rooms [ROOM NUMBERS]), 4. The building's central linoleum flooring was cracked and dingy, and 5. The shower room had cracked, discolored tiles, and peeling paint. These failures resulted in Residents 15 and 36 to verbalize discomfort and disgust, and living in dirty conditions had the potential for unhappiness and a decreased level of self-worth of all 61 residents. Findings: During an observation on 7/25/22 at 9:20 a.m., the hallway carpet of the North Hall of the facility appeared visibly dirty. There were large blackened stains on them, and discoloration of the actual fibers, making the carpet appear old and in poor condition. In addition, litter and unidentified particles were observed on the carpet, as if it had not been vacuumed recently. During a second observation on 7/25/22 at 9:43 a.m., a used glucometer strip (A small, plastic strip that help to test and measure blood glucose levels) was found on the hallway carpet of the North Hall, accessible to anybody passing by. On close inspection, the glucometer strip was noted to have dry blood on it, indicating it had been used. The Director of Nursing (DON), who was notified about the observation, stated used glucometer strips were supposed to be placed in the biohazard bag, and that she would have the floors vacuumed right away. During a concurrent observation and interview on 7/25/22 at 9:22 a.m., in the room shared by Resident 15 and Resident 36, Resident 15 stated there was urine on the floor. Resident 15 stated she had Page 1 of 48 056296 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some already notified housekeeping staff about it, but nobody had come in to clean it, and by now, the urine had been there for days. A large yellow dry stain was indeed noted by Resident 36's bedside floor. The stain was right below Resident 36's urinary catheter bag (Urine drainage bags collect urine. The bag is attached to a catheter (tube) that is inside the person's bladder) as if it had leaked from the bag, or spilled while emptying the bag. Resident 15 also stated she had asked facility staff to empty an overflowing, large trash can, and overflowing dirty linen bin inside the room, but according to Resident 15, nobody had come in to empty them. The smell in the room was strong, offensive and unbearable, and appeared to be coming out of the trash can or dirty linen bin. It smelled like concentrated feces and urine. Resident 15 stated the smell came from the dirty linen bin, which included linens soiled with feces due to Resident 36's recent episodes of diarrhea. Resident 15 stated she was bothered by the smell, and even more so when staff closed the residents' room door. Later that same day, Resident 15's results of a recent COVID-19 test came out positive, and roommate, Resident 36, also became symptomatic, therefore, the soiled linen and overflowing trash bins had the potential to be contaminated with the COVID-19 virus at the time of this observation. During an interview on 7/25/22 at 9:38 a.m., Licensed Staff P confirmed the room shared by Resident 36 and Resident 15 smelled terrible. She was asked how often the trash and dirty linens bin had to be emptied. Licensed Staff P stated they were supposed to be emptied when they were ¾ full, but the Certified Nursing Assistant (CNA) assigned to that room had an appointment and would be back. The Director of Nursing (DON), who was also present, stated the trash can and dirty linen bins were supposed to be emptied when they were full since the facility was having difficulty obtaining plastic bags (liners) for the containers. The DON confirmed there was urine on the floor, and stated housekeeping had not had a chance to clean the room yet. During an observation on 7/25/22 at 9:24 a.m., room [ROOM NUMBER]'s floor was dull and sticky. During an observation on 7/25/22 at 11:20 a.m., room [ROOM NUMBER]'s floor was sticky. During an observation on 7/25/22 at 12:34 p.m., room [ROOM NUMBER]'s floor was sticky. The fall mats adjacent to the beds were stained, and not unlike the floors, were also sticky. During an observation of room [ROOM NUMBER]'s sticky floor and concurrent interview on 7/26/22 at 3:29 p.m., Licensed Staff G stated, Oh yeah, the floors here could get sticky. During an observation on 7/27/22 at 9:44 a.m., the linoleum floors located centrally in the building were cracked and dingy. During a concurrent interview, the Maintenance Director stated the linoleum was mopped daily, but confirmed the floors were old, stained, and in need of repair. During an observation on 7/27/22 at 10:44 a.m., the floor mat located at the entrance of the shower room appeared unswept, with particles of debris littered on its surface. The shower room had cracked and missing tiles noted at several places. The room's wall paint was flaking. The shower stalls appeared unscrubbed, with gray/orange discoloration noted accumulating throughout the bases and corners. Black anti-slip strips were torn and coming loose from the shower stall floors. During a concurrent interview, Unlicensed Staff T stated the shower needed some work. Unlicensed Staff T stated she lays a blanket on the floors during showers to prevent slips and falls. During an interview on 7/27/22 at 11:21 a.m., Resident 22 complained about the floor being dirty, and staff not emptying the trash for days in the residents' rooms. Resident 22 stated it used to be better. Resident 22 also stated there were offensive smells in the hallways of the facility. 056296 Page 2 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0584 Level of Harm - Minimal harm or potential for actual harm During an interview on 7/27/22 at 10:37 a.m., the DON stated the Maintenance Department was required to take out the trash and empty the dirty linen bins inside the residents' rooms, yet, during another interview on 7/28/22 at 3:14 p.m., the Maintenance Director stated the CNAs were responsible for emptying the trash cans and linen bins, therefore it could not be determined who had the responsibility for emptying them since different Department Heads could not agree on a definite answer. Residents Affected - Some Record review of the facility policy titled, Housekeeping-Resident Rooms, last revised in September of 2020, indicated, The Housekeeping Department coordinates the daily cleaning of all resident rooms . The Floor is swept or vacuumed. The floor is damp-mopped with disinfectant solution A review of the facility policy titled, Housekeeping - General, dated October 16, 2020, indicated, Purpose: To ensure that the Facility is clean, sanitary, and in good repair at all times so as to promote the health and safety of residents, staff and visitors . All rooms of the Facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents. The Housekeeping Staff's general duties are to: i. Sweep and mop, or vacuum, all floors . Empty and clean all waste containers. 056296 Page 3 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to protect one of 27 sampled residents (Resident 35) from verbal abuse when the two facility staff witnessed a licensed staff (Licensed Staff E) swear at one sampled resident (Resident 35), hit the side of her helmet, and shove her back in her wheelchair. This failure placed Resident 35 at risk for further physical and/or mental health harm from verbal and physical abuse. Findings: Resident 35 was [AGE] years old with a diagnosis of Huntington's Disease (a rare movement disorder that causes the progressive breakdown (degeneration) of nerve cells in the brain), muscle spasms (painful, involuntary and unpredictable contractions and tightening of muscles) and aphasia (a disorder that affects how you communicate). Resident 35 was totally dependent on staff for provision of care. During an observation and concurrent interview on 7/25/22 at 9:49 a.m., Resident 35 was in front of the nursing station, in a reclining wheelchair, asleep. Resident 35 was wearing a helmet. Per Infection Preventionist (IP), Resident 35's diagnosis included Huntington's disease and she exhibited chorea (an involuntary, unpredictable body movements). IP stated Resident 35 had uncontrolled flailing of arms, and leg movements. IP stated Resident 35 was non interviewable. IP stated Resident 35 would answer yup to all questions, although Resident 35 might not be understanding the questions. During a concurrent interview and review of documents on 7/28/22 at 10:14 a.m., of SOC 341 (a state form used to report allegation of abuse) and Interdisciplinary Team (IDT) notes dated 6/17/22, the Administrator verified an abuse allegation occurred on 6/12/22, but was not reported to her until 6/16/22. Administrator stated Licensed Staff E (alleged perpetrator of the abuse) was an ex-[NAME]. Administrator stated there were two staff who witnessed the incident on 6/12/22. She stated the incident occurred in the activity room around lunch time. Administrator stated a Certified Nurse Assistant (CNA) student witnessed Licensed Staff E hit the right side of Resident 35's helmet and shove her backwards. Administrator stated the CNA reported that she heard Licensed Staff E say to Resident 35, Can you stop f______ moving? Administrator stated when the red liquid that Licensed Staff E was giving to Resident 35 spilled, Licensed Staff E allegedly said, Are you f______ kidding me, why can't you just quit moving. Administrator stated the CNA student and Unlicensed Staff F did not report this allegation to her right away because the CNA student knew Licensed Staff E from the community and they shared the same babysitter. Administrator stated Unlicensed Staff F was introverted and was a victim of abuse in the past. Administrator stated she believed these two witnesses were also stunned when the abuse incident occurred. The Administrator stated both the CNA student and Unlicensed Staff F were afraid of Licensed Staff E. Administrator stated the expectation was that abuse allegations be reported to her within 30 minutes. She stated that for this incident, the protocol was not followed. Administrator stated late reporting of abuse incidents could place residents at risk for harm. During a review of facility's policy and procedure (P/P) titled Abuse-Prevention Program and Abuse-Reporting and Investigation, both policies revised on 11/2016, the P/P stated the facility must ensure the health, safety and comfort of residents by preventing abuse and allegations of abuse are to 056296 Page 4 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0600 be reported to the Administrator/Designee immediately. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056296 Page 5 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to report an abuse allegation timely for one out of one sampled residents (Resident 35). This failure placed Resident 35 at risk for serious physical and/or mental health consequences and potential ongoing abuse for Resident 35 and all residents in the facility when not reported immediately. Findings: Resident 35 was [AGE] years old with a diagnosis of Huntington's Disease (a rare movement disorder that causes the progressive breakdown (degeneration) of nerve cells in the brain), muscle spasms (painful, involuntary and unpredictable contractions and tightening of muscles) and aphasia (a disorder that affects how you communicate). Resident 35 was totally dependent on staff for provision of care. During an observation and concurrent interview on 7/25/22 at 9:49 a.m., Resident 35 was in front of the nursing station, in a reclining wheelchair, asleep. Resident 35 was wearing a helmet. Per Infection Preventionist (IP), Resident 35's diagnosis included Huntington's disease and she exhibited chorea (an involuntary, unpredictable body movements). IP stated Resident 35 had uncontrolled flailing of arms, and leg movements. IP stated Resident 35 was non interviewable. IP stated Resident 35 would answer yup to all questions, although Resident 35 might not be understanding the questions. During a concurrent interview and review of documents on 7/28/22 at 10:14 a.m., of SOC 341 (a state form used to report allegation of abuse) and Interdisciplinary Team (IDT) notes dated 6/17/22, the Administrator verified an abuse allegation occurred on 6/12/22, but was not reported to her until 6/16/22. Administrator stated the abuse allegation was reported to her four days late. Administrator stated Licensed Staff E (alleged perpetrator of the abuse) was an ex-[NAME]. Administrator stated there were two staff who witnessed the incident on 6/12/22. She stated the incident occurred in the activity room at around lunch time. Administrator stated a Certified Nurse Assistant (CNA) student witnessed Licensed Staff E hit the right side of Resident 35's helmet and shove her backwards. Administrator stated the CNA reported that she heard Licensed Staff E say to Resident 35, Can you stop f______ moving? Administrator stated when the red liquid that Licensed Staff E was giving to Resident 35 spilled, Licensed Staff E allegedly said, Are you f______ kidding me, why can't you just quit moving. Administrator stated the reason why the CNA student and Unlicensed Staff F did not report this allegation to her right away was because the CNA student knew Licensed Staff E from the community and they shared the same babysitter. Administrator stated Unlicensed Staff F was introverted and was a victim of abuse in the past. Administrator stated she believed these two witnesses were also stunned when the abuse incident occurred. The Administrator stated both the CNA student and Unlicensed Staff F were afraid of Licensed Staff E. Administrator stated facility staff were trained to report abuse allegations immediately. She stated the expectation was that abuse allegations be reported to her within 30 minutes. She stated that on this incident, the protocol was not followed. Administrator stated late reporting of abuse incidents could place residents at risk for harm. During a review of facility's policy and procedure titled, Abuse-Prevention Program and Abuse-Reporting and Investigation, both policies revised on 11/2016, stated the facility must ensure the 056296 Page 6 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few health, safety and comfort of residents by preventing abuse and allegations of abuse are to be reported to the Administrator/Designee immediately. Review of facility policy and procedure Abuse - Reporting & Investigations, last revised on 11/15/15, indicated, Purpose: To protect the health, safety, and welfare of Facility residents by ensuring that all reports of resident abuse, mistreatment . are promptly and thoroughly investigated. Policy: The facility will report all allegations of abuse as required by law and regulations to the appropriate agencies. 056296 Page 7 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to appropriately respond to resident abuse allegations for two of three residents sampled for abuse (Residents 207 and 12), when: Residents Affected - Some a. Resident 207's abuse allegation was not promptly reported and investigated, and failed to suspend from duty the staff member who was the alleged perpetrator, and b. The facility failed to complete and maintain documentation of a thorough investigation of Resident 12's abuse allegation, with the alleged perpetrator reinstated back to work after 45 minutes of suspension. These failures had the potential to result in further abuse of Resident 207 and Resident 12, and other vulnerable residents from the staff member. Findings: a. During an interview on 2/1/22 at 10:54 a.m., Administrator stated she was the facility's abuse coordinator. During a record review and concurrent interview on 2/1/22 at 3:17 p.m., a progress note in Resident 207's medical record dated 9/3/21 indicated, at 3:16 [family member named] made allegation of verbal abuse against a licensed nurse at facility. [Police department] notified at 5:10pm. [Police officer named] arrived at facility. Circumstances explained to the officer. 1. Allegation made today from an event that occurred supposedly on 7/1/2021 2. The Officer stated what occurred did not rise to the level of abuse; and read to me PC (penal code) 368 defining elder abuse including verbal, physical, etc. Investigation concluded at this point. No further report made as the situation did not meet abuse criteria. Administrator stated she remembered reporting it to the police, but when the police said it was not abuse, she did not do any further reporting or investigation. Administrator verified she did not report it to the ombudsman (resident rights advocate) or the Department, nor did she investigate the allegation. When asked if the police investigated the allegation, Administrator stated they did not. A copy of an email, dated 9/3/21, addressed to Administrator and written by Resident 207's family member, was provided by Administrator. The email indicated that on 7/1/21 Licensed Staff E had yelled the F-word with an impatient, raised voice in response to Resident 207's request for pain medication while she was on the phone with Resident 207. The email further indicated that last month August (August 2021) the writer went to Resident 207's window and observed Licensed Staff E force feeding Resident 207 his medication in a spoonful of applesauce. The email indicated, [Resident 207] was trying to tell him he didn't want to take it with applesauce and when he'd open his mouth to speak [Licensed Staff E] roughly forced the spoon into his mouth. During a record review on 2/1/22 at 4 p.m., Administrator provided an untitled document dated 9/3/21 with the allegations of the email dated 9/3/21 followed with the typed statements, Interviewed [Licensed Staff E]. He denied. The police stated not abuse . Spoke with [licensed nurse named]. Med was given . Interviewed all nurses. Everyone noted to give meds with applesauce. The document did not indicate the resident was interviewed or any further investigation into the allegations, and did not indicate any outcome had been determined. 056296 Page 8 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0610 Level of Harm - Minimal harm or potential for actual harm Review of Resident 207's face sheet revealed he was his own responsible party. Review of Resident 207's progress note dated 9/7/21 at 1:14 p.m. (four days after the allegation was received) indicated, SSD (social services director) spoke with resident and asked, 'Are you afraid of anyone that passes medication out to you in the facility?' Resident stated, 'No, I used to be and that was a long time ago.' SSD notified administration of response. Residents Affected - Some Review of Licensed Staff E's time sheets revealed he was clocked in to work the following shifts: 9/4/21 6:30 a.m. to 3 p.m., 9/5/21 6:30 a.m. to 3 p.m., 9/6/21 6:30 a.m. to 3:30 p.m., and 9/7/21 6:30 a.m. to 3:45 p.m. During an interview on 2/3/22 at 4:25 p.m., Administrator stated Licensed Staff E was not suspended from work after Administrator received the allegation of verbal abuse on 9/3/21. Administrator verified Licensed Staff E worked at the facility between 9/4/21 and 9/7/21, which was the day Resident 207 was asked if he was afraid of any staff. When asked if the email dated 9/3/21 would be considered a report of abuse, Administrator stated, Yes, that's why I called the police. When asked if the allegation should also have been reported to the Department and the ombudsman, Administrator stated she did not consider it an allegation of abuse anymore when the police said it was not abuse. When asked if a prompt and thorough investigation was completed per policy, Administrator stated she got written statements from the nurses that Resident 207 took his medications in applesauce and asked Resident 207 if he was afraid of anyone. When asked if a thorough investigation included an interview with the resident involved, Administrator stated, Yes, and stated the interview with Resident 207 on 9/7/21 was an afterthought. During an interview on 2/15/22 at 2:21 p.m., Ombudsman confirmed she had not been notified by the facility of the abuse allegation made against Licensed Staff E by Resident 207's family member. During an interview on 5/24/22 at 11 a.m., Licensed Staff E stated he never used curse words around residents and he never forced pills into Resident 207's mouth. When asked how he would respond if a resident who always took their pills in applesauce changed their mind, Licensed Staff E stated that if a resident changed their mind and wanted pudding instead of applesauce, he would get them pudding. During an interview on 7/21/22 at 9:35 a.m., when asked about the potential outcome to residents if abuse allegations were not reported and investigated, Administrator stated there could be continued abuse. b. Resident 12 was [AGE] years old with a diagnosis of Major Depression with Psychotic features (a mental disorder in which a person has depression along with loss of touch with reality)and Lewy body Dementia (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function.). Review of Resident 12's MDS (Minimum Data Set-a resident assessment instrument) assessment dated [DATE], indicated Resident 12 was interviewable and Resident 12's Brief Interview for Mental Status (BIMSa structured evaluation aimed at evaluating aspects of cognition in elderly patients) score was 11 which indicated moderate impairment During a concurrent observation and interview on 7/27/22 at 3:38 p.m., Resident 12 was in bed and awake. Resident 12 stated her name. During an interview on 7/27/22 at 3:43 p.m., Licensed Staff G stated she received a report from the night shift charge nurse that Resident 12 made an allegation against unlicensed Staff H. Licensed 056296 Page 9 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0610 Staff G stated the report included Resident 12 stating Unlicensed Staff H grabbing her arm and hitting her. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and SOC 341 and witnessed statement record review on 7/27/22 at 4:11 p.m., Administrator stated the incident occurred early in the morning, about 2 a.m. She stated she received a call from the staff and was notified that Resident 12 had alleged that Unlicensed Staff H was hitting her and hurting her. She stated Resident 12 had a history of making allegations. Administrator stated law enforcement was called about the abuse allegation. Law enforcement went to the facility and interviewed Resident 12 after which the law enforcement deemed Resident 12's allegation unsubstantiated. Administrator stated when she learned about the allegation, Unlicensed Staff H was placed on 45 minutes suspension. She stated Unlicensed Staff H remained in the building at the front lobby during the time he was suspended. Administrator stated Unlicensed Staff H was reinstated after 45 minutes because there were witnesses that can attest the allegation did not occur. Administrator further stated she reinstated Unlicensed Staff H because law enforcement deemed the allegation unsubstantiated. Residents Affected - Some During an interview on 7/28/22 at 10:48 a.m., Administrator stated she decided to place Unlicensed Staff H back on the floor based on written statements and the police determination that the allegation was unfounded. She stated Unlicensed Staff H was reliable and the fact that there was another staff who had visually observed how careful and gentle Unlicensed Staff H was while working with Resident 12, she deemed it appropriate to lift Unlicensed Staff H's suspension and put him back on the floor. Administrator stated Resident 12 was removed from Unlicensed Staff H care, however, he continued to work on the same wing. Administrator stated had this been any other incident, she would have at least made a visual confirmation that Resident 12 was okay and conduct an interview if Resident 12 was able. Administrator stated these were not done prior to lifting Unlicensed Staff H suspension due to the time of alleged incident. Administrator was made aware that based on Resident 12's MDS assessment, she was interviewable and had a BIMS score of 11. When presented with this information, Administrator stated she did not interview Resident 12 because she had history of making up stories. The Administrator once again mentioned the early morning timing of the abuse. Administrator stated she had instructed the nurse to wait on police determination before allowing Unlicensed Staff H back on the floor. Administrator stated this was not the first allegation of abuse against Unlicensed Staff H. During a phone interview on 7/28/22 at 10:31 p.m., Licensed Staff I stated Resident 12 was being cared for alone by Unlicensed Staff H. Licensed Staff I stated Unlicensed Staff H was changing Resident 12's incontinence (loss of bladder and/or bowel control) pad by himself. She stated that while Unlicensed Staff H was providing incontinence care to Resident 12, Unlicensed Staff J was by the door and had seen and heard how Unlicensed Staff H cared for Resident 12, calmly and nicely. Licensed Staff I stated she heard Resident 12 yelling and that was when she came into the room and Resident 12 then told her how Unlicensed Staff H was hurting her. Licensed Staff I verified there were no visible marks on Resident 12 when she did her assessment. During an interview on 7/28/22 at 1:41 p.m., Director of Nursing (DON) stated for an investigation to be thorough and to prove the abuse did not occur, the Abuse Coordinator, or in this case, the Administrator, should interview the resident and staff and request for witness statements, check for injuries and harm, notify police and review their findings. DON stated it would be difficult to prove/unsubstantiate an abuse allegation without doing these tasks first. She stated 45 minutes of staff suspension may not be enough to prove or disprove whether an abuse occurred. She stated it was important to verify the findings with your own eyes. She stated that not thoroughly investigating an abuse 056296 Page 10 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some could lead to repeat offense, or incident happening again. She stated this could lead to harm, emotional distress, fear and being distressed all the time. During an interview on 7/28/22 at 2:19 p.m., Administrator stated she defines thorough investigation, among other things, as speaking to all parties involved and interviewing resident if they were able to. She stated that on this case she deemed it unnecessary to talk to Resident 12 because the incident was simple and Resident 12 was strictly a behavioral resident. Administrator stated there was also a reliable RN (registered nurse) who reported the incident and a CNA who briefly saw what happened. Administrator also added that Resident 12 had history of making up stories and police officer's stating the allegations were unfounded. When Administrator was reminded again that Resident 12 was interviewable and had a BIMS score of 11, Administrator was quiet. Review of facility policy and procedure Abuse - Reporting & Investigations, last revised on 11/15/15, indicated, Purpose: To protect the health, safety, and welfare of Facility residents by ensuring that all reports of resident abuse, mistreatment . are promptly and thoroughly investigated. Policy: The facility will report all allegations of abuse as required by law and regulations to the appropriate agencies. Procedure: I. Administrator as Abuse Prevention Coordinator A. When the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment . the Administrator or designee, will initiate an investigation immediately . II. Immediate Action A. The administrator or designee will provide for a safe environment for the resident as indicated by the situation . ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with facilities [sic] policies. The administrator or designee conducting the investigation will interview individuals who may have information relevant to the allegation. i. Individuals who may have information . are the resident . Notification of Outside Agencies of Allegation of Abuse when No Serious Bodily Injury . The administrator or designee will notify Law enforcement, LTC (long-term care) Ombudsman, and CDPH Licensing and Certification by telephone immediately or as soon as practicable, and in writing . within twenty-four (24) hours including weekends . 056296 Page 11 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide discharge documentation for one resident (Resident 157). This failure had the potential for Resident 157 to leave the facility without proper care and services to maintain her health. Findings: During a Medical Record Review on 7/28/22 at 13:00 p.m., the closed record for Resident 157 did not contain the required discharge documentation (e.g., discharge summary signed by the physician, a list of medications, a care plan .). During an interview on 7/28/22 at 13:55 p.m., the Social Service Director (SSD) was asked what the process was for preparing a resident for discharge to home. The SSD stated there should be: a resident assessment, a discharge summary signed by the physician, a nurse assessment, pre-discharge assessment with instructions and medication list, arrangements for home health care [if needed], appointments for follow-up visits with a physician, physical therapy [if needed], and a care plan. The SSD confirmed the required documents were not in the closed medical record for Resident 157. During an interview on 7/28/22 at 14:10 p.m., Administrator was asked where the closed record documents were located for Resident 157. The administrator stated the facility was transitioning over to a total EMR (electronic medical records) system and there were still documents in paper files and the rest of the documents should be in the EMR. The documents for Resident 157's discharge on [DATE] was requested from the Medical Records Director, however, only the discharge nursing assessment was provided (without the resident and responsible party signatures). Review of the facility Policy and Procedure titled, Filing Discharge Charts dated, January 1, 2020, indicated, the medical record of a resident who has been discharged will be reviewed for completion and filed in a specific order at the time of discharge from the facility . VIII. These forms will be filed in the record . A. admission Record/ Face sheet, D. Discharge to home form/Continuity of Care Form/Post Discharge Plan of Care . 056296 Page 12 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Rsident 26 Residents Affected - Few Record review indicated Resident 26 was admitted to the facility on [DATE] with medical diagnoses including Paranoid Schizophrenia (A serious mental disorder in which people interpret reality abnormally) and Chronic Pain, according to the facility Face Sheet (Facility demographic). Record review indicated Resident 26's MDS dated [DATE] indicated his BIMS score was 2, which indicated his cognition was severely impaired. Record review also indicated Resident 26 required extensive assistance of one person for personal hygiene and was totally dependent on staff for showers. During a concurrent observation and interview on 7/25/22 at 3:39 p.m., Resident 26 indicated he had no concerns about his care at the facility, but his hair and beard were long, unkept, soiled and greasy as well as the clothes he was wearing. Record review of Resident 26's shower schedule from 7/1/22 to 7/27/22 indicated he had only received three showers, as only three shower sheets were available. Record review also indicated Resident 26 was only scheduled to receive one shower or bed bath per week, and his shower/bed bath was scheduled to be given during the night shift. During an interview with the Director of Nursing (DON) on 7/27/22 at 10:23 a.m., she confirmed Resident 26 was only scheduled to receive one shower/bed bath per week, and stated that was based on his preference. When asked if his preference was documented, the DON stated it was not. When asked if Resident 26's care plan reflected his preference, the DON stated it did not. When asked the reason Resident 26 was scheduled to receive showers at night time, the DON stated it was his preference. When asked if this was documented, the DON stated it was probably not documented. The DON confirmed there were only three shower sheets for Resident 26 for the month of July 2022, which indicated he had received only three showers/bed baths. The DON stated Certified Nursing Assistants (CNAs) were required to fill out shower sheets every time they provided residents with showers or bed baths. The DON was asked how the facility kept track of the showers/bed baths provided to the residents. The DON provided the Surveyor with the resident census in which she marked the residents for which no shower sheets were filed for periods of one week. This document indicated there were no shower sheets on file for 11 residents from 7/04/22 through 7/10/22. This document also indicated there were no shower sheets on file for 10 residents from 7/18/22 through 7/24/22. According to the DON, showers/bed baths were important for infection control purposes, cleanliness, peace of mind and comfort levels. During an interview on 7/28/22 at 2:51 p.m., Unlicensed Staff A stated the CNAs were required to fill out residents' shower sheets every time they gave residents a shower or bed bath, and added that if the resident refused the shower or bed bath, they had to attempt two more times, and by the third time, the Licensed Nurse assigned to the resident's care had to be notified. Unlicensed Staff A also stated shower/bed bath refusals had to be documented on the shower sheets. Record review of the facility policy titled, Bed Baths, last revised in October of 2020, indicated, A bed bath is given to residents to promote cleanliness and comfort and to stimulate circulation . Residents are given bed baths as scheduled. Record review of the facility polity titled, Showering and Bathing, last revised in January of 2020, indicated, A tub or shower bath is given to the residents to promote cleanliness, comfort and to 056296 Page 13 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0677 prevent body odors. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy titled, ADL (Activities of daily living-Daily tasks for self-care) Documentation, last revised in July of 2020, indicated, The Facility will ensure documentation of the care provided to the residents for completion of ADL tasks. Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide weekly showers and honor shower requests for two of three sampled residents (Residents 208 and 26) for ADLs (Activities of Daily Living). These failures resulted in residents, who were vulnerable and dependent on staff for ADL care, to be unkempt, feel neglected and unclean, and had the potential to negatively impact the resident's physical and psychosocial wellbeing. Findings: Resident 208 During an interview on 7/26/22 at 2 p.m., Resident 208 stated she was going to request for a shower today. Resident 208 stated she had been in the facility for about two weeks but had yet to have a shower. Resident 208 stated she was initially told her shower days were Mondays and Thursdays, but another staff had told her different days. Resident 208 stated the confusion over the schedule could not have been the only reason she had not had a shower. Resident 208 stated she asked staff for a shower last week and was told, they were too busy. Resident 208 stated she had to take herself to the bathroom the other night to wash her hair and give herself a sponge bath by the sink. Resident 208 stated, I remember it was two in the morning. I was starting to get itchy and uncomfortable; I couldn't sleep because of it. I had to do it myself. Resident 208 paused, looked down and stated in a sorrowful voice, I told them that I need help that's why I'm in this place. If they're going to be too busy to help me, then I should have stayed home. A review of Resident 208's admission Record indicated she was admitted to the facility on [DATE] with diagnoses that included muscle weakness, fall, and need for assistance with personal care. Resident 208's MDS (Minimum Data Set - a clinical assessment process providing a comprehensive assessment of a resident's functional capabilities and helps staff identify and address care needs), dated 3/9/22, indicated Resident 208 had a BIMS (Brief Interview of Mental Status) score of 13 (cognitively intact), and needed physical help in part of bathing activity. Resident 208's Plan of Care, dated 7/12/22, ADL self care performance deficit interventions indicated, BATHING: I require staff participation with bathing. During an interview on 7/27/22 at 3:43 p.m., the DON stated residents should get at least two showers a week. The DON stated the assignment sheets contain shower schedules of room and bed numbers, but staff had found the current process too difficult to understand because of frequent room changes. The DON stated, Yes, I could see how showers could be missed. When asked, the DON stated it was not acceptable to say I'm too busy when a resident requests a shower outside of their schedule. The DON stated, If a resident requests for it, then we should try our best to honor their request. During an interview on 7/28/22 at 9 a.m., Resident 208 stated did not get a shower the other afternoon and was told that it was not her scheduled shower day. Resident 208 stated she gave herself another sponge bath sink that night. 056296 Page 14 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility policy titled, Resident Rights, dated 10/16/2021, indicated, Resident's (sic) have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care . Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, assessments and plans of care, including: A. Sleeping, eating, exercise and bathing schedules . 056296 Page 15 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow-up with a cardiology referral for one of three residents (Resident 41) with an artificial cardiac pacemaker (A small device that's placed (implanted) in the chest to help control the heartbeat), for more than six months after the primary care physician ordered the referral. This failure had the potential to result in malfunction of the pacemaker, delay in care, and possible harm or death to Resident 41. Residents Affected - Few Findings: Record review indicated Resident 41 was admitted to the facility on [DATE] with medical diagnoses including Chronic Atrial Fibrillation (A type of heart disorder marked by an irregular or rapid heartbeat), and Pulmonary Hypertension (A type of high blood pressure that affects the arteries in the lungs and the right side of the heart), according to the facility Face Sheet (Facility demographic). Record review indicated Resident 41's MDS (Minimum Data Set-An assessment tool) dated 5/21/22, indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) score was 14, which indicated his cognition was intact. During an interview on 7/25/22 at 9:50 a.m., Resident 41 stated he was supposed to see his cardiologist, whom he had not seen in over a year, and was concerned because he had a pacemaker. Resident 41 stated he had not had a full heart assessment while at the facility. Record review indicated physicians' orders for Resident 41, dated 11/02/21, indicated, Referral to see [Cardiologist's name, City and State]: Residents Cardiology for Patient follow up. Record review of a second cardiology referral in physicians' orders, dated 5/30/22, indicated, Referral to [Cardiologist's name], cardiology, [City and State]. During an interview on 7/26/22 at 3:40 p.m., the Medical Records Department was requested to provide all evidence of follow-ups regarding Resident 41's physicians' orders dated 11/02/21 for a cardiology referral, but they only provided (on 7/27/22 at 10:45 a.m.) a referral sent to a Cardiologist clinic on 12/01/21, with no follow-up, no actual appointments with a Cardiologist, and an undated document written by the Social Services Director that indicated, Original referral was sent to [Name of Cardiology agency] Cardiology on 12/1/21 by [Previous Social Services Director]. During an interview on 7/27/22 at 10:52 a.m., the Social Services Director stated not being aware that Resident 41 had a pacemaker. She also stated she started working for the facility in May of 2022, and did not find out about Resident 41's referral to Cardiology until June of 2022. The Social Services Director stated as soon as she found out about the referral, she started working on it. She also stated she confirmed Resident 41 had a pacemaker, and provided Resident 41's pacemaker card with specific information about the type and [serial] number of the pacemaker. During an interview on 7/27/22 at 11:04 a.m., the Administrator stated not being aware that Resident 41 had physician's orders for a cardiology referral. The Administrator stated she oversaw the work of the Social Services Director. During a second interview with the Administrator on 7/28/22 at 11:50 a.m., the Administrator stated the Social Services Department was required to follow-up on physician referrals right away. When asked how she verified the Social Services Director was fulfilling 056296 Page 16 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0684 Level of Harm - Minimal harm or potential for actual harm her responsibilities, the Administrator stated they had stand-up meetings, but did not describe how these meetings aided in ensuring resident referrals were being followed-up on. During a second interview with the Social Services Director on 7/28/22 at 11:53 a.m., she confirmed there was no documentation of any follow-ups for Resident 41's cardiology referral ordered on 11/02/21. Residents Affected - Few Record review of the facility policy titled, Referrals to Outside Services, last revised in December of 2020, indicated, The Director of Social Services coordinates the referral or residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility . All service provider contracts are obtained from and reviewed by the Administrator The Director of Social Services is responsible for locating agencies and programs that meet the needs of residents, facilitating the execution of service provider contracts, and referring residents to existing contracted providers. 056296 Page 17 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address significant weight loss and provide nutritional and hydration services to one of six sampled residents (Resident 158), consistent with the resident's comprehensive assessment. This failure resulted in significant weight loss, and had the potential to result in further weight loss, malnutrition and dehydration for Resident 158. This finding also may have contributed to Resident 158's rapid decline in April of 2022, which lead to Resident 158's death. Residents Affected - Some Findings: Record review indicated Resident 158 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar)and History of Poliomyelitis (A viral disease which may affect the spinal cord causing muscle weakness and paralysis), according to the facility Face Sheet (Facility demographic). Nursing notes dated 4/21/22 at 5:54 p.m. indicated Resident 158 passed away the evening of 4/21/22 at the facility. Record review of Resident 158's MDS (Minimum Data Set-An assessment tool) dated 4/04/22 indicated Resident 158 required extensive assistance of one staff for eating. Record review of Resident 158's weight taken right after admission, on 10/27/17, indicated her weight was 150 lbs. A gradual weight loss occurred throughout the time she was living at the facility. By 3/21/22 at 6:55 a.m., Resident 158's weight was recorded as 121.1 lbs, a 25% weigh loss from her original admission weight. On 4/19/22 at 8:27 a.m., Resident 158's weight as recorded as 95.4 lbs, a 36% weight loss from admission, and a 21.9 % weight loss from 3/21/21. According to this document, Resident 158 lost 21.9% of her body weight in less than one month, from 3/21/22 to 4/19/22. This significant weight loss was confirmed by a change of condition summary note documented by the Director of Nursing (DON) dated 4/20/22 at 8:14 p.m., which indicated, The resident's weight has been declining, but has rapidly declined within the last week. Record review of physicians' orders dated 2/16/22 and active in April of 2022, indicated, CCHO (Controlled carbohydrate diet) NAS (No added salt) diet Mechanical Soft (A type of texture-modified diet for people who have difficulty chewing and swallowing) with chopped meat texture, Thin liquids consistency, Fortified diet (Nutrients added to the food), Provide finger goods whenever possible to promote independence with meals. Record review of a facility document titled, Documentation Survey Report v2, indicated the meal and fluid percentages ingested throughout the month of April, 2022 by Resident 158. According to this document, on 4/01/22, 4/02/22, 4/04/22, 4/11/22, 4/13/22, and 4/21/22, the fluid and meal percentages were not recorded for the breakfast meal. It could not be determined if Resident 158 was assisted with meals on these six occasions. No lunch percentages were recorded for 4/01/22, 4/02/22, 4/04/22, 4/13/22, 4/20/22 and 4/21/22 (six meals). Dinner percentages were not documented either, on 4/01/22, 4/03/22, 4/06/22, and 4/17/22. During an interview on 7/28/22 at 3:42 p.m., the Director of Nursing (DON) was asked how she knew Resident 158 was being assisted with meals, or eating, throughout the month of April 2022, in which she had a significant weight loss, if the documentation was incomplete. The DON stated that if a resident did not have complete documentation of meal percentages, there was no evidence she was assisted with meals. 056296 Page 18 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a phone interview on 7/29/22 at 9:05 a.m., with Registered Dietician Y, assigned to Resident 158, she was asked if she was aware of the percentages of meals and fluids consumed by Resident 158 were not documented for several days in April of 2022. Registered Dietician Y did not answer this question and stated she typically asked staff during interdisciplinary team meetings for any clarifications. When asked if it was part of her assessments to check documentation of meals consumed by residents with significant weight losses to ensure they were being assisted with meals, if required, Registered Dietician Y stated it was not her job to be checking clinical documentation. During a phone interview on 7/29/22 at 9:19 a.m., Registered Dietician Z, Head of the Dietary Department, stated Registered Dieticians did have to look at percentages of meals consumed by residents with significant weight losses. During a phone interview with Witness AA on 07/29/22 at 8:10 a.m., she stated she observed Resident 158's meal trays left by her bedside table untouched, with unopened boxes of milk and food containers several times. Witness AA stated staff were not assisting Resident 158 with her meals. Witness AA stated staff eventually would remove the trays from Resident 158's bedside table before she could inquire about them. Witness AA stated Resident 158 actually gained weight during periods of time when she was able to visit her at the facility and assist her with meals. Witness AA stated Resident 158 was unable to feed herself. Record review of the policy titled, WEIGHT VARIANCE AND NUTRITION AT RISK, last revised in March of 2022, indicated, The Facility will work to maintain an acceptable nutritional status for residents by: A. Assessing the resident's nutritional status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status. B. Analyzing the assessment information to identify the medication conditions, causes and/or problems related to the resident's condition and needs. C. Defining and implementing interventions for maintaining or improving nutritional status that are consistent with resident needs, goals and recognized standards of practice. Record review of the facility policy titled, Feeding the Resident, last revised in January of 2021, indicated, Assistance is provided with eating for residents as needed . Percentage of diet consumed is recorded on the appropriate form in the resident's medical record . Report any deviation in appetite to the Charge Nurse and record in the resident's medical record. 056296 Page 19 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 oxygen therapy in accordance with standards of practice for two of two sampled residents (Residents 34 and 54) for respiratory care when: Residents Affected - Some a. Resident 34's oxygen was connected to an empty humidifier for two days, and b. Resident 54's oxygen tubing was unlabeled. This failure resulted in Resident 34 to experience dry and painful nostrils (nose) due to inadequately humidified oxygen, and the use of unlabeled oxygen tubing increased the risk for Resident 54 to develop respiratory infections. Findings: a. During an observation on 7/25/22 at 3:30 p.m., Resident 34 was asleep in bed. Resident 34 was observed wearing a nasal cannula connected to an oxygen concentrator (Oxygen concentrators take in air from the room and filter out nitrogen. The process provides the higher amounts of oxygen needed for oxygen therapy). The oxygen was running at 5 liters per minute. A bottle of empty humidifier water dated 7/19/22 was connected to the concentrator. During an observation on 7/26/22 at 10:29 a.m., the same empty humidifier bottle was found on Resident 34's concentrator. During a concurrent interview, Resident 34 stated she uses oxygen continuously, and that her nose had been dry and painful lately. A review of Resident 34's admission Record indicated she was admitted with diagnoses that included chronic obstructive pulmonary disease (a group of long-term lung diseases that block airflow and make it difficult to breathe). During an interview on 7/26/22 at 10:42 a.m., Licensed Staff G stated oxygen tubing and supplies get changed every seven days. Licensed Staff G stated, I was just there this morning, it was fine, and added that Resident 34's oxygen setup was supposed to be changed tonight. When asked if the humidifier bottle lasts a full seven days on continuous use, Licensed Staff G did not respond. During an interview on 7/27/22 at 3:59 p.m., the DON stated oxygen equipment got changed every Tuesday and as needed. The DON stated she expected the staff to include checking the residents' bedsides, including their equipment, as they go into the room. When queried about Resident 34's empty humidifier bottle, the DON stated, That should have been changed as soon as it was seen, if the nurses were really looking at it. b. Resident 51 was [AGE] years old with a diagnosis of Epilepsy (disorder of the brain characterized by repeated seizures) and Anoxic Brain Damage (harm to the brain due to a lack of oxygen.) During an observation on 7/25/22 at 11:22 a.m., Resident 51 was in bed, asleep. She was receiving oxygen at 2 liters per minute via nasal cannula. The nasal cannula was undated. During an observation on 7/26/22 at 10:15 a.m., the nasal cannula was still undated. 056296 Page 20 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 7/26/22 at 3:47 p.m., Unlicensed Staff C verified Resident 51's nasal cannula was not dated. She stated nasal cannula's should be changed and dated for infection prevention. She stated this was an infection control issue. During an interview on 7/26/22 at 3:55 p.m., Licensed Staff D stated it was the facility's policy to change and date the nasal cannula. She stated nasal cannula's should be changed weekly. She stated staff should put a date on when the nasal cannula was changed. She stated this was an infection control measure. She stated that in this particular case, Resident 51 had an oxygen humidifier (a medical device used to humidify supplemental oxygen.) Licensed Staff D stated water could be trapped in nasal cannula tubing and cause molds formation. She stated this could affect Resident 51's breathing. Licensed Staff D stated the facility's policy was not followed when the tubing was not dated and changed weekly. During an interview on 7/27/22 at 11:00 a.m., Infection Preventionist (IP) nurse stated the facility's policy was for staff to change the nasal cannula weekly. IP stated the new nasal cannula's should be dated. She stated if the nasal cannula was not dated then the nasal cannula could be considered not changed. She stated that if the nasal cannula was not dated when it was changed, then the facility policy was not followed. IP stated this was an infection control issue and residents could get sick with respiratory infection. During an interview on 7/28/22 at 2:57 p.m., Director of Nursing (DON) stated the facility policy was for staff to change and date nasal cannula weekly. DON stated if that was not the case then the policy was not followed. She stated this was an infection control issue. DON stated this practice could put residents at risks for respiratory infection. A review of facility's policy and procedure (P/P) titled, Oxygen Therapy, revised 5/15/21, indicated, oxygen therapy was to be administered under safe and sanitary conditions to meet resident needs. It stated oxygen tubing, mask, and cannulas should be changed no less than every seven (7) days and as needed. 056296 Page 21 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six residents (Resident 158) sampled for pain, received adequate pain management consistent with nursing standards of practice, the resident's individualized care plan and facility policy. Licensed nurses did not implement interventions to reduce her pain, on several occasions when her pain was as high as 8/10 (Pain Scale: a tool health care professionals utilize to help assess a person's pain; the pain scale is from 0 to 10, where 0 is no pain, and 10 is the worst pain imaginable). This had the potential to result in feelings of helplessness, suffering, and extreme discomfort for Resident 158. Residents Affected - Some Findings: Record review indicated Resident 158 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar)and History of Poliomyelitis (A viral disease which may affect the spinal cord causing muscle weakness and paralysis), according to the facility Face Sheet (Facility demographic). Nursing notes dated 4/21/22 at 5:54 p.m. indicated Resident 158 passed away the evening of 4/21/22 at the facility. Record review of Resident 158's care plan for pain, indicated, Goal: I will remain free from pain or at a level of discomfort acceptable to the resident through the review date .Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness .Heat/cold applications as ordered and as tolerated. Record review indicated Resident 158 had two prescriptions for pain medications for the month of April, 2022. The first physician order, dated 3/29/22 at 7:33 a.m., indicated, Norco (HYDROcodone-Acetaminophen - A controlled medication used to treat moderate to severe pain) Tablet 5-325 MG (milligrams) Give 1 tablet by mouth two times a day for pain. This medication was scheduled at 9:00 a.m. and 9:00 p.m., daily. In addition to this order, Resident 158 had a second prescription for pain medication to be administered as needed. The second physician order, dated 3/29/22 at 7:08 a.m., and active in April of 2022 indicated, Norco Tablet 5-325 MG Given 1 tablet by mouth every 6 hours as needed for breakthrough pain DO NOT MEDICATE PRN (as needed) MORE THAN 2X (Two times) in 24 Hrs (Hours). During an interview with the Director of Nursing (DON) on 7/28/22 at 11:19 a.m., she was asked what Licensed Nurses were required to do if they noted residents were having pain levels of 5/10 or higher. The DON stated Licensed Nurses were required to give analgesics as needed, and mentioned a few different types. She also stated Licensed Nurses were required to notify the physician and document the pain levels. The DON stated it was not acceptable to document a high pain level and fail to implement any interventions to help manage it. Record review of Resident 158's Medication Administration Record (MAR) for April, 2022, indicated Resident 158 had a pain level of 7/10 on 4/05/22 at 10:00 a.m. Resident 158's MAR and entire medical record had no documentation of interventions implemented to manage or reduce this pain level. No pharmacological (Interventions consisting of administering medications) or non-pharmacological (Interventions not consisting of medication administration) interventions were recorded, and the only PRN pain medication available, the Norco tablet 5/325 mg was not documented as administered. Resident 158's MAR for April, 2022, also indicated she had pain levels of 8/10 at 10:00 a.m., and 6/10 at 2:00 p.m., and no interventions (pharmacological or non-pharmacological) were documented to help manage her pain. Again, on 4/13/22, Resident 158's pain levels were documented as 5/10 at 10:00 a.m., and 5/10 056296 Page 22 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0697 Level of Harm - Minimal harm or potential for actual harm at 2:00 p.m. with no interventions (pharmacological or non-pharmacological) documented to help relieve her pain. The DON was asked to provide all evidence of interventions to manage Resident 158's pain levels during the above dates and times in April of 2022. On 7/28/22 at 3:26 p.m., the DON provided a few clinical progress notes, in response to this request, and stated, That is all I have. The progress notes did not indicate any interventions to manage the high pain levels documented. Residents Affected - Some During a phone interview with Witness AA on 7/29/22 at 8:10 a.m., she stated she observed Resident 158 on several occasions, on excruciating pain, crying and saying, It hurts, and making verbal expressions of pain. Witness AA stated staff would not medicate Resident 158 to help relieve her pain, even when she requested it. During a phone interview with Witness BB on 07/28/22 at 4:20 p.m., he stated he heard Resident 158 say, It hurts, please help me, several times and staff would not give her pain pills because they were too busy. Record review of the facility policy titled, Pain Management, last revised in August of 2019, indicated, A Licensed Nurse will assess residents for pain on admission, quarterly, when there is a new onset of pain, or significant change in condition. Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible . The Licensed Nurse will document resident's pain and response to interventions in the medical record on the weekly summary and as indicated on the progress notes. 056296 Page 23 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview and record review, the facility failed to have sufficient nursing staff to provide nursing services to ensure resident safety and meet the healthcare needs of the residents, when: Residents Affected - Some a. the facility failed to provide sufficient Licensed Nurses and Certified Nursing Assistants (CNAs) to meet resident's needs; and b. the facility failed to ensure Licensed Staff B had the appropriate competencies and skills to provide care to the resident population. These failures placed residents at risk of not achieving their highest practicable physical, mental, and psychosocial well-being, and placed them at risk of serious harm or death. Findings: During a concurrent observation and interview on 7/25/22 08:48 a.m., Resident 31 rang the [hand-held] bell at 8:50 a.m. for a few minutes but no staff came to answer her bell. Resident 31 stated she needed help repositioning herself. She stated current position in bed was getting uncomfortable. Resident 31 rang the bell again at 8:55 a.m. and no staff came to answer her bell. Resident 31 was becoming anxious. She stated staff was great but wished they were more attentive to resident's calls for help. She stated this was not the first time staff took a while to answer her bell. She stated it was frustrating to be waiting and waiting. At 9:00 a.m., the Director of Nursing (DON) attended to Resident 31's bell. Total wait time was 10 minutes. DON was silent when asked if this was a normal wait time for staff to answer call bell. During an interview on 7/27/22 at 12:40 p.m., Unlicensed Staff A stated that, for the most part, there was sufficient staffing. He stated sometimes there would be emergency calls offs. He stated when this occurred, the CNA's working on the floor would divide the absent staff's residents amongst themselves. He stated this placed additional residents on each CNA's workload and they were finding it hard to complete their tasks on time. He stated there were only four CNA's scheduled to work on a.m. and p.m. shifts (which would be 15-16 residents for each CNA to care for). During an interview on 7/28/22 at 11:16 a.m., the Administrator stated the Director of Nursing (DON) was off on Thursdays and Fridays. The Administrator stated DON only worked on the floor after her 8 hour shift or during her days off. The Administrator stated the facility scheduled two [licensed] nurses on each shift. The Administrator stated the treatment nurse comes daily on weekdays. The Administrator stated there were four CNA's on a.m. and p.m. shift and three CNA's on night shift for a census of 59-63. She stated the facility census for today was 62. When asked about workload of 31 residents per nurse, 20 to 21 residents per CNA's on night shift, and if staff were able to complete their tasks during their shift, the Administrator was momentarily silent. She then stated if there were CNA call-offs, nurses could also work as CNA's. The Administrator stated she adjusted the schedule based on acuity (intensity of care) and the facility census. On 7/28/22 at 4:20 p.m., during a concurrent interview and nurse schedule record review for the month of July the Administrator verified that on 7/8/22 and 7/22/22, the facility did not have a registered nurse for eight hours in the building. The Administrator was silent when asked about the risk 056296 Page 24 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0725 of not having a registered nurse in the building. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/28/22 at 1:51p.m., the DON stated the facility was not adequately staffed. The DON stated she was very vocal and would always tell the Administrator that the facility needed more nurses and CNA's on the floor. She stated staff would be able to provide more care if there were more staff on the floor. She stated medication pass alone was heavy with only 2 nurses on the floor. DON verified there were four CNA's on the floor on a.m. and p.m. shift and three CNA's on night shift. DON stated there were two nurses on all shifts, and 1 treatment nurse on weekdays. DON stated sometimes the treatment nurse would come on a weekend. She stated if treatment nurse could not come on a weekend, the nurses on the floor would have to do both medication pass and wound treatments. DON stated this could result to resident missing wound treatments, nurses unable to assess residents for changes in condition and nurses unable to complete their tasks timely. DON stated she had had staff and residents come to her and complain about staff shortage. Residents Affected - Some During an interview on 7/29/22 at 9:38 a.m., Infection Preventionist (IP) and Director of Staff Development/ Minimum Data Set Coordinator (DSD/MDS) both stated they were short staffed. DSD stated she was also the MDS coordinator and usually worked Monday's on the floor (for this month). IP stated she fills in and worked on the floor frequently. DSD/MDS coordinator stated that she was behind on some of her MDS assessments. Both IP and DSD/MDS stated the facility could do more for the residents. IP stated the risk for being short staffed would be staff forgetting something important then causing harm to residents. DSD/MDS stated the reason why there was such difficulty finding staff to work was because the caseload in the facility was heavy. DSD/MDS stated it was difficult to work on the floor with so many residents. She stated that having two nurses on the floor with 31 residents each can cause increased medication errors, increased falls and decreased time to assess residents properly. During an interview on 7/29/22 at 9:51a.m., the DON was observed to be working in the COVID unit. DON stated she worked as charge nurse frequently and that she was behind on a lot of her DON tasks. She stated she was unable to give the exact dates when she worked as a charge nurse. She stated she worked as charge nurse to fill in shifts, not just on her days off. She stated she was emotionally and physically exhausted. She stated there was no back up DON if she worked as a charge nurse on the floor. During a concurrent interview and orientation/skills checklist record review on 7/29/22 at 10:08 a.m., the DSD/MDS was emotional and was crying. She stated she felt like she was letting the facility down. She stated that a lot of things gets missed because she was doing MDS and DSD tasks and she often worked as charge nurse on the floor. DSD/MDS verified the skills check for mechanical lift and gait belt usage for Licensed Staff B was not done prior to Licensed Staff B's orientation on the floor. DSD/MDS also verified Licensed Staff B's clinical competency was not done. DSD/MDS stated the skills check for mechanical lift and gait belt usage was supposed to be done prior to Licensed Staff B's orientation on the floor. DSD/MDS stated these skills-checks were not done because she was working as a charge nurse on the floor when Licensed Staff B came for her orientation on 7/22/22. She stated that not completing the checklist could be a safety issue for the residents. She stated residents could be at risk for harm if staff were not aware of how to use the mechanical lift and gait belt appropriately and safely. Facility's policy and procedure for Staffing and Onboarding was requested but not provided. 056296 Page 25 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0726 Level of Harm - Minimal harm or potential for actual harm Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Some 1. Evaluate the competencies of the treatment nurse, and 2. Document medication administration assessments for six residents (Resident 13, Resident 21, Resident 22, Resident 38, Resident 56, and Resident 107) on paper medication administration records when the facility power went down. These failures potentially resulted in the treatment nurse misidentifying a pressure injury (also called pressure ulcers or decubitus ulcers; damage to skin and underlying tissues caused by prolonged pressure on the skin) for Resident 207, and had the potential to negatively affect all residents with skin treatments; and resulted in an incomplete medical record for residents. Findings: 1. On 1/20/22, the Department received a complaint that Resident 207 had been sent to an acute care hospital where it was discovered he had multiple, severe pressure injuries on his backside and hips. Review of Resident 207's medical records from the acute care hospital revealed Resident 207 was admitted to the hospital on [DATE]. Resident 207's document titles, History and Physical, dated 11/2/21, indicated, Large decubitus ulcer of the right hip that is unstageable (unable to determine the depth of the wound). Appears to have necrotic tissue (death of most or all the cells) centrally. Copious amounts of foul-smelling purulence drainage (pus) coming from the wound. Resident 207's surgical consult note, dated 11/3/21, indicated, [Resident 207] is a [sic] [AGE] year old male who presents from an [sic] SNF (skilled nursing facility) with bilateral (both right and left sides) pressure ulcers. The right side is worse than the left side. Over the right trochanteric area (bony area of the hip) there was approximately 6 cm (centimeters) area of probable full-thickness (to the underlying muscle or bone) necrotic skin. On the left side over the trochanteric area there is a 1 - 2 cm area of possible dermal necrosis. Resident 207's Operative Report & Post Op[erative] Notes, dated 11/4/21, indicated, Procedure: Debridement (removal of damaged tissue) of necrotic pressure ulcer - right hip. There was an area of necrotic skin of approximately 6 cm in diameter. This necrotic skin . was excised (surgically removed). Thick yellow pus was obtained. Total wound size was 12 - 15 cm. During an interview on 5/24/22 at 11:12 a.m., Adminsitrator stated Licensed Nurse P was the facility treatment nurse. During a record review and concurrent interview on 5/24/22 at 1:12 p.m., Licensed Staff P stated she had been working at the facility for over five years and stated she was wound certified. Licensed Staff P stated she documented skin assessments in the residents' electronic medical records. Licensed Staff P stated she also had a skin binder with a file for each resident that she was treating and listed all the documentation she made including how a wound was healing, how she staged the wound and measured it, how their diagnoses related to the wound, and how cooperative the resident was with 056296 Page 26 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care. When asked about Resident 207's wounds, Licensed Staff P stated Resident 207's wounds were not pressure ulcers. Licensed Staff P stated Resident 207's wounds were self-inflicted and were caused by scratching himself. Licensed Staff P stated Resident 207's wounds would heal and then he would open them back up again. Licensed Staff P stated she had a good relationship with Resident 207 and he cooperated with her treatments. Licensed Staff P opened in the computer Resident 207's document, Weekly Skin check and Wound Assessment dated 11/1/21. The document indicated Resident 207 had skin issues in the areas of his right trochanter and left trochanter, among others. Under section titled Description, the right trochanter area had mechanical pressure documented, and the left trochanter had re-open area frim [sic] scratching TX (treatment) on board with no other information documented. When asked about the term mechanical pressure, Licensed Staff P stated the term meant scratching and it was self-inflicted. When asked where she documented descriptions of the wounds, Licensed Staff P stated, It's right there, mechanical pressure. This is my charting! When asked if she documented the presence of drainage, the size, or the wound's appearance, Licensed Staff P stated she only documented those aspects of a wound if it was a pressure ulcer or if the wound was showing signs of infection. Licensed Staff P stated never in 20 years had she ever been told to describe what scratches looked like. Licensed Staff P verified that Resident 207's skin over his right trochanter had what looked like scratches from fingernails. During an interview on 6/29/22 at 12:44 p.m., Medical Director stated he provided the orders for the treatment of pressure ulcers, and the treatment nurse would update him on whether the treatment was effective. When asked if he examined pressure ulcers during his monthly visits, Medical Director stated he relied on the nurses, which was what any medical director would do. Medical Director stated he gave the nurses carte blanche. When asked if Resident 207's right trochanter wound, which had a six-centimeter area of necrotic tissue down to his muscle and large amounts of purulent drainage, could be caused by scratching, Medical Director stated Resident 207's wound was the result of neurological damage caused by immobility and also the vascular issues that had caused his stroke. In response to a request for Licensed Staff P's competency evaluations, Licensed Staff P's document titled Annual Skills Check dated 5/28/19 was provided. The document listed 34 nursing tasks followed by two sets of initials after each task. Review of the list of tasks included Emergence of New Wounds and no other wound or skin-specific skills. During an interview on 6/30/22 at 10:14 a.m., Director of Nursing (DON) stated she had been the facility's DON for one year. DON stated skills check-offs were supposed to be done once a year, but it's been a train wreck with the virus. DON stated she had not done a skills evaluation with Licensed Staff P. DON stated the purpose of the skills evaluations were to make sure the nurses knew what they were doing. DON verified Licensed Staff P should have had a skills evaluation since 2019. When asked if she had a system to ensure the skills evaluations got done annually, DON stated she had a folder with the nurses names in alphabetical order. DON stated she had tried to get caught up, but there were a few she had missed. DON stated the skills evaluation check list she used for the nurses did not include wound or treatment skills. DON stated she was not sure who evaluated Licensed Staff P on those skills. When asked if wounds were discussed at skin committee meetings, DON stated Licensed Staff P just tells us here and there what's going on, but they did not have skin committee meetings that she knew of. DON stated Licensed Staff P had just begun attending the nutrition and weight meetings. DON stated it was her expectation that signs and symptoms of wound infection should be documented on the treatment administration record as an area to treat. When queried, DON verified signs of wound infection should also be documented in the resident's progress notes. DON reviewed Resident 207's medical record and stated she found a wound progress note written by Licensed Staff P, dated 10/27/21, and began to 056296 Page 27 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some read it aloud. DON read a description of a full-thickness wound 8.1 cm by 6 cm on Resident 207's right hip. When asked if she knew Resident 207 had this wound, DON stated Resident 207 had a history of this because he could not move. DON stated Resident 207 would just sit and sit, he would refuse to get up, he definitely had a history of this. DON verified this wound was both a pressure ulcer and from scratching. During an interview on 7/21/22 at 9:35 a.m., Administrator stated that DON was responsible for evaluating Licensed Staff P's wound and treatment skills. Administrator stated she expected DON to know who she was responsible for evaluating. Administrator stated she expected the skills evaluation to be a return demonstration at the resident's bedside, and she expected the skills evaluation to be completed annually. Administrator verified Licensed Staff P's last skills evaluation was done in 2019 and Licensed Staff P should have had one annually since then. Administrator stated she did not know what system DON used to ensure the annual skills evaluations were completed timely, or a system to know if the skills evaluations were past due. Administrator stated the outcome to residents could be negative if a nurse was not performing skills correctly. Review of facility document Treatment Nurse Job Description, not dated, indicated, Under the direction of the Director of Nursing Services, the Treatment Nurse is responsible for all the treatments that are prescribed by the attending physician for all residents in the facility. Document skin assessment findings during weekly assessment on weekly Nurse's Skin Wound Progress Report form . Review of facility document Facility Assessment Tool, dated 8/18/17, indicated, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Sub-section Staff training/education and competencies indicated, Consider if it would be helpful to indicate which competencies are reviewed at the time the staff member is hired, and how often they are reviewed after that. Further review of the document revealed this information was not included in the assessment. 2. During a complaint investigation for medication administration on 11/15/21 at 9.30 a.m., the Director of Nursing (DON) stated the internet power was down in the facility and in the entire city. During an observation and concurrent interview on 11/15/21 at 9:45 a.m., Licensed Staff AA was administering medications to residents in the [NAME] Hall. Licensed Staff AA was new to the facility and was asked if she had enough time to give medications to residents in a timely manner. Licensed Staff AA stated she received a good orientation but did not feel she had enough time to give medications. Licensed Staff AA stated, There are lots of pills to give, right now the internet is down, and we have to work on paper Medication Administration Records (MARs) . we can get help from the DON. During an interview on 11/15/21 at 10:00 a.m., Licensed Staff E was asked if he had enough time to administer medications to residents in a timely manner. Licensed Staff E stated he usually had enough time to administer medications and there was sufficient back up to help, if needed. Licensed Staff E stated, We are using paper MARs today because the internet is down. When asked how often the internet is down Licensed Staff E stated it seemed to go down more often lately. During an interview on 11/15/21 at 11:00 a.m., Resident 108 was asked how her medical care was, she stated the weekend care was terrible. Resident 108 stated, You ring the bell, and no one comes for a long time . I have lots of pain and the computers are down, and my blood pressure is high, and I cannot be stressed. Resident 2 stated the medications were not given until 3 p.m., yesterday and that she usually received her medications in the morning, but not yesterday. 056296 Page 28 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 11/15/21 at 11:35 a.m., the Director of Staff Development (DSD) was asked what she does when the Internet system is down. She stated we use paper MARs and take lots of notes. We have MARs on a flash drive as back-up. During an interview on 11/15/21 at 12:30 p.m., Licensed Staff BB was asked how she was administering medications when the internet was down. Licensed Staff BB stated she was working off paper MARs which are changed out every month and are updated daily so the current orders are reflected. The current MARs are backed-up daily on a flash drive. Licensed Staff BB was observed charting vital signs on a paper sheet. During an interview on 11/15/21 at 12:40 p.m., Licensed Staff E was working on the East and South Hallways, a request was made to observe medication administration and the paper MARs for the East and South Hallways. Licensed Staff E stated he did not have the binder with the paper MARs because he could not find the binder. When questioning Licensed Staff E if he gave the AM medications to residents in that hallway, he stated he did not. When asked what he would do, Licensed Staff E stated he would notify the Medical Director (MD) and tell the DON that the medications will be given late and documented in the medical record. During a follow-up call to the facility on 3/24/22 at 9:10 a.m., spoke with the interim DON (I-DON) and asked how often the Internet and power go down at the facility, she stated every now and then. The interim DON was asked what the back-up plan was when the power goes down. She stated we have a disaster emergency closet that is locked and has a flash drive with all the resident MARs. The flash drive must be updated frequently with the current MARs, when the power goes down, we can print copies of the paper MARs. Requested copies of the Resident MARs in the East and South Hallways for the month of November 2021, they were not sent. During a follow-up call to the facility on 4/27/22 at 10:00 a.m., the administrator was asked if she could send the MARs for the Residents in the East and South Hallways for the month of November 2021 and a copy of the Policy and Procedure for Medication Administration during Power Outage. During a record review on 4/27/22, six sampled residents (Resident 13, Resident 21, Resident 22, Resident 38, Resident 56, and Resident 107) MARs were reviewed for medication administration on 11/15/21. The MARs reviewed showed medications were not documented as given, but indicated 9 (other/see nurses note) by Licensed Staff E. During an interview on 7/28/22 at 13:30 p.m., the administrator was asked if there was documentation to show the residents in the East and South Hallways received their AM medications on 11/15/21. The administrator stated Licensed Staff E did speak to her about not finding the paper MAR binder until the afternoon and stated he wrote nurses notes in each sampled resident's ( Resident 13, Resident 21, Resident 22, Resident 38, Resident 56, and Resident 107) medical record and called the MD letting him know medications were given late due to the power outage. A request for a copy of the nurses notes and paper MARs for medication administration was requested for the sampled residents, only one nurses note for Resident 107 was provided, no paper MARs were provided. Review of the electronic medical record (EMR) did not show the nurses notes or resident paper MARS for residents' (13, 21, 22, 38, 56, and107) were file in the medical record. Review of the facility Policy and Procedure titled, Emergency/Disaster/Medication Administration during Power Outage dated, January 1, 2018, indicated: 1. MARs are printed monthly, and updated on a flash drive daily . 2. If the power goes out, nursing staff are able to document on paper mars . and 056296 Page 29 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0726 3. Any paper MARs used will be scanned into the resident clinical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 056296 Page 30 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on observation, interview, and record review the facility did not ensure monthly medication regimen reviewsn (MRR) were conducted by the Medical Director (MD) and Director of Nursing (DON) addressing the follow-up recommendations from the pharmacist. These failures had the potential to place residents at risk for harm or adverse consequences from medications administered. Findings: During an interview on 7/27/22 at 10:00 a.m., the Director of Nursing (DON) was asked for the facility's MRR binders along with the policy and procedures. The DON did not have binders and stated all the MRR documents were in the Electronic Medical Records (EMR). MRR documents were requested for the months of April, May, and June. During an interview on 7/28/22 at 08:30 a.m., the MD was present in the facility and conducting resident assessments with the DON. The MD was asked if he reviewed the consultation reports provided by the consultant pharmacist when monthly MRR's were conducted and he stated he does review the pharmacist's recommendations with the DON. During an interview on 7/28/22 at 9:43 a.m., the MRR consultation reports for the months of April, May, and June were requested from the DON. The DON only provided consultant pharmacist and MD consultation reports from March and April. Several of the MD consultation reports were signed but not dated. The MRR records reviewed were not completed and did not show a full review conducted by the MD and DON for the month of March and April. When questioned for the reports for May and June the DON stated she was a little behind and did not have anything else to provide. During an interview on 7/28/22 at 14:53 p.m., the consultant pharmacist was asked how often she comes to the facility. The Consultant Pharmacist stated she comes to the facility once every three months and she conducts remote MRR reviews monthly. The June MRR documents and recommendations for Gradual Dose Reduction (GDR) for residents on antipsychotic/antidepressant medications was requested from the consultant pharmacist. These documents were provided by the consultant pharmacist and did not show that the MD or DON completed the reviews for the month of June 2022. During an interview on 07/29/22 at 08:19 p.m., the DON stated the physician checks the MRR reports monthly. When asked how the facility ensured the physician had reviewed the MRR reports for the months of April, May, June and July 2022, the DON stated, I saw him look at it. The DON stated the MRRs provided to the surveyors were not photocopies, and confirmed they were unsigned by the physician. When asked how the facility verified the MRRs had been reviewed with the reports missing physician signatures, the DON shrugged her shoulders and stated, Well he's the doctor . Review of the facility policy and procedure titled Drug Regimen Review dated May 2020, indicated the facility must ensure that a pharmacist reviews each resident's medical chart every month and performs a drug regimen review; II. At each month's UR (utilization review) meeting, facility will confirm with their medical director receiving a copy and reviewing the drug regimen review; and III. The facility must develop and maintain policies and procedures for the monthly MRR that includes timeframes for the different steps in the process . 056296 Page 31 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure medications were stored and maintained using safe medication practices when: a. Expired COVID-19 PCR (transcription polymerase chain reaction) test vials were found in the medication refrigerator, b. Medication disposal container in the medication storage room was unsecured, c. Expired medications for one resident (Resident 21) were located on a medication cart, and d. Medications were not re-ordered timely to ensure one resident (Resident 12) received a prescribed dose of medication These failures had the potential to alter the integrity of stored medications and put residents at risk for adverse consequences of medications administered. Findings: During an observation of the medication storage room on 7/26/22 at 9 a.m., four to five boxes of COVID-19 PCR test vials were found in the medication refrigerator. The expiration date on the test vials was 11/15/2020. Also, the top of the medication disposal container was found unsecured and the entire top came off rendering the contents easily accessible. The container contained disposed pills and insulin pens. During an interview on 7/26/22 at 9:15 a.m., the DON was questioned about the expired COVID-19 test vials and the medication disposal container. The DON stated the facility does not use the PCR tests much and she would check with the infection preventionist (IP) nurse about the status of the COVID-19 tests. The DON stated she would look into replacing the medication disposal bucket. When asked how often the medication storage room was checked, and who was responsible for checking and disposing expired medications, the DON stated the medication storage room is checked every shift and the NOC (night shift) nurse was responsible to dispose of expired medications. When the DON was asked who was responsible for re-ordering the prescription medications, the DON stated the nurses that work on the medication carts should review the medications to ensure there is enough to administer and re-order if the stock is low. During an interview on 7/26/22 at 14:51 p.m., the DON was asked how controlled medications (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) are maintained and disposed of. The DON stated she destroyed controlled medication with the pharmacist and kept expired and discharged residents' control medications under lock and key until they were destroyed. During an interview on 7/26/22 at 15:00 p.m., the Infection Preventionist (IP) was asked if the facility was still using the COVID-19 PCR tests stored in the medication storage refrigerator. She stated they do not use them much and were in the process of getting rid of them. The IP stated that the facility received an expired extension from the health department for 6-months to use the test kits. 056296 Page 32 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A copy of the expired extension was requested. The facility provided an extension letter for use of the BinaxNOW COVID-19 Ag Cards not the COVID-19 PCR test vials. During a medication pass observation on 7/27/22 at 12:53 p.m., Licensed Nurse G was dispensing Entacapone (medication used for Parkinson's Disease, a disease of the central nervous system) 200mg (milligrams) PO (by mouth) for Resident 21. While the Surveyor reviewed the medication packet it was observed that the expiration date on the packet was 4/30/22. When Licensed Staff G was asked about the expiration date, she stated, she should have checked the expiration date and opened a new medication packet. Licensed Staff G was observed removing 3-4 packets of expired mediations from the medication cart. During a continued medication pass observation on 7/27/22 at 13:15 p.m., Licensed Nurse G was dispensing Vancomycin (antibiotic) 125mg/ii (two) tabs (tablets) PO for Resident 12. Licensed Nurse G stated only one tablet was available in the medication vial, she went into the medication E-Kit (a kit of medications relegated for emergency use) for another Vancomycin tablet. The E-kit did not contain the required Vancomycin dose. Licensed Nurse G only gave one tablet of the prescribed dose (which was two tablets) and stated she would call the pharmacy to order more medication and call the physician to report the missed dose. When asked who was responsible for re-ordering prescription medications, Licensed Staff G stated the nurses were responsible and should check [all medication counts] each shift. Review of the facility Policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 5/1/10, indicated, 5. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration date for open medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 15. Facility should ensure that medication and biologicals for expired or discharged residents are stored separately, away from use, until destroyed or returned to the provider. 056296 Page 33 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 24) for dietary services received the meal portions she required. This finding had the potential to result in unintended weight loss, malnutrition, and reduced caloric intake for Resident 24. Findings: Record review indicated Resident 24 was admitted to the facility on [DATE] with medical diagnoses including Protein-Calorie Malnutrition (A nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and Anemia (A condition in which the blood does not carry enough oxygen to the rest of the body, most commonly caused by not having enough iron), according to the facility Face Sheet (Facility Demographic). Record review of Resident 24's tray ticket for lunch on 7/27/22, indicated, LARGE PT (Large food portions), CHOP MEAT. During tray line observation on 7/27/22 at 12:28 a.m., Dietary Aid X was observed serving the main entrees on four residents' plates. Each of the four plates had the exact same portions of food, consisting of medium portions. One of these plates belonged to Resident 24. The Dietary Manager was asked how Dietary Aids ensured residents on other than medium portions, received their prescribed portion sizes. The Dietary Manager asked Dietary Aid X if he was following food portion orders for the residents, to which Dietary Aid X responded, Probably not. Dietary Aid X was then observed adding more food to Resident 24's plate. Dietary Aid X was observed throughout the entire tray line observation from 12:15 p.m. to 1:05 p.m. on 7/27/22 serving plates using the same size serving scoops and utensils, on all the residents, regardless of their diet portion orders. There were no smaller scoops used for residents on smaller portions, all residents received the same portions, but this was specifically apparent on Resident 24's plate. No weight scale for the meats was observed, all residents received the same sized portions of fish Italiano on 7/27/22 for lunch. During an interview on 7/28/22 at 11:16 a.m., Resident 24 stated she received small portions at least daily in one of her meals, and she knew she was supposed to receive large portions. Resident 24 stated she did not eat much anyway but was aware she was not receiving her prescribed food portions. Record review of the facility policy titled, Portion Control dated 2018, indicated, To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food. Scoops are sized by number. The smaller the number, the larger the size . A diet scale should be used to weigh meats. 056296 Page 34 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure meals were served at appropriate temperatures affecting their safety, attractiveness and palatability. This failure had the potential to result in food-borne illnesses, reduced caloric intake, malnutrition, and weight loss among the residents of the facility. Residents Affected - Some Findings: During an observation on 7/25/22 at 1:23 p.m., it was noted the last lunch tray was just served to the residents of the North Hallway of the facility. During a concurrent observation and interview on 7/27/22 at 1:30 p.m., a taste-test tray was savored in the facility's conference room where Surveyors were working, in the presence of the Dietary Manager. This was done right after all residents of the facility were served their lunch trays, a process that took from 7/27/22 at 12:30 p.m., until 1:28 p.m. The temperatures of all the entrees and fluids on the tray were taken by the Dietary Manager. The temperature of the milk on the tray was 56 degrees Fahrenheit, and so was the temperature of the cranberry juice. The Dietary Manager confirmed this finding, and stated the temperature of the milk and juice were supposed to be below 40 degrees Fahrenheit, and he could not understand how this happened, since the drinks were placed in ice during tray line. The milk and juice felt slightly warm during the tasting process, and this made them unappetizing. During an interview on 7/28/22 at 11:14 a.m., Resident 46 stated food was too hot or too cold frequently, and it was not appetizing that way. During an interview on 7/28/22 at 11:16 a.m., Resident 24 stated being served food that was too hot or too cold frequently and did not eat the food if it was not at the right temperature. Record review of the facility policy titled, REHEATING AND COOLING OF POTENTIALLY HAZARDOUS FOODS, dated 2018, indicated, Potentially hazardous foods shall be served and held at the required temperatures on the tray line or during meal services. If cold food is above 41°F (Degrees Fahrenheit) or hot food is below 140°F, corrective action shall be taken. 056296 Page 35 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that fluid preferences were honored for one of six sampled residents (Resident 46) for food/fluid preferences. This had the potential to cause nutritional deficiencies, dehydration and weight loss for Resident 46. Findings: Record review indicated Resident 46 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar) and Osteomyelitis (Inflammation of bone or bone marrow, usually due to infection), according to the facility Face Sheet (Facility demographic). Record review of Resident 46's MDS (Minimum Data Set-An assessment tool) dated 5/20/22 indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) score was 15, which indicated her cognition was intact. Record review of Resident 46's tray meal for lunch on 7/27/22, indicated, Dislikes - No Juice No Milk. During tray line observation in the facility kitchen on 7/27/22 at 12:20 p.m., Resident 46's lunch meal and drinks was plated and the tray was placed inside the food cart to be delivered. Before delivery, the meal trays were checked, and it was noted that Resident 46's only fluids on the tray consisted of a cup of milk, and a cup of cranberry juice. This was brought to the attention of the Dietary Manager, who confirmed the finding, and told the Dietary Aid serving the meals (Dietary Aid W) to check for dislikes on the meal tickets. During an interview on 7/28/22 at 11:14 a.m., Resident 46 stated she did not want milk and juice on her meal trays, and received them, all the time. Resident 46 added, I don't want them, referring to the juice and milk served on her meal trays. Record review of the facility policy titled, FOOD PREFERENCES dated 2018, indicated, Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. 056296 Page 36 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

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 store and prepare meals in a sanitary manner, when: Residents Affected - Some a. Spoiled and expired food was found in the kitchen refrigerator, b. Unlabeled food was found in the kitchen refrigerator, c. The floor in the kitchen and dry storage areas were dirty and sticky, d. Dented cans were found stored along with the canned foods in good condition, e. The facility's ice machine was soiled, f. The toaster in the kitchen was soiled, and g. Two Dietary Aids prepared and served food after contaminating their hands with the lid of a trash can. These failures had the potential to cause foodborne illness and spread of infections to the vulnerable resident population. Findings: During an initial tour of the kitchen, with the Dietary Manager present, on 7/25/22 at 8:25 a.m., chopped, spoiled and unlabeled watermelon was found in the kitchen refrigerator in a small cup. The watermelon had a soggy, slimy appearance. This was observed by the Dietary Manager, who discarded it immediately. During the observation, unlabeled applesauce and unlabeled milk cups were also found in the refrigerator. This was also observed by the Dietary Manager. In addition, a fruit fluff was found in the refrigerator labeled with with a preparation date of 7/21/22. The label stated, UB (Use by) 7/24/22. The Dietary Manager stated it was supposed to have been thrown away. An unlabeled peanut butter sandwich was also found in the refrigerator. In the food preparation area, the toaster, which was being used for residents' food preparation, according to the Dietary Manager, was soiled with grease and food particles outside and inside the appliance. It did not appear to have been cleaned in a prolonged period of time. According to the Dietary Manager, it needed to be cleaned. When asked how often it should be cleaned, the Dietary Manager did not answer the question, and actually asked a Dietary Aid, who stated he had not cleaned it today. The kitchen floor had stains that appeared to be from food residue and dirt. In addition, small food particles were visible on the floor, as if it had not been swept and mopped recently. The kitchen floor was also wet in some areas. In the dry storage area, the floor was sticky while walking on it. During a second tour of the kitchen on 7/26/22 at 10:45 a.m., with the Dietary Manager present, the floor in the dry storage room was again noted to be sticky and dirty. The Dietary Manager confirmed it was sticky and stated maintenance personnel were supposed to clean it and wax it during the night shift. A dented can containing fruit cocktail was found on one of the shelfs in the dry storage, stored with other food cans in good condition. The Dietary Manager confirmed the finding, and stated they had a designated rack for dented cans. He proceeded to discard the dented can. The Dietary 056296 Page 37 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Manager was asked about the labeling process for food items in the kitchen refrigerator. According to Dietary Manager, staff were required to label all food in the refrigerator with preparation date and use by date. During a concurrent observation and interview on 7/26/22 at 2:08 p.m., the ice machine in the kitchen appeared dirty on the outside, although all inside cleaning processes were confirmed to be taking place per manufacturer's instructions. The outer walls of the ice machine, a couple inches behind the ice dispenser, were wiped with a slightly damp paper towel to check how soiled they were, as the black plastic housing made it difficult to visualize. The white paper towel became soiled with large black-brown stains. They Dietary Manager confirmed the outside of the ice machine was dirty and needed to be cleaned more often. During a concurrent observation and interview on 7/27/22 at 12:52 p.m., Dietary Aid U and Dietary Aid V were both observed washing their hands after food preparation, and then grabbed the soiled lid of the only trash can visible in the facility, removed it and threw away the paper towels used to dry their hands after handwashing which recontaminated their hands in the process. This trash can had a plastic lid that had to be manually removed to discard items inside. After recontaminating their hands, both Dietary Aids proceeded to continue preparing and serving residents' meals. Right after these observations, they were interviewed and confirmed the findings. Record review of the facility policy titled, SANITATION, dated 2018, indicated, The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving and storing of food .Each employee shall know how to operate and clean all equipment in his specific work area .All utensils, counters, shelves and equipment shall be kept clean .Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. Record review of the facility policy titled, FOOD PREPARATION, dated 2018, indicated, 1. Storage of leftovers . b. Label and date. c. Use refrigerated leftovers within 72 hours. Record review of the facility policy titled, PROCEDURE FOR REFRIGERATED STORAGE, dated 2018, indicated, Leftovers will be covered, labeled and dated. Record review of the facility policy titled, HAND WASHING PROCEDURE, dated 2018 indicated, Hand washing is important to prevent the spread of infection .WHEN HANDS NEED TO BE WASHED: 8. Touching trash can or lid. Record review of the facility policy titled, FOOD STORAGE-DENTED CANS, dated 2018, indicated, Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used by the facility. 056296 Page 38 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to develop comprehensive action plans for identification, analysis, correction, and evaluation of systemic care issues, including repeat survey deficiencies. This failure had the potential to prevent timely recognition and improvement of care services that do not meet standards of quality for all 61 residents. Findings: During an interview on 7/29/22 at 8:40 a.m., the Adminstrator stated their QAPI (Quality Assessment and Performance Improvement) projects were based on several sources such as CASPER reports, previous survey findings, and concerns identified by the department heads. A review of the facility's CASPER 3 ([Certification and Survey Provider Enhanced Reporting] a report compiled of survey findings that demonstrate the facility's performance) indicated a pattern of repeat deficiencies related to infection control, dirty environment, and kitchen services, from 2017 to 2019. During an interview on 7/29/22 at 9:02 a.m., the Adminstrator stated there was no current QAPI plans for the kitchen since 2018, as issues have since been resolved. However, the Adminstrator confirmed kitchen deficiencies continued to be cited in the facility during its last recertification survey in 2019. When asked if the kitchen should have been included in the QAPI, the Adminstrator did not respond. During an interview on 7/29/22 at 9:55 a.m., the Adminstrator stated the facility had infection control deficiencies during its previous recertification and/or recent focused infection control surveys. But when asked for QAPI plans related to infection control, the Adminstrator stated there were none. The Adminstrator stated it was hard to conduct audits and observations of infection control practices by the staff without them [staff] knowing, but when asked if further approaches were tried to collect data, the Adminstrator did not respond. A concurrent review of the facility's QAPI and PIP (Performance Improvement Project) binders, projects included falls, call light installation, and psychotropic medication orders. Said projects were dated 2021. When asked for subsequent revisions, updates, and/or monitored data for tracking the effectiveness of the projects after 2021, the Adminstrator stated there were none. During an interview on 8/20/21 at 10 a.m., when asked how the QAPI committee would be able to effectively monitor their efforts to improve care concerns without data tracking and methods to evaluate interventions, the Adminstrator did not respond. A review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), dated 2021-2022, indicated, The QAPI Program at [facility] will aim for safety and high quality with all clinical interventions . by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis . [Facility] will put in place systems to monitor care and services, drawing data from multiple sources . It will include performance indicators . and reviewing findings against benchmarks and/or goals . The QAPI team at [facility] will prioritize opportunities for improvement, taking into consideration the importance of issues (high risk, high frequency and/or problem prone). 056296 Page 39 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

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** j. During an observation and concurrent interview on 5/24/22 at 11:44 a.m., Resident 18 was in her wheelchair against the wall across from the nurses' station. Unlicensed Staff R came out of a resident room, picked Resident 18's mask up off the floor and put it on Resident 18's face. When queried about putting a mask that has been on the floor on a resident, Unlicensed Staff R stated, That was a stupid thing to do. I'll go get a clean one right now. Residents Affected - Many During an interview on 7/28/22 at 4:16 p.m., IP stated Unlicensed Staff R should not have put the fallen mask back on the resident. A review of the facility policy titled, Personal Protective Equipment, dated 12/31/2021, indicated, iii. Face masks are changed when they become soiled or moist. k. During a concurrent observation and interview on 7/29/22 at 9:51 a.m., DON was observed wearing a surgical mask in the COVID/Red Zone unit. When asked why she was wearing a surgical mask when she was working in the COVID/Red Zone unit, DON stated, I guess I screwed up then proceeded to change into an N95 respirator, without performing hand hygiene. A review of the facility policy titled, COVID-19 Mitigation Plan, revised 7/14/022, stated, 3. All employees who work directly with COVID-19 or Presumptive COVID-19 residents must use the following PPE: a. N95 mask, b. Isolation gown, c. Gloves, d. Eye shields/goggles . Based on observation, interview, and record review, the facility failed to maintain effective infection prevention and control practices when: a. A symptomatic COVID-negative resident (Resident 36) was cohorted with a confirmed COVID-positive roommate (Resident 15) in the Red Zone, b. Three resident visitors were wearing inappropriate PPE during their visits, c. Surgical masks were improperly worn by multiple staff, d. Staff were touching residents' face masks without performing hand hygiene, e. A staff did not doff his PPE before leaving an isolation room, f. A staff was wearing a cloth mask in the facility, g. A bearded staff was wearing an N95 respirator mask and working in an isolation room, h. PPE signs were not posted outside of an isolation room, i. Vaccination status of facility visitors were not verified, j. A resident's mask was placed on her face after it fell on the floor, and k. A staff was wearing a surgical mask in the Red Zone. 056296 Page 40 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many These failures have the cumulative potential to spread infections, including COVID-19, and increased the risk for cross-contamination among all 61 vulnerable residents in the facility. Findings: a. During an interview on 7/26/22 at 8:30 a.m., Administrator stated Resident 15 had tested positive for COVID-19 last night. Resident 15's roommate, Resident 36, remained negative but was symptomatic. Administrator stated both residents were placed together in the Red Zone (a designated area in a facility for confirmed COVID-19 residents last night. During an interview on 7/26/22 at 11 a.m., Infection Preventionist (IP) confirmed that Resident 36 continue to test negative this morning. When asked about cohorting practices, IP stated the facility followed the County, State, and Federal guidelines. When queried about the decision to cohort Residents 15 and 36 together, IP replied, Even if [Resident 36] has been symptomatic for days, and there's this new variant going on, [Resident 36] can't be moved to the Red Zone? During an interview on 7/26/22 at 1 p.m., IP stated she had contacted the County Public Health Department which confirmed that Resident 36 should not be in the Red Zone. A review of the grid titled, COVID-19 PPE, Resident Placement/Movement, and Staffing Considerations by Resident Category, contained in AFL 20-74.1 dated July 22, 2021, indicated, Symptomatic, Suspected COVID, Awaiting Test Results: Do not move to COVID-positive Red Area until test results confirm COVID-19 positive. b. During an observation on 7/26/22 at 10:43 a.m., a visitor went into an isolation room wearing a surgical mask. Staff were observed handing the visitor additional PPE (Personal Protective Equipment), to which the visitor stated, Are we back to that again? During an observation on 7/26/22 at 3:45 p.m., a visitor was observed entering an isolation room wearing an N95 respirator (a type of double-strapped respirator mask that offers the highest level of protection against infectious particles, such as the COVID-19 virus) with one strap unsecured, and a yellow disposable gown. During an observation on 7/27/22 at 10:19 a.m., an unmasked visitor was observed walking along the South Hall. During an interview on 7/28/22 at 4:16 p.m., IP stated visitors were notified of the PPE requirements upon entry to the facility. IP stated surgical masks were required while visiting, and an N95 respirator, gown, gloves, and eye protection were required in isolation rooms. IP confirmed difficulties in visitors' adherence to PPE requirements but expected staff to monitor and offer PPE as they see inappropriate use. A review of the facility policy titled Visitation-Covid-19, revised 11/16/2021, indicated, All visitors must wear a surgical mask while in the facility . Personal Protective Equipment (PPE) is required for contact with the resident due to quarantine or COVID-19 positive isolation status (including fully vaccinated visitors), it must be donned and doffed according to instructions by Health Care Personnel. c. During an observation on 7/26/22 at 8:53 a.m., Licensed Staff P was walking away from the 056296 Page 41 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0880 nursing station. The top of Licensed Staff P's surgical mask was pulled below her nose. Level of Harm - Minimal harm or potential for actual harm During an observation on 7/26/22 at 8:57 a.m., Unlicensed Staff K was intermittently pulling the top of his surgical mask below his nose as he talked to other staff. Residents Affected - Many During an observation on 7/27/22 at 9:33 a.m., Unlicensed Staff L was walking outside the Dining Room with the top of her surgical mask pulled below her nose. Unlicensed Staff L pulled her mask to cover her nose when she saw this surveyor, and said, Sorry. During an observation on 7/27/22 at 9:55 a.m., Unlicensed Staff Q was mopping the hallway. The top of his surgical mask was pulled below his nose. During an observation on 7/28/22 at 8:10 a.m., Licensed Staff P was hunched over two residents as she wheeled them from the Dining Room. Licensed Staff P was talking and laughing with the residents, with the top of her surgical mask pulled below her chin. Licensed Staff P pulled up the top of her mask when she saw this surveyor. During an observation on 7/28/22 at 11:14 a.m., Unlicensed Staff M was seated by the lobby entrance with the top of her surgical mask pulled below her nose. During a concurrent interview, Unlicensed Staff M stated she has asthma, and covering her nose with the mask makes it harder for her to breathe. When asked if she had reported her difficulties with the mask to the IP or the Administrator, Unlicensed Staff M stated, No. Unlicensed Staff M stated no one in the facility had ever corrected her mask usage. During an interview on 7/28/22 at 4:16 p.m., IP stated the usage of masks by Licensed Staff P and Unlicensed Staffs K, L, M and Q were incorrect. IP stated, Masks should cover the nose. d. During an observation and concurrent interview on 5/24/22 at 11:16 a.m., Resident 18 was in her wheelchair against the wall across from the nurses' station. Resident 18 had a surgical mask in her lap. A staff member sitting at the nurses' station got up and replaced Resident 18's mask on her face without performing hand hygiene before or after touching the mask. Resident 18 took her mask off, and another staff member walking by stopped to put Resident 18's mask back on her face without performing hand hygiene before or after touching the mask. Resident 18 took her mask off again, and Unlicensed Staff S put Resident 18's mask back on her face without performing hand hygiene before or after touching the mask. Unlicensed Staff S then walked over to another resident sitting in a wheelchair, wheeled the resident to her room, and helped the resident into bed. When queried, Unlicensed Staff S verified she did not perform hand hygiene between touching Resident 18's mask and taking the other resident to her room. During an interview on 5/24/22 at 4:50 p.m., Director of Staff Development (DSD) stated that in response to the observed lapses with hand hygiene, she was starting a refresher in-service for the staff on hand hygiene between residents and with masks. DSD verified it was her expectation that staff perform hand hygiene before and after touching a resident's mask. During an observation on 7/27/22 at 1:52 p.m., Licensed Staff N was seen touching a resident's face mask and pulled it over the resident's nose. Licensed Staff N proceeded to do the same thing to another resident who was seated close by. There was no hand hygiene observed during the interaction. During a concurrent interview, Licensed Staff N stated, I guess I should have done hand hygiene in 056296 Page 42 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0880 between each contact, huh? Level of Harm - Minimal harm or potential for actual harm During an interview on 7/28/22 at 4:16 p.m., IP confirmed Licensed Staff N's practice was unacceptable, and stated there should have been hand hygiene between each resident contact. Residents Affected - Many Review of facility policy and procedure Standard Precautions, dated 10/2016, indicated, Standard Precautions are used in the care of residents regardless of their diagnoses, or suspected or confirmed infection status . Standard Precautions include the following practices: A. Hand Hygiene i. Hand hygiene refers to hand washing with soap (antimicrobial or nonantimicrobial) OR using alcohol-based hand rubs (gels, foams, rinses) that do not require access to water. Review of the Centers for Disease Control and Prevention publication Morbidity and Mortality Weekly Report: Guideline for Hand Hygiene in Health-Care Settings, dated 10/25/2002, revealed, Transient flora, which colonize the superficial layers of the skin, are more amenable to removal by routine handwashing. They are often acquired by HCWs (healthcare workers) during direct contact with patients or contact with contaminated environmental surfaces within close proximity of the patient. Transient flora are the organisms most frequently associated with health-care-associated infections . e. During an observation on 7/25/22 at 9:26 a.m., Unlicensed Staff K came out of an isolation room wearing an N95 respirator, face shield, gown, and gloves. During a concurrent interview, Unlicensed Staff K stated he should have removed his PPE before leaving the isolation room. A review of the facility policy and procedures titled, CoronaVirus - COVID 19- Donning/Doffing PPE, dated March 31, 2021, indicated, Doffing: Doff gloves and place them in RED [NAME] in bathroom, Doff gown, rolling it into itself so the contaminated side is covered and place it in the RED [NAME] in the bathroom (please keep lids on barrels), Wash your hands for 20 seconds per facility protocol in the resident room bathroom, With mask and goggles/faceshields on, leave the resident room closing door behind you, Use hand sanitizer from the hallway dispenser, Remove mask and place in garbage can marked MASKS, Use hand sanitizer a second time from the hallway dispenser, Replace surgical mask on face, [NAME] on gloves and use an individual bleach wipe located in drawer of ISO cart to disinfect the hand sanitizer used to clean hands after doffing, Discard gloves and wipe in the hallway trashcan marked TRASH, Sanitize hands after removing gloves. f. During an observation on 7/27/22 at 1:52 p.m., Licensed Staff N was observed in the nursing station wearing a black cloth mask. During a concurrent interview, Licensed Staff N stated, I was just matching my mask to my outfit today. Licensed Staff N stated no one had told her that she had to wear a surgical mask in the facility. During an interview on 7/28/22 at 2:50 p.m., IP stated cloth masks have not been allowed for staff use in the facility since 2020. A review of the facility policy titled, COVID-19 Mitigation Plan, revised 7/14/022, indicated, All staff wear surgical masks while in the building unless indicated to wear N95s. g. During an observation on 7/26/22 at 8:57 a.m., Unlicensed Staff H was observed wearing an N95 respirator. Unlicensed Staff H has a full beard under his mask. During a concurrent interview, Unlicensed Staff H stated he had his beard even during his recent fit testing. When asked if he was offered alternatives to an N95 respirator due to his beard, Unlicensed Staff H stated, No. 056296 Page 43 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 7/28/22 at 2:50 pm., IP stated Unlicensed Staff H completed a qualitative fit testing (a subjective method used on half-masks that relies on senses such as taste and smell, to detect air leakage from the respirator), and confirmed that Unlicensed Staff H was bearded during his fit testing. When asked how a proper respirator seal could be verified with a beard on, IP stated, [Unlicensed Staff H] confirmed it. Residents Affected - Many A review of the facility policy titled, COVID-19 Mitigation Plan, revised 7/14/022, indicated, Do not use N95 mask with beards which may interfere with the direct contact between the face and the sealing surface. A review of OSHA (Occupational Safety and Health Standards) guidance titled Respiratory Protection, indicated, 1910.134(g)(1)(i) The employer shall not permit respirators with tight-fitting facepieces to be worn by employees who have: 1910.134(g)(1)(i)(A) Facial hair that comes between the sealing surface of the facepiece and the face . h. During an observation on 7/25/22 at 8:35 a.m., Unlicensed Staff O entered a room wearing an N95 mask, gown, and gloves. There was no isolation nor PPE requirements posted by the door. During a concurrent interview, Unlicensed Staff O stated the room was on the Isolation List that was kept in the nursing station binder. Unlicensed Staff O stated the list keeps changing and added it would be more convenient and less confusing if there were signs outside of isolation rooms. During an interview and concurrent observation of the room on 7/25/22 at 9 a.m., IP stated isolation rooms should have PPE signages by the door. IP confirmed PPE signs on doors were not updated over the weekend, as changes occurred. A review of the facility policy titled, COVID-19 Mitigation Plan, revised 7/14/022, indicated, All occupied quarantine/isolation rooms have signs posted stating type of PPE to be worn . i. During an interview on 7/28/22 at 11:14 a.m., Unlicensed Staff M stated visitors were screened for signs and symptoms of COVID-19 prior to facility entry. Unlicensed Staff M stated screening included temperature checks, hand hygiene and PPE instructions. When asked if visitors' vaccinations were verified, Unlicensed Staff M stated, I don't think so. During an interview on 7/28/22 at 4:16 p.m., IP confirmed visitors were screened at the entrance, but their vaccination statuses were not checked. IP stated the decision to not check visitors' vaccine cards came from the County. During an interview on 7/29/22 at 9:55 a.m., Administrator stated the facility used to check visitors' vaccination status and kept copies of vaccine cards in a secured binder. Administrator received an email directive from the Ombudsman to not keep copies of the vaccine cards, and was referred to memo QSO 20-39. Concurrent review of QSO 20-39, revised 3/10/2022, indicated, Visitors are not required to be tested or vaccinated (or show proof of such) as a condition of visitation. A comparative review of AFL 22-07, dated February 7, 2022, indicated, In compliance with the Public Health Order issued February 7, 2022, beginning February 8, 2022, SNFs must verify visitors are fully vaccinated or have provided evidence of a negative SARS-CoV-2 test within one day of visitation for antigen tests, and within two days of visitation for PCR tests for indoor visitation. 056296 Page 44 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0880 Level of Harm - Minimal harm or potential for actual harm Administrator stated the facility follows the most stringent among the overlapping Federal, State, and County guidelines, and confirmed that between the AFL and QSO memo, the former had the more stringent regulation. Residents Affected - Many 056296 Page 45 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a concurrent observation and interview on 7/25/22 at 9:22 a.m., Resident 15 stated nobody came to assist her when she rang her bell, even after thirty minutes of ringing it. A small metal bell was observed sitting on her bedside table. Resident 15 stated they did not have an electrical call light system and were using [hand-held] metal bells instead. Resident 15 stated she had to wait an hour for staff to respond to her call light that morning. Resident 15 stated the facility used to have an electrical call bell system in place, but the system malfunctioned and was replaced by metal bells that they had to manually ring. Resident 15 stated the issue with the electrical call light system had been going on for four years. Resident 15 stated she ended up having two incontinent accidents as a result of the having to wait so long for staff to respond to the bells. During the interview, a hole in the wall, covered with plastic, was observed in Resident 15's room. According to Resident 15, this was where the electrical call bell system used to be. Residents Affected - Many Record review of an e-mail sent by Witness BB, dated 7/25/22 at 12:50 p.m., indicated, The facility used to have a standard call bell system like many of those frequently found in hospitals. The resident pushed the button and a signal was sent to the nurse's station, which in-turn alerted staff to a need for assistance. The old system apparently became unserviceable and it was said it would be replaced. However, it's been well over a year and probably closer to two years since it was last in use. The temporary fix was to provide residents bells with handles that they have to manually ring when they needed assistance. Any inquiry about the status of the new call system is met with excuses and assurances it should be installed soon. The use of bells residents must ring repeatedly and continuously until answered by a nurse is completely impractical and ineffective. Not to mention during the numerous and often lengthy Covid-19 lockdowns implemented by the facility all residents' doors are closed. Thus, all but eliminating the likelihood of the bells being rung inside the closed room being able to be heard from any distance. During an interview on 7/28/22 at 2:51 p.m., Unlicensed Staff A stated the [hand-held] bells were difficult to hear unless staff really listened, and then they could hear the metal bells ringing (for residents attempting to notify staff they needed assistance) but these [hand-held] bells were difficult to hear when the residents' doors were closed. Several residents' room doors were closed at the time of the interview due to COVID-19 isolation precautions. Unlicensed Staff A stated the call bell system would be more effective if it consisted of an electrical call bell system. He also stated an electrical call bell system had not been in place at the facility for more than a year. During an interview on 7/29/22 at 8:02 a.m., the DON stated [hand-held] bells had been used in the facility since the call light system broke years ago. When asked if the current plan had been determined effective in summoning staff the DON stated, I don't know. The DON stated it could be hard for staff to hear the bells behind closed doors. When asked how residents who could not use the bells call for assistance, the DON stated, Well, they've got their voices too. During an interview on 7/29/22 at 8:40 a.m., the Administrator stated the facility had been working on the installation of a new call light system since it broke down in January 2020, and residents were provided bells. The Administrator stated the installation had been delayed due to multiple factors including shipment delays, unforeseen changes in the plans, and labor shortage. The Administrator stated some residents were given cow bells upon request, but confirmed there had not been any further follow up. The Administrator stated she did not know residents had issues with the current call system. When asked about the bell usage for the facility's confused and visually-impaired residents, 056296 Page 46 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the Administrator stated, We were just following our emergency disaster plan. When asked if the current call system should have been checked for its effectiveness and appropriateness, as it was used in the past 30 months, the Administrator did not respond. Record review of the facility policy titled, Communication-Call System, last revised in January of 2020, indicated, The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities . Upon admission, each resident will be instructed on how to use the call bell system. Call cords will be placed within the resident's reach in the resident's room . Nursing Staff will answer call bells promptly, in a courteous manner . If call bell is defective, it will be reported immediately to maintenance and replaced immediately. Based on observation, interview, and record review, the facility failed to provide an effective and inclusive call system. This failure led to delays for expressions of frustration and feelings of neglect by the delayed provision of care for residents, and increased the potential to negatively affect the psychosocial well-being of all 61 vulnerable residents. Findings: During an interview on 7/25/22 at 9:18 a.m. in her room, Resident 56 pointed to a hand-held bell on her bedside table and stated those bells were currently used to call for staff. Resident 56 stated the call lights [system] have been broken for about two years now. During an observation of the adjacent bed on 7/25/22 at 9:24 a.m., Resident 22's bedside table was against the wall, located approximately three feet from the resident's bedside. A similar hand-held bell was on the table. Resident 22 exhibited marked confusion during an attempted interview. Resident 56, who was present in the room at the time of the interview, stated her roommate was blind, very confused, and only spoke Spanish. During an interview on 7/25/22 at 11:34 a.m., Resident 48 stated it took some time, maybe 30 minutes for staff to come to the room after ringing the bell. When asked how that made her feel, Resident 48 stated, It's hard. My room is at the end of the hallway, I don't even know if they could hear when I call. It is what it is. During an observation of the East Hall on 7/25/22 at 12:39 p.m., a bell rang for about 15 seconds behind the closed door of Resident 17's room. The sound stopped for about 30 seconds, rang again, then stopped. This went on again at 12:47 p.m., 12:49 p.m., 12:50 p.m. At 1:07 p.m., the same pattern reoccurred. The bell rang five more times before it stopped. No staff was observed going into the resident's room during or after the bell was used. During an observation on 7/25/22 at 1:37 p.m., a bell rang intermittently from room [ROOM NUMBER], for about 10 seconds each time. A female voice was heard yelling from inside the room. A staff answered the call six minutes later. During an interview on 7/25/22 at 3:52 p.m., Resident 17 confirmed she was calling for staff during lunchtime today. Resident 17 stated her arms were getting tired from ringing the bell and added, You could only do it so much, and they don't even come to you. During an interview on 7/26/22 at 10:29 a.m., Resident 34 stated it took staff about 20 to 40 minutes to get to her room. Resident 34 stated it was frustrating, especially when she was in pain. 056296 Page 47 of 48 056296 08/01/2022 Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Resident 34 pointed to a cow bell on her bedside and stated, I had the small [hand-held] bell before but I don't know if they could even hear it so I told them . They gave me a cow bell. Resident 34 stated it was louder than the little [hand-held] bell, but was also heavier, and not very convenient to use [for prolonged ringing]. During an observation on 7/26/22 at 1:20 p.m., Resident 40 was standing by his door, yelling, Nurse! Nurse! I need my catheter bag emptied. During an interview on 7/26/22 at 2:49 p.m., Resident 40 stated he had a little bell to use to call for staff but did not want to use it earlier because he was told that it wakes other people up so he could only use it for an emergency. 056296 Page 48 of 48