Health inspection·June 14, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure dignity was maintained for two of three residents (Resident 35 and 500) when Resident 35 and 500 had their urinary catheter drainage/collection bags (bags which collect and hold urine) not covered with dignity bags (a bag used to the cover and hold the catheter drainage/collection bag, so it is not visible). These failures resulted in the urine of both residents (Resident 35 and 500) to be visible to residents and staff within the facility which had the potential to compromise the residents' privacy and feelings of dignity and respect. Findings: 1a. During a review of Resident 35's admission Record (clinical record with demographic information), the admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses which included, acute kidney failure (kidneys suddenly become unable to filter waste), metabolic encephalopathy (dysfunction in the absence of primary structural brain disease), obstructive and reflux uropathy (disorder of the urinary tract that is obstructed urinary flow). During an observation on June 10, 2024, at 12:29 PM, Resident 35 was sitting at the edge of the bed. Resident 35's urinary catheter bag was hanging on the side of the bed. It was uncovered, with yellowish urine visible. During a further observation on June 13, 2024, at 9:00 AM, Resident 35 was lying in bed in a semi-upright position, watching television. Resident 35's urinary catheter bag was hanging on the floor, uncovered, with yellowish urine visible. During a concurrent observation and interview on June 13, 2024, at 9:15 AM, with the Infection Preventionist (IP), Resident 35 was standing in the doorway of his room, room [ROOM NUMBER]B, the urinary catheter bag was hanging on the floor, uncovered, with yellowish urine visible. The IP stated each urinary catheter bag must have a dignity bag at all times. 1b. A review of Resident 500's admission Record, (contains demographic and medical information), indicated Resident 500 was admitted to the facility on [DATE], with diagnoses which included fournier gangrene (is a rare, life-threatening bacterial infection of your scrotum, penis, or perineum [the area between your genitals and rectum]), abnormalities of gait (walking) and mobility, and muscle weakness. Page 1 of 14 555162 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0550 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on June 11, 2024, at 1:53 PM, with Resident 500, Resident 500 was lying in bed and had a foley catheter (a device that drains urine from your urinary bladder into a drainage bag outside of your body). The urinary catheter drainage bag had urine in it and was not covered with a dignity bag. Resident 500 stated the facility did not offer or provide him a cover (dignity bag) for his catheter. Residents Affected - Few During an interview on June 14, 2024, at 9:31 AM, with the Director of Nursing (DON), the DON stated all urinary catheter bags should be covered with a dignity bag. The DON further stated dignity bags were used for resident privacy and to maintain dignity. During a review of the facility's policy and procedure titled, Promoting/Maintaining Resident Dignity, dated December 12, 2022, the policy indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .Compliance Guidelines: .11. Maintain resident privacy. Record review with IP on June 13, 2024, at 10:00 AM, with the Director of Nurses (DON), the facility's policy and procedure (P&P), titled, Catheter Care, dated December 19, 2022, was reviewed. The P&P indicated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. The DON stated the policy was not followed. 555162 Page 2 of 14 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

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 observation, interviews, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for one of one resident (Resident 33) sampled for accidents when the Resident 33's RAI-MDS, dated [DATE], did not indicate the resident sustained a fall since admission. Residents Affected - Few This failure had the potential to result in unmet care needs for Resident 33 which can potentially jeopardize the residents' health and safety. Findings: A review of Resident 33's admission Record, (contains demographic and medical information), indicated Resident 33 was admitted to the facility on [DATE], with diagnoses which included hemiparesis and hemiplegia (weakness and paralysis) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), muscle weakness, and repeated falls. During a concurrent observation and interview on June 11, 2024, at 11:45 AM, Resident 33 was lying in bed and stated he fell a few weeks ago while in the facility. During a review of Resident 33's clinical record a document titled, Resident Care Conference Review, (meeting notes from a team of interdisciplinary members [staff from different disciplines]), dated May 10, 2024, was reviewed. The document indicated, .Areas reviewed: Falls .recent fall no injuries .floor mats recommended by rehab with verbal instructions for safety . During a review of Resident 33's physician's progress notes, dated May 23, 2024, indicated, Chief complaint/reason for this visit: Change in condition: fall, pulled foley (indwelling urinary catheter) out .This AM[morning] Pt [patient] had a fall onto his fall mat [a cushioned mat which may aid in lessening the severity of injury during a fall] on the floor, did not experience any head trauma; however, he did pull out his foley in the process . During a review of Resident 33's RAI-MDS assessment dated [DATE], the RAI-MDS assessment indicated in section J1800. Any falls since admission/Entry or Reentry . indicated no. During a concurrent interview and record review on June 14, 2024, at 9:36 AM, with Minimum Data Set Nurse 1 (MDS 1), MDS 1 stated the facility did not have a policy and procedure regarding completion of the MDS assessments and the facility followed the RAI manual in regards to completion of the MDS assessments. MDS 1 further stated she was the individual who completed Resident 33's RAI-MDS assessment dated [DATE]. MDS 1 stated when completing the MDS assessment section for falls, she reviews the facility's risk management report and also reviews progress notes in the resident's clinical record. MDS 1 stated when she reviewed the facility's risk management report when completing Resident 33's MDS assessment, dated May 24, 2024, there were no falls indicated. MDS 1 reviewed Resident 33's clinical record and stated the MDS dated [DATE], was coded incorrectly in section J1800 for falls and that it was a mistake and should have indicated the resident had a fall. MDS 1 stated the MDS was coded wrong in error. During a review of CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility 555162 Page 3 of 14 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident Assessment Instrument (RAI) 3.0 User's manual, dated October 2023, version 1.18.11, the manual indicated on page J-34, Steps for Assessment .Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. 4. Review nursing home incident reports, fall logs and the medical record (physician, nursing, therapy, and nursing assistant notes) Code 1, Yes: if the resident has fallen since the last assessment . 555162 Page 4 of 14 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

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 observations, interviews, and record review, the facility failed to ensure one of one resident (Resident 33) reviewed for accidents had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) on both sides of his bed as was specified in the resident's care plan (an individualized plan for the medical care of a resident). This failure had the potential for the Resident 33 to sustain a serious injury during a fall in which the severity of the injury may have been lessened if the fall mat had been in place. Findings: A review of Resident 33's admission Record, (contains demographic and medical information), indicated Resident 33 was admitted to the facility on [DATE], with diagnoses which included hemiparesis and hemiplegia (weakness and paralysis) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), muscle weakness, and repeated falls. During a concurrent observation and interview on June 11, 2024, at 11:45 AM, Resident 33 stated he fell a few weeks ago while in the facility. Resident 33 had only one fall mat on the left side of his bed (the side of the bed closest to the door). During a concurrent observation and interview on June 13, 2024, at 11:46 AM, with the Registered Nurse 2 (RN 2), Resident 33 was lying in bed and had only one fall mat on the left side of his bed. RN 2 stated Resident 33 had only one fall mat but he was supposed to have two fall mats, one on each side of his bed. RN 2 further stated she did not know why the Resident 33 only had one fall mat in place. During a review of Resident 33's care plan titled, [Resident 33] is at risk for falls r/t [related to] disease process generalized weakness and poor gait [walking] and balance . dated February 29, 2024, the care plan indicated, Goal .The resident will be free of minor injury through the review date .Interventions .Follow facility fall protocol . During a review of Resident 33's care plan titled, Risk for falls post fall (episodic), dated October 20, 2023, the care plan indicated, .Interventions .Fall mats placed on both sides of bed . During an interview on June 14, 2024, at 9:32 AM, with the Director of Nursing (DON), the DON stated the purpose of the resident's care plan was for staff to have basic knowledge regarding the resident's plan of care. The DON further stated the care plan interventions were supposed to be followed. During a review of Resident 33's clinical record a document titled, Resident Care Conference Review, (meeting notes from a team of interdisciplinary members [staff from different disciplines]), dated May 10, 2024, was reviewed. The document indicated, .Areas reviewed: Falls .recent fall no injuries .floor mats recommended by rehab with verbal instructions for safety . During a review of the facility's policy and procedure titled, Fall Risk Assessment, dated December 19, 2022, the policy indicated, It is the policy of this facility to provide an environment that is 555162 Page 5 of 14 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0656 Level of Harm - Minimal harm or potential for actual harm free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents .3. A fall care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. 4. The fall care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. Residents Affected - Few During a review of the facility's policy and procedure titled, Fall Prevention Program, revised December 28, 2023, the policy indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. During a review of the facility's policy and procedure titled, Comprehensive Care Plans, dated December 19, 2022, the policy indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .f. Resident specific interventions that reflect the resident's needs . 555162 Page 6 of 14 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to implement their fall prevention program for one of one resident (Resident 33) reviewed for accidents, in accordance with the facility's policies and procedures when the facility did not complete a post fall risk assessment (an assessment that identify the factors that cause the fall) on Resident 33, and did not review or update Resident 33's care plan (an individualized plan for the medical care of a resident) for falls, after he experienced a fall on May 24, 2024. This failure had the potential for Resident 33 to be at risk for repeated falls and for the facility to not identify potential new causative factors contributing to falls which can cause harm and injury to resident 33. Findings: A review of Resident 33's admission Record, (contains demographic and medical information), indicated Resident 33 was admitted to the facility on [DATE], with diagnoses which included hemiparesis and hemiplegia (weakness and paralysis) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), muscle weakness, and repeated falls. During a concurrent observation and interview on June 11, 2024, at 11:45 AM, Resident 33 was lying in bed and stated he fell a few weeks ago while in the facility. During a review of Resident 33's physician's progress notes, dated May 23, 2024, it indicated, Chief complaint/reason for this visit: Change in condition: fall, pulled foley (indwelling urinary catheter) out .This AM [morning] Pt [patient] had a fall onto his fall mat on the floor, did not experience any head trauma; however, he did pull out his foley in the process . During a review of Resident 33's clinical record, there was no documented evidence a post fall risk assessment was performed by facility staff. During a review of Resident 33's care plan titled, Risk for Falls Post Fall (Episodic), dated October 20, 2023, the care plan indicated the most recent revision was dated May 8, 2024, and there was no revision or update after the residents fall on May 24, 2024. During a review of Resident 33's care plan titled, [Resident 33] is at risk for falls r/t [related to] disease process generalized weakness and poor gait [walking] and balance . dated February 29, 2024, the care plan indicated, Goal .The resident will be free of minor injury through the review date .Interventions .Follow facility fall protocol . There was no revision or update to the care plan after the residents fall on May 24, 2024. During an interview on June 13, 2024, at 10:55 AM, with the Director of Nursing (DON), the DON stated the facility performed a fall risk assessment on all residents upon admission and after any subsequent falls. The DON further stated after a fall, the Interdisciplinary team (IDT) was supposed to meet each time to discuss the incident and implement interventions which would be updated in the resident's care plan. 555162 Page 7 of 14 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0689 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on June 13, 2024, at 11:08 AM, with the DON, Resident 33's clinical record was reviewed. The DON stated, Resident 33 should have had a post fall risk assessment done, the fall care plan should have been updated, IDT should have met regarding the incident, and a change of condition should have been initiated, but stated there was no evidence it was done. Residents Affected - Few During a review of the facility's policy and procedure titled, Fall Risk Assessment, dated December 19, 2022, the policy indicated, It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents .3. A fall care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. 4. The fall care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. During a review of the facility's policy and procedure titled, Fall Prevention Program, revised December 28, 2023, the policy indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .8.l When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. C. complete an incident report .e. Review the resident's care plan and update as indicated . 555162 Page 8 of 14 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free of medication errors for 1 of 42 residents (Resident 10) when Resident 10's insulin Lispro (medication to treat high blood sugar) was not given according to physician's orders. Residents Affected - Few This failure placed Resident 10 at risk for hypoglycemia (low blood sugar) and had the potential to jeopardize his health and safety. Findings: During a review of resident 10's admission Record (clinical record with demographic information), the admission Record indicated, Resident 10 was admitted to the facility on [DATE], with diagnoses which included, hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side (paralysis of partial or total body function on one side of the body with one-sided weakness), type 2 diabetes mellitus with hyperglycemia (a spike in blood sugar levels), urinary tract infection (an infection of the urinary system) and calculus of kidney (kidney stones). A medication administration observation for Resident 10 by a Licensed Vocational Nurse (LVN 1) was conducted on June 12, 2024, at 5:33 AM, in Resident 10's room. LVN 1 injected 2 units (U - unit of measurement) of insulin Lispro subcutaneously (medication injected in the fatty tissue, under the skin) to Resident 10's right arm. LVN 1 stated Resident 10's blood sugar was 154. During a concurrent interview and record review on June 12, 2024, at 7:30 AM, with LVN 1, LVN 1 reviewed Resident 10's physician's orders, dated April 26, 2024. The physician's orders stated, Insulin Lispro Solution 100 unit/ml (ml - milliliters, unit of measurement), inject as per sliding scale: if 131-170 = 2 units; IF BLOOD GLUCOSE 330 AND ABOVE, GIVE 8 UNITS AND CALL MD, subcutaneous before meals for DMII [type 2 diabetes mellitus]. Not to be administered sooner than 15 minutes to meals. LVN 1 stated the physician's orders for insulin Lispro was not followed. LVN 1 further stated she did not read the full order and she administered the insulin Lispro 2 hours before mealtime. During a concurrent interview and record review on June 12, 2024, at 7:40 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P), titled, Prescriber Medication Orders, dated April 2008, was reviewed. The P&P indicated, Policy: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe . Procedures: A. Elements of the Medication Order . 1. Medication orders specify the following: . a. Name of medication, b. Strength of medication, where indicated c. Dose and dosage form, d. Time or frequency of administration, e. Route of administration (If facility policies allow, orders are assumed to be P.O. [by mouth] unless otherwise specified), .g. Diagnosis or indication for use . The DON stated the policy was not followed. During a concurrent interview and record review on June 12, 2024, at 7:50 AM, with the DON, the facility's P&P titled, Medication Administration - General Guidelines, dated October 2017, was reviewed. The P&P indicated, .B. Administration .2). Medications are administered in accordance with written orders of the attending physician.10). Medications are administered within 60 minutes of schedule time (1 hour before and 1 hour after), except before or after meal orders, which are administered based on mealtimes. The DON stated the policy was not followed. 555162 Page 9 of 14 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

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. Based on observation, interviews and record review the facility failed to ensure secure storage of intravenous medications (IV - medications administered through the vein) for one of one IV medication cart, (a mobile cart used by licensed nurses to transport medications to resident rooms) when the IV medication cart was unlocked while unattended by license nurse. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 42 residents. Findings: During a concurrent observation and interview, on June 10, 2024, at 12:18 PM, at the nurses station 1, with the Registered Nurse (RN 1), the IV medication cart was parked in front of the nurses station, and it was unlocked and unattended. RN 1 was sitting down, working on the computer. RN 1 then reviewed the contents of the IV medication cart. The IV medication cart was equipped with IV supplies including syringes needles (thin, sharp hollow tubes, used to deliver and to draw fluid), antibiotics (medications to treat infections). RN 1 stated, the IV medication cart should not be left open and that it was very bad that it was open because they have residents' information printed on the medication labels. RN 1 further stated that it was also, unsafe for the ambulatory residents. During a further interview on June 10, 2024, at 12:52 PM, with RN 1, RN 1 stated she was the only one who had access to the IV medication cart and she forgot to lock it. During a concurrent interview and record review on June 12, 2024, at 12:58 PM, with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled Specific Medication Administration Procedures, dated April 2008, was reviewed. The P&P indicated, . A. Medication cart is locked at all times unless in use and under the direct observation of the medication nurse. The DON stated the policy was not followed. The DON further stated, his expectations was for the nurses to lock the IV Medication cart when it's not in use. 555162 Page 10 of 14 555162 06/14/2024 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 observations, interviews, and record review the facility failed to ensure staff followed safe Infection control practices when: Residents Affected - Many 1. Three staff members, one Certified Nursing Assistant (CNA 1), the Activities Director (AD), and the Infection Preventionist (IP), were wearing acrylic nails longer than the tip of the fingers, on June 11, 2024. 2. One resident's (Resident 35) urinary catheter bag (a bag connected to a flexible tube inserted into the bladder and collects urine), was on the floor, on June 13, 2024. 3. One resident's (Resident 33's) urinary catheter tubing (the tubing which connects an indwelling urinary catheter to a urinary drainage bag) was dragging on the floor, on June 11, 2024. These failures had the potential to result in cross-contamination (spread of bacteria) causing serious infections to 42 vulnerable residents. Findings: 1. During an observation on June 11, 2024, at 10:25 AM, with Certified Nursing Assistant (CNA 1), CNA 1 was performing care to one resident while wearing long acrylic nails. CNA 1, then entered room [ROOM NUMBER] and then room [ROOM NUMBER] and performed resident care to two other residents on the [NAME] Wing of the facility. CNA 1 was wearing acrylic nails, over one inch long. CNA 1 stated, she was allowed to wear acrylic nails, as long as they are not over one inch. During an observation on June 11, 2024, at 10:27 AM, on the [NAME] Wing, with the Activities Director (AD), the AD was passing out water and snacks to the residents, from room [ROOM NUMBER]A through room [ROOM NUMBER] C. The AD was wearing acrylic nails over one inch long. During a concurrent observation and interview, on June 11, 2024, at 10:31 AM, at the nurses' station, with the Infection Preventionist (IP), the IP was sitting at the nurses' station, working on the computer and was wearing acrylic nails. The IP stated, staff is allowed to wear acrylic nails, as long as they are short. The IP further stated, the staff knows it and it is for the direct care staff. During a record review on June 11, 2024, at 10:50 AM, with the Director of Nursing (DON). The DON reviewed the Employee Handbook, undated, The Employee Handbook indicated, . Direct Patient Care, Food Services, Medical Supply Staff: . Employees are prohibited from any form of artificial fingernails or fingernail enhancements or nail changes that have been found to increase the colonization and transmission of pathogens to patients. Therefore, only well-groomed nails of reasonable length (no longer that [sic] ¼ beyond the fingertip) are permitted for health care workers with direct patient contact or contact with patient food or medical supplies. Fingernails must be neat, of reasonable length, and may be polished. Health care professional observed wearing artificial nails or fingernail enhancement must be removed prior to next scheduled workday. The DON stated, the facility did not follow the employee handbook. During a record review on June 11, 2024, at 10:55 AM, with the Director of Nursing (DON). The DON 555162 Page 11 of 14 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0880 Level of Harm - Minimal harm or potential for actual harm reviewed the Employee Handbook, undated, the Employee Handbook indicated, . All employees Dress Code, . Fingernails: Fingernails must be clean and lightly manicured. Employees whose duties include direct resident care may not have long fingernails extending beyond the fingertip. Artificial and acrylic nails and acrylic overlays are not allowed to be worn by any employees whose job description includes direct resident care. The DON stated the employee handbook was not followed. Residents Affected - Many 2. During a review of Resident 35's admission Record (clinical record with demographic information), the admission Record indicated, Resident 35 was admitted to the facility on [DATE], with diagnoses which included, acute kidney failure (kidneys suddenly become unable to filter waste), metabolic encephalopathy (dysfunction in the absence of primary structural brain disease), obstructive and reflux uropathy (disorder of the urinary tract that is obstructed urinary flow). During an observation on June 12, 2024, at 10:05 AM, with Resident 35, Resident 35 came out of his room wearing briefs, the urinary catheter drainage bag was hanging down from his left leg, and it was dragging on the floor. During an observation on June 13, 2024, at 9:15 AM, Resident 35 was coming out of his room, and stopped at the door and the urinary catheter drainage bag was on the floor. During an interview on June 13, 2024, at 10:00 AM, with the Infection Preventionist ( IP), the IP stated the tubing and urinary catheter drainage bag should not be dragging on the floor due to infection control. IP further stated, no tubing or bags should be dragging on the floor or lying on the floor. During a concurrent interview and record review on June 13, 2024, at 11:00 AM, with the DON, the facility's policy and procedure (P&P), titled, Infection Surveillance, dated December 19, 2022, was reviewed. The P&P indicated, . A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to prevention and control practices in order to reduce infections and prevent the spread of infections. 5. Surveillance activities will be monitored facility-wide, and may be broken down by department or unit, depending on the measure being observed. A combination of process and outcome measures will be utilized. ii. Observations of staff including the identification of ineffective practices, if any . The DON stated the policy was not followed. 3. A review of Resident 33's admission Record, the admission Record indicated, Resident 33 was admitted to the facility on [DATE], with diagnoses which included hemiparesis and hemiplegia (weakness and paralysis) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). During a concurrent observation and interview on June 11, 2024, at 11:37 AM, in the hallway, with Restorative Nursing Assistant 1 (RNA 1), Resident 33 was seen self-propelling himself in his wheelchair down the hallway while his foley catheter tubing (the tubing of an indwelling urinary catheter) was dragging on the floor. As Resident 33 wheeled down the hallway, he passed next to two staff members who were walking down the hallway in the opposite direction but neither of the two staff members assisted Resident 33 to prevent his foley catheter tubing from dragging on the floor. Restorative Nursing Assistant 1 (RNA 1) was also in the hallway and stated Resident 33's foley catheter tubing was dragging on the floor and was not supposed to be dragging on the floor. During a review of Resident 33's clinical record, a care plan (the individualized medical plan of 555162 Page 12 of 14 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many care for a resident) titled, The resident has indwelling catheter . dated November 13, 2023, indicated, . uropathy [blockage of the urinary tract] at risk for infection .goals .the resident will show no s/sx [signs and symptoms] of urinary infection . During an interview on June 14, 2024, at 9:55 AM, with the DON, the DON stated urinary catheter tubing should not be dragging on the floor because it is a risk of infection. During an interview on June 14, 2024, at 10:38 AM, with the IP, the IP stated urinary catheter tubing should not be dragging on the floor and that it was important to prevent the tubing from dragging on the floor because it was an infection control issue and the tubing could get lodged on something or yanked on as it dragged on the floor. During a review of the facility's policy and procedure titled, Catheter Care, dated November 19, 2022, the policy indicated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care . During a review of the facility's policy and procedure titled, Infection Prevention and Control Program, dated December 19, 2022, the policy indicated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 555162 Page 13 of 14 555162 06/14/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure their walk-in refrigerator and walk-in freezer were maintained in safe operating condition when both the fridge and the freezer were identified to not be operating correctly and unable to maintain acceptable temperatures on June 10, 2024. Residents Affected - Many This failure had the potential for food spoilage and increased risk for foodborne illness (illness caused by eating contaminated food) for all 42 residents who received food from the facility's kitchen. Findings: During a concurrent observation and interview on June 10, 2024, at 9:43 AM, with the Dietary Services Supervisor (DSS), in the facility's walk-in refrigerator and walk-in freezer, both the fridge and freezer felt like they were at room temperature and the facility had removed the thermometers. The facility had food stored in both the fridge and the freezer. The DSS stated the facility's walk-in refrigerator, and walk-in freezer were identified to not be working at 4:00 AM on June 10, 2024, and had broken sometime overnight. During a record review of the facility's walk-in refrigerator and walk-in freezer temperature log titled, Record of Refrigeration Temperatures, dated June 2024, the log indicated on June 10, 2024, the refrigerator temperature was documented as 55 degrees Fahrenheit (°F) and the freezer temp was documented as off. The document further indicated, Code for adequate temperature: Refrigeration: Not greater than 41 °F .Freezer: Not greater than 0 °F or food maintained solid . During an observation on June 11, 2024, at 8:56 AM, with the Registered Dietician (RD), the facility's walk-in refrigerator temperature was 36.3 degrees °F and the walk-in freezer temperature was 38.3 degrees °F. During a record review of the facility's walk-in refrigerator and walk-in freezer temperature log titled, Record of Refrigeration Temperatures, dated June 11, 2024, the log indicated the walk-in freezer temperatures from 8:30 AM, through 2:15 PM, ranged between 10 degrees °F and 35 degrees °F. During a concurrent interview and record review on June 14, 2024, at 11:57 AM, with the Dietary Services Supervisor, the facility's policy and procedure titled, Physical Environment: Electrical Equipment, dated December 19, 2022, was reviewed. The policy indicated, Policy: The facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition .4 .Examples of essential equipment include, but are not limited to: .e. Kitchen refrigerator/freezer . The DSS stated the facility was supposed to maintain the fridge and freezer in safe operating condition and stated the facility policy was not followed. 555162 Page 14 of 14