Health inspection·May 5, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a care plan for one of eight sampled residents (Resident 1) who was on oxygen therapy. This failure had the potential to cause inaccuracy in identifying Resident 1's health care and support needs. Findings: During an observation on May 3, 2023, at 8:20 AM, Resident 1 was lying on bed, awake, and alert. Resident 1 was observed with oxygen via nasal cannula (medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) at 2.5 Liters (L - unit of measure). During a review of Resident 1's admission Record (document that contains demographic and clinical data), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included mild intermittent asthma (a respiratory condition causing difficulty of breathing), Type 2 Diabetes Mellitus (a condition characterized by elevated blood sugar) with Hyperglycemia (elevated blood sugar). During a review of Resident 1's Active Orders Summary Report on May 3, 2023, at 9:00 AM, the Active Orders Summary Report indicated May have Oxygen via nasal cannula @ 2-4 LPM (liters per minute) as needed, may titrate (measure and adjust) to maintain O2 sat (saturation), above 91% (percent). During a review of Resident 1's clinical record on May 3, 2023, at 9:15 AM, there was no care plan noted for the use of oxygen therapy. During a concurrent interview and record review with Registered Nurse (RN 1), on May 5, 2023, at 10:36 AM, Resident 1's care plan was reviewed. RN 1 verified there was no plan of care documented for the use of oxygen therapy. RN 1 stated there should have been a nursing care plan for the use of oxygen therapy. During a concurrent interview and record review with the Director of Nursing (DON), on May 5, 2023, at 10:39 AM, Resident 1's care plan was reviewed. The DON verified there was no plan of care documented or the use of oxygen therapy. The DON stated there should have been a nursing care plan for the use of oxygen therapy. Page 1 of 7 555162 555162 05/05/2023 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

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 provide clean oxygen tubing when a nasal cannula (NC- a device used to deliver supplemental oxygen to ease breathing) was not changed according to their Oxygen Administration policy for three of three sampled residents (Resident 4, Resident 48, and Resident 102). Residents Affected - Few This failure had the potential to place Resident 4, Resident 48, and Resident 102 at risk for respiratory infection, and inadequate delivery of oxygen due to clogging which could compromise residents' overall health condition. Findings: 1. During a review of Resident 4's face sheet (demographic data), the face sheet indicated Resident 4 was initially admitted to the facility on [DATE], with diagnoses that includes end stage renal disease (ESRD-a condition in which kidneys cannot function normally), and acute and chronic respiratory failure (a condition in which lungs cannot get enough oxygen to the blood) with hypoxia (low oxygen in the body). During an observation on May 2, 2023, at 9:45 AM, Resident 4 was observed lying in bed with NC attached to her nose with oxygen delivered at 3 liters (L-oxygen flow rate). A review of Resident 4's Order Entry (physician order), dated February 24, 2023, indicated, Resident 4 had an order to receive oxygen via NC. During a concurrent observation and interview on May 2, 2023, at 9:51 AM, in Resident 4's room, with the Certified Nurse Assistant (CNA 1), the CNA 1 verified Resident 4's NC tubing was not labeled with a date. The oxygen bag attached to the oxygen delivering machine was labeled as April 21, 2023. The CNA 1 stated, April 21, 2023, seemed to be the last date the oxygen tubing was changed. The CNA 1 further stated, she did not know how often NC should be changed. During a concurrent observation and interview on May 2, 2023, at 10:16 AM, in Resident 4's room, with the Licensed Vocational Nurse (LVN) 1, the LVN 1 verified, Resident 4's NC tubing was not labeled with date, and the oxygen bag attached to the oxygen delivering machine was labeled as April 21, 2023. The LVN 1 stated, she was not sure about the facility's policy for changing NC tubing, and April 21, 2023, seemed to be the date the NC tubing was changed. The LVN 1 further stated, NC tubing should be changed to prevent respiratory infection such as pneumonia and clogging of the tube. During an interview on May 2, 2023, at 2:35 PM, in the nursing station, with the Director of Nursing (DON), the DON stated, NC tubing needs to be changed every seven (7) days and more frequent if the tubing is contaminated. 2. During a review of Resident 48's face sheet, the face sheet indicated Resident 48 was admitted into the facility on March 16, 2023, with diagnoses that includes chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing related problems) and dependence on supplemental oxygen. During an observation on May 2, 2023, at 10:26 AM, Resident 48 was observed lying in bed with NC 555162 Page 2 of 7 555162 05/05/2023 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0695 Level of Harm - Minimal harm or potential for actual harm attached to her nose with oxygen delivered at 2 L. Resident 48 stated, she had been using supplemental oxygen for a while. A review of Resident 48's Order Entry, dated March 16, 2023, indicated, Resident 48 had an order to receive oxygen via NC. Residents Affected - Few During a concurrent observation and interview on May 2, 2023, at 10:28 AM, in Resident 48's room, with the LVN 1, the LVN 1 verified Resident 48's NC tubing and oxygen bag attached to the oxygen delivery machine were not labeled with a date to indicate the last time NC tubing was changed. The LVN 1 stated, I would change the NC tubing today. LVN further stated, NC tubing should be changed to prevent respiratory infection such as pneumonia and clogging of the tube. During an interview on May 2, 2023, at 2:35 PM, in the nursing station, with the DON, the DON stated, NC tubing needs to be changed every seven (7) days and more frequent if the tubing is contaminated. 3. During a review of Resident 102's face sheet, the face sheet indicated Resident 102 was admitted to the facility on [DATE], with diagnoses that includes hemiplegia (inability to move on one side of the body), hemiparesis (muscle weakness on one side of the body), and asthma (a condition of narrow and swelling of airways which make breathing difficult). During an observation on May 2, 2023, at 10:00 AM, Resident 102 was observed lying in bed with NC attached to his nose with oxygen delivered at 3 L. A review of Resident 102's Order Entry, dated May 2, 2023, indicated, Resident 102 had an order to receive oxygen via NC. During a concurrent observation and interview on May 2, 2023, at 10:23 AM, in Resident 102's room, with the CNA 2, the CNA 2 verified Resident 102's NC tubing was labeled as April 21, 2023. CNA 1 stated, she did not know how often NC tubing should be changed. 555162 Page 3 of 7 555162 05/05/2023 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 food prepared for two of two sampled residents (Resident 16 and Resident 36) on a Pureed Diet (blended to pudding consistency) was not served with a palatable lunch and the taste not comparable to the food served for residents receiving a Regular Diet (diet with no restrictions). Residents Affected - Few This failure had the potential for Resident 16 and Resident 36 to experience a decrease in food intake which could lead to poor nutrition and health outcomes. Findings: During a concurrent interview and meal taste test of the lunch that was served on May 3, 2023, at 12:45 PM, in the dining room, with the Dietary Supervisor (DS), in the presence of the Registered Dietitian, sample trays of the Regular Diet and Pureed Diet for lunch were tested for palatability, appearance, texture, and temperature. The sample trays consisted of baked pork chop, wild rice pilaf, seasoned asparagus tips, green beans, bread roll, ravioli with rose sauce, and peach shortcake. The regular diet tray was flavor full, but the pureed wild rice pilaf tasted saltier, and was not comparable in flavor to the regular wild rice pilaf served. The DS stated the pureed wild rice pilaf was saltier than the regular wild rice pilaf served. During a record review of the Resident 16's clinical record, the admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE], with diagnoses of dysphagia (difficulty swallowing) and protein-calorie malnutrition (calorie intake less than recommended). Doctors order summary indicated; purred diet was ordered on October 6,2022. During a concurrent interview and record review on May 3, 2023, at 12:56 PM, with the Registered Dietician (RD 1), the RD stated, the pureed diet meals should taste like the regular diet meals for the residents. During a record review of the Resident 36's clinical record, the admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE], with diagnoses of essential hypertension (high blood pressure) and gout (pain full joints) Doctors order summary indicated, purred diet was ordered on February 14, 2023. During a concurrent interview and record review on May 3, 2023, at 12:56 PM, with the Registered Dietician (RD 1), the RD stated, the pureed diet meals should taste like the regular diet meals for the residents. During an interview on May 3, 2023, at 1:00 PM, in the room of Resident 16, Resident 36 were non interview able. During a review of the facility document titled [name of corporate] Dietitians Menus, under Week at a Glance, dated May 3, 2023, the menu indicated, baked pork chop, wild rice pilaf, seasoned asparagus tips, green beans, bread or Roll & butter or Margarine, ravioli with rose sauce, and peach shortcake and choice of Beverage will be served. 555162 Page 4 of 7 555162 05/05/2023 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

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 maintain a sanitary kitchen in accordance with professional standards for food service safety when: Residents Affected - Many 1) There was diet and grime built on top of the stainless-steel dishwashing machine which had the potential for microorganism growth that could be transferred to the food. 2) Plastic food storage containers were stacked and stored wet, which prevented them from drying and had the potential to allow an environment where microorganisms can begin to grow. 3) There was food, black grime, and trash build-up found behind and, underneath the stove. This had the potential for microorganism growth that could inadvertently be transferred to food. These failures had the potential to cause foodborne illness in a highly susceptible population of 47 residents who received food from the kitchen. Findings: 1. During an observation and concurrent interview with the Floater on May 2, 2023, at 10:01 AM, in the Kitchen, noted dirt and grime build up on top of the stainless-steel dish washing machine. Floater stated, he cleans it once a week. During an observation and concurrent interview with the Dietary Supervisor (DS) on May 2, 2023, at 10:05 AM, in the Kitchen, there was dirt and grime build up on top of the stainless-steel dish washing Machine. DS stated her expectation are that it should be clean daily, and it was not cleaned. During an interview with Registered Dietitian (RD) on May 5, 2023, at 11:32 AM, she stated floater is responsible for cleaning the dish washing machine and her expectations are that it should be cleaned daily for outside. During a review of the facility policy with RD on May 5, 2023, at 11:35 AM, entitled Dish machine Clean up, dated 08/31/2018, the policy indicated: .Make certain all equipment is turned off, water drained, dish room clean and sanitized before leaving. RD stated policy was not followed. 2. During an observation and concurrent interview with the Dietary Supervisor (DS) on May 2, 2023, at 11:32 AM in the kitchen, plastic food storage containers were stacked and stored wet. DS stated, these containers should have been air dried before storing. During an interview with registered dietitian (RD) on May 5, 2023, at 11:40 AM, she stated, her expectations are that food storage containers should be dry before staking and storing. During a review of the facility's policy and procedure (P&P) entitled Dry Storage-Dish and utensils, revised on 02/01/2012, the P&P indicated: .Dishes must be stored to promote air drying i.e. use dish rack or trays with plastic mesh that allow air to circulate and air dry the dishes . RD stated, P&P was not followed. During a review of the FDA Federal Food Code, dated 2017, the Food Code indicated 4-901.11 555162 Page 5 of 7 555162 05/05/2023 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment, and utensils: (A) Shall be air-dried . 3. During an observation and concurrent interview with the DS on May 2, 2023, at 9:55 AM, in the kitchen, there was food, black grime, and trash build-up underneath the stove. The DS stated, her expectations are that the area should be kept clean. During an interview with RD on May 5, 2023, at 11:00 AM, she stated, her expectations are that floors should be clean under the stove. During a review of the FDA Federal Food Code, dated 2017, the Food Code indicated 4-202.16 Nonfood-Contact Surfaces. Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. 555162 Page 6 of 7 555162 05/05/2023 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed in between resident's care in accordance with infection control standard of practice affecting one of two residents (Resident 19). Residents Affected - Few This failure had the potential for the spread of infection (process of bacteria or viruses invading the body or making someone ill), between residents and staff. Findings: During a review of Resident 19's clinical record, the face sheet (contains demographic information) indicated Resident 19 was admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). During a medication administration observation, with the Licensed Vocational Nurse (LVN 2), on May 4, 2023, at 6:00 AM, the LVN 2 was inside Resident 19's room with gloves on. She then walked out of the resident's room into the hallway where the medication cart was located, with gloves on, and proceeded to open the medication cart. During a continued observation on May 4, 2023, at 6:15 AM, with the LVN 2, inside Resident 19's room, LVN 2 performed hand-hygiene, don (put on) two pairs of gloves. She then started cleaning the resident and administered the ointment cream. The LVN 2 removed the first pair of gloves, discarded it, then continued to perform patient care with the gloves that she already had on. During an interview with the LVN 2, on May 4, 2023, at 6:36 AM, the LVN 2 stated, she did walk out of the resident's room with gloves on, and opened the medication cart with gloves on, she was sorry that she forgot. The LVN 2 added, I did put on two gloves on for the procedure, in case something happens, I still have clean gloves on, I don't know what can happen when working with body parts. During an interview, with the Infection Preventionist (IP) on May 5, 2023, at 10:15 AM, the IP stated it was not acceptable for the staff to wear gloves outside the room and in the hallway. The IP further stated a basic infection control is for the staff to remove gloves and wash hands to prevent cross contamination. During a concurrent interview and record review on May 5, 2023, at 2:15 PM, with the DON. The DON reviewed the facility's policy and procedure (P&P) titled Hand Hygiene, dated September 2, 2022. The P&P indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .6a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves . The DON stated this is what we expect from all the staff. 555162 Page 7 of 7