Health inspection·November 22, 2019

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview and record review, the facility failed to ensure three (Resident 79, 48, 42) of 80 sampled residents were provided with a clean and sanitary environment, when thick, dark brown, dried matter was sticking all over the commode and toilet bowl in a shared bathroom between room [ROOM NUMBER] and 22. This failure resulted in Resident 79, 48 and 42 to not receive a clean, sanitary and homelike environment. Findings: During an observation of shared bathroom between room [ROOM NUMBER] and 22, accompanied by Certified Nursing Assistant (CNA 4) on 11/8/19 at 10:08 a.m. thick dark brown matter was sticking inside toilet bowl and all over a light blue colored commode placed over the toilet bowl. CNA 4 was unable to state what was sticking on the toilet bowl and the commode. During another observation of the bathroom with CNA 4 and Housekeeper (HK 1) on 11/8/19 at 10:12 a.m., HK 1 stated its pee (urine) pointing towards the stains on the toilet bowl. HK 1 then stated commode was old and should be changed. HK 1 also stated the thick brown matter sticking on the commode was rust and she sprayed bleach on the commode and toilet bowl. During a concurrent interview and review of maintenance log book with Maintenance Supervisor (MS) on 11/18/19 at 10:55 a.m., MS stated the commode looks ugly, and it was never brought to my attention. MS confirmed maintenance log book for station 2 did not have any entry to replace the commode in shared bathroom between room [ROOM NUMBER] and 22. MS also stated he was planning to replace the commode. During a follow up interview with HK 1 on 11/19/19 at 8:18 a.m., HK 1 stated the commode was dirty for a long time and it would not get cleaned with bleach. HK 1 further stated they put it in garbage now. During an interview with CNA 3 on 11/20/19 at 8:29 a.m., CNA 3 confirmed Resident 79, 48 and 42 used the shared bathroom between room [ROOM NUMBER] and 22 on a daily basis. Review of facility's Housekeeping Check-off List dated 11/17/19 showed Toilet was a part of housekeeping check off for that day. Page 1 of 22 056381 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two (Resident 43 and 42) of 80 sampled residents received an accurate assessment when: Residents Affected - Some 1. Resident 42's Minimal Data Set (MDS- an assessment tool) did not reflect ambulation and range of motion (ROM) services being provided during the Restorative Nurse Aide (RNA) program. 2. Resident 43's MDS was inaccurately coded for using no bed rails when bed rails were being used every day. This failure resulted in Resident 42 and 43's MDS's to reflect inaccurate clinical status. Findings: 1. Review of Resident 42's MDS dated [DATE] showed Resident 42 walked in corridor only once or twice and did not receive RNA services for ROM exercises and walking in 7-day look back period (reference period for the assessment). During a concurrent interview and review of Resident 42's Restorative Nursing Care Flow Record dated 9/2019 and 10/2019, with RNA 1 on 11/20/19 at 8:13 a.m., RNA 1 confirmed Resident 42 was receiving 15 minutes of ROM and 15 minutes of walking during RNA program. Review of Restorative Nursing Care Flow record for 9/2019 and 10/2019 showed Resident 42 received RNA services for ROM and walking on 9/26/19, 9/28/19 and 10/1/19 during 7- day look back period for MDS assessment dated [DATE]. During an interview with MDS Coordinator (MDSC) on 11/20/19 at 2:09 p.m., MDSC confirmed Resident 42's MDS dated [DATE] was coded incorrectly for ambulation. Review of Centers of Medicare & Medicaid Services (CMS)'s RAI (Resident Assessment Instrument) Version 3.0 Manual dated 10/2019 showed, Coding tips for functional status include: Consider all episodes of the activity that occur over a 24-hour period during each day of the 7-day look-back period. Further review showed, Restorative Nursing Program: Walking- Code activities provided to improve or maintain the resident's self-performance in walking, with or without assistive devices and Restorative Nursing Program: range of motion -Code provision of passive movements in order to maintain flexibility and useful motion in the joints of the body. Code exercises performed by the resident, with cueing, supervision, or physical assist by staff that are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record. 2. During three consecutive observations on 11/18/19 at 8:40 a.m., 10:25 a.m., and 12:56 p.m., Resident 43 was lying in bed with bilateral bed rails up. During a concurrent observation at Resident 43's bedside and interview on 11/18/19 at 12:56 p.m., Certified Nursing Assistant (CNA 9) stated bed rails were kept up for safety. Review of Resident 43's Activities of Daily Living (ADL) care plan initiated on 3/13/19 showed Resident 43's half rails were up for mobility for safety. 056381 Page 2 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 43's MDS assessment dated [DATE] showed Resident 43 was not using bed rails in the 7-day look back period. It also indicated Resident 43 had severe cognition impairment. During an interview on 11/18/19 at 1:45 p.m., MDSC stated when she observed Resident 43, he was in wheelchair. MDSC stated she did not ask the direct care staff if Resident 43 was using the bed rails when she conducted the MDS assessment. MDSC further confirmed review of ADL care plan showed he was using bed rails since 03/2019. During another interview on 11/18/19 at 2:00 p.m., MDSC stated bed rails were kept up so Resident 43 did not roll out of bed. MDSC further stated it was not a restraint and did not need to be coded in MDS assessment. MDSC then stated this information was not from the RAI Manual and she just knew it. During an observation at Resident 43's bedside accompanied by CNA 8 on 11/21/19 at 8:42 a.m., Resident 43's bed rails were up while he was lying in bed. CNA 8 stated staff left the bed rails up because he tries to get up and bed rails help to prevent him from falling. CNA 8 then asked and gave cues to Resident 43 to hold onto the bed rails multiple times, Resident 43 did not follow CNA 8's directions and kept looking at CNA 8. During another observation accompanied by Director of Staff Development (DSD) on 11/22/19 at 9:09 a.m., Resident 43 was lying in bed with bilateral bed rails up. DSD asked Resident 43 to hold onto the rails, but he kept looking at her. DSD then confirmed Resident 43 was not able to follow directions and was not able to remove the bed rails if he wanted to. Review of Centers of Medicare & Medicaid Services (CMS)'s RAI Version 3.0 Manual dated 10/2019 showed, PHYSICAL RESTRAINTS: Any manual method or physician or mechanical device, material or equipment attached or adjacent to resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. 056381 Page 3 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 records review, for one (Resident 63) of 80 sampled residents the facility failed to monitor and develop a nursing care plan to address Resident 63's Left Lower Leg edema (swelling). Residents Affected - Few This deficient practice had the potential for Resident 63's condition went unnoticed or delayed for treatment. Findings: Review of the admission Record indicated Resident 63 was admitted on [DATE] with multiple diagnosis including, Diabetes (high blood sugar). Review of the physician's (MD) order, dated 11/4/19, indicated, Ultrasound (a test that uses high-frequency sound waves to measure the amount of blood flow through the arteries and veins) Left Lower Extremity. In an observation and concurrent interview on 11/19/19 at 1:03 p.m., Resident 63 was awake sitting in a wheelchair by her bed. Resident 63 stated her left lower leg was swollen. Resident 63 stated that her leg hurts a little but she got pain medicine from the nurses. In an interview with the Licensed Vocational Nurse (LVN) 1 on 11/19/19 at 1:46 p.m., LVN 1 stated that she had assessed Resident 63's lower extremities this morning. LVN1 added that Resident 63's leg had pulses and was not swollen. In an observation and concurrent interview on 11/19/19 at 1:50 p.m., LVN 1 asked Resident 63 to show her lower extremities. LVN1 stated that Resident 63's Left lower extremity was significantly swollen than the right leg. LVN 1 added that she was not able to feel the pulses. Review of the Nurse Practitioner (NP) notes dated, 11/12/19, 11/5/19; 10/31/19; 10/22/19 indicated Resident 63 had edema on the Left Lower Extremity. NP added that Resident 63 was at high risk for Deep Vein Thrombosis (DVT). Review of the Hospitalist History and Physical, dated 10/16/19, indicated, Respiratory: . shortness of breath, wheezing and stridor. Cardiovascular: . orthopnea, leg swelling . Review of the admission Nursing assessment dated , 10/19/19 indicated, under the section of venous presence of edema was not completed. Nursing assessments conducted on 11/19/19, 11/20/19, 11/21/19, 11/22/19 and 11/23/19 showed that staff left the assessment blank for the presence of edema on the lower extremities. According to the Radiology Results Report, dated 11/6/19, the Ultrasound was taken due to Resident 63's left leg edema. Conclusion indicated that Resident 63 had Bilateral arterial disease (reduce blood flow to the limbs) left leg. Review of the clinical records indicated no care plan to address left lower leg edema and arterial disease. 056381 Page 4 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

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 interview and record review, the facility failed to provide quality of care to two (Resident 184 and 73) of 80 sampled residents, when: Residents Affected - Few 1. the facility failed to reassess pain for Resident 184 after she was given Tylenol for pain due to a fall. 2. For Resident 73, an initial smoking assessment was not completed. This failure resulted in Resident 184 to stay in pain for four hours until she was transferred to Acute Care Hospital (ACH) 1 where she was diagnosed with bilateral lower extremities fractures. Findings: 1. Review of Resident 184's Minimal Data Set (MDS- An assessment tool used to guide care) dated 10/19/19 showed Resident 184 is cognitively intact. During a concurrent interview and record review on 11/20/19 at 10:23 a.m., LVN 3 stated at 9:55 a.m. on 11/4/19, Resident 184 was lying on her back on the floor between the bed and the sliding door stating her legs were hurting. LVN 3 stated Resident 184 had abrasions on both knees, and a skin tear on the right arm. LVN 3 stated she provided treatment to abrasions and skin tear, however Resident 184 kept saying her legs were hurting. LVN 3 further stated even after Resident 184 was transferred back to bed, she was saying her legs were broken. During further interview and record review on 11/20/19 at 10:23 a.m., LVN3 stated she received an MD (Physician) order of Norco and X-ray for her legs right after the fall since the MD was at facility at that time, however did not transcribe the MD's orders until Resident 184 left the facility for ACH 1 for further evaluation. LVN 3 stated she gave Tylenol 650 milligrams (mg) at 10:50 a.m. (one hour after the fall) to Resident 184 for pain. LVN3 stated Resident 184 did not confirm if Tylenol was effective for the pain she was having after the fall. LVN3 confirmed she did not give Norco to Resident 184 because I was more concerned about her transfer back to bed (after fall) and getting the people to transfer her to the hospital. When asked if Resident 184 should have received Norco for pain, LVN3 stated, maybe. LVN3 confirmed Resident 184 was sent to ACH 1 at 1:55 p.m. that day for further evaluation, which was four hours after the fall incident. During an interview on 11/20/19 at 10:57 a.m., CNA5 stated Resident 184 was complaining of pain after the fall stating my leg, my leg. CNA5 stated Resident 184 was moaning and was scared from the incident. Review of Physician's orders-Chart Copy dated 11/4/19 showed the MD ordered to do X-ray bilateral knees, right elbow, right forearm for fracture and to give Norco 10/325 by mouth one tablet every 6 hours PRN pain. Further review showed MD had written a triplicate for Norco to process the order of (controlled) medication from the pharmacy. During an interview with the Director Of Nursing (DON) on 11/20/19 at 11:51 a.m., the DON stated Pain is what patient says and nurse can check the facial expressions. The DON further stated Resident 184 was very alert, so if it was my patient, I would have given her Norco. The DON further confirmed 056381 Page 5 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0684 Level of Harm - Minimal harm or potential for actual harm facility had an emergency supply of Norco 10/325 tablets. The DON stated ,I would have gotten it from the E-Kit (emergency supply). Review of facility's E-Kit 80637188 at Station 1 showed E-Kit had eight tablets of Norco 10/325 mg available. Residents Affected - Few During another interview on 11/20/19 at 12:33 p.m., CNA 1 also confirmed Resident 184 was crying, and stating her legs were broken after the fall. CNA 1 stated she visited Resident 184 later on that day and she was in a lot of pain. During an interview on 11/20/19 at 1:08 p.m., CNA6, who was also at the fall scene also stated Resident 184 was in too much pain and she did not want to be moved. Review of Physician Orders Summary dated 12/2/18 showed to give Two tablets of Tylenol by mouth every four hours for pain. During a concurrent interview and record review on 11/21/19 at 9:49 a.m., the DON stated Medication Administration Record (MAR) dated 11/4/19 showed Resident 184 received Tylenol 650 mg at 10:50 a.m. for pain level of 4 out of 10. The DON stated MAR showed effectiveness of Tylenol was unknown. The DON stated licensed nurses were expected to check the effectiveness of pain medication, and if it does not work and there is another order, give that medication. The DON also stated staff could provide non therapeutic (non-medication) measures such as repositioning, massage for pain management. The DON stated if resident was still suffering, MD 1 should be notified. The DON further confirmed Resident 184's clinical record did not indicate if non therapeutic measures, and/or MD was made aware of uncontrolled pain. The DON also stated MD 1's order for Tylenol did not specify the level of pain for which it should be given. The DON also stated licensed nurse should have clarified the Tylenol order with MD 1 and fixed it. During a concurrent interview and review of Orders-Administration note dated 11/5/19 with Clinical leader (CL1) (in presence of DSD) on 11/21/19 at 2:44 p.m., CL1 stated Resident 184's pain was not evaluated by LVN3 after she gave Tylenol at 10:50 a.m. on 11/4/19. CL1 confirmed follow up note for Tylenol was documented by another nurse who worked on 11/5/19, when Resident 184 was not even at the facility. During a phone interview on 11/21/19 at 11:58 a.m., MD 1 stated he did not examine Resident 184 after the fall that morning. MD 1 stated when he was about to leave the facility, licensed nurse told him Resident 184 had fallen and had abrasions on the knees. MD 1 confirmed he gave an order to do X-ray and to give her Norco for pain and left the facility shortly after the fall. MD 1 stated he was notified by facility's staff again that Resident 184's condition had worsened, she was in more pain and her injuries were much more severe. MD 1 confirmed he was not aware that facility did not administer Norco that he had ordered for Resident 184 after the fall. MD 1 also stated he was not aware Resident 184's transfer to ACH 1 that did not occur until four hours after the incident of fall. MD 1 stated if Tylenol is unsuccessful to manage the pain, then opioids are given. Review of Resident 184's Care plan for Pain showed interventions for pain management initiated on 2/28/18 were to Anticipate the resident's need for pain relief and respond immediately for complaint of pain. And notify physician if interventions are unsuccessful or if current complaint is significant change from residents past experience of pain. 056381 Page 6 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent review of Resident 184's Medication Administration Record (MAR) for 11/2019 and interview with Medical Records Personnel (MR) on 11/20/19 at 3:08 p.m., MR confirmed that LVN3 transcribed the order for Norco 10/325 mg on 11/4/19 at 3:00 p.m., which was after Resident 184 was sent to ACH 1. Review of Resident 184's ACH 1's History and Physiology dated 11/4/19, Resident 184 was admitted to ACH 1 at 2:30 p.m. that day and was diagnosed with Closed fracture of right distal femur, Closed fracture of left proximal tibia, and Closed fracture of proximal end of left fibula. Review of facility's policy and procedure titled Pain Assessment and Management revised 7/22/17 showed, Pain management is a multidisciplinary care process that includes the following: b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; e. Developing and implementing approaches to pain management; g. Monitoring for effectiveness of interventions; and h. Modifying approaches as necessary. Possible behavioral signs of pain : a. verbal expressions such as groaning, crying Report the following information to the physician or practitioner: 3. Prolonged, unrelieved pain despite care plan interventions. 2. Review of Resident 73's Minimal Data Set (MDS- an assessment tool) dated 11/5/19 showed Resident 73 smoked cigarettes. Review of Resident 73's admission record showed Resident 73 was admitted to the facility on [DATE]. During a concurrent interview and record review on 11/19/19 at 12:36 p.m., the SSD 2 stated that the facility completed a smoking assessment as soon as the facility found out Resident 73 was a smoker. The SSD 2 then looked through Resident 73's medical record and found an undated and incomplete smoking assessment with Resident 73's name on it. SSD 2 stated she was unaware that the facility had not completed a smoking assessment for Resident 73. Review of the facility's policy and procedure titled, Smoking Policy-Residents revised on 6/14/17 showed, The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: d. Ability to smoke safely with or without supervision. A resident's ability to smoke safely will be re-evaluated quarterly . Residents who have independent or without independent smoking privileges are not permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. 056381 Page 7 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a safe environment for one (Resident 184) of 80 sampled residents, when two-person staff assist was not provided while repositioning Resident 184 resulting in her falling out of bed. This failure resulted in Resident 184 sustaining bilateral leg fracture (broken bone). Findings: Review of Resident 184's admission Record dated 10/21/19 showed Resident 184 was admitted to the facility on [DATE]. Review of the Morse Fall Scale-V2 (a fall risk assessment) dated 10/23/19, showed Resident 184 was at High risk for falls due to impaired mobility. During an interview on 11/20/19 at 10:23 a.m., Licensed Vocational Nurse (LVN3) stated Resident 184 fell at 9:55 a.m. on 11/4/19. During an interview on 11/20/19 at 10:57 a.m., Certified Nursing Assistant (CAN) 5 stated after putting an incontinent brief on Resident 184, while Resident 184 was lying in her bed, CNA 5 then turned Resident 184 facing towards the sliding door, away from CNA 5's own body. CNA 5 stated she was standing on the left side of Resident 184's bed. CNA 5 stated Resident 184 made a funny move and put her leg too far out of the bed. CNA 5 stated Resident 184 held onto the side rail on her right side while CNA 5 was holding Resident 184's waist on the left side. CNA 5 then stated she screamed for help and CNA 1 came into the room. During a phone interview on 11/20/19 at 11:51 a.m., CNA 1 stated Resident 184 was hanging onto the bed's right side rail while kneeling onto the ground when CNA 1 saw her on 11/4/19. Review of the Minimal Data Set (MDS- An assessment to guide care) dated 10/19/19, indicated Resident 184 required two persons' physical assist for Bed mobility (repositioning in bed). During an interview with Licensed Vocational Nurse (LVN) 3 on 11/20/19 at 2:24 p.m., LVN 3 stated direct care staff was told to either turn the residents' towards them during care or get another person if resident was being turned away from their own body. During a follow up interview on 11/21/19 at 9:07 a.m., CNA 5 stated she was aware that Resident 184 needed two staff persons to assist with bed mobility, however she was the only one helping Resident 184 on 11/4/19. CNA 5 added she always did it by herself. Record review of Progress Note, dated 11/4/19, indicated, .found resident (184) lying on the floor . MD in SNF and made aware of fall . Resident (184) transported . to [ACH1] for x-ray to bilateral knees to be done and for further evaluation per MD. Review of Resident 184's Acute Care Hospital (ACH) H&P dated 11/4/19, indicated Resident 184 was admitted to the ACH at 2:30 p.m. that day and was diagnosed with a Closed fracture of the right distal 056381 Page 8 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0689 Level of Harm - Actual harm femur (fracture of leg bone just above the knee joint), a closed fracture of the left proximal tibia (a fracture of shin bone just below the knee) and a closed fracture of the proximal end of the left fibula (a fracture of bone just below the knee). Residents Affected - Few 056381 Page 9 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

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 observation, interview and record review, for one (Resident 70) of 80 sampled residents, the facility failed to address resident's significant weight loss. Residents Affected - Some This failure resulted in Resident 70's fifteen percent weight loss over six months. Findings: Review of the admission Record indicated Resident 70 was admitted on [DATE] with multiple medical history including, Diabetes (high blood sugar), Dysphagia and Muscle Weakness. During an observation and concurrent interview on 11/18/19 at 8:45 a.m., Resident 70 was awake in bed. Resident 70 stated that she did not like hard foods because it was hard to chew. Resident 70 added she had missing teeth. Review of physician's order dated 11/4/19 indicated, Consistent Carbohydrate, No Added Salt diet, Regular texture . Review of the MD orders dated 10/9/19 indicated, Dental evaluation and treatment as indicated. In an interview with SSD2 on 11/21/19 10:27 a.m., SSD2 stated dental consent was not completed and was overlooked since admission. SSD2 added Resident 70 must sign the consent prior to the dental visit. SSD2 confirmed that since Resident 70 did not sign the consent form since admission, Resident 70 was not scheduled for the dental consult. Review of Resident 70's weights record indicated, Resident 70 weighed 140 pounds (lbs) in 5/2/19 and on 11/3/19 Resident 70 weighed 119 lbs. Resident 70 lost 21 pounds, a total of fifteen percent weight loss in six months. In an interview with the Registered Dietician (RD) on 11/21/19 at 9:11 a.m. RD stated that she was aware of Resident 70's weight loss. RD added that it was the Dietary Manager (DM) and nursing services' responsibility to report the weight loss to the MD and to initiate the care plan. Review of the Dietician Consultant Report, dated 9/25/19 indicated, RD observed Resident 70's continued weight loss - dislike facility food, prefers fast foods, Low serum sodium. RD's recommendation, Will revise goal range if Resident maintains weight for several months. In an interview of the Nursing Team Leader (NL1) on 11/21/19 at 9:30 a.m., NL1 stated Resident 70's weight loss was discussed in the Interdisciplinary Team meeting on 9/5/19, 9/19/19 and 11/7/19 but was not reported to the MD. Review of the Weight and Height Log, dated 9/9/19 indicated, the physician was not notified of Resident 70's six pounds weight loss. Review of the Medication Administration Record (MAR), dated November 2019 indicated staff were not monitoring the weekly Intake and Output every shift. Intake and Output were not completed on November 2, 3, 8 through 17, 2019. 056381 Page 10 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0692 Level of Harm - Minimal harm or potential for actual harm Review of the care plan (a document that provides guidance to staff on the resident's care) dated 10/4/19 and revised on 11/7/19, showed no intervention to address Resident 70's actual and rapid weight loss. In an interview with the DM on 11/21/19 at 9:15 a.m., DM confirmed that there was no care plan to address the issue of weight loss. DM stated that she did not consult with the RD regarding the care plan. Residents Affected - Some In an interview with MD on 11/21/19 at 11:58 a.m., MD stated that he was aware of Resident 70's declining weight but assumed that staff would follow up with a plan. Review of the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol Guidelines, dated, 8/4/17 indicated, The threshold for significant unplanned and undesired weight loss will be based on the following criteria: . 6 months - 10% weight loss is significant; greater than 10% is severe.The Physician will review possible causes of anorexia or weight loss with the nursing staff and/or Dietician before ordering interventions. a. The Dietitian will estimate calorie, nutrient and fluid needs and with the Physician, will identify whether the resident's current intake is adequate to meet his or her nutritional needs . 056381 Page 11 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview and record review, the facility failed to assess, explain risks and benefits and obtain an informed consent prior to using bed rails for six of (Resident 43, 186, 79, 42, 47, and 36) of 80 sampled residents. This failure had the potential for the above listed 6 residents to suffer from avoidable and hazardous accidents such as entrapment, entanglement, skin injuries, and the feeling of isolation, agitation, due to being restrained. Findings: During an observation on 11/18/19 at 10:00 a.m., Residents 43, 186, 79, 42, 47, and 36 were noted with bilateral half/quarter bed rails up while they were lying in bed. During a concurrent interview and Resident 43's medical record review on 11/18/19 at 2:07 p.m., Infection Control Nurse (ICN) confirmed Resident 43 was not assessed and/ or had physician's orders, and/ or had informed consent for use of bed rails. During an interview on 11/18/19 at 2:18 p.m., the Licensed Vocational Nurse (LVN 3) stated We do not do bed rail assessment if it's not a full bed rail. During an interview with the Clinical Leader (CL1) on 11/20/19 at 10:01 a.m., CL1 stated facility was sometimes using bed rails for residents to prevent them from falling. CL1 stated, We do not put the side rails down; otherwise residents would fall out of bed. CL1 continued by stating, The social worker was supposed to call the family to explain risks and benefits prior to using the bed rails. CL1 further confirmed that the, facility did not complete an assessment and/or obtained a physician order prior to putting bed rails up for all residents residing at the facility. CL1 then stated the risks of having the bed rails up were residents could get hurt, choked, if a resident get got stuck in it-side (bed) rails could kill them. CL1 further stated, the risks of injuries from a fall was much higher, without the side (bed) rails up than when not in use. During an interview on 11/20/19 at 1:24 p.m., Social Services Director (SSD) 2 stated she was not aware of any risks from bed rail use. During an interview on 11/21/19 at 10:34 a.m., the Director of Nursing (DON) stated all beds at the facility had bed rails. It was part of the bed and was not a concern for her. The DON then stated bed rails were not a restraint, so the facility did not need to obtain an informed consent. The DON stated she was not sure if a physician order and an assessment was required to use bed rails. During an interview on 11/21/19 at 12:46 p.m., Certified Nursing Assistant (CNA 2) stated while the residents were in bed, they had to leave the bilateral side (bed) rails up for safety reasons. CNA 2 further confirmed staff was not putting the side (bed) rails down while residents were in bed. CNA 2 also stated the facility's Director of Staff Development (DSD) trained the staff to use side (bed) rails that way. CNA 2 further stated, full side (bed) rails were even better but the facility was using only half side (bed) rails at that time. 056381 Page 12 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a follow up interview on 11/21/19 at 1:11 p.m., the DSD stated she did not train the facility staff on bed safety at all. During an interview on 11/22/19 at 9:54 a.m., the facility's administrator (ADM) stated bed rails being used at the facility were not a restraint, so the facility was not required to complete an assessment for bed rail use. The ADM also stated the facility did not have a policy and procedure regarding the use of bed rails. Review of Centers of Medicare & Medicaid Service's (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated 10/2019 showed, Bed rails include any combination of partial or full rails. Bed rails could create visual barrier and deter physical contact from others. Involuntary movements, resident weight, and gravity's effects may lead to the resident's body shifting toward the edge of bed the resident could be at risk for entrapment .While the bed rails may not constitute a physical restraint, they may affect the resident's quality of life and create an accident hazard. 056381 Page 13 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 safe storage of laboratory test supplies when expired laboratory sample collection kits were found stored with currently used laboratory collection kits. This failure had the potential to jeopardize the quality of the collected data and could result in inaccurate result impacting physician's treatment decisions. Residents Affected - Some Findings: During an observation on [DATE] at 11:01 a.m. the following laboratory biological test kits were found in the Dirty Utility Room: 1. Three E-Swabs Collection Transport System for Aerobic (requiring oxygen), Anaerobic (not requiring oxygen) and Fastidious (requiring specific nutrient) Bacteria test kits with expiration date of [DATE] were stored in the drawer mixed with currently used laboratory test kits. 2. Four Nasopharyngeal Sample Collection Kits for Viruses with Expiration date of [DATE] were stored in the drawer mixed with currently used laboratory test kits. In an interview with the Licensed Vocational Nurse (LVN) 1 on [DATE] 11:03 a.m. LVN 1 stated that the test kits were currently used to collect sample for bacteria in the wound and viruses in the nasal cavities. LVN 1 confirmed that they were expired. LVN 1 gathered the expired test kits to be discarded. Review of the facility's policy indicated, there was no policy regarding the storage of laboratory biological test kits. 056381 Page 14 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0791 Provide or obtain dental services for each resident. 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 the physician's order to provide routine dental services for two (Residents 19 and 70) of 81 sampled residents, when: Residents Affected - Few 1. Resident 19 did not receive routine follow up dental services for broken and decayed teeth. 2. Resident 70 did not receive routine dental services since admission. These failures had the potential to cause resident avoidable dental issues and weight loss. Findings: 1. Review of the admission Record indicated Resident 19 was admitted on [DATE] with multiple diagnosis including, Dysphagia (difficulty swallowing) and Diabetes (high blood sugar). In an observation and concurrent interview with Resident 19 on 11/18/19 at 09:10 a.m., Resident 19 was awake in bed complaining that it has been awhile since she saw a dentist. Resident 19 added that she would like her broken teeth fixed. Review of the physician's order dated 4/1/16, indicated, Dental evaluation and Treatment as needed. Review of the Dentist progress notes dated 2/12/19 indicated, Resident 19 had broken/decayed teeth: #2, 4, had moderate plaque. Review of the social services notes dated 7/14/19, indicated Resident 19 had dental appointment on 7/15/19. There were no documentation of the Dentist's plan, instructions and recommendations post dental appointment. In an interview with the Social Services Director (SSD2) on 11/19/19 at 9:44 a.m., SSD2 stated that Resident 19's last dental visit was with her private dentist on 7/15/19. SSD2 confirmed that there were no records from that dental visit and the facility was not aware of the dentist assessment and plan. Review of the facility's policy titled Medication and Treatment Orders, Dental Services, dated 6/12/17 indicated, The resident's Attending Physician must be informed of the treatment and medications ordered by the dentist. 2. Review of the admission Record indicated Resident 70 was admitted on [DATE] with multiple medical history including, Diabetes (high blood sugar), Dysphagia (difficulty swallowing) and Muscle Weakness. During an observation and concurrent interview on 11/18/19 at 8:45 a.m., Resident 70 was awake in bed. Resident 70 stated that she did not like hard food because it was hard to chew. Resident 70 added she had missing teeth. Review of Resident weights indicated that Resident 70 weighed 140 pounds (lbs) on 5/1/19 and 119 lbs on 11/3/19. Resident 70 lost 21 pounds, a 15% weight loss in six months. 056381 Page 15 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0791 Review of the MD orders dated 10/9/19 indicated, Dental evaluation and treatment as indicated. Level of Harm - Minimal harm or potential for actual harm In an interview with SSD2 on 11/21/19 10:27 a.m., SSD2 stated dental consent was not completed and was overlooked since admission. SSD2 added Resident 70 must sign the consent prior to the dental visit. SSD2 confirmed that since Resident 70 did not sign the consent form since admission, Resident 70 was not scheduled for the dental consult. Residents Affected - Few 056381 Page 16 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow its policy and procedure for food storage, when following food items were stored in freezer section of Medication room [ROOM NUMBER]'s Medication Refrigerator: a. One undated and unlabeled brown colored drink frozen hard in a Jack in the Box plastic cup. b. One undated and unlabeled, with no open date, box of Fudgsicles with 11 fudgsicles left in the box. This failure resulted in facility not following its safe food handling practices. Findings: During a medication room [ROOM NUMBER] observation accompanied by Licensed Vocational Nurse (LVN) 3 on 11/18/19 at 10:30 a.m., one undated, unlabeled brown colored frozen hard drink in [NAME] in the Box plastic cup was stored in Medication Refrigerator's freezer section. LVN 3 stated she did not know who did the drink belong to and she threw it away. LVN 3 then took out a box of Fudgsicles from the freezer section. The box was unlabeled and undated and has 11 fudgsicles left inside. LVN 3 stated staff should have labeled and put the open date on the box when the box was opened. LVN 3 further stated licensed nurses at nursing station 2 were supposed to check the refrigerator every day. During an interview on 11/18/19 at 10:33 a.m., LVN 5 who worked at nursing station 2, stated she did not check the medication refrigerator that morning. Review of facility's policy and procedure titled Food Receiving and Storage dated 10/2017 showed All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of facility's another policy and procedure titled Storage of Medications dated 5/16/18 showed, Other foods such as employee lunches and activity department refreshments are not stored in this (medication) refrigerator. 056381 Page 17 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide services to safely store and reheat residents' food brought in by family/visitors. Residents Affected - Some This failure resulted in residents to waste the leftovers brought in families and/or visitors and feel left out at the facility. Findings: During medication room rounds with Licensed Vocational Nurse (LVN) 3 on 11/18/19 at 10:26 a.m., LVN 3 stated staff was not reheating residents' leftover foods brought in by family/visitors. LVN 3 stated Kitchen had told nursing staff to not reheat the food. During an interview with the Facility Manager (FM) on 11/18/19 at 11:30 a.m., the FM stated We do not have enough space to have residents' food, so we do not encourage them to keep the leftovers. We tell them to either finish the food or visitors should take the leftovers. Review of Resident Council Suggestion dated 10/29/19 showed, Resident are concerned that they no longer have a place to heat up their food. During the Resident Council Meeting on 11/19/19 at 11:07 a.m., Residents expressed Food would taste better if it was hot and staff refused to reheat their food brought in from home or restaurant. Residents also stated that they had to waste the food because facility could not store the leftovers. Residents stated it made them feel left out because they cannot enjoy that food. Review of facility's policy and procedure titled Food brought by family/Visitors dated 10/2017 showed, Food brought to the facility by visitors and family is permitted. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Facility staff will assist the resident with accessing his or her food if unable to do so independently. During an interview on 11/21/19 at 10:53 a.m., Director of Nursing (DON) stated licensed nurses were trained on facility's policy titled Foods brought by family/visitors. DON further stated she was not able to recall when the training was provided. DON then stated facility was not following the policy at that time. 056381 Page 18 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow infection prevention practices when following were observed: Residents Affected - Some 1. Two sets of personal clothing items were stored in medication room [ROOM NUMBER] at the nursing station; 2. Resident 51's oxygen cannula attached to nebulizer was not changed for 15 days. This failure had the potential to spread infections to the residents whose medications were stored and/or prepared in the medication room [ROOM NUMBER] and Resident 51 to suffer from respiratory infections from using the oxygen cannula that was not changed per facility's policy. Findings: 1. During an observation of Medication room [ROOM NUMBER], accompanied by Licensed Vocational Nurse (LVN 3) on 11/18/19 at 10:26 a.m., One black jacket with hoodie and one blue colored full sleeve female top were hanging on a hook on the back of the medication room door. LVN 3 stated staff at nursing station 2 did not know who did the clothing items belonged to. LVN 3 further stated staff should not store personal items in medication rooms to prevent infections. LVN 3 also stated staff was supposed to store their personal items in the break room. During a follow up interview with facility's Clinical Leader (CL 1) on 11/20/19 at 9:56 a.m., CL 1 stated personal items should not be in the medication rooms, it is to prevent infections. During an interview on 11/20/19 at 10:50 a.m., Director of Staff Development (DSD) stated medication rooms were only to store medications. DSD further stated all staff received and signed the facility handbook which guides them to store their personal items in break room lockers. Review of facility's Employee Handbook dated 10/15/13 showed, The lockers are to put your belongings while you are at work. 2. Review of Resident 51's Comprehensive Assessment Details dated 4/11/19 showed Resident 51 had a diagnosis of Lung cancer. During an observation and concurrant interview at Resident 51's bedside on 11/18/19 at 11:05 a.m., oxygen cannula was attached to a nebulizer machine. A white tape dated 11/6/19 was attached to the Oxygen cannula. Resident 51 stated he used the nebulizer that morning. During an interview on 11/18/19 at 11:13 a.m., LVN 5 confirmed oxygen cannula was dated 11/6/19. LVN 3 stated night shift nurse was supposed to change the cannula every seven days. When asked if cannula was supposed to be changed on 11/13/19, LVN 5 stated, I don't know. Review of Resident 51's Medication Administration Record showed Resident 51 was receiving Albuterol Sulphate Nebulization Solution (2.5 milligrams/3 milliliters) 0.083% 1 unit via nebulizer. During an interview with Infection Control Nurse (ICN) on 11/18/19 at 11:19 a.m., ICN confirmed 056381 Page 19 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 51 was using the nebulizer four times a day every day. ICN stated, once the tubing (cannula) is hooked to equipment, it needs to be changed in seven days. During a concurrent interview review of Resident 51's physician orders with CL 1 on 11/20/19 at 9:51 a.m., CL 1 stated Resident 51 was receiving nebulizer treatment since 5/10/19 and we missed to put the order to change the cannula for Resident 51. CL1 also stated facility was following Oxygen administration and Storage policy and procedure for Nebulizer treatment. CL 1 further stated if tubing was not replaced as directed, it could cause infections. Review of facility's policy and procedure titled Oxygen administration and Storage dated 3/6/17 showed Oxygen cannula and mask are changed weekly or more frequently as needed and labeled with the date that the cannula/mask was changed. Document in the medical record. 056381 Page 20 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide at least 80 square feet per resident for residents who occupied the following multiple resident bedrooms: Rooms 1, 3, 5.6, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 23, 24, 25, 26, 27, 29, 31, 32, 33, 34, 35, 37 and 39. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside. Findings: In an observation and concurrent interview with the Maintenance Supervisor (MS) on 11/19/19 at 10:30 a.m., MS measured the resident's bedrooms. MS stated that there were no complaints from the residents and staff regarding the size of the bedrooms. The following multiple resident rooms were identified having below the required 80 square feet requirement per resident: Room Activity Number of Beds Floor Area 1 Rt room [ROOM NUMBER] 75.75 sq.ft/bed 3 Rt room [ROOM NUMBER] 75.56 sq.ft/bed 5 Rt room [ROOM NUMBER] 76.23 sq.ft/bed 6 Rt room [ROOM NUMBER] 75.93 sq.ft/bed 9 Rt room [ROOM NUMBER] 75.33 sq.ft/bed 10 Rt room [ROOM NUMBER] 75.33 sq.ft/bed 11 Rt room [ROOM NUMBER] 78.00 sq.ft/bed 12 Rt room [ROOM NUMBER] 75.86 sq.ft/bed 14 Rt room [ROOM NUMBER] 78.56 sq.ft/bed 15 Rt room [ROOM NUMBER] 79.73 sq.ft/bed 16 Rt room [ROOM NUMBER] 76.77 sq.ft/bed 17 Rt room [ROOM NUMBER] 78.35 sq.ft/bed 18 Rt room [ROOM NUMBER] 76.76 sq.ft/bed 19 Rt room [ROOM NUMBER] 79.76 sq.ft/bed 056381 Page 21 of 22 056381 11/22/2019 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0912 20 Rt room [ROOM NUMBER] 79.76 sq.ft/bed Level of Harm - Minimal harm or potential for actual harm 23 Rt room [ROOM NUMBER] 73.84 sq.ft/bed 24 Rt room [ROOM NUMBER] 73.70 sq.ft/bed Residents Affected - Some 25 Rt room [ROOM NUMBER] 72.36 sq.ft/bed 26 Rt room [ROOM NUMBER] 70.26 sq.ft/bed 27 Rt room [ROOM NUMBER] 73.44 sq.ft/bed 29 Rt room [ROOM NUMBER] 72.83 sq.ft/bed 31 Rt room [ROOM NUMBER] 73.39 sq.ft/bed 32 Rt room [ROOM NUMBER] 73.39 sq.ft/bed 33 Rt room [ROOM NUMBER] 73.39 sq.ft/bed 34 Rt room [ROOM NUMBER] 73.39 sq.ft/bed 35 Rt room [ROOM NUMBER] 73.08 sq.ft/bed 37 Rt room [ROOM NUMBER] 73.39 sq.ft/bed 39 Rt room [ROOM NUMBER] 73.39 sq.ft/bed During random observations of care and services from 11/18/19 to 11/22/19, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in these rooms. Granting of room size waiver is recommended. 056381 Page 22 of 22