Health inspection·May 6, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to treat one of 12 sampled residents (Resident 19) with dignity and respect when Resident 19's fingernails were untrimmed and covered with black and brown matter. This failure resulted in the potential harm of Resident 19 not reaching her highest practicable well being. Findings: During a review of Resident 19's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/4/22, the AR indicated, Resident 19 was admitted from an acute care hospital on 9/20/19 to the facility, whose diagnoses included Major Depressive Disorder (a persistent feeling of sadness and loss of interest), Unspecified Psychosis (a mental condition causing the person to experience false beliefs, seeing or hearing things that others do not see or hear), and Altered Mental Status (disruption in how brain works that causes a change in behavior). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment, dated 3/31/22, the MDS indicated Resident 19's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 7 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact). During a review of Resident 19's Care Plan (CP), dated 10/3/19, the CP indicated, . The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] confusion and dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) . Interventions . PERSONAL HYGIENE/ORAL CARE: The resident requires extensive assistance from one person . During a concurrent observation and interview on 5/3/22, at 4:58 p.m., with CNA 1, in Resident 19's room, CNA 1 stated, Resident 19's fingernails on both hands were untrimmed and dirty, covered by brown and black substance. CNA 1 stated Resident 19's fingernails should be kept clean at all times. CNA 1 stated she and other nursing staff were responsible in making sure Resident 19's fingernails were clean at all times. CNA 1 stated Resident 19 could develop skin or stomach infection because of her dirty fingernails. CNA 1 stated Resident 19 used her hands to eat her meals. During a concurrent observation and interview on 5/3/22, at 5:05 p.m., with LVN 2, in Resident 19's Page 1 of 17 555347 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0550 Level of Harm - Minimal harm or potential for actual harm room. LVN 2 stated, Resident 19's fingernails on both hands were untrimmed and covered by a black and brown substance. LVN 2 stated Resident 19's fingernails should be kept clean at all times. LVN 2 stated facility staff did not follow Resident 19's personal hygiene care plan. LVN 2 stated Resident 19 used her hands to eat her meals, and the dirty fingernails could cause stomach problems such as nausea, vomiting, and diarrhea. LVN 2 stated Resident 19 could potentially have skin infection due to dirty fingernails. Residents Affected - Few During an interview on 5/6/22, at 9:26 a.m., with the Director of Staff Development (DSD), DSD stated Resident 19's untrimmed and dirty fingernails were unacceptable, and a dignity and infection control issue. DSD stated cleaning of Resident 19's fingernails was part of the ADLs (Activities of Daily Living) care plan. DSD stated Resident 19 should be treated with kindness, respect, and dignity at all times. During an interview on 5/6/22, at 12:43 p.m., with the Director of Nursing (DON), DON stated Resident 19's untrimmed and dirty fingernails were an infection control and dignity issue. DON stated Resident 19's personal hygiene care plan was not followed. DON stated staff should have cleaned Resident 19's hands and fingernails before and after meals, and as needed. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 1/2018, the P&P indicated . Employees shall treat all residents with kindness, respect, and dignity . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . During a review of the facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails, dated 2/2018, the P&P indicated . The purpose of this procedure is to clean the nail bed, to keep nails trimmed . 10. Gently remove the dirt from around and under each nail with an orange stick. 11. Wipe the dirt from the orange stick with a paper towel . 22. Make the resident comfortable . 555347 Page 2 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

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 implement a person-centered comprehensive care plan for one of 24 sampled residents (Resident 19) when Resident 19's personal hygiene care plan was not implemented. This failure resulted in Resident 19's fingernails on both hands to be untrimmed and dirty, covered by brown and black substance and had the potential to result in Resident 19 to develop skin infection and or stomach problems such as nausea, vomiting, diarrhea or stomach infection. Findings: During a review of Resident 19's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/4/22, the AR indicated, Resident 19 was admitted from an acute care hospital on 9/20/19 to the facility, whose diagnoses included Major Depressive Disorder (a persistent feeling of sadness and loss of interest), Unspecified Psychosis (a mental condition causing the person to experience false beliefs, seeing or hearing things that others do not see or hear), and Altered Mental Status (disruption in how brain works that causes a change in behavior). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 19's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 7 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact). During a review of Resident 19's Care Plan (CP), dated 10/3/19, the CP indicated, . The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] confusion and dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) . Interventions . PERSONAL HYGIENE/ORAL CARE: The resident requires extensive assistance from one person . During a concurrent observation and interview on 5/3/22, at 4:58 p.m., with CNA 1, in Resident 19's room, CNA 1 stated, Resident 19's fingernails on both hands were untrimmed and dirty, covered by brown and black substance. CNA 1 stated Resident 19's fingernails should have been kept clean at all times. CNA 1 stated she and other nursing staff were responsible in maintaining Resident 19's fingernails were clean at all times. CNA 1 stated Resident 19 could develop skin or stomach infection because of her dirty fingernails. CNA 1 stated Resident 19 used her hands to eat her meals. During a concurrent observation and interview on 5/3/22, at 5:05 p.m., with LVN 2, in Resident 19's room. LVN 2 stated, Resident 19's fingernails on both hands were untrimmed and covered by a black and brown substance. LVN 2 stated Resident 19's fingernails should be kept clean at all times. LVN 2 stated facility staff did not follow Resident 19's personal hygiene care plan. LVN 2 stated Resident 19 used her hands to eat her meals, and the dirty fingernails could cause stomach problems such as nausea, vomiting, and diarrhea. LVN 2 stated Resident 19 could potentially have skin infection due to dirty fingernails. 555347 Page 3 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0656 During an interview on 5/6/22, at 9:26 a.m., with the Director of Staff Development (DSD), Level of Harm - Minimal harm or potential for actual harm DSD stated Resident 19's untrimmed and dirty fingernails were unacceptable, and a dignity and infection control issue. DSD stated cleaning of Resident 19's fingernails was part of the ADLs (Activities of Daily Living) care plan. Residents Affected - Few During an interview on 5/6/22, at 12:43 p.m., with the Director of Nursing (DON), DON stated Resident 19's untrimmed and dirty fingernails were an infection control and dignity issue. DON stated Resident 19's personal hygiene care plan was not followed. DON stated staff should have cleaned Resident 19's hands and fingernails before and after meals, and as needed. DON stated the untrimmed and dirty fingernails could cause skin infection and stomach problems such as diarrhea, nausea, abdominal pain, and vomiting. During a review of the facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails, dated 2/2018, the P&P indicated . The purpose of this procedure is to clean the nail bed, to keep nails trimmed . 10. Gently remove the dirt from around and under each nail with an orange stick. 11. Wipe the dirt from the orange stick with a paper towel . 22. Make the resident comfortable . During a review of the facility's Licensed Vocational Nurse (LVN) Job Description (JD), dated 10/2015, the JD indicated . The LVN contributes to nursing assessments and care planning, provides direct patient care, and supervises patient care provided by unlicensed staff . 2. Care Planning . 2.3. Implements the plan of care . 555347 Page 4 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0759 Ensure medication error rates are not 5 percent or greater. 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 a medication error rate of less than five percent when 10 medication errors were observed during 35 medication administration opportunities, which resulted in an error rate of 28.57 percent. Residents Affected - Some These failures resulted in Resident 21 not being informed of the medications being administered and had the potential for unsafe medication administration. Findings: During a review of Resident 21's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/4/22, the AR indicated, Resident 21 was readmitted from an acute care hospital on 3/18/22 to the facility, whose diagnoses included Major Depressive Disorder (a persistent feeling of sadness and loss of interest), Infection due to Nephrostomy Catheter (a tube use to drain urine directly from the kidney), and Pyelonephritis (a type of kidney infection). During a review of Resident 21's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 21's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact). During a concurrent observation and interview on 5/14/22, at 8:42 a.m., with Licensed Vocational Nurse (LVN) 1, outside Resident 21's room, LVN 1 stated she was giving Resident 21 the following medications: Amlodipine (blood pressure medication), Aspirin (pain, fever, and inflammation reducer), Lorazepam (anti-anxiety medication), Sodium valproate (mood stabilizer medication), Ferrous sulfate (treats low iron levels), Memantine (use to treat moderate to severe confusion due to memory loss), Hydrocodone/acetaminophen (pain and fever reducer), Sertraline (antidepressant medication), Pantoprazole (use to decrease the acid produced in the stomach), and Nutritional Supplement (oral formula for those with damaged kidneys). LVN 1 entered Resident 21's room, Resident 21 was lying in bed with the head of the bed approximately 35-40 degrees elevated. LVN 1 asked Resident 21 if she was ready for her medication and Resident 21 replied yes. LVN 1 gave the medications from the medication cup to Resident 21. Resident 21 was observed swallowing all her medications and drank 8 oz (ounce - unit of measurement) of water. LVN 1 did not inform Resident 21 of what medications were administered to her. LVN 1 validated the observation. LVN 1 stated she forgot to explain Resident 21's medications. LVN 1 stated Resident 21 has the right to know the medications that she was about to take. LVN 1 stated she failed to follow the facility's policy on medication administration. During an interview with the Director of Nursing (DON), on 5/6/22, at 12:58 p.m., DON stated LVN 1 should have stated the name and indication of each medication prior to handing the medication to Resident 21. DON stated LVN 1 did not follow the facility's policy on medication administration. DON stated giving the medication without stating the medication name and indication was a medication error. During a review of the facility's Licensed Vocational Nurse (LVN) Job Description (JD), dated 10/2015, the JD indicated . The LVN contributes to nursing assessments and care planning, provides direct 555347 Page 5 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some patient care . 3. Provision of Direct Patient Care: 3.1 Administers medications and performs treatments per physician orders . During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, undated, the P&P indicated, . Policy: Medications are administered as prescribed in accordance with good nursing principles and practices . During a review of a professional reference titled, Involve Patients in Medication Checks, 2022, from the Institute for Healthcare Improvement retrieved from: http://www.ihi.org/resources/Pages/Changes/InvolvePatientsin MedicationChecks.aspx indicated, Patients have an important role in the medication administration process . Before administering any medications, clinicians should review the medication, its purpose, and the dose with the patient and ask him to verify that all are correct. The clinician should offer an opportunity for the patient to ask questions or raise concerns, and if anything is unclear the administration should be delayed until everything is resolved. This extra line of defense before the last step can be crucial in preventing adverse drug events . 555347 Page 6 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

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, interview, and record review, the facility failed to ensure drugs and biologicals (substances such as vaccines, drugs, or supplements) were stored in accordance with the facility's policy and procedure, titled, Medication Storage in the Facility, for one of 12 sampled residents (Resident 21), when Resident 21's therapeutic nutritional shake (an oral formula for those with kidney disease [damaged kidneys causing difficulty and inability to create urine]) was opened and placed inside the medication cart for storage, instead of the refrigerator. This failure had the potential for Resident 21's therapeutic nutritional shake to not be stored per manufacture's recommendation, which had the potential to reduce efficacy of the shake and for adverse reactions such as nausea, vomiting, or diarrhea. Findings: During a review of Resident 21's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/4/22, the AR indicated, Resident 21 was readmitted from an acute care hospital on 3/18/22 to the facility, with diagnoses that included Major Depressive Disorder (a persistent feeling of sadness and loss of interest), Infection due to Nephrostomy Catheter (a tube use to drain urine directly from the kidney), and Pyelonephritis (a type of kidney infection). During a review of Resident 21's Order Summary Report (OSR), dated 5/4/22, the OSR indicated, . [Brand Name therapeutic nutrition shake] two times a day for supplement. Give 4OZ [ounce - unit of measurement] with meds [medications] . Order Date . 4/12/2022 . During a concurrent observation of the medication cart and interview with the Infection Preventionist (IP), on 5/4/22, at 10:24 a.m., an opened container of therapeutic nutrition shake, 237 ml [milliliters - unit of measurement]/8 oz [ounce, unit of measurement] dated 5/4/22, was left inside the medication cart. The IP stated the therapeutic nutrition shake should have been kept in the refrigerator after opening to prevent bacterial growth and maintain medication effectiveness. The IP stated Resident 21 could potentially have stomach issues such as nausea, vomiting, or diarrhea from drinking a therapeutic nutrition shake that was not refrigerated after it was opened. The IP stated the opened therapeutic nutrition shake container stored in the medication cart was ready for Resident 21's use. During an interview with the Director of Nursing (DON), on 5/6/22, at 12:43 p.m., the DON stated the therapeutic nutrition shake should have been kept inside the refrigerator after it had been opened to prevent bacterial growth and maintain medication efficacy. The DON stated the licensed nurse did not follow the manufacturer's instruction for use, the therapeutic nutrition shake requires refrigeration once opened. The DON stated Resident 21 could get sick from consuming the therapeutic nutrition shake that was left inside the medication cart. The DON stated the opened therapeutic nutrition shake container stored inside the medication cart was ready for Resident 21's use. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, undated, the P&P indicated, . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations . K. Medications requiring 'refrigeration' . are 555347 Page 7 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0761 kept in a refrigerator . Level of Harm - Minimal harm or potential for actual harm During a review of the therapeutic nutritional shake manufacturer's recommendation for storage, undated, the manufacture's recommendation indicated, . Store unopened at room temperature. Shake well prior to opening. Once opened, reclose, refrigerate and use within 48 hours . Residents Affected - Few 555347 Page 8 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety when: Residents Affected - Some 1. Two of two five-pound packs of ground beef were placed in the kitchen refrigerator to thaw without a documented pulled date (the date the frozen meat was removed from the freezer and placed in the refrigerator) or use-by date (the date the meat should be discarded); 2. The temperature of the water for the hand-washing sink in the kitchen was measured at 84 degrees Fahrenheit (F), below the expected temperature range of 100 to 108 degrees F per the facility policy and procedure. 3. The green salad on the kitchen assembly line on 5/4/22 had an internal temperature of 50 degrees F, rather than the expected temperature of 41 degrees or less per the Food Code. These failures had the potential to place residents at risk for serious complications from foodborne illness (disease or period of sickness caused by food contamination). Findings: 1. During a concurrent observation and interview on 5/3/22 at 10:15 a.m., with [NAME] 1, in the facility's kitchen, two thawed five-pound packs of ground beef were in a bin placed on the bottom rack of the kitchen's refrigerator. [NAME] 1 stated, the ground beef was place in the refrigerator to thaw but they did not know when the ground beef had been placed in the refrigerator since there was no label on the bin or on the meat packages. [NAME] 1 stated a label was required to indicate a pull date and used by date. During an interview on 5/3/22 at 11:52 a.m., with the Dietary Supervisors (DS) 1 and DS 2, DS 2 stated the ground beef was pulled on 5/2/22 by a kitchen staff. DS 1 stated, the kitchen staff should have labeled the ground beef with a pull date and used by date. DS 2 stated, the used by date was three days from the pull date to minimize foodborne illness. During an interview on 5/5/22 at 11:54 a.m., with [NAME] 2, [NAME] 2 stated [NAME] 2 removed the two five-pound packs of ground beef from the freezer on 5/2/22 and placed it in the refrigerator to thaw. [NAME] 2 stated a label was required to indicate when the ground beef should be used by. [NAME] 2 stated it was important to label the ground beef, so staff knew when to discard the meat. [NAME] 2 stated consuming meat passed the used by date can cause foodborne illness. [NAME] 2 stated, they should have labeled the ground beef. During a review of the facility's policy and procedure (P&P) titled, Food Preparation. Policy: Thawing of Meats, dated 2018, the P&P indicated, Procedure: Thawing meat properly can be done in these four ways: 1. In a refrigerator at 41 degrees F or colder. Allow 2 to 3 days to defrost, depending on quantity and total weight of meat. Labeling meat with pull and used by date. During a review of the professional reference retrieved from https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/big-thaw-safe-defrosting-meth titled, The Big Thaw - Safe Defrosting Methods, dated 6/15/13, indicated, After thawing in the refrigerator, 555347 Page 9 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some items such as ground meat, stew meat, poultry, seafood, should remain safe and good quality for an additional day or two before cooking; red meat cuts (such as beef, pork or lamb roasts, chops and steaks) 3 to 5 days. 2. During a concurrent observation and interview on 5/4/22 at 10:06 a.m., with [NAME] 1, in the facility's kitchen, the hand washing sink's hot water temperature was 84 degrees F when measured with a thermometer. [NAME] 1 used the facility's kitchen thermometer and validated the temperature was 84 degrees F. [NAME] 1 stated, the hot water should have been between 100 and 108 degrees F. During a concurrent observation and interview on 5/4/22 at 10:38 a.m., with the Maintenance staff (MS), in the facility's kitchen, the hand washing sink's hot water was measured with the MS's thermometer while the hot water was running. The hot water's temperature was 84 degrees F. MS stated the temperature should have been over 100 degrees F. During a concurrent interview and record review on 5/5/22 at 12:30 p.m., with the Regional Maintenance Supervisor (RMS), the facility's policy and procedure (P&P) titled, Hand Washing Procedure, dated 2020, was reviewed. The P&P indicated, Hand washing is important to prevent the spread of infection. Procedure: 1. Use warm running water (100 - 108 degrees F) and soap, preferably from a dispenser. RMS stated water temperature between 100 and 108 degrees F was required for effective handwashing to minimize spread of infection. 3. During a concurrent observation and interview on 5/4/22 at 11:51 a.m., with [NAME] 1 and DS 1, in the facility's kitchen, the tray line assembly for lunch preparation was measured with a food thermometer. The green salad's internal temperature was measured with the food thermometer, and thermometer indicated 50 degrees F. [NAME] 1 and DS 1 stated, the serving temperature of the green salad should have been 41 degrees or less to minimize foodborne illness. During an interview on 5/5/22 at 3:40 p.m., with the Registered Dietician (RD) and Administrator (ADM), RD stated, cold food should be stored at the proper temperature (below 41 degrees F) to prevent foodborne illness. The RD stated the elderly were at risk for foodborne illness. During a professional reference review of the Food Code - U.S. (United States) Food & Drug Administration 2017, dated 2017, the professional referenced indicated, .Historical Record of Cold Holding Temperature Provisions .41°F became the standard for cold holding . During a review of the professional reference retrieved from https://www.fda.gov/regulatory-information/search-fda-guidance-documents/guidance-industry-guide-minimize-microbial-fo titled, Guidance for Industry: Guide to Minimize Microbial Food Safety Hazards of Fresh-cut Fruits and Vegetables, dated February 2008, the professional reference indicated, Processing fresh produce into fresh-cut products increases the risk of bacterial growth and contamination by breaking the natural exterior barrier of the produce (Ref. 6).The release of plant cellular fluids when produce is chopped or shredded provides a nutritive medium in which pathogens, if present, can survive or grow (Ref. 6). Thus, if pathogens are present when the surface integrity of the fruit or vegetable is broken, pathogen growth can occur and contamination may spread. The processing of fresh produce without proper sanitation procedures in the processing environment increases the potential for contamination by pathogens (see Appendix B, Foodborne Pathogens Associated with Fresh Fruits and Vegetables.) .The potential for pathogens to survive or grow is increased by the high moisture and nutrient content of fresh-cut fruits and vegetables, the absence of a lethal process (e.g., heat) during production to eliminate pathogens, and the potential for temperature abuse during 555347 Page 10 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0812 Level of Harm - Minimal harm or potential for actual harm processing, storage, transport, and retail display (Ref. 6). Importantly, however, fresh-cut produce processing has the capability to reduce the risk of contamination by placing the preparation of fresh-cut produce in a controlled, sanitary facility . Residents Affected - Some 555347 Page 11 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

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 maintain an effective infection control and prevention program when: Residents Affected - Some 1. One of four staff (Certified Nurse Assistant [CNA] 2) failed to follow the facility's policy titled, Scope of Infection Control Program, when CNA 2 did not wear a face mask before entering the facility's screening area and main lobby. This failure had the potential to place residents, visitors, and staff at increased risk for transmission (a process on how an infectious agent can be transferred from one person to another) of SARS-CoV-2 (the virus that causes a respiratory disease called Coronavirus disease 19 [COVID-19]. The virus is spread from person to person through droplets released when an infected person coughs, sneezes, or talks). 2. Licensed Nurses (LNs) and CNAs failed to ensure one of 12 sampled residents' (Resident 19) personal hygiene care plan was implemented when Resident 19's fingernails were untrimmed and covered with black and brown matter. This failure had the potential to result in Resident 19 developing skin infection and or stomach problems such as nausea, vomiting, diarrhea or stomach infection and the potential for cross contamination of any surfaces or objects that Resident 19 touches. Findings: 1. During a concurrent observation and interview on 5/4/22, at 5:45 p.m., with CNA 2, in the facility lobby, CNA 2 was observed entering the facility's screening area and main lobby without a face mask. CNA 2 validated the observation that she entered the facility's screening area and main lobby without a face mask. A posted sign on the facility's entry door indicated, Please wear a mask before entering . You are required to wear a face mask while in the building at all times . During an interview on 5/5/22, at 5:39 p.m., CNA 2 stated it was important to wear a face mask when entering the facility to prevent the spread of coronavirus. CNA 2 stated wearing a face mask was important to protect facility residents and staff from COVID-19 virus (Coronavirus disease, an infectious disease caused by the SARS-CoV-2 virus). During an interview on 5/5/22, at 5:44 p.m., with Infection Preventionist (IP), IP stated staff must wear a face mask before entering the facility to protect residents and staff from COVID-19 virus. IP stated source control (use of well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory discharges when they are breathing, talking, sneezing, or coughing) was important to minimize the spread of COVID-19 virus. During an interview on 5/6/22, at 9:15 a.m., with Screener Receptionist (SR), SR stated staff and visitors must wear a face mask when entering the facility. Screener stated wearing a face mask would protect the residents, visitors, and staff from COVID-19 virus. During an interview on 5/6/22, at 9:26 a.m., with the Director of Staff Development (DSD), DSD stated staff and visitors must wear a face mask prior to entering the facility. DSD stated wearing a 555347 Page 12 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0880 face mask would protect everyone in the facility from COVID-19 virus. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/6/22, at 1:20 p.m., with the Director of Nursing (DON), DON stated CNA 2 did not follow the facility's infection control policy. DON stated staff should wear a face mask before entering the facility to protect residents and staff from COVID-19. DON stated source control was important to minimize the spread of COVID-19 virus. Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Scope of Infection Control Program, dated 8/2016, the P&P indicated, . The scope of the program includes prevention, detection, management and control of spread of infection . 3. Infection control precautions and measures - includes safeguard and provision of personnel protective equipment as well as the use of transmission-based precautions, also known in California as enhanced standard precautions . During a professional reference review of the CDC, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 2/2/22, the professional reference indicated, . Health Care Provider (HCP) who are up to date with all recommended COVID-19 vaccine doses . They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors) . 2. During a review of Resident 19's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/4/22, the AR indicated, Resident 19 was admitted from an acute care hospital on 9/20/19 to the facility, whose diagnoses included Major Depressive Disorder (a persistent feeling of sadness and loss of interest), Unspecified Psychosis (a mental condition causing the person to experience false beliefs, seeing or hearing things that others do not see or hear), and Altered Mental Status (disruption in how brain works that causes a change in behavior). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 19's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 7 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact). During a review of Resident 19's Care Plan (CP), dated 10/3/19, the CP indicated, . The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] confusion and dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) . Interventions . PERSONAL HYGIENE/ORAL CARE: The resident requires extensive assistance from one person . During a concurrent observation and interview on 5/3/22, at 4:58 p.m., with CNA 1, in Resident 19's room. CNA 1 stated, Resident 19's fingernails on both hands were untrimmed and dirty, covered by brown and black substance. CNA 1 stated Resident 19's fingernails should be kept clean at all times. CNA 1 stated she and other nursing staff were responsible in maintaining Resident 19's fingernails were clean at all times. CNA 1 stated Resident 19 could develop skin or stomach infection because of her dirty fingernails. CNA 1 stated Resident 19 used her hands to eat her meals. During a concurrent observation and interview on 5/3/22, at 5:05 p.m., with LVN 2, in Resident 19's 555347 Page 13 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0880 Level of Harm - Minimal harm or potential for actual harm room. LVN 2 stated, Resident 19's fingernails on both hands were untrimmed and covered by a black and brown substance. LVN 2 stated Resident 19's fingernails should be kept clean at all times. LVN 2 stated facility staff did not follow Resident 19's personal hygiene care plan. LVN 2 stated Resident 19 used her hands to eat her meals, and the dirty fingernails could cause stomach problems such as nausea, vomiting, and diarrhea. LVN 2 stated Resident 19 could potentially have skin infection due to dirty fingernails. Residents Affected - Some During an interview on 5/5/22, at 5:44 p.m., with the Infection Preventionist (IP), IP stated Resident 19's untrimmed and dirty fingernails was unacceptable and an infection control issue. During an interview on 5/6/22, at 12:43 p.m., with the Director of Nursing (DON), DON stated Resident 19's untrimmed and dirty fingernails were an infection control and dignity issue. DON stated Resident 19's personal hygiene care plan was not followed. DON stated staff should have cleaned Resident 19's hands and fingernails before and after meals, and as needed. DON stated the untrimmed and dirty fingernails could cause skin infection and stomach problems such as diarrhea, nausea, abdominal pain, and vomiting. During a review of the facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails, dated 2/2018, the P&P indicated . The purpose of this procedure is to clean the nail bed, to keep nails trimmed . 10. Gently remove the dirt from around and under each nail with an orange stick. 11. Wipe the dirt from the orange stick with a paper towel . 22. Make the resident comfortable . 555347 Page 14 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation during the survey period of 5/3/22 to 5/6/22, the facility failed to provide the minimum of at least 80 square feet per resident in 15 out of 16 rooms (Rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16). This failure had the potential for residents in Rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16 to not have reasonable privacy or adequate space. Findings: During an observation on 5/5/22, at 10:06 a.m., an environment tour was conducted with the maintenance supervisor, the inspection indicated the following rooms did not meet the minimum square footage as required by regulation. These rooms were as follows: Room Number Square Feet Number of Residents room [ROOM NUMBER] 145.75 2 room [ROOM NUMBER] 144.64 2 room [ROOM NUMBER] 144.64 2 room [ROOM NUMBER] 145.55 2 room [ROOM NUMBER] 555347 Page 15 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0912 144.64 Level of Harm - Potential for minimal harm 2 room [ROOM NUMBER] Residents Affected - Some 144.64 2 room [ROOM NUMBER] 144.64 2 room [ROOM NUMBER] 143.73 2 room [ROOM NUMBER] 143.73 2 room [ROOM NUMBER] 143.73 2 room [ROOM NUMBER] 143.73 2 room [ROOM NUMBER] 144.83 2 room [ROOM NUMBER] 144.83 555347 Page 16 of 17 555347 05/06/2022 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0912 2 Level of Harm - Potential for minimal harm room [ROOM NUMBER] 144.64 Residents Affected - Some 2 room [ROOM NUMBER] 144.64 2 However, variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Recommend waiver be continue in effect. 555347 Page 17 of 17