Health inspection·July 15, 2021

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 ensure the care plan was developed and implemented, for one of 21 residents (Resident 139), when the nutrition care plan was not updated to include a nutritional supplement, and adequate monitoring of that supplement. This failure had the potential to result in a decline in Resident 139's condition, including unintended weight loss, which could lead to negative clinical outcomes. Findings: Resident 139's medical record was reviewed. Resident 139 was admitted on [DATE], with diagnoses that included protein calorie malnutrition and dementia (degenerative disorder of the brain). Resident 139's admission weight was 95-pounds. The Diet Requisition, dated 7/10/21, included healthshakes with meals, three times per day. The care plan included, Diet as ordered, and Monitor meal consumption, but had not been updated to reflect the healthshake, and monitoring of the amount of healthshake consumed. During an observation, on 7/12/21 at 2:55 pm, Resident 139 had a healthshake (nutritional supplement) on her bedside table that had not been touched by the resident. Resident 139 reported that she didn't like the healthshake, but would be willing to try a different flavor. On 7/13/21 at 9:51 am, Resident 139 had a healthshake sitting on her bedside table and none of it had been consumed. Resident 139 again reported that she did not like it, but would be willing to try a different flavor. At 10:20 am, the healthshake was still untouched on her bedside table. At 12 pm, Resident 139 had received her lunch and another healthshake was on her lunch tray. Resident 139's lunch tray was taken away at 1:04 pm, along with the untouched healthshake. During an interview, on 7/14/21 at 8:55 am, the Registered Dietitian (RD) reported, that as of this time, the percentage of supplements consumed by the residents was not being documented when the supplements were given with the meal trays. She said she had first contacted corporate, in March, to see how it could be done, but they had not come back with a response. She said she requested more information in June. The RD said if it was documented, then she could tell if the resident was drinking it, or not, and if it needed to be changed to another supplement. During a concurrent interview, and record review, on 7/14/21 at 9:43 am, the Director of Staff Development (DSD) and Director of Nursing, reviewed Resident 139's medical record, and reviewed the Page 1 of 8 555200 555200 07/15/2021 Almond View Care Center 1224 E Street Williams, CA 95987

F 0656 Level of Harm - Minimal harm or potential for actual harm percentage of meal intake for today and yesterday. She said the supplement consumption was included with the meal intake. The DSD could not say how much of the supplement had been consumed, if any, since it was included with the meal and not separated. Residents Affected - Few 555200 Page 2 of 8 555200 07/15/2021 Almond View Care Center 1224 E Street Williams, CA 95987

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to ensure that the resident environment remained free of accident hazards when the bathroom hot water temperature for numerous residents exceeded 120° degrees Fahrenheit (°F). This failure had the potential to result in burns for residents who had access to this hot water source, which could lead to pain, and negative clinical outcomes. Findings: The interpretive guidelines provided by the Centers for Medicare and Medicaid Services (CMS) indicated: Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. A third degree thermal burn may occur after: 1 minute of exposure to 127°F water, 3 minutes of exposure to 124°F water, and 5 minutes of exposure to 120°F water. During observations, on 7/14/21 at 10:37 am, the hot water temperature was 125.5°F in the bathroom shared by residents in room [ROOM NUMBER], and 205. The residents in room [ROOM NUMBER] were mobile in their wheelchairs, and used their bathroom. Additional random hot water temperatures on this hall were checked and were noted to be: 126.2°F at 10:40 am in the bathroom shared by the residents in rooms [ROOM NUMBERS]; 124.6°F in room [ROOM NUMBER] at 10:45 am; 126°F in room [ROOM NUMBER] at 10:51 am; 126°F in room [ROOM NUMBER] at 11:09 am; 126°F in room [ROOM NUMBER] and 123°F in room [ROOM NUMBER] at 11:15 am. Random hot water temperatures in resident bathrooms, in the locked Alzheimer's unit, were checked at 11 am and were: room [ROOM NUMBER] was 129.6°F, room [ROOM NUMBER] was 123.8°F; room [ROOM NUMBER] was 123°F, room [ROOM NUMBER] was 124°F, and room [ROOM NUMBER] was 129°F. During an interview, on 7/12/21 at 11:02 am, Certified Nursing Assistant (CNA) 2 confirmed, that the residents in room [ROOM NUMBER] do use the bathroom, and would use the sink to wash their hands. During an interview, on 7/12/21 at 11:09 am, Resident 3 in room [ROOM NUMBER]A, reported that she uses the bathroom and washes her hands in the sink. During an interview, on 7/12/21 at 11:15 am, Resident 30 in room [ROOM NUMBER], reported that she uses the bathroom and washes her hands in the sink. During a concurrent observation, and interview, on 7/12/21 at 11:42 am, the Plant Maintenance 555200 Page 3 of 8 555200 07/15/2021 Almond View Care Center 1224 E Street Williams, CA 95987

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Director (PM) checked the bathroom water temperature for the bathroom shared by the residents in rooms [ROOM NUMBERS], with his thermometer, and it showed 124°F. The surveyor's thermometer indicated the temperature was 124.7°F. The PM reported that he tries to keep the temperature between 104°F and 116°F. He checked the nursing station water temp and it was 122°F. He said he will turn down the water temperature, and will recheck the water temperatures. The PM said he usually takes random water temperatures on Tuesdays. During an interview, on 7/12/21 at 11:55 am, the Administrator in training (AIT) stated they had no policy on water temperatures monitoring, but they do comply with all state and federal regulations. The AIT said they have told the CNAs to make sure the water is not too hot, and the PM was currently fixing the problem. During a subsequent interview, on 7/12/21 at 4:30 pm, the PM said the hot water heater had been set at a temperature of 125°F. He said he turned it down, and rechecked temperatures in rooms around the facility and they were all at 116°F and below, this was verified by the survey team as well. 555200 Page 4 of 8 555200 07/15/2021 Almond View Care Center 1224 E Street Williams, CA 95987

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff were properly trained, and educated on hand hygiene during medication administration for four of eight sampled residents (Residents 68, 27, 33, and 26). This failure had the potential for residents to be at risk for cross contamination from dirty contaminated hands during medication pass, which could lead to negative clinical outcomes. Findings: The facility's policy and procedure titled, Specific Medication Administration Procedures, dated 3/4/14, was reviewed, and indicated that staff are to cleanse their hands using an antimicrobial soap and water, or facility approved hand sanitizer before having any contact with the residents. The facility's policy titled, Handwashing/Hand Hygiene, dated 2/28/17, was reviewed, and indicated that staff are to cleanse their hands using an antimicrobial soap and water, or facility approved hand sanitizer before and after direct resident care contact. Resident 68's medical record was reviewed. Resident 68 was admitted to this facility on 9/4/20, with diagnosis that included dementia (degenerative disorder of the brain), muscle weakness, and high blood pressure. Resident 27's medical record was reviewed. Resident 27 was admitted to this facility on 10/19/16, with diagnosis that included diabetes, dementia, and difficulty walking. Resident 33's medical record was reviewed. Resident 33 was admitted to this facility on 8/23/19, with diagnosis that included high blood pressure, diabetes, and muscle weakness. Resident 26's medical record was reviewed. Resident 26 was admitted to this facility on 10/16/19, with diagnosis that included dementia (memory loss), muscle weakness, and failure to thrive. During a concurrent observation, and interview, on 7/13/21 at 8 am, with Licensed Nurse (LN) 1, medication administration was observed for Residents 33 and 27. LN 1 did not perform hand hygiene prior to administering medication. LN 1 stated, I forgot to wash my hands prior to giving the medications. During a concurrent observation, and interview, on 7/13/21 at 8:20 am, with LN 3, medication administration was observed for Residents 68 and 26. LN 3 did not perform hand hygiene prior to administering medication. LN 3 stated, I did not realize that I was supposed to wash my hands before I administer the medication to the residents. During a concurrent interview, and record review, on 7/13/21 at 10:30 am, with the Director of Nursing, the facility policy titled, Specific Medication Administration Procedures, dated 3/4/14, and Handwashing/Hand Hygiene, dated 2/28/17 were reviewed. The DON confirmed that hand hygiene is expected to be performed prior to preparation of medications, and again prior to administration, and once again following the administration. 555200 Page 5 of 8 555200 07/15/2021 Almond View Care Center 1224 E Street Williams, CA 95987

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 interview, and record review, the facility failed to ensure that outdated medication were removed from the medication cart, and disposed of per manufacturer's guidelines for one of eight sampled residents (Resident 11). This failure caused this resident to receive outdated medication for seven days, which had the potential to cause infection, or for the medication to longer be effective. Findings: The facility's policy and procedure titled, Medication Storage in the Facility, dated [DATE], was reviewed, and indicated that no expired medication are to be administered to a resident. Resident 11's medical record was reviewed. Resident 11 was admitted to this facility on [DATE], with diagnosis that included dementia (a degenerative brain disorder), and glaucoma (increased pressure in eyes). During a concurrent observation, interview, and record review, on [DATE] at 9 am, with Licensed Nurse (LN) 3, Latanoprost solution 0.005% eye drops (medication to control pressure in the eyes) was observed open in the medication cart for dispensation for Resident 11, with an expiration date of [DATE]. Resident 11's Medication Administration Record (MAR), dated July, 2021 was reviewed. The MAR indicated, that at 8 PM on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], that Resident 11 had received the expired eye drops administered into both eyes. LN 3 confirmed the expiration date on the Latanoprost eye drops, and that there were no other eyes drops available in the cart. 555200 Page 6 of 8 555200 07/15/2021 Almond View Care Center 1224 E Street Williams, CA 95987

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of 21 residents (Resident 20) was provided the specialized cup for meals, as ordered by his physician. Residents Affected - Few This failure had the potential to result in swallowing difficulties which could cause aspiration (when liquids enter the airway), which could lead to negative clinical outcomes. Findings: Resident 20's medical record was reviewed. Resident 20 was readmitted to this facility on 6/17/21, with diagnoses that included obstructive uropathy (condition in which the flow of urine is blocked), heart disease, and dysphagia (difficulty swallowing). Resident 20's record contained a recommendation from the Speech Therapist (ST) on 6/21/21, to place Resident 20's food in bowls with a small spoon, and nectar thick liquids in a nosey cup (an adaptive drinking cup with a U-shaped cut-out on one side which provides space for the nose, allowing the user to tilt the cup for drinking without bending the neck or tilting the head) for all meals. This recommendation was signed by the physician as an order. Resident 20's care plan for nutrition included the nosey cup. On 7/13/21 at 7:34 am, a Certified Nursing Assistant (CNA) was observed with Resident 20 and was supervising him as he fed himself. The breakfast tray was on his bedside table, and included a small spoon but no nosey cup. All liquids were in regular glasses. The tray card (specified the type and texture of diet and any specialized equipment) which included the nosey cup. On 7/13/21 a CNA was observed entering Resident 20's room at 1:10 pm, and helped Resident 20 with his lunch. At 1:13 pm the Registered Dietitian (RD) was asked if Resident 20 had a nosey cup as ordered. RD said, no those are not nosey cups, I'll go get one and left to go to kitchen and returned with a couple of nosey cups. During an interview, on 7/14/21 at 11 am, The ST said the small spoon and nosey cup was to help Resident 20 slow down his eating and prevent swallowing problems. He said, with the nosey cup the resident doesn't have to tilt his head back all the way when he drinks. 555200 Page 7 of 8 555200 07/15/2021 Almond View Care Center 1224 E Street Williams, CA 95987

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food services when several resident trays and plate covers were not allowed to dry fully before being stacked. This failure had the potential to result in bacteria growth and cause foodborne illness to residents who received food from these items. Findings: According to the Federal Food Code 2017, Section 4.901.11, after cleaning and sanitizing, equipment and utensils shall be air dried. During an observation, in the kitchen with the Registered Dietitian (RD), on 7/14/21 at 8:15 am, the Dietary Aide (DA) took several trays off the drying rack, and stacked them on a cart while they were still wet. She then took several plate covers off the drying rack and stacked them on a cart while they were still wet. The RD left and spoke with the Dietary Supervisor for a brief moment then returned. The RD confirmed that the items should have been completely dry before being stacked, and said all those items would be rewashed. On 7/15/21 at 9:48 am, the RD was asked to provide the training that had been given to DA regarding drying of dishes. The RD provided an inservice which had been provided to dietary staff including DA. The RD pointed out the following on the second page of the inservice: Allow all dishes to air-dry in racks before stacking and storing. 555200 Page 8 of 8