Health inspection·July 16, 2021

F 0558 Reasonably accommodate the needs and preferences of 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 ensure three of 20 sampled residents (Resident 65, Resident 54, and Resident 42) had their call light control within reach when: Residents Affected - Some 1. Resident 65's call light was clipped to the bed behind the resident and not in the resident's reach; 2. Resident 54's call light was under her bed and resident was not able to call for assistance; and 3. Resident 42's call was hanging on the side rail out of resident's reach and the resident was unable to call for help. These failures had the potential for the delay in the residents needs to be met timely and placed the residents at risk for accidents. Findings: 1. According to the admission Record, Resident 65 was admitted to the facility in 2016 with multiple diagnoses which included muscle weakness and a history of falling. Resident 65's Minimum Data Set (MDS, a comprehensive care assessment tool) dated 6/28/21 indicated resident's cognitive skills for daily decision-making were impaired. The MDS indicated Resident 65 required extensive assistance from staff for bed mobility, transfer, toilet use, and bathing. A review of Resident 65's care plan titled, High risk for falls and injury, initiated on 5/5/21, indicated resident will be able to follow safe technique .to prevent falls and injury. One of the interventions to reach resident's goal was to have call light within reach. During an observation on 7/13/21 at 11:20 a.m., Resident 65 was sitting in a wheelchair in her room and the resident's call light control was clipped to her bed behind resident's wheelchair and not within resident's reach. During an interview with a Licensed Nurse 5 (LN 5) on 7/13/21, at 11:25 a.m., LN 5 confirmed Resident 65's call light was out of her reach and the resident was not able to call for assistance. LN 5 stated resident was able to state her needs, and at times she used her call light. 2. Resident 54 was admitted to the facility in 2016 with multiple diagnoses which included generalized muscle weakness. Resident 54's medical history indicated resident was legally blind and had Page 1 of 23 555049 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some history of multiple falls. Resident 54's MDS dated [DATE] indicated resident had moderate cognitive impairment and required extensive assistance from staff with bed mobility, personal hygiene, and toileting. A review of Resident 54's clinical records revealed a 'High risk for falls and Injury due to limitation of mobility, history of falls, impaired vision' care plan developed on 9/5/18. One of the interventions to prevent resident's falls and injury directed staff to Have things needed by the resident within reach including call light. During an observation and interview with Resident 54 on 7/14/21, at 3:35 p.m., resident was lying in her bed. Resident 54 kept looking around her bed attempting to locate her call light. Resident 54 stated, I am lying wet, so uncomfortable, need to be changed. Resident 54 stated she was not able to call for assistance because she could not find her call light and added, No idea where my call button is. Upon further observation the call light control was observed on the floor under the resident's bed. During a concurrent observation and interview with Certified Nursing Assistant 1 (CNA 1) on 7/14/21, at 3:40 p.m., CNA 1 stated Resident 54 was able to use a call light to call for assistance. CNA 1 confirmed the call light was on a floor under the residents bed and out of resident's reach. CNA 1 added, Before I leave the room, I got to make sure resident has a call light within reach. 3. Resident 42 was admitted to the facility at the end of last year with multiple diagnoses which included fractured vertebra (small bones forming the backbone), muscle weakness, and repeated falls. Resident 42's MDS dated [DATE] indicated resident was cognitively impaired and required extensive assistance for bed mobility, personal hygiene, and toileting. Resident 42's clinical records indicated resident had multiple falls, including falls with injuries while residing in the facility. A review of Resident 42's High risk for falls and injury care plan developed 12/1/20 directed staff to keep things needed by the resident within reach including call light, and to provide assistance with care. During an observation and interview on 7/16/21, at 8:10 a.m., Resident 42 was awake sitting up in her bed. Resident 42 stated she needed help to get to her wheelchair which was parked away from her bed. When the resident was asked how she called for help, Resident 42 stated, I have a call light somewhere. Resident 42 was observed looking for her call light and then attempted to push a button on a remote bed control which was attached to her side-rails. Resident became frustrated and stated the button was not working. Resident 42 stated if she could not reach her call light, she would yell help me, help me. Resident's call light was observed hanging on the side-rail almost touching the floor and was out of resident's reach. During an interview with LN 3 on 7/16/21, at 8:30 a.m., LN 3 described Resident 42 as forgetful, but stated resident was able to use the call light to call for help. LN 3 stated Resident 42 was at high risk for falls. LN 3 confirmed resident's call light was out of resident's reach and she was unable to use it to call for assistance. In an interview with Director of Nursing (DON) on 7/16/21, at 11:05 a.m., the DON stated having call lights within their reach enabled residents to communicate with nursing staff and call for assistance. The DON stated the call lights should be accessible to all residents at all times. 555049 Page 2 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's policy titled, Call Light Answering, dated 7/12, indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff .The nursing staff will check the placement of the call light during care .Place the call light device within resident's reach before leaving the room. Review of the 'Accommodation of Needs' policy, dated 8/2009, indicated, The resident's individual needs and preferences shall be accommodated to the extent possible. The policy indicated the facility's environment and staff behaviors were directed toward assisting residents in maintaining and/or achieving independent functioning, dignity and well-being. . 555049 Page 3 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to protect the residents rights to personal privacy and confidentiality of his/her personal and medical records for a census of 67 residents. Residents Affected - Some This deficient practice failed to safeguard residents privacy of personal and medical information on all residents when the Electronic Medical Record (EMR) was left unsecured. Findings: During an observation on 7/13/21 at 10:20 a.m., Licensed Nurse 6, (LN 6), failed to secure the EMR attached on med cart by the hallway of Station 1. Residents and staff constantly walked in the hallway of Station 1 and could easily read the unsecured EMR. During an interview on 7/13/21 at 10:25 a.m., LN 6, stated she left the computer turned on, I went to wash my hands at the nurses station. She further stated, I'm not supposed to leave the EMR turned on when I'm not using it. During an interview on 7/14/21 at 1:50 p.m., the DON stated the staff should log off and should not leave the EMR turned on when not using it. The staff should turn it off or hide the screen to protect the resident's medical information. During a review of the facility's policy and procedure titled, Resident Rights, revised December 2016, stated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. Theses rights include the resident's right to: .t. Privacy and confidentiality . 555049 Page 4 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview and record review the facility failed to revise a fall care plan for one of 20 sampled residents (Resident 45) following two unwitnessed falls. Residents Affected - Few This failure had the potential risk to result in further falls and injury. Findings: According to Resident 45's physician's 'History and Physical Examination', dated 5/26/21, she had a history of frequent falls. Resident 45 had recently fallen and sustained a left eyelid laceration which was repaired on 5/17/21 in the emergency room. Resident 45 had a partial laminectomy (a surgical operation to remove one or more of the small bones forming the backbone) and laminoplasty (a surgical procedure of relieving pressure on the spinal cord on 5/21/21. A review of Resident 45's 'Fall Risk Screens' dated, 5/29/21 and 7/3/21 indicated she scored 65 (a score of 45 and above is considered a high risk for falls). During the Initial Pool on 7/13/21 at 10:57 a.m., Resident 45 was observed sitting in her wheelchair near the nurse's station one. Resident 45 stated she was admitted to the facility after she fell at home. A review of Resident 45's 'Change of Condition Evaluation' dated 5/29/21 indicated she was found kneeling at the side of her bed while attempting to go to the toilet at 4 a.m. Resident 45's 'Change of Condition Evaluation' dated 7/3/21 indicated, Resident was on the toilet, resident attempted to transfer self, slipped and slowly placed self on the floor. Resident 45's physician orders were reviewed and reflected an order dated, 5/26/21 for Seroquel (an antipsychotic medication used to treat mental conditions). The use of antipsychotic medications in the elderly population increases the risks for falls. Resident 45's 'Post Fall Assessments' dated, 5/29/21 and 7/3/21 were reviewed and did not indicate she was currently taking an antipsychotic medication. A review of Resident 45's most recent Minimum Data Set (MDS, an assessment tool) dated, 6/1/21 indicated she needed extensive assistance of one person to use the toilet. The fall on 7/3/21 documentation indicated she was found on the floor of the toilet with no staff present. A review of Resident 45's 'IDT Notes' (IDT, a team of professional staff) dated, 6/1/21 and 7/5/21 indicated the resident continued on therapy and nursing staff continued to monitor. There were no additional IDT interventions to mitigate falls. Further review of Resident 45's at risk for fall care plan dated 5/25/21 indicated there were no revisions or updates of the care plan made following the falls on 5/29/21 and 7/3/21 as of 7/16/21. During a concurrent interview and Resident 45's care plan review with the MDS staff on 7/16/21, at 10:35 a.m., the MDS staff stated the Licensed Nurses (LNs) were responsible for identifying the 555049 Page 5 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few causes of the falls and implementing new fall prevention interventions. The MDS staff further stated the LNs were responsible for revising the fall care plan and implementing short term care plans following a fall. The MDS staff validated the fall risk care plan for Resident 45 was not revised and there were no documented short term fall care plans. An interview conducted with LN 1 on 7/16/21, at 10:43 a.m., LN 1 stated Resident 45 short term fall care plans should have been initiated by the nurse who was assigned to the resident during the fall on 5/29/21 and 7/3/21. LN 1 concurrently reviewed Resident 45's care plans and stated there were no documented short term care plans and the fall risk care plan initiated on admission was not revised or updated following the two falls. Review of the facility's Assessing Falls and Their Causes policy dated 3/2018 indicated, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . When a resident falls . [document] appropriate interventions taken to prevent future falls. An interview conducted with the Director of Nursing (DON) on 7/16/21, at 10:55 a.m., the DON stated Resident 45's fall care plan should have been revised by the nursing staff. 555049 Page 6 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow the physician's order for Resident 66 for the census of sixty seven residents when blood pressure (BP) was performed in Resident 66's left arm and fluid restriction had not been followed by the nursing staff. Residents Affected - Some This failure had the potential to compromise Resident 66's dialysis access resulting in infection or blood clotting, and fluid overload for not following the physician's order of fluid restriction. Findings: According to Resident 66's admission RECORD, dated June 2021, indicated she had a history of End Stage Renal Disease (failure of kidney to function normally), and presence of other Vascular Implants and Grafts (dialysis access). She was scheduled for Hemodialysis (process used to remove toxins and fluid from blood) per physician's order. During a concurrent interview and record review on 7/15/21 at 2:10 p.m. with the Director of Nursing (DON), Resident 66's Order Summary Report (OSR), dated, 6/6/21 was reviewed. The OSR indicated, No Venipuncture, No BP, No Injection, No restraint on Left arm. The Blood Pressure Summary, documentation was reviewed with the DON and he confirmed the nursing staff did not follow the physician's order, and performed the BP reading to Resident 66's Left arm. During a review of Resident 66's Blood Pressure Summary, for the month of June 2021 indicated her blood pressure was performed on her Left arm 35 times by the nursing staff. During a review of the facility's policy and procedure titled, Hemodialysis Access Care, revised on September 2010, indicated, . To prevent infection and/or clotting: .Do not use the access arm to take blood pressure. A review of Resident 66's OSR, dated 3/12/21 indicated, Fluid Restriction of: 1200 ml/24 Hours . During a review of Resident 66's MEDICATION ADMINISTRATION RECORD, for the month of June 2021, showed, her twenty four hour fluid intake on June 9, 10, 11, and 13 exceeded the physician's order of 1200 ml/24 hour. Excess fluid intake could cause Congestive Heart Failure (causing fluid to back up into the lungs) in dialysis patients. During an Interview with the DON on 7/15/21 at 2:15 pm, the MEDICATION ADMINISTRATION RECORD, (MAR) was reviewed with the DON and he confirmed the nursing staff did not follow the physician's order. During a review of the facility's policy and procedure titled, Encouraging and Restricting Fluids, revised on October 2010. indicated, The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids .1. Verify that there is a physician's order for this procedure .1. Follow specific instructions concerning fluid or restrictions . 555049 Page 7 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure one of 20 sampled residents (Resident 55) received care for overgrown toenails per physician's order. Residents Affected - Few This failure resulted in Resident 55 having long and unsanitary toenails. Findings: Resident 55 was admitted to the facility earlier this year with diagnoses which included muscle weakness. Resident 55's Minimum Data Set (MDS, a comprehensive care assessment tool) dated 6/10/21 indicated the resident was cognitively intact and required extensive assistance from staff for personal hygiene. Review of the physician's order dated 2/27/21 indicated Resident 55 was to have podiatry care every 60 days or as needed for toenails and other foot problems. Review of Resident 55's care plan 'Self-Care Deficit,' developed 2/27/21, indicated Resident 55 required assistance in bathing and personal hygiene. None of the care plan interventions addressed care for toenails. During an observation on 7/13/21, at 9:30 a.m., Resident 55 was observed lying in bed with her feet exposed. The resident's nails were yellow in color, thick, brittle, long, and curled over the toes. Resident 55 stated she could not remember when she had her toenails trimmed last. During an interview on 7/14/21, at 3:50 p.m., the Director of Staff Development (DSD) explained that every time Certified Nursing Assistants (CNAs) gave a resident a shower or bath, they were required to document on the skin check sheet the status of resident's toenails and mark if they needed to be trimmed. The DSD stated the charge nurses co-signed each skin check sheet indicating they reviewed resident's toenails. A review of Resident 55's skin check sheets indicated resident received shower or bath on 7/10, 6/30, 6/26, 6/23, 6/12, and 6/7/21. None of the 6 reviewed skin check sheets indicated resident's toenails needed clipping. All 6 skin check sheets contained the signatures of the charge nurse. During a concurrent observation and interview on 7/14/21, at 4:05 p.m., CNA 3 confirmed Resident 55's toenails were unsanitary and long and needed to be clipped. CNA 3 stated she was familiar with Resident 55's care, but did not notice that Resident 55's toenails were that long. In a concurrent observation and interview on 7/14/21, at 4:15 p.m., Director of Nursing (DON) confirmed Resident 55's toenails were long and needed to be clipped. During a concurrent interview and review of Resident 55's skin check sheets on 7/14/21, at 4:30 p.m., the DON acknowledged the skin check sheets did not indicate the resident's toenails needed to be clipped and the sheets were not accurate. The DON stated Resident 55 should be seen by the podiatrist every 60 days and as needed as ordered by resident's physician. The DON was not able to provide the date for Resident 55's most recent podiatry visit. The DON stated the social services department arranged for podiatry care. 555049 Page 8 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/14/21, at 4:35 p.m., the Social Services Director (SSD) with the DON present, stated Resident 55 was scheduled to be seen by podiatrist on 5/10/21, but she missed the visit due to being out of the facility. The DON did not answer when asked if the podiatrist should have been contacted to provide care when the resident missed the visit in May. The SSD stated the facility did not attempt to arrange for Resident 55 to be seen by the podiatrist as an outpatient and the resident had to wait two months for another podiatry visit. Review of the facility's policy titled, Foot Care, revised 3/18, indicated, Residents will receive appropriate care and treatment in order to maintain .foot health .Residents will be provided with foot care and treatment in accordance with professional standards of practice .Residents .foot disorders .will be referred to qualified professionals .Residents will be assisted in making transportation appointments to and from specialist (podiatrist .). 555049 Page 9 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 implement interventions to reduce the risk for falls for one of 20 sampled residents (Resident 42), when the Interdisciplinary Team (IDT, a care team consisting of different disciplines) did not conduct thorough post fall investigations to determine root causes for resident's falls and did not make recommendations for resident-specific interventions to reduce further avoidable falls and injuries for Resident 42. This failure resulted in Resident 42's multiple falls in which resident sustained face laceration, fractured clavicle, and fractured wrist, experienced lots of pain, and had the potential to further affect resident's health and safety. Findings: Review of the facility's policy titled Assessing Falls and Their Causes, revised 3/18, indicated, .Falls are a leading cause of morbidity among the elderly in nursing homes .Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and/or environmental risk factors. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly .After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred .Try to identify possible or likely causes of the incident. Refer to resident-specific evidence including medical history, known functional impairments. According to admission Record, Resident 42 was admitted to the facility at the end of last year with multiple diagnoses which included dementia (impaired memory and reasoning ability), fractured vertebra (small bones forming the backbone), muscle weakness, and repeated falls. A review of Resident 42's Minimum Data Set (MDS, a comprehensive care assessment tool) dated 5/27/21 indicated resident was cognitively impaired and required extensive assistance from staff for bed mobility, transfer, personal hygiene, and toileting. Review of Resident 42's admission fall risk assessment, dated 11/17/20, indicated resident exhibited weak gait (manner of walking) and identified the resident as a high risk for falls. Review of the Resident 42's 'High risk for falls and injury' care plan initiated on 11/17/20, indicated the resident's goal was that risk factors will be managed to minimize falls and injury through the next review. The care plan interventions directed staff to introduce self to resident, explain care and procedure to be done, orient resident to person, place, time, routine, and event, keep resident's bed in low position, keep room and common areas free from clutter, and observe for presence of syncopial episode and notify a physician. The care plan did not contain resident-specific interventions addressing Resident 42's care needs, including to check on resident frequently, assist with bed mobility and transfer to the wheelchair, to keep the call light within reach and encourage/educate to call for assistance, and to provide non-skid shoes or socks. A review of Resident 42's Post Fall assessment dated [DATE] indicated resident sustained a fall on 12/1/20 while attempting to self-ambulate. The section of the assessment asking nursing staff what immediate interventions were initiated post-fall was left blank. Review of Resident 42's post-fall 555049 Page 10 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some IDT notes dated 12/1/20, indicated, No injuries noted .Nursing continues to monitor and report to MD [physician] as needed. There was no documented evidence the IDT addressed the root cause of resident's fall, evaluated the effectiveness of current care plan interventions, and recommended new resident-centered interventions to prevent further falls. A review of Resident 42's High risk for falls and injury care plan developed 12/1/20, directed the staff to keep things needed by the resident within reach including call light, and to provide assistance needed with transfer .ambulation .toileting and do not leave resident unattended. A review of Resident 42's Post Fall assessment dated [DATE] indicated resident sustained a fall on 12/7/20 at 11:49 p.m., while responding to bladder urgency. The post-fall IDT notes dated 12/8/21 indicated, No injuries noted. Patient is confused .Patient encouraged to ask for assistance. Nursing continues to monitor and report to MD as needed. There was no IDT evaluation of the resident's fall, no evaluation if current fall prevention interventions were sufficient and effective, and no new recommendations to prevent further occurrences. Resident 42's 'Actual Fall Incident' care plan, initiated on 12/7/20 did not have measurable interventions implemented, including frequent checks and/or frequency of assisting with toileting. A review of Resident 42's nursing progress note dated 1/21/21 at 3:44 a.m., indicated resident sustained a fall hitting her face on a corner edge of nurse [sic]station and described resident's injury as deep facial laceration to right cheek with bleeding. The nurse documented the resident complained of left knee and left shoulder pain and was sent to the hospital. Resident 42's clinical record indicated at the hospital resident had her cheek laceration sutured and received treatment for left shoulder contusion [a bruise] after the fall. The IDT notes dated 1/22/21 indicated resident's physician and family were notified, and Nursing continues to monitor and report to MD as needed. There was no documented evidence the IDT analyzed root cause of Resident 42's fall, analyzed if current interventions were effective, and there were no new recommendations to implement to prevent further falls and injuries. A review of Resident 42's Post Fall assessment dated [DATE] indicated resident sustained a fall on 2/4/21 at 11 a.m., while sitting in her wheelchair in the hallway reaching for something. The assessment indicated environmental factors such as slippery cushion contributed to the resident's fall. The IDT post fall notes dated 2/5/21 indicated resident complained of headache and left elbow pain and was sent to the hospital to be evaluated. The IDT notes did not include any documentation whether current safety measures were effective and did not recommend the implementation of new safety measures, including placing non-skid mat on resident's wheelchair cushion to prevent her from slipping and further falls and injuries. A review of Resident 42's Post Fall assessment dated [DATE] indicated resident walked to bathroom without assistance .responding to bladder urgency and fell. The IDT notes dated 2/8/21 indicated resident complained of left arm and neck pain, was sent to the hospital for further follow up returned with . clavicle [collarbone] fracture. The IDT documented that resident is very impulsive, constantly being reminded by staff to not stand up without assistance. Nursing continues to monitor and report to MD as needed. The IDT notes did not include any documentation whether current safety measures were effective and did not recommend the implementation of additional safety measures to prevent Resident 42's further falls and injuries. A review of Resident 42's IDT notes dated 2/15/21 indicated resident sustained an assisted fall from her wheelchair while ambulating in the hallway .no injuries noted .very impulsive .requires much 555049 Page 11 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cuing for safety .Nursing continues to monitor and report to MD as needed. There was no documented evidence the IDT analyzed the effectiveness of the current safety measures and there were no recommendations for new safety measures to prevent Resident 42's further falls and injuries. A review of Resident 42's IDT notes dates 2/26/21 indicated resident sustained another fall in her room while attempting to transfer self back into bed .Sustained injury to right wrist .sent to hospital for follow up .returned to facility with cast/brace to right wrist. Nursing continues to monitor and report to MD as needed. The IDT notes did not include any documentation regarding what safety measures were recommended to prevent Resident 42's further falls. Review of nursing progress notes dated 2/27/21, at 12:46 a.m., indicated Resident 42 returned from the hospital with diagnosis of right radial (wrist bone) fracture and had a hard cast to right hand. The progress notes dated 2/27/21 and 2/2/8/21 indicated Resident 42 had right wrist swelling, was experiencing pain, and was medicated with strong pain medications. A review of the care plan titled, The resident has had an actual fall with (SPECIFY: minor injury) Poor Balance, developed on 2/26/21 indicated, Continue interventions on at -risk plan, but did not list the interventions. Review of Resident 42's 'actual fall' care plans, indicated resident's 'High risk for fall and injury' care plan contained no updates after each fall that identified root cause of the resident falls or resident -specific interventions to prevent further avoidable falls. During an observation on 7/14/21, at 4:05 p.m., Resident 42 was observed standing by her bed barefoot attempting to reach the wheelchair parked in the corner. Resident was unable to reach the wheelchair handle, stood up and in a very unstable gait attempted to get closer to her wheelchair. A Certified Nursing Assistant (CNA 3) was summoned to assist resident with transfer to wheelchair. CNA 3 stated resident had history of falls and required constant supervision. During an observation on 7/15/21, at 11:45 a.m., Resident 42 was moving slowly in her wheelchair in the hall across the nursing station. Resident looked very confused, at one point attempted to enter other resident's room, and stated she was trying to find her room. Two staff were present at the nursing station and did not attempt to redirect or assist Resident 42. During an observation and interview on 7/16/21, at 8:10 a.m., Resident 42 was awake in her bed and was able to carry a small conversation, but did not recall details regarding the circumstances of her falls. During the interview, Resident 42 lowered her legs attempting to reach the floor. Resident 42's bed was noted to be not in the lowest position. Resident 42 stated she needed help to get to her wheelchair which was parked away from her bed. When the resident was asked how she called for help, Resident 42 stated, I have a call light somewhere. Resident 42 was observed looking for her call light and then attempted to push a button on a remote bed control which was attached to her side-rails. Resident 42 became frustrated and stated the button was not working. Resident 42 stated if she could not reach her call light, she would yell help me, help me. Resident's call light was observed hanging on the side-rail almost touching the floor and was out of resident's reach. A Licensed Nurse 3 (LN 3) was summoned to Resident 42's room on 7/16/21, at 8:30 a.m. The LN 3 stated resident was forgetful, but was able to use the call light to call for help. LN 3 acknowledged Resident 42's bed was not in a lowest position and call light was out of resident's reach. LN 3 stated Resident 42 was high fall risk, but she was not aware if resident had any falls in the past. 555049 Page 12 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 7/16/21, commencing at 11:05 a.m., the facility's Director of Nursing (DON) stated he was aware that Resident 42 had multiple falls, including falls with injuries. The DON stated when IDT met to discuss residents' falls, they were supposed to review documentation of the events, determine root causes why fall happened, discuss if prior measures to prevent falls were effective or not effective, and recommend steps to implement new interventions to prevent future falls. The DON stated he expected IDT's recommendations to be reflected in resident's care plans. In a continued interview and review of IDT notes regarding Resident 42's multiple falls, on 7/16/21, commencing at 11:05 a.m., the DON acknowledged the IDT notes did not contain documentation of root causes of resident's falls. The DON stated, The root cause because she gets up and attempts to walks . Nothing could have been done - she got up and fell. Most likely she will keep falling. Nothing could be done to prevent it. The DON did not provide any answer when asked if IDT analyzed if Resident 42's care plan interventions were effective. In a further interview on 7/16/21, commencing at 11:05 a.m., Resident 42's care plan interventions were discussed. The DON stated the facility did not attempt to assign a specific staff to supervise resident one-to-one more closely at all times. The DON agreed that scheduled frequent checks on Resident 42 might have helped to prevent some of the falls. The DON stated the facility used non-skip mats placed on other resident's wheelchair to prevent residents from slipping, but did not provide any explanation why the facility did not use it for Resident 42's wheelchair cushion. When asked if the IDT reviewed if Resident 42's medications have been contributing to resident's falls, the DON stated resident's medications were not reviewed until May 2021. The DON stated Resident 42's care plans related to her falls were supposed to be revised by nursing and if the current measures were not effective, he would expect the new interventions were added. A review of the facility's policy titled, Safety and Supervision of Resident, with the last revision date of 7/17, indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents .The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents .The care team shall target interventions .including adequate supervision .Monitoring the effectiveness of interventions .include the following: a. Ensuring that interventions are implemented correctly and consistently; b. Evaluating the effectiveness of interventions; c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions. 555049 Page 13 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide three doses of a physician ordered medication for one 1 of 20 sampled residents (Resident 53). This failure caused Resident 53 to be hospitalized for acute encephalopathy (brain dysfunction) and benzodiazepine (depressant medication) withdrawal. Findings: A review of Resident 53's admission Record indicated he was initially admitted to the facility in January 2000 with multiple diagnoses including anoxic brain damage (brain injury when the brain is deprived of oxygen), epilepsy (seizures), and dementia (impairment of brain function including loss of memory and judgment). He was readmitted on [DATE] from the acute care hospital with diagnoses including acute encephalopathy and benzodiazepine withdrawal. A review of Resident 53's Minimum Data Set (MDS- an assessment tool) Section C- Cognitive Patterns, dated 6/9/21, indicated he had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 4 out of 15 that indicated he was severely cognitively impaired. A review of Resident 53's Medication Administration Record for 6/1/21- 6/30/21 indicated Resident 53 did not receive his clonazepam (a drug used to prevent seizures) doses on 6/26/21 at 4 p.m. or on 6/27/21 at 8 a.m. and 12 p.m. as ordered. A review of a Progress Note for Resident 53, dated 6/26/21 written at 4:55 p.m., indicated Clonazepam Tablet .Give 1 mg (milligram) by mouth three times a day for Myoclonus (muscle twitching) related to seizure activity .Order date: 3/26/2012 .Medication currently unavailable at this time. Pharmacy informed. Awaiting delivery . A review of a Progress Note for Resident 53, dated 6/27/21 written at 9:02 a.m., indicated Clonazepam Tablet .awaiting pharmacy delivery . A review of a Progress Note for Resident 53, dated 6/27/21 written at 12:48 p.m., indicated Clonazepam Tablet .awaiting pharmacy delivery . A review of Resident 53's INTERACT Change in Condition Evaluation, dated 6/27/21, indicated Resident 53 had a change of condition including hyperactivity and hyperhidrosis (excessive sweating). He had a pulse rate of 153 and a respiratory rate of 26. A review of Resident 53's INTERACT Transfer Form, dated 6/27/21, indicated he was transferred to the acute care hospital. A review of a Progress Note for Resident 53, dated 6/27/21 written at 11:48 p.m., indicated At approximately 1445 [2:45 p.m.], Received resident in bed while noting to be sweating excessively and erratic, thrashing in bed which noted to be even more severe from usual behavior after last MD's [medical doctor] evaluation Resident noted with tachycardia [heart rate greater than 100 beats per minute] and tachypnea [rapid shallow breathing] MD notified and ordered to send resident to [acute care 555049 Page 14 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospital] ER [emergency room] .EMTs [emergency medical technicians] were made aware that resident did not received [sic] his clonazepam after contacting pharmacy on 6/26 pm [evening] shift for his dose and MD was made aware. Pharmacy was contacted at time to request STAT [urgent] and or e kit [emergency kit with medications]. No refill order was left. [Name of neurologist] office was also contacted. No verbal order received on 6/26. Resident missed morning and noon dose for today 6/27 per AM [day shift] nurse. Spoke with [representative from pharmacy] .they reached out to [name of neurologist] on the 23rd and 25th of June for continuation but did not received [sic] fax or reply back. [Name of neurologist] office was also contacted but office was close [sic] and left a voicemail. No on-call doctor was available. A review of a Discharge Summaries Notes for Resident 53 from the acute care hospital indicated he was admitted on [DATE] and discharged on 7/1/21. The History and Physical written on 6/27/21, indicated Resident 53 was admitted to the acute care hospital for acute encephalopathy likely secondary to withdrawal from benzodiazepine and benzodiazepine withdrawal with delirium. The Admissions Notes indicated .comes to the emergency department because of altered level of consciousness .They were specifically concerned as he is on clonazepam when neurology tries to decrease his clonazepam dose he has issues with tremulousness and reacts like he is withdrawing from it Nevertheless it seems like per the the people at [nursing facility] they confess that he has missed several doses of at least 2 doses yesterday and 1 dose this morning of the clonazepam. Skilled Nursing Facility Orders indicated Make sure to continue Clonazepam 1 mg TID [three times a day] and obtain refills before prescription ran out. The Discharge Summaries Notes included acute encephalopathy and benzodiazepine withdrawal as the final diagnoses. A review of Resident 53's History and Physical Examination, written on 7/15/21 by MD, indicated .admitted after D/C [discharge] from [acute care hospital] d/t [due to] acute encephalopathy, benzodiazepine withdrawal per history, pt [patient] apparently ran out of med [medication]- clonazepam which was ok'd by neuro but did not arrive in time, pt noted to have change in mental status & sweaty & restless & transferred to ER. During an interview with on 7/15/21 at 11:45 am. with the Director of Nursing (DON), reviewed that Resident 53 was sent to the hospital on 6/27/21 due to altered level of consciousness. Reviewed that 3 doses of clonazepam were missed on 6/26/21 and 6/27/21 due to unavailability of medication. He stated the nurses are expected to communicate with the MD and the pharmacy. He stated the nurse needed to contact the MD. During an interview and record review on 7/15/21 at 11:50 a.m. with Licensed Nurse (LN) 3 reviewed 3 missed doses of clonazepam for Resident 53 on 6/26/21 and 6/27/21. She stated [name of neurologist] was notified to renew medication. Order request was faxed to his office. She stated that the attending MD did not order this medication, as he deferred to the neurologist. Reviewed Progress Note written on 6/27/21 and that it does not indicate that the attending MD was contacted when the neurologist did not respond. She stated the medical director could also have been contacted to sign order. She acknowledged that the the Progress Note on 6/27/21 does not indicate the medical director was contacted for the order. LN 3 was asked if the E kit contained clonazepam. She stated it did, but medication could not have been given without the order. During a telephone interview on 7/15/21 at 1:40 p.m. with the Pharmacist Consultant (PC) for [pharmacy], reviewed missing medication doses for Resident 53 on 6/26/21 and 6/27/21. The PC stated that clonazepam is a controlled drug that requires authorization. On 6/23/21 and 6/25/21, a continuation letter (authorization letter) was faxed to the MD to renew the medication. The nurse had requested a 555049 Page 15 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0755 Level of Harm - Minimal harm or potential for actual harm refill on 6/27/21. A care conference was held on 6/28/21 with the MD. The MD said Resident 53 had gone to the hospital on 6/27/21, so hadn't signed the order. The pharmacy sent a 30 day supply to the facility on 6/28/21 after receiving the order from the neurologist. When the PC was asked if the missing doses could have caused withdrawal or breakthrough seizures, he stated it could have caused either one. The PC stated the medication could have been given from E kit if the facility had an order. Residents Affected - Few During an interview on 7/15/21 at 2:45 p.m. with the DON, reviewed that the the faxed controlled drug request for Resident 53's clonazepam was not in the Controlled Drug binders at the nurse's station. He stated he will look for it. Reviewed the hospital Discharge Summaries Notes with the DON. The DON acknowledged Resident 53 did miss medications but questioned whether that caused hospitalization as he is receiving multiple seizure medications. Reviewed the acute care Discharge Summaries Notes that stated benzodiazepine withdrawal was a discharge diagnosis. The DON confirmed that benzodiazepine withdrawal was a discharge diagnosis. During a concurrent observation and interview on 7/16/21 at 9:55 a.m. with LN 5, reviewed that the Controlled Drug binder at the nursing station did not contain a faxed request for clonazepam for Resident 53 on 6/23/21. LN 5 confirmed that request was not in the binder for orders on 6/23/21, 6/24/21 or 6/27/21. LN 5 stated once the order is signed and sent to the pharmacy it is placed in the Controlled Drug binder at the nursing station. If not signed by the physician. it may be in the narcotic book on the med cart. Physicians have a folder at the nurse's station for MD to review including drug requests. Reviewed [MD] folder, clonazepam request was not in the folder. During a subsequent interview on 7/16/21 at 10:15 a.m. with LN 3, reviewed the Antibiotic and Controlled Drug binder on the medication cart. This binder contains forms Prescriptions for Controlled Substance that come with the medication when delivered. This form is placed in the physician's folder for signature. Nurses check the folders for physician's signature and then fax to the pharmacy once signed. During a telephone interview on 7/16/21 at 11:00 am with the MD, reviewed hospitalization of Resident 53 on 6/27/21. He stated nurse's documentation showed Resident 53 was shaky and had altered mental status. He was aware that the hospital discharge summary indicated Resident 53 had withdrawal from clonazepam. He was not sure if resident had missed doses. During an interview on 7/16/21 at 12:35 p.m. with the DON, he provided a communication from the pharmacy demonstrating that the facility sent a refill request for clonazepam for Resident 53 to the pharmacy on 6/23/21, without a nurse name, date or time and with a note 8 Left. On 6/24/21 the facility re-faxed the same request to the pharmacy that was signed by a nurse. The pharmacy faxed a continuation letter to MD on 6/23/21. This letter was faxed again on 6/25/21 and 6/27/21. Pharmacy did not receive the signed continuation letter from the MD until 6/29. The DON stated the nurses were trying to get the medication, but there are sometimes delays with pharmacy delivery. When asked what the nurse could have done to get an order to give the medication from the E kit since it had not been delivered from the pharmacy, the DON stated that the medical director could have been contacted to order the medication to be given from the E kit. A review of facility policy Medication Ordering and Receiving from Pharmacy, dated April 2008, indicated Medications and related products are received from the dispensing pharmacy on a timely basis Reorder medication five days in advance of need to assure an adequate supply is on hand The refill order is called in, faxed, or otherwise transmitted to the pharmacy The emergency kit or emergency 555049 Page 16 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0755 drug supply as applicable is used when the resident needs a medication prior to pharmacy delivery . Level of Harm - Minimal harm or potential for actual harm A review of the facility policy Administering Medications, revised December 2012, indicated .Medications must be administered in accordance with the orders Residents Affected - Few 555049 Page 17 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure its' medication error rate was less than five (5) percent for a census of 67 residents. Residents Affected - Some This failure had the potential to compromise the health and safety. Findings: During a Medication Administration Observation on 7/14/21, Licensed Nurses (LNs) were observed administering medications to 6 residents; 2 (two) errors of 25 opportunities were observed constituting a medication error rate of 8 percent. During an observation of medication administration on 7/14/21, starting from 7:20 a.m., LN 2 was observed preparing the morning medications for Resident 16. LN 2 used a small plastic spoon to get MiraLax powder from its' container and put it in a small plastic cup that contained an unmeasured amount of water, stirred the contents and administered it to Resident 16. A review of Resident 16's physician order dated, 7/13/21 directed to give 'MiraLax Powder 17 gram [unit of measurements] per scoop by mouth in the morning for constipation. Mix with 4-8 ounces of juice or water.' During a continued observation of medication administration on 7/14/21, starting from 7:55 a.m., LN 2 was observed preparing the morning medications for Resident 130. LN 2 used a small plastic spoon to get MiraLax powder from its' container and put it in a small plastic cup that contained an unmeasured amount of water, stirred the contents and administered it to Resident 130. A review of Resident 130's physician order dated, 7/2/21 directed to give 'polyethylene glycol (same as MiraLax) 17 gram by mouth in the morning for constipation. Mix in 4-8 ounces of water, soda, coffee, juice, or tea.' During an interview with LN 2 on 7/14/21, at approximately 8:15 a.m., LN 2 was asked what dosage of MiraLax was ordered for Resident 16 and Resident 130 and he stated the order was for 17 grams. When LN 2 was asked how he measured the MiraLax powder to ensure the residents received the 17 grams, he looked at the directions on the MiraLax container and stated he should have administered 2 small spoons or more. A review of the MiraLAX label on the container under the directions, indicated the bottle top was a measuring cap marked to contain 17 gram of powder when filled to the indicated line (white section in cap). The instructions further directed, 'fill to top of white section in cap which is marked to indicate the correct dose (17 gram).' The facility's 'Administering Medications' policy dated, 12/2012 was reviewed and directed, Medications shall be administered in a safe and timely manner, and as prescribed . Medications must be administered in accordance with the orders . The individual administering the medication must check the label THREE (3) times to verify the right . dosage . An interview conducted with the Director of Nursing (DON) on 7/14/21, at 3:45 p.m., the DON stated LN 2 should have administered the Miramax to Resident 16 and Resident 130 as ordered by the 555049 Page 18 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0759 physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555049 Page 19 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

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. Based on observation, interview, and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety, when the failed to ensure it's thermometers were properly calibrated. Additionally, the dietary staff failed to maintain milk at 41° F or lower during lunch meal. This failure resulted in milk served to residents at an unsafe temperature and had the potential for 66 vulnerable residents to eat food at unsafe temperatures. Findings: During a tray line observation (a process for plating residents' food) on 7/14/21, at 11:35 a.m., the Certified Dietary Manager (CDM) explained that the facility calibrated thermometers used to measure cooked food temperatures to confirm if food was within safe temperatures once a week. [NAME] 1 was asked to demonstrate the facility's process of thermometer calibration. [NAME] 1 inserted three thermometers used by kitchen staff into ice water and explained the thermometers readings should be 32° F. After being submerged in the ice water for approximately 5 minutes, the thermometer readings were at 38.3° F, 39.7 ° F, and 40.1° F respectively. The CDM removed the thermometers from the ice water and proceeded to measure the temperatures of the food on the steam table. The CDM did not ensure the thermometers were calibrated properly before measuring food temperatures. According to the United States Department of Agriculture, Food Safety and Inspection Services, a properly calibrated thermometer would read 32 ° (degrees F (+/- 2 degrees) in ice water. On 7/14/21, at 12:05 p.m., the CDM was directed to check the temperature of the thickened milk in an eight ounce glass taken from one of the trays immediately before the cart containing residents' food was ready to leave the kitchen. The temperature read at 46.7° F. The CDM placed the glass of the milk back on the resident's tray and the dietary staff proceeded to deliver milk for resident's consumption. In a follow up interview with the CDM on 7/14/21, at 12:10 p.m., the CDM stated the temperature of the milk should be 41 degrees F or less before serving to the resident. The CDM acknowledged the thickened milk temperature was not at the safe temperature and stated it should not be served to the resident. The CDM stated, Supposed to take the milk out and not serve it. In a further interview the CDM was asked why it was important to calibrate the thermometers before using them for measuring food temperatures. The CDM stated, To avoid foodborne illnesses .If not calibrated as supposed to be, the food temperatures won't be accurate. The CDM stated if the staff was not able to calibrate the thermometers, they should throw thermometers away and get new ones. In an interview with a Registered Dietician (RD) on 7/15/21, at 11:10 a.m., the RD stated the purpose of the calibration of the thermometer was to accurately take residents' food temperatures to avoid foodborne illnesses. The RD stated if the thermometer could not be calibrated, it should not be used. According to the RD, the milk should not be served if more than 41° F. Review of the facility's policy titled, Thermometer use and Calibration, dated 2018, indicated, Food thermometers are to be used properly and calibrated to ensure accurate temperature reading .If the thermometer does not read 32° F, then the thermometer must be calibrated or discarded. 555049 Page 20 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0812 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy titled, Meal Service, dated 1/2019, indicated, Meals .will be served at the appropriate temperatures .Cold items will be placed on the trays as close to serving time as possible to assure the temperature is below 41° F. Residents Affected - Some 555049 Page 21 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow infection control guidelines for a census of 67 residents, when: Residents Affected - Few 1. Certified Nursing Assistant 6's (CNA 6) isolation gown was torn and not tied up at the neck while inside the isolation room; 2. CNA 7 was not wearing Personal Protective Equipment (PPE) while in Resident 121 and Resident 222's isolation rooms while passing ice water; and 3. The Director of Nursing (DON) was not wearing PPE while inside the isolation room of Resident 222. These failures had the potential to spread infection and disease among residents, staff and visitors. Findings: 1. During an observation on 7/13/21 at 9:30 a.m., while inside an isolation room, CNA 6's isolation gown was improperly secured and exposing her to infection. During an interview on 7/13/21 at 9:32 a.m., CNA 6 confirmed, her isolation gown was torn and not tied up at the neck. She said, it should be tied up at the back and at the neck to protect me from infection. CNA 6 further stated, she should have taken off the isolation gown, stepped out of isolation room and put on a clean gown before continuing with her task. Resident 121's admission RECORD, indicated she was admitted in the facility in July 2021 with a diagnosis of Urinary Tract Infection, site not specified. Resident 222's admission RECORD, indicated she was admitted in the facility in July 2021 with a diagnosis of Sepsis (a blood infection). 2. During an observation on 7/13/21 at 10:05 a.m., CNA 7 was not wearing a Personal Protective Equipment (PPE) while inside the isolation rooms while passing ice water to Resident 121 and Resident 222. After she passed ice water, CNA 7 stepped out of Resident 121 and Resident 222's isolation room without sanitizing her hands. During an interview on 7/13/21 at 10:10 a.m., CNA 7 confirmed she was not wearing PPE's in Resident 121 and Resident 222's isolation room while passing out ice water. She further stated, I'm supposed to wash my hands or sanitized but I forgot to do that too 3. During an observation on 7/14/21 at 8:05 a.m., the DON was not wearing a PPE while inside Resident 222's isolation room. During an interview on 7/14/21 at 1:30 p.m., the DSD/IP confirmed, the DON was inside Resident 222's isolation room without wearing PPE. He should be wearing PPE while inside the isolation room. All staff must wear PPE when inside the isolation room and wash or sanitize their hands. She further stated, CNA 6 should have stepped out of the isolation room and changed her gown. She should not 555049 Page 22 of 23 555049 07/16/2021 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0880 continue wearing a torn isolation gown in isolation room. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/14/21 at 1:50 p.m., the DON stated, All staff should wear PPE when inside the isolation room to protect themselves from infection. Residents Affected - Few During a review of the facility's policy and procedure titled, Personal Protective Equipment - Using Gowns, revised on September 2010 indicated, .Objectives 1. To prevent the spread of infections; 2. To prevent splashing or spilling blood or body fluids onto clothing or exposed skin .7. Secure at the neck (tie or Velcro) . 555049 Page 23 of 23