Health inspection·May 2, 2019

F 0659 Provide care by qualified persons according to each resident's written plan of care. 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 follow the physician's written plan of care for two of 25 sampled residents (Residents 26 and 37) when: Residents Affected - Few 1. The facility did not give the ordered amount of tube feeding for Resident 37. This had the potential to result in additional weight gain. 2. The facility did not give a medication with food as ordered by the physician. This had the potential to cause stomach distress. Findings: 1. A review of Resident 37's record indicated she was admitted to the facility on [DATE] with diagnoses that included dementia and dysphagia (difficulty swallowing). Resident 37 received all her nutrition and fluids through a feeding tube. A review of the physician's orders indicated an order, dated 3/25/19, to give tube feeding 110 milliliters (ml) for 10 hours (equal to 1100 ml) and 65 ml of water for 10 hours (equal to 650 ml). Both the tube feeding (TF) and water were to start daily at 7 pm. The prior tube feeding order was dated 5/2/18 and was for 110 ml for 11 hours. Resident 37 had gained weight and the physician had ordered the TF to be decreased from 11 hours per day to 10 hours per day. A review of the Medication Administration Record (MAR) for 3/2019 and 4/2019 indicated on some days, Resident 37 received 1210 ml total TF as opposed to the amount ordered by the physician of 1100 ml. The MAR also indicated, on some days, 650 ml water was not documented as given. During a concurrent interview and record review on 4/30/19 at 3:40 pm, the Director of Nurses (DON) confirmed the amount of tube feeding did not equal the amount ordered by the MD on all days in April and the amount of water charted as given was also not the amount ordered by the MD on some of the days. She stated this resident had gained some weight and that was the reason for the order to decrease the amount from 11 hours to 10 hours. A review of the amount documented on the MAR for the TF was 1210 instead of 1100 from 4/1 to 4/12/19. The amount of water documented was 60 or 65 ml instead of 650 on 4/1, 4/8, and 4/9, and was 710 and 715 ml on 4/3 - 4/6 and 4/11/19. The DON stated the amount which was ordered 650 ml, should have been charted. Other water included in flushes after medication administration should have been charted elsewhere on the MAR under the section for flushes. A review of the Enteral Tube Feeding via Continuous Pump policy dated 11/2018, read as follows Page 1 of 15 555147 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0659 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few under the documentation section. The person performing this procedure should record the following information in the resident's medical record: 3. Amount and type of enteral feeding. 2. A review of Resident 26's record indicated he was admitted to the facility on [DATE] with diagnoses that included heart failure and gout (a disease in which defective metabolism causes arthritis especially in the smaller bones of the feet causing episodes of acute pain). A review of the monthly pharmacy medication regimen review for 10/2018 indicated the pharmacist had recommended that allopurinol (medication used to treat gout) be given with food and full glass of water. (This medication can cause stomach upset when given on an empty stomach). The physician signed this as an order on 10/9/18. A review of the MAR indicated this order had been transcribed as, Allopurinol should be given with a full glass of water, but did not include give with food. The MAR for 5/2/19 was signed to indicate Resident 26 had been given Allopurinol at 8 am. During an interview on 5/2/19 at 11:30 am, Certified Nursing Assistant (CNA) B confirmed resident did not eat breakfast today and refused it because he said he just wanted to sleep. He had just awakened. During an interview on 5/2/19 at 11:35 am, Resident 26 stated he had slept through breakfast and had not eaten. He stated he just woke up and asked for coffee. During an interview on 5/2/19 at 11:45 am, DON confirmed the MAR did not indicate that the medication was to be given with food and should have been since that was what the physician ordered. She stated this resident rarely refuses breakfast so usually he would get this medication with breakfast at 8 am. 555147 Page 2 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents using oxygen (O2), have continuous oxygen applied as ordered by the physician (Resident 81). Residents Affected - Few This failure had the potential that residents could suffer with inadequate oxygenation and respiratory distress and/or shortness of breath (SOB). Findings: The facility policy and procedure titled Oxygen Administration, dated 10/2010, read Steps in the Procedure . 12. Check the mask, tank, humidifying jar, etc to be sure they are in good working order .13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . Resident 81's record was reviewed. Resident 81 was readmitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD- a lung disease that causes narrowing of the airways and difficulty in breathing), pneumonia, shortness of breath, and difficulty walking. Resident 81 made his own health care decisions. Resident 81's physician's order for O2, dated 10/4/18, and renewed monthly, read O2 @ 6 l/min (liters per minute) via NC (nasal cannula - a tube to the nostrils from the oxygen source) to maintain O2 Sats (saturation of O2 in the blood) greater 90%. During an observation on 4/29/19 at 9:50 am, Resident 81 was in his room, alert and sitting upright in his wheel chair, with a NC in place with tubing leading to an O2 cylinder secured to his wheel chair. At the same time it was observed that the tank his oxygen tubing was connected to was empty. Resident 81 did not appear to be in distress and was unaware he had run out of oxygen. The Assistant Director of Nursing (ADON) was immediately contacted and acknowledged that Resident 81 should not have been on an empty tank of oxygen and changed his tubing to his continuous oxygen concentrator in his room. ADON stated that he was not sure that Resident 81 was ordered continuous oxygen. During a concurrent interview and record review of Resident 81's physician's orders with ADON and Licensed Vocational Nurse Charge (LVN) C on 4/29/19 at 9:55 am, both acknowledged that Resident 81's current order was for continuous oxygen and that he should not have been on an empty tank. LVN C stated that the licensed nurses are responsible for oxygen administration and all staff are to be checking that residents on oxygen cylinders do not run out. 555147 Page 3 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received the correct psychotropic (affects mind, emotions, behavior) medication for the exhibited behavior per physican order for one of one five sampled residents (Resident 27). This resulted in Resident 27 to receive an unecessary psychotropic medication for four months. Findings: A review of facility's policy titled, Psychotropic Medication Use, updated on March 2018, indicated Psychotropic medications may be used if medications are necessary to treat specific condition, diagnosed and documented in medical record. Behavioral interventions, unless contraindicated, will be used to meet the individual needs of the residents. 1.Residents will only receive Psychotropic medications when necessary to treat specific condition, diagnosed and documented in medical record. 2.Psychotropic medication management for the resident will involve the facility interdisciplinary team consideration of the following: indication and clinical need for medication, dose, duration, and adequate monitoring for efficacy and adverse consequences. Management will also include preventing, identifying, and responding to adverse consequences; and identifying person-centered non-pharmacological interventions, unless contraindicated, to meet the individual needs of the resident, and minimize or discontinue the use of Psychotropic medication. 3.PRN (as needed) Psychotropic medication will be used only if necessary to treat a diagnosed specific condition that is documented in the clinical record. 4.The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. A review of Resident 27's admission record indicated he was admitted to the facility on [DATE], with diagnoses which included stroke, encounter for attention to gastrostomy (PEG tube, flexible feeding tube placed through the stomach wall into the stomach for nutrition, fluids and/or medications), and anxiety. Resident 27 was unable to make health care decisions for himself. A review of Resident 27's anxiety care plan dated 9/10/17, indicated he was receiving Ativan (for treatment of anxiety) for behavior of pull at tubes and clothes leading to exhaustion. An intervention was to attempt non pharmalogical approaches (activity of talk therapy, out of room outside for fresh air) before administering medications (Ativan). A review of Resident 27's care plan that address his risk for unmet needs dated 8/15/18, for behaviors of repetitive verbalization's of yelling out/moaning that lead to exhaustion. There were 5 approaches listed in the care plan that included distraction therapy, comfort, and physical/social activity. There was no documentation found in nursing progress notes that Resident 27 received any 555147 Page 4 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0758 non-pharmaceutical interventions attempted before administration of Ativan. Level of Harm - Minimal harm or potential for actual harm A review of Resident 27's physician order written 1/21/19, for Ativan 0.5mg one tab, via feeding tube, twice a day, as necessary (PRN) for behaviors of pulling at feeding tube and clothes that leads to exhaustion. Residents Affected - Some A review of behavioral monitoring record that documented Resident 27's observed yelling out and/or moaning leading to exhaustion, indicated 40 times in January 2019, 54 times in February 2019, 40 times in March 2019, and 33 times in April, for a total of 167 times over four months. A review of Resident 27's PRN Medication Administration Record indicated he was given Ativan for yelling and/or calling out in six times in January 2019, 18 times in February 2019, 10 times in March 2019, 7 times in April 2019, for a total of 41 times over four months. A review of Resident 27's Interdisciplinary team (IDT, health care disciplines that discuss resident plan of care) psychotropic gradual dose reduction (GDR, ensures the lowest effective dose), dated 2/11/19, indicated IDT, physician and pharmacist reviewed Resident 27's Ativan for side effects and behaviors. Patient continues with behaviors noted, there was no identification that the Licensed Nurses (LNs) were giving Ativan to Resident 27 for yelling and/or calling out behaviors and were not following the physician orders. During an observation 4/30/19 at 9 am, Resident 27 was lying on his back in bed, awake, calm and noted to only have an incontinence brief and blanket covering him. When asked questions, Resident 27 mumbled answers and pointed a lot. He was able to answer Yes and No questions clearly. During an observation 5/1/19 at 9:30 am, Resident 27 was calm sitting up in bed reading a book. No yelling, mumbling and pointing observed. During an observation 5/1/19 at 10:40 am, Licensed Vocational Nurse (LVN) F offered a nutritional supplement given through feeding tube to Resident 27, and he refused, without yelling. During a concurrent interview and record review of the Medication Administration Record (MAR) of Ativan on 5/1/19 at 10:45 am, LVN F confirmed Ativan was given to Resident 27 for yelling and this did not follow his physicians orders. During an interview on 5/1/19 at 1:05 pm, Certified Nursing Assistanct (CNA) B and LVN F both confirmed that Resident 27 did not pull at his feeding tube and actually had begun protecting it when assisted when putting on his clothes and tranferring. During an concurrent observation of Resident 27 with CNA B and I on 5/1/19 at 4:24 pm, he was calm and watching television. CNA B and I confirmed Resident 27 do yell or call out when he needs something, for example when he needs his television remote control, once assisted his yelling resolves. CNA I stated that sometimes Resident 27 picked at his skin around the feeding tube and did not pull on it. During a concurrent interview and record review on 5/1/19 at 4:45 pm, Director of Nursing (DON) confirmed that LVNs did not follow physician orders when administering Ativan to Resident 27 for yelling. The DON confirmed there was no nursing documentation of non-pharmacologic interventions in the nurses notes for Resident 27 and about him pulling on feeding tube or pulling off clothing causing 555147 Page 5 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some exhaustion. The DON confirmed the IDT notes only spoke to the GDR of Ativan, and there was no identification that Ativan was given for yelling and/or calling out behaviors by LVNs. During an interview 5/2/19 at 9:40 am, CNA I (working evening shift) stated sometime in early evening on 5/1/19, Resident 27 had an outburst of yelling from his room. CNA I explained it took a long time to understand Resident 27, and once she determined his need (television off) he became calm. CNA I reported to an evening LVN that Resident 27 had yelled out to turn off television. 555147 Page 6 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility pharmacy and nurses failed to provide an accurate label for one of one sampled resident receiving IV (Intravenous) medications (Resident 105) when the label had two conflicting infusion rate directions that would result in the medication being delivered over 30 minutes or 60 minutes depending on how the directions were interpreted. This failure had the potential for the medication to be administered at inconsistent infusion rates and at a rate other than prescribed, as well as resident frustration at the inconsistent length of time to administer. Findings: A facility policy titled Medication Labels, revised 8/2014, read: 1) If the physician's direction for use change or the label is inaccurate, the nurse may place a change of order--check chart label on the container indicating there is change in direction for use, taking care not to cover important label information. 2) When such a label appears on the container , the medication nurse checks the resident's medication administration record (MAR) or the physician's order for current information. 3) The dispensing pharmacy is informed prior to the next refill of the prescription so the new container will contain an accurate label and quantity . H. Medication containers having soiled, damaged, incomplete, illegible, confusing, or makeshift labels are[returned to the dispensing pharmacy for relabeling .] Resident 105's record was reviewed. Resident 105 was admitted to the facility on [DATE] with diagnoses that included after care for left shoulder surgery, infection, cellulitis (a skin infection) as well as adjustment and management of vascular device-IV. Resident 105 had a peripherally inserted central catheter (PICC - a IV line that runs into the central venous system) for IV medications and fluids. Resident 105 made his own health care decisions. A physician's ordered antibiotic, dated 3/29/19, read Nafcillin recon soln (reconstituted solution- meaning the medication vial is in powder form and normal saline is added, as instructed, to dissolve the powder into the fluid solution, and the label is attached to the saline bag) 2 grams, intravenous Special instructions: Cellulitis, run over 30 minutes Every 4 hours; . This order was to be discontinued on 5/2/19. During a medication observation and concurrent interview on 5/01/19 at 11:00 am, with Assistant Director of Nursing (ADON) he prepared a vial of Nafacillin 2 Grams by reconstituting with 50 milliliters (ml) of normal saline (NS) then applied the pharmacy supplied label to the IV saline bag with the 2 grams of the Nafacillin. ADON then went to Resident 105 checked his PICC line to ensure it was patent (open to flow) and started the Nafacillin at an infusion rate of 100 ml per hour. ADON stated that the infusion should be complete in about 30 minutes. Upon review of the pharmacy provided label that had been applied to the IV bag attached to Resident 555147 Page 7 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105, it read Nafcillin 2 gm in 50 ml NS bag . Infuse IV over 60 minutes every 4 hours . res vol:100 ml, rate 100 ml/hr . ADON acknowledged that the label infusion rate was incorrect as his NS bag of 50 ml infused at 100 ml/hr would infuse over 30 minutes as ordered not 60 minutes as the label had instructed. ADON stated that the pharmacy had been notified of the label error but he had no evidence. ADON stated a direction change sticker should have been applied to any label that has incorrect information and that it had not been done for Resident 105's IV Nafcillin. ADON also stated that the label error from the pharmacy had been in place for some time and that Resident 105 would receive his last dose at midnight. During a concurrent interview Resident 105 stated that he had to correct nurses for some time about the pharmacy label error. 555147 Page 8 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow their menus and measure portion sizes correctly for residents receiving Controlled Carbohydrate (CCHO-an eating plan designed to help regulate blood sugar; carbohydrate--food that provides energy) diets during lunch. This had the potential to prevent 32 residents who received a CCHO diet from getting the proper amount of food to meet their nutritional needs. Findings: Review of the facility document titled, Resident Orders, dated 5/2/19, showed that each resident had a diet ordered by a physician based on their individual needs and preferences. Some diets were designed to meet special needs such as ground up to be easy to chew and swallow, or low in salt or fat. CCHO diets were often ordered for residents with diabetes (a disease of blood sugar regulation). These orders were to be followed by the kitchen staff when preparing meals. CCHO plans help stabilize (keep steady) blood sugar levels by creating uniformity (consistency) of carbohydrate intake across all meals. The goal is for the amount of carbohydrates eaten each day and at each meal to remain the same (Academy of Nutrition and Dietetics). A three-bean salad contains carbohydrates. Review of a facility menu showed three different meal sizes based on calories. Small contained 1600-1900 calories, regular contained 2100-2400 calories, and large contained 2500-2800 calories. All diet types had directions for small, regular, and large portions that were to be followed when dishing up the food. A registered dietitian reviewed and approved the menus for use. Review of a facility menu showed that three-bean salad was to be served as part of lunch on 4/30/19. It should have been well-drained and served in a portion size of ¼ cup for all CCHO diet sizes. During a concurrent observation and interview on 4/30/19 at 11:45 am, [NAME] 2 confirmed that the three bean salad had been measured in a portion size of ½ cup for all resident meals, including the CCHO diets. 555147 Page 9 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, the facility failed to consistently follow their Nutritionally Enhanced Meal (NEM-added extra calories or protein) plans during breakfast. This failure had the potential to prevent some residents from receiving the nutrition needed to maintain their weight and health which could have negatively affected their well-being. Findings: Review of the facility document titled, Resident Orders, dated 5/2/19, showed that each resident had a diet ordered by a physician based on their individual needs and preferences. Some diets were designed to meet special needs such as ground up to have been easy to chew and swallow, or low in salt. The physician's order also contained directions for NEMs. These orders were to be followed by the kitchen staff when they prepared meals. Review of the facility's policy titled, Fortification (enrichment or strengthening) of Food: Increasing Calories and/or Protein in the Diet, dated 1/1/18, showed its purpose was to increase the calories or protein in food to help improve the nutrition status of certain residents who weren't eating enough. Calories or protein were to be added to foods using items such as margarine or mayonnaise. Staff who prepared the food would have been familiar with the fortification process for each item chosen to be used in the facility. During an observation on 5/2/19 beginning at 8:30 am, Dietary Aide (DA) C was plating breakfast meals in the main dining room. It was noted while Certified Nursing Assistants (CNAs) accurately read the NEM diet order to DA C, the meals being plated were no different than a regular diet. Review of a facility menu for Spring 2019 showed that it had been reviewed by a dietitian on 3/4/19. For hash brown potatoes served at breakfast, the directions indicated that ½ ounce of melted margarine should have been put on top of the potatoes. During an interview on 5/2/19 at 8:45 am, dietary services DA C stated that NEM directions were on the menu spreadsheet (a computer printout). DA C gave an extra pat of butter or margarine on the side of the plate for the NEM that day instead of melted margarine. In a follow up observation on 5/2/19 beginning at 8:50 am, random observation resident NEM meal trays revealed that greater than three random trays did not have extra butter. An additional two random trays had one pat of unused butter. During a concurrent interview and record review on 5/2/19 at 8:50 am, Licensed Dietitian (LD) confirmed that the spreadsheet indicated melted margarine was to have been placed on top of the hash brown potatoes for NEM as the responsibility of dietary staff to fortify the meal prior to presenting to residents. 555147 Page 10 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

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 meet food safety requirements when: Residents Affected - Some 1. the kitchen ice machine sanitizer solution was not checked for concentration before use; 2. nutritional supplement shakes stored in the refrigerator were not dated when pulled from the freezer and the temperature of the shakes was 44.2 degrees Fahrenheit (F.); 3. nursing staff did not sanitize their hands between residents when handing out plates of food in the dining room; 4. a plastic scoop was stored inside a container of dry goods during use; 5. kitchen staff did not follow the facility's policy on facial jewelry and beard covers. These practices had the potential to cause harm to all residents by putting them at risk for eating food contaminated by germs or chemicals. Eating contaminated food could have led to complications such as diarrhea, vomiting, dehydration, and malnutrition. Findings: 1. Review of an undated facility document titled, Guide to Service, showed a description of icemaker cleaning and sanitizing procedures. The recommended ice machine cleaner was to have been mixed as three and one-third ounces in two gallons of water. Review of a Flake Ice Machine Installation, Use & Care Manual, dated 7/1/09, showed instructions for cleaning and sanitizing the make and model of ice machine used in the kitchen. A revised version was found online, dated 12/1/16. Both manuals directed the user to sanitize with the manufacturer's Ice Machine Sanitizer, to spray all interior bin surfaces and the evaporator discharge spout, and to not rinse after sanitizing. The sanitizer concentration was to be mixed as one-half ounce of solution in one gallon of water. During an interview on 5/1/19 at 8:14 am, Maintenance Assistant (MA) stated that he put bleach in a spray bottle and misted the inside of the ice machine to disinfect it. He did not know how many parts per million (ppm-a measure of concentration of a chemical solution) the bleach mixture was. During a concurrent observation and interview on 5/1/19 at 8:30 am, MA prepared a bleach solution in four quarts of water. A chlorine test strip was inserted into the bleach solution and turned a dark purple, which was compared to the label on the test strips bottle and showed a level of 200 ppm, the maximum testing level for the strip. 2. Review of a facility policy titled, General Receiving of Delivery of Food and Supplies, dated 1/1/18, showed a description of the procedure for inspecting and putting away food when it was delivered to the facility. It directed staff to carefully inspect the deliveries for proper labeling, temperature, and appearance. Deliveries were to be put away as quickly as possible and labeled with the delivery date or a use-by date. 555147 Page 11 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a kitchen observation on 4/29/19 at 9:45 am, there were three boxes containing individual four ounce cartons of nutritional supplement called mighty shakes (drinks that provided extra protein, vitamins and calories) in refrigerator number five. The mighty shakes were delivered frozen and then moved to the refrigerator. A delivery date of 4/10/19 was on a sticker on one box, a delivery date of 4/16/19 was on a second box, and a delivery date of 3/28/19 was on a third box. According to the manufacturer's directions, the shakes were good for 14 days after they were taken out of the freezer. There were no dates on the cartons that indicated what day they were moved from the freezer to the refrigerator. During a kitchen observation on 4/29/19 at 9:45 am, a digital temperature probe was inserted into a nutritional supplement mighty shake carton. The temperature of the shake was 44.2 degrees F. During a concurrent observation and interview on 4/29/19 at 9:45 am, Licensed Dietitian (LD) confirmed there were no freezer pull dates written on the three boxes of nutritional supplement mighty shakes that were in refrigerator number five. 3. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 1/1/17, showed that the facility considered hand hygiene its primary means to prevent the spread of infections. It directed staff to wash hands with soap and water when their hands were visibly soiled and also after contact with a resident who had infectious diarrhea. In addition, staff were directed to use an alcohol-based hand rub to kill germs on their hands in the following situations: before and after direct contact with residents, before and after eating or handling food, and before and after assisting a resident with meals. During a dining observation on 5/2/19 from 8:14 am to 8:35 am, several Certified Nursing Assistants (CNAs) touched the inner edges of plates of food with their bare thumbs while delivering meals to the tables. They were seen touching their faces and touching residents without sanitizing their hands in between tasks. During a concurrent observation and interview on 5/2/19 at 8:50 am, LD and Director of Nurses (DON) demonstrated the method of holding the plates from the edges. They confirmed that the thumb of the person holding the plate at times touched the inside of the plate near the food. 4. Review of the facility's policy titled, Storage of Food and Supplies, dated 1/1/17, showed that food and supplies should have been stored properly and in a safe manner. Dry bulk foods such as flour, beans, spices, or food thickener, should have been stored in seamless metal or plastic containers with tight covers, or in bins that were easily sanitized. Scoops should not have been left in the containers. During a concurrent observation and interview on 4/30/19 at 9:27 am, Dietary Services Supervisor (DSS) confirmed that a plastic scoop was inside a container of food thickener powder. The open date written on the container was 4/21/19 and the use-by date was 4/24/19. 5. Review of the facility's policy titled, Dress Code for Men and Women, reviewed 1/1/18, showed its purpose was to describe appropriate dress in the Food & Nutrition Department. It directed staff to wear no facial jewelry and to cover all facial hair. During a concurrent observation and interview on 5/1/19 at 9:31 am, [NAME] 1 had a beard cover that was pulled down around his neck and not covering his beard. He stated that beard covers should have 555147 Page 12 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0812 been worn all the time. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 5/2/19 at 11:40, Dietary Supervisor Assistant (DSA) stated that the piece of metal jewelry which was exposed on her right upper cheek had been surgically implanted and could not have been removed. She thought she was allowed to wear studs. Residents Affected - Some During a concurrent observation and interview 5/2/19 at 11:42, Dietary Aide (DA) D touched the metal hoop hanging from the left side of his nose and stated he thought that jewelry that wasn't dangling was allowed to be worn. 555147 Page 13 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to dispose of a lancet (a device used for obtaining blood from a finger), that was contaminated with blood, into a sharps container (a plastic container that prevents access after disposal) and instead discarded the contaminated lancet into a the residents shared bathroom garbage can for one of two tests observed during survey (Resident 123). Residents Affected - Few This failure had the potential for anyone handling the garbage to be subjected to a sharps injury and disease from blood borne illness. Findings: A facility policy titled Sharps Disposal, dated 1/2012, read 1. Whoever uses contaminated sharps (any device that pierces the skin) will discard them immediately or as soon as feasible into designated containers. Resident 123's record was reviewed. Resident 123 was admitted to the facility on [DATE] with diagnoses that included diabetes and long term use of insulin. During an observation on 4/30/19 at 4:49 pm, a blood sugar (BS) glucometer testing of a Resident 123 was observed with Registered Nurse (RN) E. After the blood was obtained for the test by using a lancet to pierce a hole in Resident 123's finger, the used lancet (with a retractable cover) was placed with other items used for the testing (BS test strip, alcohol wipe, and disposable cup) into Resident 123's bathroom garbage can. A plastic sharps container was noted and labeled on the wall in Resident 123's bedroom. Upon leaving Resident 123's room RN E was asked about the disposal of the lancet in the resident garbage. She stated that the lancet should not have been thrown in the resident garbage can and that she would immediately retrieve it and place the lancet in the sharps container. 555147 Page 14 of 15 555147 05/02/2019 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition when two gaskets (seals) on refrigerator doors were broken. This failure could have caused food to not be stored at safe temperatures. Improper temperatures could have caused a growth of germs in the food that potentially could lead to food borne illness. Residents Affected - Some Findings: During a kitchen observation on 4/29/19 at 9:30 am, the black rubber gaskets on both doors of refrigerator number two were split and separated. During a concurrent interview and record review on 5/1/19 at 9:40 am, Dietary Services Supervisor (DSS) stated that the entry about the seal on the refrigerator number two door was made after the California Department of Public Health (CDPH) inspection was done on 4/29/19. Review of a facility document titled, Quality Assurance Action Plan, dated 4/23/19, showed a typed entry that read, Replace gaskets on all cold units. Review of a facility document on 5/1/19 at 10:12 am, showed a list of kitchen work orders. Two hand-written entries dated 4/29/19 read, left door of cook frig., REF #2, seal needs to be fixed, and on order. 555147 Page 15 of 15