Health inspection·March 1, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to protect the dignity and privacy of one of 28 sampled residents (Resident 92), when Resident 92's entire back side of body was exposed in the hallway while Certified Nursing Assistant was transferring Resident 92 from shower room. This failure had the potential to negatively affect Resident 92's self-esteem and cause embarrassment. Findings: During a review of Resident 92's Face Sheet, printed on 2/29/24, the Face Sheet showed Resident 92 was originally admitted to the facility in January 2024 with a diagnosis of cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain). During a record review of Resident 92's Minimum Data Set (MDS- a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 1/8/24, Resident 92's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve is an indication of moderate cognitive impairment.) was 11 out of 15. Review of section GG (Functional Abilities and Goal) indicated Resident 92 was dependent on staff for shower and toileting. During an observation on 2/28/24 at 9:05 a.m., Certified Nursing Assistant (CNA )4 brought Resident 92 out of the shower room into the hallway in the shower chair. CNA 4 did not cover Resident 92's back for privacy and was exposed in the hallway. During an interview on 2/28/24 at 9:27 a.m. with CNA 4, CNA 4 stated Resident 92 is confused, and she forgot to cover Resident 92s back as she was rushing. CNA 4 also stated it is important to cover residents for privacy and dignity. During an interview on 2/29/24 at 10:35 a.m. with Director of Nursing (DON), DON stated staff should always make sure residents are covered fully to prevent exposure when taken for a shower. DON stated when residents are exposed it affects their dignity and privacy. During a review of the facility's undated Policy and Procedure (P&P) titled, Resident Dignity and Privacy, printed on 2/29/24, the P&P indicated, Procedure .3. Drape and dress residents appropriately Page 1 of 14 056422 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0550 Level of Harm - Minimal harm or potential for actual harm at all times to avoid exposure and embarrassment. 4.Maintain resident privacy during toileting, bathing, and other activities of personal hygiene .a. Use a top sheet or blanket as a cover-up during bedside care. B. Cover resident during transfer to shower or toilet. Residents Affected - Few 056422 Page 2 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

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** 3. During a review of Resident 69's admission Record, printed on 2/29/24, the admission Record showed Resident 69 was admitted to the facility in February 2024 and is deaf and mute. Residents Affected - Some During a record review of Resident 69's MDS, dated [DATE], Resident 69's BIMS score was 13 out of 15, indicating intact mental status. Review of section GG (Functional Abilities and Goal) indicated Resident 69 was dependent on staff for self-care. During a concurrent observation and interview on 2/26/24 at 11:30 a.m. with Certified Nursing Assistant (CNA) 8, Resident 69 had long fingernails with black matter underneath. CNA 8 stated the Nurses and CNA's can trim resident 69's nails. During a concurrent observation and interview on 2/26/24, at 11:32 a.m., with CNA 8 and Resident 69, CNA 8 stated Resident 69 is deaf and mute. Resident 69 indicated through gestures and facial expression that she would like to have her nails trimmed and cleaned. During an interview on 2/29/24, at 9:38 a.m. with Unit Manager (UM)2, UM2 stated Resident 69 is Diabetic and Licensed Nurses are responsible to trim resident 69's fingernails. Stated it is important to maintain the dignity of resident. During an interview on 2/29/24 at 10:35 a.m. with Director of Nursing (DON), DON stated the risk of not providing nail care is that food materials, and other dirt can get stuck, and resident can scratch themselves which can lead to skin issues and can be a source of infection. During a review of Resident 69's Care Plan-Self-care deficit dated 2/10/24, the care plan indicated to assist resident 69 in ADL (Activities of daily living) to maintain comfort and dignity. During a review of the facility's undated Policy and Procedure (P&P) titled, Fingernails/Toenails, Care of, printed on 2/29/24, the P&P indicated, Purpose-Care of fingernails promotes circulation to the hands and helps prevent small tears around the nails that could lead to infections. Based on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Resident 35, Resident 69, and Resident 5) were assisted with Activities of Daily Living (ADLs, Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.) when: 1. Resident 35 had long and chipped fingernails; 2. Resident 69 had long fingernails with black matter underneath; 3. Resident 5 did not received showers as scheduled. These failures resulted in Resident 5 feeling upset; and placed Resident 69 and Resident 35 at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails. 1. During a review of Resident 35's Face Sheet, undated, the Face Sheet indicated Resident 35 was 056422 Page 3 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitted to the facility in August 2022, with medical diagnoses to include cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain) and dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a review of Resident 35's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 12/03/23, the MDS indicated Resident 35's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information.) score was seven (7) out of 15, indicating severely impaired in mental status. The MDS assessment also indicated that Resident 35 required maximum assistance with personal hygiene. During a concurrent observation and interview on 2/28/24 at 10:05 a.m. with Certified Nursing Assistant (CNA) 6, Resident 35 had long and chipped fingernails about 1/4 inch in length on both hands. CNA stated that Resident 35's fingernails needed trimming however he did not provide it. During concurrent observation and interview on 2/28/24 at 2:55 p.m. with Registered Nurse (RN) 2, RN 2 stated Resident 35's fingernails were due for trimming. RN 2 also stated that Resident 35 did not have a diagnosis of diabetes (a long-term chronic disease in which the body cannot regulate the amount of sugar in the blood), so CNAs could trim Resident 35's fingernails. RN 2 stated, if long fingernails were left untrimmed, it could cause Resident 35 to suffer from infection and skin injury. During a review of facility's policy and procedure (P&P) titled Fingernail Care, undated, the P&P indicated, Care of fingernails promotes circulation to the hands and helps prevent small tears around the nails that could lead to infections .use nail clippers to cut fingernails. 2. During a review of Resident 5's Face Sheet, indicated, Resident 5 was admitted to the facility in June 2021, with medical diagnoses to include cerebral infarction and hemiplegia (the loss of muscle function on one side of the body). During a review of Resident 5's MDS, dated 12/30/23, the MDS indicated Resident 5's BIMS score was 14 out of 15, indicating an intact mental status. The MDS assessment also indicated that Resident 5 required maximum assistance with showers. During a review of Resident 5's Self-Care Deficit Care Plan, dated December 2023, the care plan indicated, Resident will be provided with needed assistance in ADL. During an interview on 2/26/24 at 10:00 a.m. with Resident 5, Resident 5 stated her shower schedule was every Wednesday and Saturday, however, she did not receive three showers as scheduled two weeks ago. Resident 5 also stated that it made her very upset to not received her showers as scheduled. During a review of facility's Daily Shower Schedule, the schedule indicated, Resident 5's showers were every Wednesdays and Saturdays in the morning. During an interview on 3/1/24 at 8:09 a.m. with Director of Staff Development (DSD), DSD stated that CNAs should filled out the Shower Day Skin Inspection and complete the Point of care ADL Report on the electronic health record for shower task completion. 056422 Page 4 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 3/1/24 at 8:12 a.m. with DSD, facility's form titled Shower Day Skin Inspection, dated 2/21/24 was reviewed. The form had a section that includes Resident 5's name and Room number. Additionally, there were checklists provided to document shower, tub baths and bed baths if rendered or if refused. The form indicated Resident 5 was provided bed bath on that 2/21/24. DSD stated he interviewed Resident 5 and she confirmed that she also received shower on 2/17 and 2/24, however, DSD did not find the forms for those dates. During a concurrent interview and record review on 3/1/24 at 8:16 a.m. with DSD, Resident 5's Point of care ADL report on bathing, dated 2/12/24 through 2/25/24 was reviewed. The Point of care ADL report indicated there was no documentation for Resident 5 bathing for morning shift on Wednesdays/Saturdays falling on 2/17/24, 2/21/24 and 2/24/24. DSD stated if shower completion was not documented on that shift, it was not provided. During a telephone interview on 3/1/24 at 9:08 a.m. with CNA 7, CNA 7 stated she did not provide a shower to Resident 5 on 2/17/24. During a review of the facility's policy and procedure (P &P) titled, Tub Bath and Shower, undated, the P&P indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident. 056422 Page 5 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 70 and Resident 42) environment remained free of accident hazards when housekeeping staff placed a bedsheet in the bathroom floor in front of the toilet. This deficient practice had the potential to place Resident 70 and Resident 42 at risk for falls and possible injury. Findings: During a concurrent observation and interview on 2/27/24 at 11:07 a.m., with Certified Nursing Assistant (CNA) 1, a folded white bedsheet was observed on the bathroom floor in front of the toilet under the raised toilet seat in the shared bathroom in Resident 70's and Resident 42's room. CNA 1 stated Resident 42 urinates all over the floor and the housekeeping staff (HSK) placed the bedsheet on the floor. During an interview on 2/27/24 at 11:10 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she does not know who placed the bedsheet on the bathroom floor and this situation is not safe for residents and can cause falls. During a concurrent observation and interview on 2/27/24 at 11:15 a.m., with HSK 2, the shared bathroom in Resident 70 and Resident 42 room was observed to have the bedsheet on the floor. HSK 2 stated Resident 42 urinates all over the floor and Resident 70 puts paper towel on the floor to prevent his sock from getting wet. HSK stated she cleans the bathroom in the morning and puts the bedsheet on the floor. During an interview on 2/29/24 at 10:43 a.m. with Director of Nursing (DON), DON stated putting bedsheet on the toilet floor is a hazard as residents can trip and fall. During an interview on 2/29/24 at 12:24 p.m. with CNA 2, CNA 2 stated Resident 70 and Resident 42 are able to independently go to the bathroom and use the toilet. During a review of Resident 70's Face Sheet, printed on 2/29/24, the Face Sheet showed Resident 70 was originally admitted to the facility on [DATE] with a diagnosis of sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). During a record review of Resident 70'S Care Plan on fall prevention, initiated 4/12/23, the Care Plan indicated to keep the environment free of hazards and clutter. During a review of Resident 42's Face sheet, printed on 2/29/24, the Face Sheet showed Resident 42 was originally admitted to the facility in January 2020 with a diagnosis to include cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain). During a record review of Resident 42's Care Plan on fall prevention, initiated on 4/11/23, the 056422 Page 6 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0689 Care Plan indicated to keep environment free of hazards and clutter. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's undated policy and procedure (P&P) titled, Safety Supervision of Residents, the P&P indicated, Individualized, Resident -Centered Approach to Safety .1. Our individualized, resident -centered approach to safety addresses safety and accident hazards for individual residents. 3.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Residents Affected - Few During a review of the facility's undated P&P titled, Fall management, the P&P indicated, Purpose- Based on previous evaluations and current date, the staff will identify interventions related to the resident's risks and causes to try to reduce the risk of the resident falling and try to minimize complications from falling. 056422 Page 7 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of the residents for one of three sampled residents (Resident 73) when buspirone (medication that treats anxiety) was not available for medication administration. This failure had the potential to result in ineffective medication regimen and Resident 73 suffering from unnecessary anxiety. Findings: During a review of Resident 73's Face Sheet, undated, the Face Sheet indicated Resident 73 was admitted to the facility in August 2021 with diagnoses that included anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 73's Physician Order Report for 1/28/24- 2/28/24, the Physician Order Report indicated an order to administer buspirone 10 milligram (mg, a unit of measurement) tablet one tablet by mouth three times daily for anxiety. During an interview and concurrent record review on 2/28/24 at 1:02 p.m. with LVN 1, Resident 73's Medications Administration History (MAH) from 2/1/24-2/28/24 was reviewed. LVN 1 stated buspirone was not given to Resident 73 during medication pass administration because the medication was not available. Resident 73's MAH indicated an order to administer buspirone 10 milligram tablet, one tablet by mouth three times daily. The MAH indicated buspirone was Not administered: Drug/Item unavailable. During an observation for medication pass administration on 2/28/24 at 9:50 a.m. with LVN 1, LVN 1 administered scheduled morning medications (a total of 11 pills) to Resident 73 except buspirone. During an interview on 2/28/24 at 1:02 p.m. with LVN 1, LVN 1 stated she did not give buspirone because it was not available. During a review of Resident 73's MAH from 2/1/24-2/28/24, the MAH indicated Resident 73 did not receive six doses of buspirone on 2/23/24 and 2/24/24. During a review of Resident 73's Progress Notes, dated 2/23/24, the Progress Notes indicated Resident 73 Is showing behavior issues earlier. [Resident] kept on asking for pain medication every hour and kept reasoning it's not working .Also noticed that resident is exaggerating stories. Another Progress Notes, dated 2/23/24 at 12:08 p.m. indicated Resident 73 Kept coming to the nursing station and complaining of pain all over the body .threatened to call 911 .has drug seeking behavior . 056422 Page 8 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure that its medication error rates are less than five percent when four medication errors were observed out of 26 opportunities. The medication error rate was calculated as follows: four divided by 26 then multiplied by 100, which was equal to 15 percent. Residents Affected - Few This failure had the potential to result in ineffective medication regimen for the affected residents (Residents 73 and 74). Findings: 1. During a review of the manufacturer's insert for Breo Ellipta (fluticasone furoate and vilanterol inhalation powder, medication used for asthma), the manufacturer's insert indicated, Instructions For Use .BREO ELLIPTA .How to use your inhaler .Step 2 .While holding the inhaler away from your mouth breathe out (exhale) fully. Do not breathe out into the mouthpiece .Step 3. Put the mouthpiece between your lips and close your lips firmly around it. Your lips should fit over the curved shape of the mouthpiece. Take one long, steady, deep breathe in through your mouth. Do not breathe in through your nose .Remove the inhaler from your mouth and hold your breath for about 3 to 4 seconds (or as long as comfortable for you) .Step 4. Breathe out slowly and gently .Step 6. Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water . During an observation on 2/28/24 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 did not instruct Resident 73 to breathe out as much air as possible prior to the administration of Breo Ellipta. LVN 1 did not provide water for mouth rinse after breathing in the Breo Ellipta. During an interview on 2/28/24 at 10:36 a.m. with LVN 1, LVN 1 stated she did not follow Step 2, Step 3 and Step 6 as indicated by the Breo Ellipta manufacturer's insert. LVN 1 stated she did not instruct Resident 73 to breathe out as much air prior to administration. LVN 1 stated it was important to exhale before administration to open the airway for the medication to work effectively. LVN 1 stated she forgot to give Resident 73 water for mouth rinse. LVN 1 stated mouth rinse after inhaler administration was important to prevent development of oral candidiasis (a fungal infection). During an interview and concurrent record review on 2/28/24 at 1:02 p.m. with LVN 1, Resident 73's Medications Administration History (MAH) from 2/1/24-2/28/24 was reviewed. LVN 1 stated buspirone (treats anxiety-intense, excessive, and persistent worry and fear about everyday situations. Fast heart rate, rapid breathing may occur) was not given to Resident 73 during medication pass administration because the medication was not available. Resident 73's MAH indicated an order to administer buspirone 10 milligram tablet, one tablet by mouth three times daily. The MAH indicated buspirone was Not administered: Drug/Item unavailable. 2. During an observation on 2/28/24 from 10:05 a.m. to 10:30 a.m. with LVN 2, LVN 2 took out Flovent HFA from an unopened box, labeled the box and the inhaler with an opened-on date. LVN 2 handed the Flovent HFA to Resident 74 without priming the medication and without giving instructions on how to use the inhaler medication. Resident 74 took the medication from LVN 2 and administered two quick puffs to self. LVN 2 did not provide water for Resident 74 for mouth rinse. During a review of the manufacturer's insert for Flovent HFA (fluticasone propionate inhalation aerosol, medication for asthma), the manufacturer's insert indicated, Instructions For Use .Priming 056422 Page 9 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Your Flovent Inhaler .Shake the inhaler well for 5 seconds .Spray the inhaler 1 time into the air away from your face .Shake and spray the inhaler like this 3 more times to finish priming it .How to use your FLOVENT HFA inhaler .Follow these steps every time you use FLOVENT HFA .Step 2. Hold the inhaler with the mouthpiece and shake it well for 5 seconds .Step 3. Breathe out through your mouth and push as much air from your lungs as you can .Step 4 .breathe in deeply and slowly through your mouth .Step 6. Hold your breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as you can .Step 7. Rinse your mouth with water after breathing in the medicine. During an interview on 2/28/24 at 10:32 a.m. with LVN 2, LVN 2 stated not giving instructions on how to take the medication to Resident 74. LVN 2 stated realizing she had made multiple errors that included failing to give instruction to Resident 74 to take only one puff of the inhaler medication. During a review of Resident 74's Physician Order Report from 1/28/24-2/28/24, the Physician Order Report indicated an order dated 12/29/22 for Flovent HFA aerosol inhaler, inhale one puff by mouth twice daily, rinse off mouth thoroughly after each use. During a review of the facility's policy and procedure (P&P) titled Metered-Dose Inhaler (MDI) printed 2/28/24, the P&P indicated procedures to administer inhaler medications that included, 8. Remove the cap from the mouthpiece. It is recommended to 'test-spray' the inhaler .by spraying four times into the air before using for the first time .9. Have resident breath[e] out through the mouth .11. While breathing in deeply and slowly through the mouth, press down firmly and fully on the top of the metal canister with index finger .12. Continue to inhale and try to hold breath for 5-10 seconds. Before breathing out, remove inhaler from mouth and release finger from the canister. 13. Exhale slowly through pursed lips. 056422 Page 10 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

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, distribute, and serve food under sanitary conditions when: Residents Affected - Some 1. Multiple food items in freezer #1 and freezer #2 were opened and undated. 2. Food items in freezers #1 and #2 had expired. 3. Multiple individually packaged food items in an opened box in the dry storage had expired. 4. Freezer #3 was not clean. 5. The three-compartment sink was not clean. 6. One scoop from the clean drawer for scoops was not clean. This failure had the potential to cause cross contamination and an outbreak of food borne illness to 90 residents who received food from the kitchen. Findings: During a concurrent observation and interview on 2/26/24 at 9:20 a.m. accompanied by the Dietary Manager (DM) and Registered Dietician (RD), Freezer #1 had brown patties in a plastic package and light brown patties in another plastic package that were not labeled with open dates. There was diced, cooked chicken in a plastic package with no open date. There were two Sysco stuffed cabbage rolls with beef and sauce in the box with date 7/7/23. DM confirmed the stuffed cabbage rolls had expired. Freezer #2 had one plastic package of potato wedge not labeled with an open date, one plastic package of French toast with no open date or use by date. Freezer # 2 also had garlic bread in a plastic package with label dated 9/15/23, and ice cream in a box with received date of 8/31/23. DM acknowledged the French toast, garlic bread, and ice cream were outdated. Freezer #3 was dirty with brown paper from the bottom of one of the Original Cakerie, a frozen dessert, stuck to the surface of the freezer. Also, on the surface of the freezer were whitish particles. DM acknowledged the freezer was dirty. The three-compartment sink near the cooking area was dirty with water and white particles on the right top counter. On the counter, were the red and green buckets with towels soaked in solution in the red bucket. In the middle sink of the three-compartment sink were two deep pans stacked together, with white substance around the sides of the pan stacked inside, filled with some water. Inside the sink was some brownish particles. DM stated they do not use the three-compartment sink and acknowledged it was dirty. One scoop with blue handle in the clean drawer for scoops was dirty with yellowish green substance at the back, between the scoop and handle. DM stated it needed to be rewashed. During a concurrent observation and interview on 2/27/24 at 8:14 a.m. with DM and RD in the dry storage room, there were multiple individual use half and half milk in an open box with a use by date 12/31/23. DM stated they needed to be thrown away. During an interview on 2/28/24 at 2:45 p.m. with RD, RD stated the food items should always have 056422 Page 11 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some received date and open date. RD stated the three-compartment sink area should be clean and dry. RD stated it was not okay for the scoop to be dirty and put in the drawer. During a review of the facility's policy and procedure (P&P) titled, Food receiving and storage of cold foods, dated 2023, the P&P indicated, .All open food items will have an open date and use-by date per manufacturer's guidelines .cold food storage will be clean, dry, and free of contamination by condensation, stored following proper storage hierarchy, . During a review of the facility's P&P, titled, Suggested Freezer Storage Guidelines, the P&P indicated Ice Cream Recommended Maximum Storage Period 3 months. During a review of the facility's P&P titled, Cleaning and Defrosting Freezers, dated 2023, the P&P indicated Reach-In freezers will be cleaned and sanitized once a week .or more often as necessary. According to the Federal Food Code (2022), Warewashing Equipment, Cleaning Frequency. A Warewashing machine; the compartments of sinks, basins, or other receptacles used for washing and rinsing equipment, utensils, or raw foods, or laundering wiping cloths; . shall be cleaned: (A) Before use; (B) Throughout the day at a frequency necessary to prevent recontamination of equipment and utensils and to ensure that the equipment performs its intended function; and (C) If used, at least every 24 hours .Warewashing Sinks, Use Limitation. If the wash sink is used for functions other than warewashing, such as washing wiping cloths or washing and thawing foods, contamination of equipment and utensils could occur. 056422 Page 12 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

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 ensure staff followed the infection prevention and control policy to prevent spread of infection when: Residents Affected - Some 1) Clean personal clothing of residents was not covered and were stored exposed in the laundry room. 2) Housekeeping Staff (HSK) 1 did not perform hand hygiene after cleaning resident rooms and did not perform hand hygiene before entering and exiting room and touched multiple high touch surface areas in resident rooms. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff. Findings: 1. During a concurrent interview and observation on 2/28/24 at 8:46 a.m., with Laundry Staff (LS), a blue container for residents personal clothing was open and exposed to air towards the back side of the dryer and washer. LS stated that clean clothing should always be covered, and it is not considered clean when it is open and exposed to air. LS also stated the clothes can get dusty and cause itchiness and coughing for residents. During an interview on 2/28/24 at 3:16 p.m. with Infection Preventionist (IP), IP stated the clean linen and clothes should be covered to protect from getting contaminated with bacteria and dust. During a review of the facility's undated Policy and Procedures (P&P) titled, Linen storage, printed on 3/1/24, the P&P indicated, Purpose- Store linen in a manner that prevent cross-contaminated. 2. During an observation on 2/28/24 at 9:16 a.m., HSK 1 was observed to exit room [ROOM NUMBER] after cleaning the room and discarded the gloves and without performing hand hygiene took the mop from housekeeping cart and swept waste from the floor on the hallway. HSK 1 then entered room [ROOM NUMBER] again without performing hand hygiene and put mini waste collection plastic bags on the two tray tables in room [ROOM NUMBER]. HSK 1 then exited room [ROOM NUMBER] and without hand hygiene entered room [ROOM NUMBER]. HSK 1, without donning gloves, proceeded to mop the floor of room [ROOM NUMBER] and clean the room. HSK 1 then touched the door handle without performing hand hygiene. HSK 1 then exited room [ROOM NUMBER] with waste bag and discarded waste and without performing hand hygiene entered room [ROOM NUMBER] again. HSK 1 then continued to grab supplies from HSK cart and entered room [ROOM NUMBER] without performing hand hygiene. During an interview on 2/28/24 at 9:49 a.m., with HSK 1, HSK 1 stated she should always use gloves when cleaning inside the room and must discard and sanitize hands after removing gloves. HSK 1 stated it is important to do hand hygiene as she can get germs. During an interview on 2/28/24 at 9:50 a.m., with Maintenance Supervisor (MS), MS stated it is important to do hand hygiene to prevent bringing germs to other rooms. During an interview on 2/28/24 at 3:22 p.m. with IP, IP stated staff should perform hand hygiene 056422 Page 13 of 14 056422 03/01/2024 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some before entering and exiting resident rooms to prevent spread of infection through direct person to person transmission and through indirect transmission. During a review of the facility's, undated P&P titled, Standard precautions, printed on 2/29/24, the P&P indicated, Purpose- All employees are expected to practice standard precautions to reduce both the risk of transmitting infections and the likelihood of exposure to bloodborne pathogens .4 .Remove gloves promptly after use, and wash hands immediately before touching non- contaminated items and environmental surfaces, and before going to another resident. 056422 Page 14 of 14