Health inspection·October 13, 2023

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 treat their residents with respect and dignity for one of 20 sampled residents when (Resident 8) was not dressed in her own clothing and was left in a hospital gown. This failure had the potential to impact Resident 8's self-esteem and self-worth. Findings: According to the Resident Face Sheet, Resident 8 was admitted to the facility in late 2022, with diagnosis including unspecified dementia (loss of memory, judgement, and intellectual functions), difficulty walking, muscle weakness, pain, and history of falling. Review of Resident 8's Minimum Data Set (MDS- an assessment tool), dated 12/22/22, indicated that for daily preferences, it was very important for Resident 8 to choose the clothes she wanted to wear and indicated Resident 8 required extensive assistance with dressing. Review of Resident 8's care plan, dated 12/15/22, indicated, Self-Care Deficit as evidenced by requiring assistance or is dependent in: bed mobility extensive, eating supervision, transfer extensive, toileting extensive, personal hygiene limited, walking extensive, locomotion extensive, bathing extensive, dressing extensive. Interventions included, .Allow resident to choose own clothing . In an observation and concurrent interview with Resident 8 on 10/12/23 at 3 p.m., observed Resident 8 lying in bed in a hospital gown. Resident 8 stated that, . They did not change me, I have been in bed the whole day, I would like to go out for activities but here I am . During an interview with Certified Nursing Assistant (CNA) 5 on 10/12/23 at 3:13 p.m., CNA 5 confirmed that Resident 8 was in bed in a hospital gown. During an interview with Director of Staff Development (DSD) on 10/13/23 at 8:55 a.m., DSD stated that, . this is unacceptable (resident remaining in bed wearing a hospital gown) and that residents need to be offered to wear what they want to wear, it is matter of dignity . During an interview with Director of Nursing (DON) on 10/13/23 at 11:06 a.m., DON stated, . we definitely need to improve on that (getting residents dressed and not leaving them in the hospital gown), that is not right, residents need to wear their clothes . Review of the facility policy and procedure titled Quality of Life-Dignity revised August 2009, Page 1 of 29 555049 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0550 indicated that Residents shall be encouraged and assisted to dress in their own clothes rather than in hospital gowns. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555049 Page 2 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

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 a Minimum Data Set (MDS, an assessment tool) assessment was conducted for one of twenty sampled residents (Resident 57) when a discharge MDS assessment was not done for Resident 57. Residents Affected - Few This failure resulted in Resident 57 to have an incomplete clinical record to reflect his condition upon discharge. Findings: A review of the clinical record indicated, Resident 57 was admitted in April of 2023, with diagnoses that included high blood pressure with chronic kidney disease. A review of the Physician's Discharge summary, dated [DATE] indicated, Resident 57 was discharged to home on 6/14/23. During a concurrent interview and record review with the MDS nurse (MDSN) on 10/12/23 at 1:57 p.m., the MDSN confirmed Resident 57 was discharged on 6/14/23 and he (Resident 57) did not have an MDS discharge assessment. She stated, they (MDSN) are given 14 days to finish an assessment after discharge, it should have been completed on 6/27/23. During an interview on 10/12/23 at 3:45 p.m., with the Director of Nursing (DON), the DON stated, he expects for the MDS assessments to be done timely, accurately, and appropriately. A review of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument Version 3.0 Manual, dated October 2019, indicated, . A Discharge assessment is required with all .types of discharges .Any of the following situations warrant a Discharge assessment, regardless of facility policies regarding opening and closing clinical records and bed holds: Resident is discharged from the facility to a private residence .This assessment includes clinical items for quality monitoring as well as discharge tracking information . 555049 Page 3 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure communication needs were met for two of twenty sampled residents (Resident 3 and Resident 327) when: Residents Affected - Few 1. Resident 3's communication care plan was not followed; and 2. Resident 327 had no care plan for her communication needs. This failure had the potential to negatively impact these resident's ability to communicate their needs to the staff. Findings: 1. A review of the clinical record indicated Resident 3 was re-admitted to the facility early 2018 with diagnoses that included high blood pressure and anxiety disorder. The most recent annual Minimum Data Set (MDS, an assessment tool) indicated Resident 3's preferred language was a non-English language and she needed an interpreter to communicate with a doctor and health care staff. A review of Resident 3's Risk for communication Deficit care plan initiated on 8/9/19 indicated, Goal .Resident's needs will be met through verbal and nonverbal content .Interventions .Provide communication board .assist resident to supplement words with pictures .communication board . During an observation on 10/10/23 at 11:59 a.m., in Resident 3's room, Resident 3 was lying in bed and responded with a smile when greeted. Resident 3 tried to communicate with hand gestures but was incomprehensible. There was no communication board or picture board at Resident 3's bedside to aid in communicating with Resident 3. Her roommate stated, Resident 3 does not speak English. During a concurrent observation and interview on 10/11/23 at 3:44 p.m., with the Licensed Nurse (LN 4), in Resident 3's room, the LN 4 stated, Resident 3 communicates to them using gestures like pointing to the water. Resident 3 observed trying to communicate in her own language to LN 4. LN 4 was unable to understand what Resident 3 was trying to communicate. LN 4 was observed looking for the communication board at bedside. LN 4 stated, there is no communication at Resident 3's bedside. During an interview on 10/12/23 at 03:45 p.m., with the Director of Nursing (DON), the DON stated, Resident 3 relays communication through gestures. The DON stated, the communication board should have been at the bedside available for use. He stated, he expects for the care plan to be followed and implemented accordingly. 2. A review of the clinical record indicated Resident 327 was re-admitted to the facility late 2023 with diagnoses that included high blood pressure and high blood sugar. A review of Resident 327's Nurses Note dated, 10/6/23 indicated, .Patient [Resident 327] is alert .speech clear, able to communicate needs only in [non english] language to staff . A review of Resident 327's list of Care Plans on 10/11/23 at 10:18 a.m., indicated, Resident 327 had no Care plan to address her communication needs. 555049 Page 4 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 10/10/23 at 9:06 a.m., in Resident 327's room Resident 327 was awake, lying in bed. When spoken to, Resident 327 only responded in a [non english] language. Resident 327 was unable to verbalize her needs in English. There was no communication board or picture board in her room to assist her with communicating her needs. During a concurrent observation and interview on 10/11/23 at 3:49 p.m., with the Licensed Nurse (LN 3) she stated Resident 327 was [non english] speaking and LN 3 was unable to locate a communication board in her room. During an interview on 10/13/23 at 8:49 a.m., the DON stated, the Language care plan should have been done as soon as the staff became aware of the Resident's language or communication needs. A review of the facility's Translation and/or Interpretation of Facility Services policy dated 5/2017 indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. 555049 Page 5 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0679 Provide activities to meet all resident's needs. 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 activities were provided for Resident 29 and Resident 18 for a census of 59. Residents Affected - Few These failures increased Resident 29 and Resident 18's risk for physical and psychosocial isolation. Findings: 1. According to the Resident Face Sheet, Resident 29 was admitted to the facility in late 2022, with diagnoses including acute respiratory failure with hypoxia (impaired gas exchange between blood and lungs causing difficulty in breathing), abnormalities of gait and mobility. Review of Resident 29's active physician's order, dated 11/11/22, indicated, May participate in activity plan if not in conflict with treatment plan. Review of Resident 29's initial activities assessment, dated 11/25/22, indicated that Resident 29's activity preferences were reading books, newspapers, or magazines; keeping up with the news; and doing favorite activities. Review of Resident 29's active care plan, dated 3/12/23, indicated, .Listen to music he/she likes, do things with groups of people, do his/her favorite activities. Interventions included, Respect resident preferences at all times possible. All staff to be aware of resident's preferences and provide care in a timely manner and provide leisure supplies for self-directed pursuits. During an interview with Resident 29 on 10/12/23 at 3:19 p.m., Resident 29 stated she was in bed all the time and that was the problem. She did not know when she was going to start activities. She had communicated that to the Activities Director (AD) a few times. Resident further stated that, .Once I had tried it, but I was very tired but that should not be an excuse to not take me for activities. During an interview with AD on 10/12/23 at 4:20 p.m., AD stated that the days that Resident 29 received room visits the activities comprised of social contact which meant AD letting Resident 29 know what they had planned for activities, if she could tolerate and would like to do it. When asked AD that Resident 29 was observed in bed through 10/10, 10/11 and the day of the interview, AD stated, .I ask her everyday if she wants to come, I tell her that if you want to come, I will set it up for you, lot of the times the CNAs do not bring them. I will advocate for the residents; I cannot transfer the residents though . 2. According to the Resident Face Sheet, Resident 18 was admitted to the facility in mid-2019, with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), difficulty walking and muscle weakness. Review of Resident 18's active physician's order, dated 8/29/2019, indicated, May participate in activity plan if not in conflict with resident's treatment plan. 555049 Page 6 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 18's activities assessment dated [DATE], indicated that Resident 18 activity preferences were listening to music; doing things with groups of people; movies; enjoys parties and socials; enjoys tv in room and activities room. Review of Resident 18's active care plan created 9/4/2019, indicated, Resident stays in her room to do one activity listening to music and reading the newspaper. Interventions included, we will continue to remind and assist resident to and from activities and continue to monitor till next review date; staff invite, encourage, and assist resident as needed to activities of choice; staff provide activity calendar on a monthly basis and upon request for additional copies; staff encourage resident to attend activities that allow resident to enjoy leisure preferences as well as use strengths to work toward goals; staff respect resident's wishes when leisure time is preferred over activity attendance. Review of Resident 18's active care plan created 7/8/21 indicated, Unable to plan/attend leisure activities r/t [related to]: Decreased social interaction; Decreased cognitive abilities d/t [due to]: diagnosis/condition; Difficulty understanding, Limited sitting/standing tolerance, Limited hearing. Interventions included, Identify leisure interests music, TV, Invite and encourage to attend activities of choices. Escort as needed. Record resident's participation and responses to activities daily. Review of Resident 18's active care plan created 7/13/21 indicated, Resident is dependent on staff for cognitive stimulation and social interaction due to immobility/the disease process of impaired cognition secondary to schizophrenia, under hospice care for dx [diagnosis] dysphagia [difficulty swallowing food and liquids]. Interventions included, Staff provide 1:1 bedside/in-room visits and activities such as listening to music, magazines, talking. Review of Resident 18's monthly Resident Activity Log (used to document visits made by Activities Staff in resident's room) for the months of September and October, indicated that there were no room visits on 9/2, 9/3, 9/5-9/11, 9/15-9/18, 9/20-9/25, 9/27-9/31, 10/1-10/3,10/5, 10/7, 10/8, 10/10-10/12. During an observation and concurrent interview with Resident 18 on 10/13/23 at 3:33 p.m., observed Resident 18 laid in bed with eyes open, when asked Resident 18 if she would like to join activities. Resident 18 replied yes. During an interview with AD on 10/13/23 at 4:36 p.m., AD stated when she did room visits, it typically means that Resident 18 has responded back to her with a gesture such as a smile or with a verbal yes or no response. AD states, Resident responds to yes and no questions appropriately. Sometimes Resident doesn't want to respond at all. During an interview with AD on 10/13/23 at 4:55 p.m., AD further stated that for residents who spend the whole day in bed, and are not able to get up, or they refuse to come for activities, she tries to make rounds and visit with them every morning. When AD was asked how she provides sensory stimulation for residents who don't attend group activites, AD stated That is the problem. When residents were in the activity room, she was required to be in the activity room with them. She did not have an assistant to help her with everyday activities for Residents who are in bed. AD further stated that, .I fit in the room visits when I get time before or after activity room activities. I have verbalized it so many times that I need help. 555049 Page 7 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0679 Level of Harm - Minimal harm or potential for actual harm During an interview with Director of Staff Development (DSD) on 10/13/23 at 8:51 a.m., DSD stated that residents need activities for mental health and socialization. During an interview with Social Services Director (SSD) on 10/13/23 at 10:05 a.m., SSD stated that . this is the area we need to work on, residents have the right to get activities . Residents Affected - Few During an interview with Director of Nursing (DON) on 10/13/23 at 1:06 p.m., DON stated, .that is unacceptable, and the activities needed to be provided to all the residents . Review of the facility policy and procedure titled Activity Programs revised June 2018, indicated that the Activities Program is provided to support the well-being of residents and to encourage both independence and community interaction. Activities are considered any endeavor other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or individual resident's needs. 555049 Page 8 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of twenty sampled residents (Resident 66) received necessary treatment to promote healing of her left heel wound when a treatment order was not initiated as ordered. Residents Affected - Few This failure placed Resident 66 at increased risk for delayed wound healing. Findings: A review of the clinical record indicated Resident 66 was re-admitted to the facility late 2023 with diagnoses that included muscle weakness and difficulty in walking. Resident 66's Braden scale assessment (used to evalute the risk for pressure ulcer development) dated 8/24/23, indicated she was confined to bed, and had very limited mobility. Her Braden score was 13 out of 18 which indicated she had moderate risk of developing a pressure ulcer. A review of Resident 66's SPECIALTY PHYSICIAN INITIAL WOUND EVALUATION & MANAGEMENT SUMMARY dated 10/2/23, indicated, .Focused Wound Exam (Site 1) .UNSTAGEABLE DTI [Deep Tissue Injury, a type of pressure ulcer, localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear ] OF THE LEFT HEEL PARTIAL THICKNESS .Etiology (quality) .Pressure . Wound Size (L x W x d) .1 x 1 x Not Measurable cm . Surface Area: .1.00 cm .DRESSING TREATMENT PLAN .Primary Dressing(s) Skin prep (a liquid film-forming dressing that forms a protective film to help reduce friction to protect the intact skin and promote healing) apply once daily for 30 days . A review of Resident 66's SPECIALTY PHYSICIAN INITIAL WOUND EVALUATION & MANAGEMENT SUMMARY dated 10/9/23, indicated, .Focused Wound Exam (Site 1) .UNSTAGEABLE DTI OF THE LEFT HEEL PARTIAL THICKNESS .Etiology (quality) .Pressure . Wound Size (L x W x D): .2 x 2 x Not Measurable cm . Surface Area: .4.00 cm .DRESSING TREATMENT PLAN .Primary Dressing(s) Skin prep apply once daily for 23 days . A review of Resident 66's Order Summary Report indicated, Left heel DTI, apply skin prep and off load. every day shift for 14 Days .start date:10/12/2023 . (ten days after the order was written). A review of Resident 66's Treatment Administration Record (TAR) dated October 2023 indicated, Left heel DTl, apply skin prep and off load .every day shift for 14 Days start Date 10/12/2023 . During a concurrent interview and record review on 10/11/23 at 11:42 a.m., with the Treatment Nurse (TN), the TN stated, Resident 66 has a closed DTI and the wound care doctor saw the Resident last Monday. Treatment was to continue with offloading, applying heel protectors and applying skin prep. The TN stated, Resident 66's treatment orders are signed and documented in the TAR. The TAR was reviewed with the TN and the TN acknowledged that the skin prep treatment order was not on the TAR and there was no documented evidence that the skin prep treatment was done. During a follow up interview on 10/11/23 at 3:35 p.m., with the TN, the TN acknowledged that the Skin prep treatment was ordered by the wound care specialist on 10/2/23 and was only entered in the TAR on 10/11/23. During an interview on 10/12/23 at 3:45 p.m., with the Director of Nursing (DON), the DON stated, treatment orders and recommendations from the wound care doctor should be care planned and carried 555049 Page 9 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0686 out as ordered. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Pressure Ulcers/ Skin Breakdown- Clinical Protocol revised, April 2018, indicated, .the nurse shall .document .the following: d. Current treatments, including support surfaces . Residents Affected - Few A review of the NIH National Library of Medicine website document, titled, Pressure Ulcer updated August 2022, indicated, .Managing decubitus ulcers [pressure ulcer] is complicated as there is no fixed treatment regime or algorithm. Once it has developed, there should be no delay in treatment, and management should start immediately . https://www.ncbi.nlm.nih.gov/books/NBK553107/ 555049 Page 10 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to maintain the usual body weight of one resident (Resident 28) who experienced an unplanned 19 pound (lb)/14.8% weight loss over 9 months. This had the potential of decreased immune function, decreased muscle mass, and loss of independence. Residents Affected - Some Findings: Resident 28 was readmitted to the facility winter of 2022 with diagnoses including COVID-19 (a disease caused by a virus that is contagious), anemia (blood condition lacking healthy red blood cells), and muscle weakness. Weight history included the following: 12/27/22=128 lbs. 1/23/23=121 lbs. 3/2/23=119 lbs. 4/5/23=116 lbs. 5/2/23=115 lbs. 6/4/23=113 lbs. 7/3/23=109 lbs. 8/1/23=110 lbs. 9/4/23=108 lbs. 10/1/23=109 lbs. This represented a decrease of 19 lbs./14.8% of her body weight. During an interview with Resident 28 conducted on 10/10/23 at 3:55 p.m., she reported that she did not like the facility food, stating that the food tasted off and the spices used to season it upset her stomach. Resident 28 stated that she would like to have ginger ale, fresh fruit, milkshakes, and tuna (mixed with mayonnaise only) sandwiches. Resident 28 stated that her usual body weight was 130 lbs. and that she had not been trying to lose weight and was unhappy about the weight loss. Lunch tray ticket from 10/11/23, included standing orders of coffee, 4 ounces of lactose free milk, and 8 ounces of water (though no food preferences were noted). There were no food items included in the dislike's column. During an interview on 10/12/23 at approximately 11:00 a.m., the Food Service Director (FSD) reported food preferences are updated when there is unplanned weight loss. She stated that Resident 28 555049 Page 11 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some liked milkshakes but was lactose intolerant. She further explained that Resident 28 often asked for egg sandwiches and ice cream at lunch or dinner, but that there were not any snacks or standing food orders for Resident 28. During a concurrent interview with the Registered Dietitian (RD) on 10/12/23 at approximately 11:00 a.m., the RD) reported that she will suggest snacks and supplements for residents with weight loss. She further stated that Resident 28 had been started on a supplemental liquid to be taken with medications due to poor food intake. The RD showed the nutrition care plan for Resident 28 but was unable to say how it had been personalized for Resident 28's situation. One of the care plan's focus areas (created 12/12/22 and revised by the FSD) included impaired nutrition and hydration status related to meal intake of less than 75% due to complaints about the taste of many foods. One of the interventions listed was to to determine food likes and dislikes. Review of care plan and dietary notes did not include food preferences. Review of facility provided policy titled Weight Monitoring and Management (Revised 1/12/19) listed the following: It is the policy of the facility to have a Weight Variance Committee that will: . Ensure that intervention(s) to manage the unplanned . weight loss/gain of the resident is appropriate and implemented in a timely manner. Under the listed procedures it included the following: 11. The Registered Dietician will assess nutrition intervention and provide dietary recommendation to manage identified weight. 12. The Registered Dietician or Designee will be responsible for reviewing the weight report, recommending any additional nutritional interventions, documenting progress in the medical record, updating the resident care plan as appropriate and discussing the weight changes with the Weigh (sic) weight Variance Committee. 555049 Page 12 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0755 Level of Harm - Minimal harm or potential for actual harm 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 accurate pharmaceutical services when Resident 73's full antibiotic course was not fully administered. Residents Affected - Few This failure had the potential for Resident 73's infection to not be fully treated or possibly get worse. Findings: A review of Resident 73's clinical record indicated Resident 73 was admitted in mid-September, 2023 and had diagnoses that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a concurrent observation and interview on 10/10/23 at 10:36 a.m. with Licensed Nurse (LN) 1 of medication cart 2, a bubble pack (a form of packaging where an individual pushes individually sealed tablets through the foil to take the medication) of azithromycin (an antibiotic medication used to treat certain bacterial infections) 250 milligrams (mg- unit of measurement) tablet for Resident 73 was found stored in the medication cart. The prescription label indicated, TAKE 1 TABLET BY MOUTH DAILY ON DAY 2-5, with fill date of 9/26/23, quantity dispensed was four, and quantity remaining in the bubble pack was one. LN 1 confirmed the observation. LN 1 stated azithromycin was not an active order for Resident 73. LN 1 further stated she did not know why the medication was still in the cart and could not explain why there was still one tablet remaining in the bubble pack. LN 1 agreed that if the full course of azithromycin therapy was given to Resident 73, there would not be one tablet remaining in the bubble pack. A review of Resident 73's clinical record indicated a physician's order of, Azithromycin Oral Tablet 500 MG (Azithromycin) Give 1 tablet by mouth one time only for congestion/ sinus pressure for 1 Day with start date of 9/26/23. A review of Resident 73's clinical record indicated a physician's order of, Azithromycin Oral Tablet 250 MG (Azithromycin) Give 1 tablet by mouth one time a day for congestion/sinus pressure for 4 Days with start date of 9/27/23. During a concurrent interview and record review on 10/10/23 at 1:58 p.m., with the Director of Nursing (DON), Resident 73's clinical records for azithromycin were reviewed. The DON stated that the azithromycin loading dose for Day 1 which was 500 mg was documented given on 9/26/23, and the remaining doses which were 250 mg for days 2-5 were documented given on 9/27/23, 9/28/23, 9/29/23, and 9/30/23. The DON agreed that if the full course of azithromycin therapy was given to Resident 73 as documented in the clinical records, there would not be one tablet remaining in the bubble pack. The DON further stated, I can't explain why there's one left [in the bubble pack]. During an interview on 10/11/23 at 9:01 a.m., with the DON, the DON stated the expectation would be that the whole duration of the antibiotic should be administered as ordered by the physician. The DON further stated if the full course of azithromycin was not fully administered, there would be a potential for the residents' infection to get worse. 555049 Page 13 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0755 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 10/11/23 at 11:11 a.m., with the DON, Resident 73's care plans were reviewed. The DON confirmed that there was no care plan for Resident 73's infection and azithromycin treatment. The DON stated if there was no care plan for the resident's infection and azithromycin treatment, there would be no documented intervention and goals of treatment which would mean there would be no direction of the care for the resident. Residents Affected - Few A review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 12/2012, indicated, 3. Medications must be administered in accordance with the orders . A review of the United States Food and Drug Administration publication titled, Combating Antibiotic Resistance, dated 10/29/19, indicated, When you are prescribed an antibiotic to treat a bacterial infection, it's important to take the medication exactly as directed .If treatment stops too soon, and you become sick again, the remaining bacteria may become resistant to the antibiotic that you've taken. (https://www.fda.gov/consumers/consumer-updates/combating-antibiotic-resistance) A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated, 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . g. Incorporate identified problem areas . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change . 555049 Page 14 of 29 555049 10/13/2023 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 three out of four sampled residents (Resident 50, Resident 23, and Resident 7) when: Residents Affected - Some 1. Licensed Nurse (LN) 1 did not follow the physician's order in administering Resident 50's prescribed medication; 2. LN 2 administered Resident 23's prescribed medication with a wrong dosage (strength of a medication); and 3. LN 2 did not administer a prescribed medication for Resident 7 which was due as ordered. These failures resulted in three medication errors identified out of 30 opportunities during the observation of medication administration; the facility medication error rate was 10%. Findings: 1. During a concurrent observation and interview on 10/10/23, within the medication administration observation started at 8:28 a.m., with LN 1, LN 1 was observed preparing medications for Resident 50. LN 1 used the bottle cap of the Miralax (a medication used to treat difficulty passing stool) container to measure how much Miralax powder to administer and put it in a small, clear, plastic cup. LN 1 poured water into the plastic cup until just above half of the cup. When LN 1 was asked how much water can fit in a cup, LN 1 stated she was not sure. The bottom of the plastic cup was checked and was labelled, 7 oz [ounceunit of measurement]. A review of Resident 50's clinical record indicated an active physician's order of, Miralax Oral Powder 17 GM (grams- unit of measurement)/SCOOP .Give 1 scoop by mouth one time a day for constipation (difficulty passing stool) prevention mix with 6-8 oz of water or juice. During an interview on 10/11/23 at 9:01 a.m., with the Director of Nursing (DON), the DON stated Miralax should be given with the appropriate amount of water and staff should make sure to follow the physician's order. 2. During an observation on 10/10/23, within the medication administration observation started at 8:53 a.m., with LN 2, LN 2 was observed preparing medications for Resident 23. LN 2 grabbed a white container with label, Vitamin C 250 mg [milligrams- unit of measurement], put 1 tablet in the medicine cup together with the other medicines, and administered it to Resident 23. A review of Resident 23's clinical record indicated an active physician's order of, Ascorbic Acid [Vitamin C] Tablet 500 MG Give 1 tablet by mouth one time a day for supplement. During a concurrent interview and record review on 10/10/23 at 1:27 p.m., with LN 2, Resident 23's active physician's order for Vitamin C was reviewed. LN 2 stated, I suppose I should've given her 2 tablets [of Vitamin C 250 mg]. LN 2 further stated Resident 23 would not have the full effect of Vitamin C if the correct dosage is not followed. During an interview on 10/11/23 at 9:01 a.m., with the DON, the DON stated if Vitamin C was given 555049 Page 15 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with a wrong dosage, the resident would not get full supplementation. The DON further stated the staff should always read the physician's order carefully and make sure to do the 5 checks for medication administration: the right patient, the right drug, the right time, the right dose, and the right route (the way a medication is administered). 3. During an observation on 10/10/23, within the medication administration observation started at 9:19 a.m., with LN 2, LN 2 was observed preparing medications for Resident 7. LN 2 administered a total of eight and 1/2 pills to Resident 7 which include ½ tablet of atenolol (a medication used to treat high blood pressure), one tablet of carbidopa-levodopa (a medication used to treat a brain disorder that causes unintended or uncontrollable movements called Parkinson's disease), two capsules of divalproex (a medication used to treat burst of uncontrolled activity of brain cells), one tablet of levetiracetam (a medication used to prevent or reduce the severity of disturbed nerve cell activity), two tablets of quetiapine (a medication used to treat a disorder that affects a person's ability to think, feel, and behave clearly called schizophrenia), one tablet of ropinirole (a medication used to treat Parkinson's disease) and one tablet of morphine sulfate (a medication used to treat moderate to severe pain). A review of Resident 7's clinical record indicated an active physician's order of, Senna S Oral Tablet 8.6-50 MG .Give 1 tablet by mouth two times a day for constipation hold for loose stool. During a concurrent interview and record review on 10/10/23 at 1:27 p.m., with the LN 2, Resident 7's active physician's order for Senna was reviewed. LN 2 stated, I was supposed to give it [Senna] to her [Resident 7] today. She is at risk for constipation. During an interview on 10/11/23 at 9:01 a.m., with the DON, the DON stated Resident 7 is at risk for constipation as a potential side effect of the other medication she was taking and should be given Senna as ordered by the physician. A review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 12/2012, indicated, 3. Medications must be administered in accordance with the orders . 555049 Page 16 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medications and supplies were properly labeled and properly stored in accordance with manufacturer guidelines, the facility's policies and procedures, and accepted professional principles for a census of 59 when: 1. Three loose pills and a medication bag with prescription label were found on the bottom of medication cart two; 2. A used insulin medication (a medication used to treat high blood glucose) vial (a glass container used for holding liquid medicines) was found in the medication cart two without a resident label; and, 3. An expired vial of an opened insulin medication was found in medication cart two. These failures had the potential for diversion of the loose medications, risk for breach of resident's personal information, medication could be given to the wrong resident, and for residents to receive medications that were expired or with unsafe or reduced potency. Findings: 1. During a concurrent observation and interview on 10/10/23 at 10:36 a.m. with Licensed Nurse (LN) 1 of medication cart two, three loose white pills and a clear medication bag with prescription label were all found on the bottom of medication cart two together with a layer of grey build-up and multiple small plastic and paper debris. LN 1 confirmed the observation. LN 1 stated the loose pills and medication bag should not be on the bottom of the medication cart. During an interview on 10/11/23 at 9:01 a.m., with the Director of Nursing (DON), the DON stated the medication cart should be regularly cleaned and not have loose pills and medication bags on the bottom of the cart. The DON further stated it would be a risk for medication diversion, possible spread of infection, cross contamination, and potential for breach of resident's personal information. A review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised 04/2007, indicated, 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner . 8 .Each resident's medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 2. During a concurrent observation and interview on 10/10/23 at 10:36 a.m. with LN 1 of medication cart two, a used insulin medication vial was found stored in medication cart two with only the opened-date and expired-date label, and without a resident's name label. LN 1 confirmed the observation. LN 1 stated there should be a resident name label on every opened medication because staff might administer the medication to a wrong resident. During an interview on 10/11/23 at 9:01 a.m., with the DON, the DON stated staff should label the opened medication with the resident's name that is receiving the medication. The DON further stated if medications are not labelled properly, the medication could be given to a wrong resident. 555049 Page 17 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's P&P titled, Storage of Medications, revised 04/2007, indicated, 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 3. During a concurrent observation and interview on 10/10/23 at 10:36 a.m. with LN 1 of medication cart two, an opened vial of insulin medication was found stored in medication cart two labeled, DATE OPENED: 8/28/23 DISCARD UNUSED PORTION AFTER 28 DAYS . LN 1 confirmed the observation. LN 1 stated the medication was expired and should not be kept in the medication cart because it might be administered to a resident. During an interview on 10/11/23 at 9:01 a.m., with the DON, the DON stated the medication that is passed the recommended days of use ones opened should be considered expired. The DON further stated expired medications should be taken out of the medication cart and should be destroyed or disposed. A review of the facility's P&P titled, Storage of Medications, revised 04/2007, indicated, 4. The facility shall not use .outdated .drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 555049 Page 18 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review the facility failed to provide food to accommodate resident allergies, intolerances, and preferences for three out of 59 residents (residents 3, 12, and 38). Residents Affected - Some These failures had the potential for allergic reactions, food intolerance and weight loss for these three residents. Findings: 1. Resident 12 was admitted in the fall of 2023 with diagnoses including type 2 diabetes (inability to process sugar), hypertensive heart disease (high blood pressure), and vitamin D deficiency. During an interview on 10/10/23 at 3:27 p.m., Resident 12 reported that he does not tolerate bell peppers and intake will lead to an upset stomach. Resident 12 stated this intolerance had been reported to the dietary department, but he continued to receive food with bell peppers such as stir-fried vegetables (in which he counted 12 slices of bell pepper). Resident 12 further explained that he doesn't understand many of the menu item's names so was unsure when to order an alternative, and if a food contains red, green, or yellow items he would not eat it fearing it may contain bell peppers. Tray ticket for Resident 12's lunch on October 11, 2023, included bell peppers under the dislikes. During an interview with the Food Service Director (FSD) on 10/11/23 at 9:23 a.m., she explained that the tray ticket computer system does not communicate with the menu computer program to eliminate offending foods. Therefore, meal service staff must review the tray ticket and not serve offending food items to the resident while replacing it with a more appropriate item which allows for human error. Review of Registered Dietitian (RD) notes on 9/22/23 and 10/12/23, did not mention Resident 12's bell pepper intolerance. The nutrition care plan for Resident 12 also did not include bell pepper intolerance. Review of facility provided document titled Food Preferences (Healthcare Menus Direct, LLC. 2023) listed the following: Policy: Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. 2. Resident 38 was admitted in the fall of 2023 with diagnoses including anemia (blood condition lacking healthy red blood cells), gastrointestinal hemorrhage (bleeding in the upper intestine), and reflux (a condition in which stomach acid or bile irritates the food pipe lining). During an interview on 10/10/23 at 3:45 p.m., Resident 38 reported an allergy for egg whites, cow's milk, and soy products which she had shared with the dietary department. Resident 38 complained of receiving a slice of Angel Food cake containing egg whites, and salad dressing containing soybean oil on her meal trays. 555049 Page 19 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 38's tray ticket from lunch on 10/11/23 included dairy and dairy products, cheese, soy products and eggs (white) under the dislikes as opposed to listing as allergies. Review of nutrition care plan did not include interventions for resident 38's food allergies. Review of facility provided document titled Food Allergies (Healthcare Menu Direct, LLC. 2023) listed the following: Policy: Residents with food allergies will be identified up admission. Procedure: 1. Allergies will be noted in the medical record. 2. All allergies will be communicated in writing directly to the FNS Director by Nursing. 3. Appropriate food substitutions will be offered for foods the resident cannot eat. 5. Allergies will be noted on the tray card, the resident diet profile, and posted in the kitchen and nursing station, if necessary. 3. Resident 3 was admitted in the winter of 2013 with diagnoses including dysphagia (difficulty swallowing), reflux (a condition in which stomach acid or bile irritates the food pipe lining), and a cerebral infarct (area of brain tissue that died due to lack of blood flow). During a 10/11/23 observation of the lunch meal plating in the dietary department at 12:08 p.m., Resident 3 was given a mashed vegetable patty as the entree. During a concurrent interview with the FSD, she stated that Resident 3 receives this daily as she traditionally followed religious diet restrictions and the facility does not provide the type of meat products required, so she has been served a vegetarian diet for the 10 years since being admitted . Tray ticket for the lunch meal on 10/11/23 listed Resident 3's diet order as Mechanical Soft, Vegetarian with dislikes of eggs, pork, chicken, beef, cottage cheese, and turkey. During a 10/12/23 interview at 9:37 a.m. with a appropriate language speaking surveyor, Resident 3 explained that she would like her native country food but realizes that there is no one here that is familiar with how to prepare this. She further explained that as an old woman, she must accept what she is given. During an interview on 10/12/23 at approximately 11:00 a.m. with the FSD and RD, the FSD explained that Resident 3 likes meaty vegetable patties, beans, yogurt, and orange juice, which she receives for most meals. Since she does not eat tofu, they have not purchased a vegetarian menu. During an interview on 10/12/23 at 4:38 p.m. with the Director of Nursing (DON), he stated that the dietary department should have an alternative menu for those who don't eat meat. He would expect that any diet ordered would have variety and options, as I don't want eat the same thing every day. During this interview, the DON was unable to show where the Care Plan addressed Resident 3's 555049 Page 20 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0806 special diet needs. Level of Harm - Minimal harm or potential for actual harm Review of facility provided document titled Food Preferences (Healthcare Menus Direct, LLC. 2023) listed the following: Residents Affected - Some Policy: Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. 555049 Page 21 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was safely stored and prepared under sanitary conditions for a census of 59 when: Residents Affected - Some 1. Items stored in the reach-in-refrigerator and walk-in-freezer were not properly dated; 2. The can opener tip was found chipped and with brown markings; 3. The steam table-pans were stored wet as well as the blender; 4. Uncooked bacon stored over hard cooked eggs; and, 5. [NAME] streaks were observed running down the sides of the kitchen stove, which were also rusted. The pipes behind the kitchen stove were rusted and covered in a dark fuzzy substance. These failures had the potential to cause foodborne illness (illness caused by consuming contaminated food) to residents receiving food from the kitchen. Findings: 1. During the initial kitchen tour on 10/10/23 at 8:18 a.m., a jar of Maraschino cherries was dated 10/20 in the reach-in-refrigerator. An opened bag of diced ham chunks dated 10/10 with no use by date. A box of cheese & garlic biscuit dough dated 10/9, a box of 12 wheat round top bread dated 10/5, and a box of 12 wheat round top bread dated 10/2 (emergency was written on the box) were all found stored in the freezer. During a concurrent observation and interview with Food Service Director (FDS) on 10/10/23 at 8:25 a.m., FDS confirmed the food items in the reach-in-refrigerator and walk-in-freezer were not dated properly. For instance, the FDS was unable to explain the year these items were to be discarded when dated 10/20, 10/10, 10/9, and 10/5. A review of the facility's policy titled, Labeling and Dating of Foods (Healthcare Menus Direct, LLC. 2023), indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. A review of the facility's policy titled, Storage of Food and Supplies, (Healthcare Menus Direct, LLC. 2023), indicated, Food and supplies will be stored properly and in a safe manner .All food will be dated - month, day, year. 2. In an observation of the kitchen on 10/10/23 at 8:29 a.m., the can opener tip was found chipped and with brown markings. During a concurrent observation and interview with FDS, on 10/10/23 at 8:30 a.m., FDS stated, The blade is dirty, bacteria could contaminate other foods and metal pieces could get into the food. According to the 2022 Federal Food and Drug Administration Food Code, Section 4-501.11 Good Repair and Proper Adjustment: (C) cutting or piercing parts of can-openers shall be kept sharp to minimize 555049 Page 22 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0812 the creation of metal fragments that can contaminate food when the container is opened. Level of Harm - Minimal harm or potential for actual harm 3. In an observation of the kitchen on 10/10/23 at 8:35 a.m., three out of eight steam table-pans were stacked and stored wet, as well as the blender jar, which had approximately one tablespoon of water at the bottom. Residents Affected - Some During a concurrent interview and observation with FDS and Cook, on 10/10/23 at 8:39 a.m., FDS stated, the steam table-pans should not be stored wet and should be dry. [NAME] stated, the blender jar should be stored dry. A review of the facility's policy titled, Dishwashing (Healthcare Menus Direct, LLC. 20123), indicated under the policy description that, All dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order. Procedures included, 5. Dishes are to be air dried in racks before stacking and storing. According to the Food and Drug Administration (FDA) Food Code 2022, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: (A) shall be air-dried . Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils (FDA Food Code Annex 4-901.11). 4. In an observation of the kitchen on 10/10/23 at 8:43 a.m. in the walk-in-refrigerator, uncooked bacon was found stored over hard cooked eggs. During a concurrent interview and observation with FDS, FDS stated, uncooked food should be stored below cooked foods/items as bacteria can drip down. A review of the facility's policy titled, Procedure for Refrigerated Storage, (Healthcare Menus Direct, LLC. 2023), indicated, (11) . Do not store meat that is thawing above eggs. 5. In an observation of the kitchen on 10/10/23 at 8:45 a.m., white streaks were observed running down the kitchen stove, which was also rusted. The pipes behind the kitchen stove were rusted and covered in a dark fuzzy substance. During a concurrent interview and observation on 10/10/23 at 8:47 a.m., with the FDS, FDS concurred and stated that she will notify maintenance. According to the FDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, it indicated that: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, 555049 Page 23 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0812 FOOD residue, and other debris. Level of Harm - Minimal harm or potential for actual harm A document review of the Food and Drug Administration FDA Food Code 2022, Section 4-602.13, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Residents Affected - Some 555049 Page 24 of 29 555049 10/13/2023 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 3. An observation of the laundry room was conducted on 10/12/23 at 07:37 a.m. with the Housekeeping staff (HS). There were white rolled towels in between the 2 washers, the side of the 2nd washer, behind the 2 washers and a pool of water behind the 2 washers. The HS confirmed the findings and she stated the Maintenance Director (MD) was aware of the leak and resulting pool of water. Residents Affected - Some A follow-up observation of the laundry room was conducted by 4 State surveyors with the Laundry Staff (LS) on 10/12/23 at 3:24 p.m. The air vent allowing the inflow from the swamp cooler (evaporative cooler, passing outdoor air over water saturated pads adding humidity and reducing the air temperature) directly above the 2 washers had blackish build up on the metal plates. The ceiling surrounding the vent was sagging and bulging with blackish discoloration on the border and the paint was peeling, bubbling and flaking. A brown box on the side of the washer was saggy and saturated on the bottom. There was brownish to blackish discoloration and peeling paint on the wall behind the 2 washers and the floor near the washer had cracks. A concurrent interview and record review was conducted on 10/12/23 starting at 4:01 p.m. The MD stated the leak was observed immediately when the washer was rebuilt 3 months ago. The MD further stated the damage in the ceiling surrounding the vent was caused by a leaking roof that was fixed a year ago. The MD confirmed the surrounding area of the vent had peeling paint and the paint could fall off in the clean linen. The MD further confirmed there was blackish build up in the air vent. The MD stated the vent was cleaned last August. The Deep Cleaning Schedule document indicated the laundry room was listed on 8/23/23. A concurrent observation and interview was conducted on 10/12/23 starting at 5:10 p.m. by 2 State surveyors with the MD and the IP inside the laundry room. The IP confirmed the vent was dusty and the peeling paint was above the washer. The MD confirmed there were cracks on the floor, the wall behind the 2 washers had water damage, there was no base board, the paint was peeling and the box near the washer had evidence of being soaked in water. The MD took a white paper towel and wiped the external area of the vent, there was blackish substance removed from the vent. In an interview on 10/12/23 at 5:25 p.m., the Administrator (ADM) confirmed the laundry room had water damage due to a leak. In an interview on 10/13/23 at 10:49 a.m., the IP stated she is involved in maintaining the cleanliness in the building including the laundry room. The IP confirmed she had not seen the vent that dusty before and her expectation was for the vent to be cleaned every month. The IP further stated if the vent was dusty, the dust can potentially attach to the laundered clothes, towels and linens used by the residents. The IP was unable to state if there was mold build up in the wall behind the 2 washers. In an interview on 10/13/23 at 12:02 p.m., the ADM stated his expectation was for the laundry to be free of filth, dirt and mold. The ADM further stated if there was a leak or issues in the building or the laundry room it should be fixed right away as it might be a risk for mold. A review of the facility's policy and procedure titled, INFECTION PREVENTION and CONTROL PROGRAM, revised 6/2021, indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases and infections .the infection prevention and control program is 555049 Page 25 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0880 a facility-wide effort involving all disciplines and individuals . Level of Harm - Minimal harm or potential for actual harm 2. A review of the clinical record indicated Resident 38 was re-admitted to the facility late 2023 with diagnoses that included Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems). Residents Affected - Some A review of Resident 38's Physician's order dated, 9/17/23 indicated, Change nebulizer set when used Q [every] week every Sunday and PRN [as needed] for soilage. as needed AND every day shift every Sun [Sunday]. A review of Resident 38's Physician's order dated, 9/17/23 indicated, Change oxygen cannula tubing Q week every Sunday and PRN for soilage. as needed AND every day shift every Sun. A review of Resident 38's Physician's order dated, 9/14/23 indicated, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML [MG,ML, unit of measurement] 3 ml inhale orally every 6 hours as needed for SOB[Shortness of Breath] or Wheezing via nebulizer. A review of Resident 38's Medication Administration Record (MAR) dated October 2023, indicated, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours for COPD start date 9/20/23 was last given on 10/10/23 at 6:00 am. During an observation on 10/10/23 at 9:04 a.m., in Resident 38's room, an oxygen mask was observed wrapped around the siderail of Resident 38's bed and a used nebulizer mask with tubings attached to the nebulizer (machine that turn liquid medications into a fine mist, allowing for easy absorption into the lungs) was on Resident 38's bedside table. Both masks were not labeled. During a concurrent observation and interview on 10/10/23 at 9:09 a.m., with the Certified Nursing Assistant (CNA 3), the CNA 3 verified the masks at Resident 38's bedside were not labeled. She stated, there should have been a label when the nurses changed them (oxygen masks and tubings). During an Interview on 10/12/23 at 12:21 p.m., with the Infection Preventionist (IP), the IP stated, resident's masks, tubings, nebulizers and humidifiers are supposed to be labeled every time the staff changes them. She stated, it is important to label every change for the staff to monitor if the tubings is less than 7 days. The IP further stated, nebulizer mask should be washed after every use and stored in the IP bag (IPpouch, a replacement technology for plastic bags used for storing reusable nasal cannula, nebulizers, and other respiratory devices). It should not have been kept on the bedside table after use. The IP further stated, it is part of the infection control practice that the nebulizer is washed and stored in the bag after use. A review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment revised, October 2018 indicated, .Semi-critical items consist of items that may come in contact with mucous membranes ( .respiratory therapy equipment) .Such devices should be free from all microorganisms .2. Critical and semi-critical items will be sterilized/disinfected in a central processing location and stored appropriately until use. A review of the NIH National Library of Medicine website document, titled, Device Cleaning and Infection Control in Aerosol Therapy indicated, .Reusable nebulizers should be cleaned, disinfected, rinsed with sterile water (if using a cold disinfectant), and air-dried between uses. The mouthpiece/mask of disposable nebulizers should be wiped with an alcohol pad, the residual volume should be 555049 Page 26 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0880 Level of Harm - Minimal harm or potential for actual harm rinsed out with sterile water after use, and the nebulizer should be replaced every 24 h [hours] . https://pubmed.ncbi.nlm.nih.gov/26070583/ Based on observation, interview, and record review, the facility failed follow and maintain an effective infection prevention and control program for a census of 59 when: Residents Affected - Some 1. Residents' non-pharmaceutical personal belongings were found stored in the medication carts with pharmaceutical products; 2. Resident 38's used oxygen masks and tubing (used to deliver oxygen to patients who need supplemental oxygen) and nebulizer (device used to deliver medicine to lungs) masks were not properly stored; and, 3. There was an unsanitary condition in the laundry room. These failures had the potential to spread germs and cause infection among residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 10/10/23 at 10:20 a.m. with Licensed Nurse (LN) 3 of medication cart 1, a resident's personal electric wrist blood pressure monitor in a white container and a 12-inch wooden handled knife with blade inserted in made-up knife sheath made of brown corrugated paper/cardboard and clear tape were found stored next to the controlled medications (medications with high potential for abuse or addiction). LN 3 confirmed the observation. LN 3 stated the resident's personal blood pressure monitor has been kept in the medication cart for two weeks, but LN 3 was not sure when they started storing the knife in the medication cart. LN 3 further stated, I cannot think of anything, when asked about possible issues related to storing residents' non-pharmaceutical personal belongings in the medication cart next to medications. During a concurrent observation and interview on 10/10/23 at 10:36 a.m. with LN 1 of medication cart two, a 6-inch torch lighter with blue grip bagged in a clear zip lock labeled with a residents' name and room number was found stored next to the controlled medications. LN 1 confirmed the observation. LN 1 stated storing residents' non-pharmaceutical belongings in the medication cart next to medications might result in contamination of the medications. During an interview on 10/11/23 at 9:01 a.m., with the Director of Nursing (DON), the DON stated having personal items in the medication cart could result in contamination or spread of germs and cause infection to the staff and/or residents. The DON further stated, The appropriate thing to do is to give it [residents' non-pharmaceutical belongings] to us right away. A review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised 04/2007, indicated, 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner . 8 .Each resident's medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 555049 Page 27 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review, the facility failed to ensure a safe and sanitary condition was maintained when there was pool of water and water damage in the laundry room, for a census of 59 residents. These failures increased the potential to cause major damage to the walls and ceiling and the growth of mold and bacteria. Findings: An observation of the laundry room was conducted on 10/12/23 at 07:37 a.m. with the Housekeeping staff (HS). There were white rolled towels in between the 2 washers, the side of the 2nd washer, behind the 2 washers and a pool of water behind the 2 washers. The HS confirmed the findings and she stated the Maintenance Director (MD) was aware of the leak and the pool of water. A follow-up observation of the laundry room was conducted by 4 State surveyors with the Laundry Staff (LS) on 10/12/23 at 3:24 p.m. The air vent directly above the 2 washers had blackish build up on the metal plates. The ceiling surrounding the vent was sagging and bulging with blackish discoloration on the border and the paint was peeling, bubbling and flaking. A brown box on the side of the washer was saggy and saturated on the bottom. There was brownish to blackish discoloration and peeling paint on the wall behind the 2 washers and the floor near the washer had cracks. A concurrent interview and record review was conducted on 10/12/23 starting at 4:01 p.m. The MD stated the leak was observed immediately when the washer was rebuilt 3 months ago. The MD further stated the damage in the ceiling surrounding the vent was caused by a leaking roof that was fixed a year ago. The MD confirmed the surrounding area of the vent had peeling paint and the paint could fall off in the clean linen. The MD further confirmed there was blackish build up in the air vent. The MD stated the vent was cleaned last August. The Deep Cleaning Schedule document indicated the laundry room was listed on 8/23/23. A concurrent observation and interview was conducted on 10/12/23 starting at 5:10 p.m. by 2 State surveyors with the MD and the Infection Preventionist (IP) inside the laundry room. The IP confirmed the vent was dusty and the peeling paint was above the washer. The MD confirmed there were cracks on the floor, the wall behind the 2 washers had water damage, there was no base board, the paint was peeling and the box near the washer had evidence of being soaked in water. The MD took a white paper towel and wiped the external area of the vent, there was blackish substance removed from the vent. In an interview on 10/12/23 at 5:25 p.m., the Administrator (ADM) confirmed the laundry had water damage due to a leak. In an interview on 10/13/23 at 10:49 a.m., the IP stated she is involved in maintaining the cleanliness in the building including the laundry room. The IP confirmed she had not seen the vent that dusty before and her expectation was for the vent to be cleaned every month. The IP further stated if the vent was dusty, the dust can potentially attach to the laundered clothes, towels and linens used by the residents. The IP was unable to state if there was mold build up in the wall behind the 2 washers. 555049 Page 28 of 29 555049 10/13/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 10/13/23 at 12:02 p.m., the ADM stated his expectation was for the laundry to be free of filth, dirt and mold. The ADM further stated if there was leak or issues in the building or laundry room it should be fixed right away as it might be a risk for mold. A review of the facility's policy and procedure titled, Maintenance Service revised 12/2009, indicated, Maintenance service shall be provided to all areas of the building .The Maintenance Department is responsible for maintaining the buildings .in a safe and operable manner at all times. 555049 Page 29 of 29